CUTANEOUS
ULCERS
DR OKORIE GABRIEL
CONSULTANT PLASTIC SURGEON
DEFINITION OF ULCER
ULCER :
• A BREACH OR DISRUPTION IN THE EPITHELIUM OF A
TISSUE OR ORGAN
SKIN : EPIDERMIS = EPITHELIUM
WOUND :
• A DISRUPTION IN THE STRUCTURE ( ANATOMIC) AND
FUNCTION ( PHYSIOLOGIC) OF A TISSUE DUE TO ENERGY
TRANSFER
CLASSIFICATION OF
ULCERS
1. BASED ON AETIOLOGY
• SPECIFIC
• NON - SPECIFIC
• NEOPLASTIC
2. ANATOMIC CLASSIFICATION
• LEG ULCER
• HAND ULCER etc
CLASSIFICATION Cont'd
3. DURATION & TYPE OF INFLAMMATORY
PROCESS
< 3WKS = ACUTE ULCER
• FEATURES OF ACUTE INFLAMMATION
• COLLAGEN ARE LAID IN AN ORGANISED PATTERN
>3 WKS = CHRONIC ULCER
FEATURES OF CHRONIC INFLAMMATION
COLLAGEN MATERIALS ARE LAID IN HAPHAZARD MANNER
SPECIFIC ULCERS
• AETIOLOGY IS KNOWN
• TYPES INCLUDE:
• TROPICAL ULCERS
• TUBERCULOUS [ BURULI ]
• SYPHILITIC
• YAW ULCER
NON SPECIFIC ULCERS
• AETIOLOGY IS UNKNOWN
• POST CELLULITIC ULCER
• ULCERS OF UNKNOWN ORIGIN
• TRAUMATIC ULCER
• ULCERS OF VASCULAR ORIGIN
1. VENOUS [GRAVITATIONAL] ULCERS
2. ARTERIAL ULCER
NON SPECIFIC ULCERS
• NEUROTROPIC [ TROPHIC] ULCERS
• DIABETIC NEUROPATHIC ULCERS
• PERIPHERAL NEUROPATHIES
NEOPLASTIC ULCER
• MARJOLIN'S ULCER
• SQUAMOUS CELL CARCINOMA ( SCC)
• BASAL CELL CARCINOMA ( BCC)
• MELANOMA
EDGE OF ULCER
1. SLOPING : 3. PUNCHED OUT:
• ULCER IN HEALING PHASE ¬ SYPHILITIC
• TROPICAL ULCER
2. UNDERMINED: 4. RAISED OR EVERTED:
• TUBERCULOUS ¬ NEOPLASTIC
EDGE OF ULCER
EDGES OF ULCER
RAISED EVERTED
PHASES OF ULCER
• 4 PHASES
1. ACUTE OR INFECTIVE
2. TRANSITION
3. HEALING
4. CHRONIC OR INDOLENT
ACUTE OR INFECTIVE
PHASE
• SYNONYM = EXPANSION PHASE
• FEATURES:
• FLOOR= CONTAINS SLOUGH
• DISCHARGE = PURULENT
• EDGE = SHARP
• SURROUNDING SKIN = OEDEMATOUS
TRANSITION
PHASE
• FLOOR = DECREASED SLOUGH
• DISCHARGE = DECREASED
• GRANULATION TISSUE = PRESENT BUT UNHEALTHY
• EDGE = SLIGHTLY SLOPING
• SURROUNDING SKIN = HYPERAEMIC OR NORMAL
HEALING PHASE
• SYNONYM: REPARATIVE PHASE
• ULCER = PAINLESS
• GRANULATION TISSUE = HEALTHY
• FLOOR = NO SLOUGH WITH EPITHELIUM
MIGRATING FROM THE EDGES
• SURROUNDING SKIN =NORMAL
CHRONIC PHASE
• SYNONYM : INDOENT OR CALLOUS PHASE
• FEATURES:
• EDGES : JAGGED
• FLOOR: MUCH SLOUGH
• DISCHARGE : PROFUSE & OFFENSIVE
• SURROUNDING SKIN : OEDEMATOUS
VENOUS ULCER
• CAUSES:
1. INCOMPETENT VALVES
• VARICOSE VEIN
• DVT VENOUS STASIS
2. VENOUS HYPERTENSION
LOCATION : ¬ GAITER AREA
ARTERIAL ULCER
• ATHEROSCLEROSIS ISCHAEMIA ULCERATION
• LOCATION:
• TOES
• DORSUM OF FOOT
• HEEL
NEUROPATHIC ULCER
• CAUSE:
• SENSORY LOSS ( FROM NEUROLOGICAL DISORDER)
• LOSS OF PAIN PERCEPTION SUSTAINED PRESSURE
ULCERATION
• LOCATION:
¬ SOLE OF FOOT
¬ OVER BONY PROMINENCES
TROPICAL ULCER
• OCCURS IN PEOPLE LIVING IN THE TROPICS
• LOCATION:
• LEGS & FEET
• CAUSE:
• SYNERGISTIC ACTION BTW ANAEROBIC
FUSOBACTERIA ( Bacteroides fusiformis) & AEROBE
( Borrelia vincenti)
• PAINFUL SEPTIC BLISTER ULCER
BURULI ULCER
• SYNONYM: BAIRNSDALE ULCER
• CAUSE : Mycobacterium ulcerans
• STARTS AS CHRONIC INFLAMMATION ULCER
CRYOPATHIC ULCER
• CAUSE: EXPOSURE TO LOW TEMP
2 TYPES :
1. CHILBLANS ( PERNIOSIS):
• INTENSE VASOCONSTRICTION OF SKIN ARTERIOLES
• TENDER,RED,PRURITIC SWELLING BLISTER
ULCER
• LOCATION: FEET AND TOES
CRYOPATHIC ULCER
cont’d
2. FROSTBITE:
CAUSE :
I. EXPOSURE TO WET COLD JUST ABOVE FREEZING
TEMP FOR PROLONGED PERIOD
ARTERIOLAR SPASM
II. STASIS OF BLOOD IN DAMAGED CAPILLARIES
WORSENING OF ISCHAEMIA
III. DENATURATION OF PROTEINS & ENZYMES
APOPTOSIS
INVESTIGATIONS
• DEPENDS ON AETIOLOGY
• VENOGRAPHY
• ANKLE-BRACHIAL PRESSURE INDEX ( ABPI)
• ARTERIOGRAPHY
• WOUND SWAB
• ZIEHL NEELSEN STAINING
• PCR
• DOPPLER / DUPLEX SCANNING
• CT /MRI ANGIOGRAPHY
MANAGEMENT OF ULCERS
• TREAT THE AETIOLOGY
•
• TIME MGT OF WOUND
T = TISSUE DEBRIDEMENT
I = INFECTION CONTROL
M = MOISTURE
E = EDGE APPOSITION OR EPITHELIAL MIGRATION
• COMPRESSION....... BANDAGE OR STOCKING
• SKIN COVERAGE
