Skin ulcers students

1. SKIN ULCERS
Definition
An ulcer is a break in the continuity of the
covering epithelium, either skin or mucus
membrane due to molecular death.
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2. Parts of an Ulcer
1. Margin: It may be regular or irregular. It may be
rounded or oval.
2. Edge: Edge is the one which connects floor of the
ulcer to the margin.
Different edges are:
Sloping edge. It is seen in a healing ulcer.
Its inner part is red because of healthy granulation
tissue.
Its outer part is white due to scar/fibrous tissue.
Its middle part is blue due to epithelial proliferation.
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3. Undermined edge is seen in a tuberculous ulcer.
Disease process advances in deeper plane (in
subcutaneous tissue) whereas (skin) epidermis
proliferates inwards.
Punched out edge is seen in a gummatous
(syphilitic) ulcer and trophic ulcer. It is due to end
arteritis.
Raised and beaded edge (pearly white) is seen in a
rodent ulcer (BCC). Beads are due to proliferating
active cells.
Everted edge (rolled out edge): It is seen in a
carcinomatous ulcer due to spill of the proliferating
malignant tissues over the normal skin.
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4. 3. Floor: It is the one which is seen. Floor may
contain discharge, granulation tissue or slough.
4. Base: Base is the one on which ulcer rests. It
may be bone or soft tissue.
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6. Classification I (Clinical)
1. Spreading ulcer: Here edge is inflamed and
oedematous.
2. Healing ulcer: Edge is sloping with healthy
pink/red granulation tissue with serous
discharge.
3. Callous ulcer: Floor contains pale unhealthy
granulation tissue with indurated edge/base.
It lasts for many months to years. Ulcer does
not show any tendency to heal.
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7. Classification II (Pathological)
1. Specific ulcers:
• Tuberculous ulcer
Syphilitic ulcer: It is punched out, deep, with “wash-
leather” slough in the floor and with indurated
base.
2. Malignant ulcers:
• Carcinomatous ulcer.
• Rodent ulcer.
• Melanotic ulcer.
3. Non-specific ulcers:
 Traumatic ulcer: It may be mechanical, physical,
chemical-common.
 Arterial ulcer: Atherosclerosis.
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8. Trophic ulcer/Pressure sores.
 Infective ulcers: Pyogenic ulcer.
 Tropical ulcers: It occurs in tropical countries. It is
callous type of ulcer, e.g. Vincent’s ulcer.
 Ulcers due to frostbite (cryopathic ulcer).
 Diabetic ulcer.
 Ulcers due to leukaemia, polycythemia, jaundice,
collagen diseases, lymphoedema.
 Cortisol ulcers are due to long time application of
cortisol (steroid) creams to certain skin diseases
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9. Wagner’s classification (grading) of ulcer
Grade 0 – pre-ulcerative lesion/healed ulcer
Grade 1 – superficial ulcer
Grade 2 – ulcer is deeper to subcutaneous tissue
exposing soft tissues or bone
Grade 3 – abscess formation
underneath/osteomyelitis
Grade 4 – gangrene of part of the tissues/limb/foot
Grade 5 – gangrene of entire one area/foot
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10. Induration of an Ulcer
Induration is a clinical palpatory sign which
means a specific type of hardness in the
diseased tissue.
It is obvious in well-differentiated carcinomas. It
is better felt in squamous cell carcinoma.
• Brawny induration is a feature of an abscess.
Induration is felt at edge, base and surrounding
area of an ulcer.
• Induration at surrounding area signifies the
extent of disease (tumour).
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11. GRANULATION TISSUE
• Is the proliferation of new capillaries and
fibroblasts intermingled with red and white blood
cells with thin fibrin cover over it.
Granuloma-term applied to nodular inflammatory lesions, usually
small or granular, firm, persistent, and containing compactly grouped
modified phagocytes such as epithelioid cells, giant cells, and other
macrophages.
Healing ulcer with healthy
granulation tissue. Note the sloping edge.
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12. Types of granulation tissue
Healthy granulation tissue: It occurs in a
healing ulcer.
characteristics of a healing ulcer:-
It has got sloping edge.
It bleeds on touch.
It has got serous discharge.
5 Ps of healthy granulation tissue—Pink,
Punctate haemorrhages, Pulseful, Painless, Pin
head granulation. Skin grafting takes up well
with healthy granulation tissue
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13. • Unhealthy granulation tissue: It is pale
with purulent discharge. Its floor is
covered with slough. Its edge is inflamed
and oedematous. It is a spreading ulcer.
• Unhealthy, pale, flat granulation tissue:
It is seen in chronic non-healing ulcer
(callous ulcer).
• Exuberant granulation tissue (Proud
flesh): It occurs in a sinus or ulcer wherein
granulation tissue protrudes out of the
sinus opening or ulcer bed like a
proliferating
mass. It is commonly associated with a
retained foreign body in the sinus cavity.
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14. • Pyogenic granuloma: It is a type of
exuberant granulation tissue. Here granulation
tissue from an infected wound or ulcer bed
protrudes out, presenting as a well localised,
red swelling which bleeds on touching.
Differential diagnosisof pyogenic granuloma:
Papilloma, skin adnexial tumours.
Treatment: Antibiotics, excision and sent for
biopsy.
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15. Causes of chronic ulcers in the skin
• Recurrent infection
• Trauma
• Absence of rest
• Poor blood supply
• Hypoxia
• Oedema of area
• Loss of sensation
• Malignancy
• Specific cause like tuberculosis
• Fibrosis
• Periostitis or osteomyelitis of the underlying
bone
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16. Assessment of an Ulcer
• Cause of an ulcer should be found – diabetes/
venous/arterial/infective.
• Clinical type should be assessed.
• Assessment of wound is important –
anatomical site; size and depth of the wound;
edge of the wound; mobility; fixity; induration;
surrounding area; local blood supply. Wound
perimeter may be useful in
assessing this
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17. • Wound imaging is done by tracing it on a
transparent acetate sheet at regular intervals.
• Presence of systemic features; regional nodal
status; function of the limb/part; joint
movements; distal pulses; sensations should be
assessed.
• Severity of infection should be assessed –
culture of discharge.
• Specific investigations like edge biopsy; X-ray
of part; blood sugar; arterial/venous Doppler;
angiogram.
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18. Different discharges in an ulcer (as well as from
a sinus)
a. Serous: In healing ulcer
b. Purulent: In infected ulcer caused by :-
Staphylococci: Yellowish and creamy
Streptococci: Bloody and opalescent
Pseudomonas: Greenish colour due to
pseudocyanin
c. Bloody: Malignant ulcer, healing ulcer from
healthy granulation tissue
d. Sero-purulent
e. Sero-sanguinous: Serous and blood
f. Serous with sulphur granules: Actinomycosis
g. Yellowish: Tuberculous ulcer
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19. INVESTIGATIONS FOR AN ULCER
• Study of discharge: Culture and sensitivity, AFB study,
cytology.
• Edge biopsy: Biopsy is taken from the edge because
edge contains multiplying cells. Usually two biopsies
are taken. Biopsy taken from the centre may be
inadequate because of central necrosis.
• X-ray of the part to look for periostitis/osteomyelitis.
• Chest X-ray, Mantoux test in suspected case of
tuberculous ulcer.
Note: Ulcer will not granulate if haemoglobin is less than
10 gm % and serum albumin is < 3 gm%.
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20. Management of an Ulcer
• Cause should be found and treated
• Correct the deficiencies like anaemia,
protein and vitamins deficiencies
• Transfuse blood if required
• Control the pain
• Investigate properly
• Control the infection and give rest to the part
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21. • Care of the ulcer by debridement, ulcer cleaning and
dressing is done
• Remove the exuberant granulation tissue
• Topical antibiotics for infected ulcers only like
framycetin, silver sulphadiazine, metronidazole gel
• Antibiotics are not required once healthy
granulation tissues are formed
• Once granulates, defect is closed with secondary
suturing, skin graft, flaps.
Ulcer cleaning is done using dilute povidone iodine
and normal saline. It should be done daily or two
times a day depending on the severity.
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22. Debridement of an ulcer
• It is removal of devitalised tissue
• Small ulcers are debrided in ward
• Large ulcers are debrided in operation theatre
under
general anaesthesia
• All dead, devitalised, necrotic tissues are removed
• Slough should be separated adequately before
debridement
• Often devitalised tissue separates on its own by
autolysis
• Enzymes like collagenase are used for
debridement.
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23. Why dressing of an ulcer is done
• To keep ulcer moist
• To keep surrounding skin dry
• To reduce pain
• To soothen the tissue
• To protect the wound
• As an absorbent for the discharge
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24. 9/25/2022 24
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25. Solutions commonly used for ulcer
dressing – povidone iodine (brownish); EUSOL
(colourless);hydrogen peroxide and normal
saline. Note the EUSOL bath.
Dilute EUSOL solution in a basin is used
wherein ulcer foot is dipped and kept in place for
20-30 minutes. EUSOL
removes the slough and cleans the ulcer bed.
Hydrogen peroxide releases nascent oxygen and
helps in removing necrotic material.
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26. TROPHIC ULCER (PRESSURE SORE)
Pressure sore is tissue necrosis and ulceration
due to prolonged pressure. Blood flow to the
skin stops when external pressure becomes
more than 30 mm Hg (more than capillary
occlusive pressure) and this causes tissue
hypoxia, necrosis and ulceration.
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27. It is more prominent between bony prominence
and an external surface.
It is due to
• Impaired nutrition.
• Defective blood supply.
• Neurological deficit.
Sites
• Over the ischial tuberosity.
• Sacrum.
• In the heel.
• In relation to heads of metatarsals.
• Buttocks.
• Over the shoulder.
• Occiput.
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29. Due to the presence of neurological deficit,
trophic ulcer may also be called neurogenic
ulcer/neuropathic ulcer.
Initially it begins as callosity due to repeated
trauma and pressure, under which
suppuration occurs and gives way through a
central hole which extends down into the
deeper plane up to the underlying bone as
perforating ulcer (penetrating ulcer).
Bedsores are trophic ulcers.
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31. Bed sore (decubitus ulcer) over the greater
trochanter, ischium and sacrum.
It is usually with punched out edge
Factors causing pressure sore
• Normal stimulus to relieve the pressure is absent
in anaesthetised patient
• Nutritional deficiencies worsens the necrosis
• Inadequate padding over the bony prominences
in
malnourished patients
• Urinary incontinence in paraplegia patient
causes
skin soiling – maceration – infection – necrosis
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32. Neurological causes
• Diabetic neuropathy
• Peripheral neuritis
• Spina bifida
• Leprosy
• Spinal injury
• Paraplegia
• Peripheral nerve injury
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33. Investigations
Study of discharge, blood sugar, biopsy
from the edge,
X-ray of the affected part, X-ray spine.
Treatment
• Cause should be treated.
• Nutritional supplementation.
• Rest, antibiotics, slough excision,
regular dressings.
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34. DIABETIC ULCER
Causes
• Increased glucose in the tissue precipitates
infection.
• Diabetic microangiopathy which affects
microcirculation.
• Increased glycosylated haemoglobin decreases
the oxygen dissociation.
• Increased glycosylated tissue protein decreases
the oxygen utilization.
• Diabetic neuropathy involving all sensory,
motor and autonomous components.
• Associated atherosclerosis.
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35. • Foot is the commonest area for diabetic
infective problems. It can cause abscess, ulcer,
osteomyelitis, gangrene, septicaemia.
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36. Sites
• Foot-plantar aspect—is the commonest site.
• Leg.
• Upper limb, back, scrotum, perineum.
• Diabetic ulcer may be associated with
ischaemia.
• Ulcer is usually spreading and deep.
Investigations
• Blood sugar both random and fasting.
• Urine ketone bodies.
• Discharge for culture and sensitivity.
• X-ray of the part to R/O osteomyelitis.
• Arterial Doppler of the limb.
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37. Treatment
• Control of diabetes using insulin.
• Antibiotics.
• Nutritional supplements.
• Regular cleaning, debridement, dressing.
• Once granulates, the ulcer is covered with
skin graft or flap.
• Toe/foot/leg amputation.
• Microcellular rubber (MCR) shoes to prevent
injuries; care of foot.
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38. Complications of Diabetic Ulcer
Neuropathy, in foot - clawing of toes, hammer
toe (due to intrinsic muscle paralysis)
 Multiple deeper abscesses; osteomyelitis of
deeper bones are common
 Reduced leukocyte function; resistant
infection; spreading cellulitis
Arterial insufficiency
Septicaemia
Diabetic ketoacidosis
Associated cardiac diseases like ischaemic
heart disease
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39. • BAIRNSDALE ULCER
• • It is a chronic, irregular, undermined ulcer due
to
• Mycobacterium ulcerans infection.
• • Deep severe form, with extensive dermal
necrosis is
• called as ‘Buruli ulcer.’
• • Discharge study will show acid-fast bacilli.
• • Antituberculous drugs resolve the ulcer
usually. Skin
• grafting may be required later.
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Venous ulcer around the ankle,
the commonest site.

41. MELENEY’S ULCER (POSTOPERATIVE
SYNERGISTIC GANGRENE)
• It is commonly seen in postoperative
wounds in abdomen and chest wall like
empyema drainage or after surgery for
peritonitis.
• It is an acute rapidly spreading ulcer with
destruction of skin and subcutaneous tissues.
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Meleney’s ulcer.
Meleney’s ulcer.
Meleney’s ulcer.

43. Aetiology
• It is common in old age and
immunosuppressed
individuals and after surgery for infected cases.
• It is caused by microaerophillic streptococci,
Staphylococcus aureus and anaerobes.
Sites
• It is common in abdomen and thorax. It
begins in wound margin and spreads rapidly. It
can also occur in other areas of skin.
• Infection is severe, often with endarteritis of
the skin leading to ulcer and destruction.
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44. Clinical Features
• Features of toxaemia.
• Spreading painful ulcer with discharge.
• Abundant granulation tissue with purple and red
zones.
Management
• Random blood sugar is checked, if diabetic it has
to be controlled.
• Antibiotics.
• Blood transfusion, critical care.
• Adequate excision of dead tissues until it bleeds.
• Once healthy granulation tissue is formed skin
grafting is done.
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45. LUPUS VULGARIS (‘lupus’—wolf)
• It is cutaneous tuberculosis which occurs in
young age group.
• Commonly seen on face, starts as typical
apple-gelly nodule with congestion of skin
around. Eventually a superficial ulcer with
undermined edge is formed.
• The ulcer is active and destruction occurs at
the periphery with healing takes place at the
centre.
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46. • Often lesion extends into nose and oral cavity
involving the mucosa.
• Due to lymphatic obstruction facial oedema
can occur.
• Long-standing lupus vulgaris can turn into
squamous cell carcinoma
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48. Investigation
ESR, discharge study, biopsy, chest X-ray.
Treatment
1. Antituberculous drugs.
2. If complete healing does not occur, then
excision and skin grafting is required.
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49. TROPICAL ULCER
• It is an acute ulcerative lesion of the skin seen
in tropical regions like Africa, India and South
America. It is associated with lower socioeconomic
group, anaemia, malnutrition and vitamin deficiency.
• It is commonly caused by Fusobacterium fusiformis
(Vincent’s organisms) and Borrelia vincenti.
• There are abrasions, redness, papule and pustule
formation, acute regional lymphadenitis and severe
pain.
• Eventually it forms a chronic large ulcer.
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50. Treatment –
 improvement in nutrition,
 penicillin,
 Eusol dressing,
 skin grafting at a later date.
GENAERAL PLAN OF EXAMINATION OF AN
ULCER
i)History-mnemonic DROPS for points to be recorded in
history
D –Duration for how long the ulcer has been present
R- Reduction or loss of weight or not
O- Mode of onset-how the ulcer developed ie following
trauma or spontaneously.
S = swelling before ulcer eg tuberculous cervical
lymphadenitis causing ulcer or sinus in the neck.
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51. Pain – inflammatory ulcers are painful
_ tuberculous ulcers are slightly painful
_syphilitic, trophic,carcinomatous, and
rodent ulcers are nonpainful
Progress –of the ulcer, past history and past
treatment Hx are noted.
Discharge from ulcer
History suggestive of associated disease /
treatment history
• Physical examination:-
General survey and local examination
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52. Local examination of an ulcer
Inspection
• Site of ulcer – arterial ulcer over the digits;
venous
ulcer over the malleoli; trophic ulcer over heel /
pressure points, rodent ulcer occurs in the face.
• Size and Shape of ulcer-carcinomatous ulcers
are irregular.
• Number- solitary or multiple
•Edge of ulcer Margin whether
regular/irregular/well defined/ill-defined
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53. • Floor of the ulcer – floor is the one that is seen.
It rests on the base. (Base is not seen; it is only
felt). Red color in floor – healing ulcer; slough
with pale /purulent discharge – nonhealing
ulcernor tubercular; wash leather slough –
syphilitic ulcer/proliferative and nodular floor –
squamous cell carcinoma; pigmented –
melanoma, pigmented basal cell carcinoma
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54. • Discharge from ulcer bed – serous,
serosanguinous, bloody, purulent; color of
discharge – greenish in pseudomonas infection
• Surrounding area to be examined for
inflammation, oedema, eczema, scarring,
pigmentation
• Inspection of the entire part/limb
Palpation
• Tenderness over edge, base and surrounding area
• Warmness over surrounding area
• Edge palpation for induration
• Palpation of base for induration/fixity
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55. • Depth of ulcer – trophic ulcer is deep with bone
as its base – often it is measured gently in mm
• Bleeding on palpation and touching
• Palpation for deeper structuresand its relation
to ulcer
• Surrounding skin and tibia/calcaneum/other
related bones for thickening
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56. • Examination of adjacent joint for mobility
• Examination of regional lymph nodes is
essential
– tenderness (acute infection), mobility,
consistency may be hard (carcinoma
metastasis)/ firm/soft and non tender
(inflammatory); fixity (malignancy); ulceration
or fungation (malignancy);
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