Skin Ulcers Overview powerpoint presentation

1. SKIN ULCERS OVERVIEW
DR OKOYE C.

2. Outline
• Introduction
• Epidemiology
• Characteristics of an ulcer
• Classification
• Specific ulcers
• Non-Specific Ulcers
• Management
– History
– Examination
– Investigation
– Treatment
• Complications
• Follow-up
• Conclusion
• References

3. Introduction
• An ulcer is the loss of continuity of the surface
epithelium.
• The underlying tissues may be affected.
• There are several causes of an ulcer but
necrosis or death of the cells is the immediate
cause

4. Epidemiology
• It accounts for about 25-30% of general plastic
surgery visits in industrialized countries
• In developing countries it constitutes about
35-40% of plastic surgery clinic
• About 80% of the ulcers are in the lower third
of the leg
• In the industrialized countries the commonest
cause are venous, diabetic trauma
• In developing countries the common causes
are infection, trauma, venous

5. Characteristics of an ulcer
EDGE
It is where the healthy skin (epithelium)begins.
• Sloping in a non-specific ulcers
• Undermined in a Tuberculous ulcers
• Raised in Malignant
• Punched out in syphilis

6. Ulcer edges
Sloping Undermined
Raised Punched
out

7. FLOOR:
It is what is seen.
• Sloughing with a profuse, offensive, yellowish
discharge
• Red granulation with a thin serous discharge
• Nodular

8. BASE:
It is what is palpated.
• It may be indurated or hard (malignant or
longstanding callous ulcer)

9. Classification of Ulcers
A . Specific ulcers:
• Tropical ulcers.
• Tuberculous ulcers.
• Buruli ulcers.
• Syphilitic ulcers.
• Yaws ulcers.

10. B. Non-specific ulcers:
• Traumatic ulcers.
• Pyogenic ulcers.
• Ulcers of vascular origin:
(i) Venous (gravitational) ulcers.
(ii) Arterial ulcers.

11. • Neurotropic (trophic) ulcers:
(i) Leprosy.
(ii) Diabetic neuropathy .
(iii) Cord lesions.
(iv) Peripheral neuropathies.
(v) Syringomyelia.

12. C. Neoplastic ulcers
• Squamous cell carcinoma.
• Rodent ulcer.
• Malignant melanoma.
• Kaposi's sarcoma.
• Penetrating malignant tumour.

13. Specific Ulcers
TROPICAL ULCER
• Acute ulcerative cutaneous lesion caused
synergistically by the anaerobic
Fusobacteria(Bacteriodes fusiformis) and the
aerobic Borrelia vincenti.
• Starts as a Painful septic blister which sloughs
to form an ulcer.

14. Predisposing Factors
• Males
• Poor personal hygiene
• Malnutrition
• Walking barefooted

15. Pathology
• Painful septic blister or vesicle containing sero-
sanguinous fluid surrounded by oedematous
inflamed skin
• Ruptures after a few days to expose a foul-smelling,
ragged, yellowish brown, grey or black slough of the
skin and subcutaneous tissues
• Lymphadenitis or lymphangitis
• Can affect deeper structures such as muscles and
tendons causing them too to slough off

16. • Blood vessels, if affected get thrombosed.
• Gangrene may result if it is an end artery.
• Bones------- periostitis.
• The slough with time liquefies, discharges
offensive pus and separates.
• A circular ulcer about 4-l0cm in diameter then
forms

17. TB ULCER
• Irregular outline and the edges are thin, blue
and undermined
• Floor is covered with pale granulations and
the discharge is thin and watery. The base is
soft.
• There may be satellite sinuses and enlarged
lymph nodes.
• There may be a tuberculous focus in the lung
or bone.

18. BURULI ULCER
• Mycobacterium ulcerans
• Temperatures lower than central body
temperature- 30-320C.
• This toxin is thought to be responsible for the
necrosis of the dermis and subcutaneous
tissues seen in typical lesions.

19. Clinical classification
• A. Pre-ulcerative disease
• B. Ulcerative disease
PRE-ULCERATIVE
– Papule
– Nodule PAINLESS
– Plaque
– Oedematous lesions
– Mixed lesions PAINFUL

20. ULCERATIVE
• Necrotic stage; typical white central plug of
necrotic fat, if not interfered with forms a
necrotic slough.
• Organising Stage: the slough separates leaving
an ulcer with edematous base and
undermined edges.
• Healing Stage: the ulcer at this stage is fairly
clean and healing starts.

21. SYPHILITIC (GUMMATOUS) ULCER
• It is now uncommon.
• It follows breakdown of a subcutaneous
gumma especially around the knee.
• It has a serpiginous outline because as it heals
in some parts it spreads in others.

22. YAWS
• Starts as a small erythematous macule which
becomes an enlarging papule up to 5cm wide.
• The skin often ulcerates and exudes a serous
fluid. It heals spontaneously.
• Ulceration and secondary infection may occur.
• Resembling syphilitic ulcers, they are punched
out with sloughing base.
• They heal spontaneously after a few weeks, the
skin over them often becoming depigmented.
The regional lymph nodes are enlarged

24. B. Non-Specific Ulcers
Skin ulcers go through the following phases.
• 1. Acute or Infective phase:
– Ulcer is painful. The sloughing floor is covered
with purulent discharge in which different types of
bacteria may be identified.
– The edge is sharp and surrounded by damaged
cells. The surrounding skin is oedematous, warm
and tender

25. • 2. Transition phase:
– The slough separates, the pus drains, infection
subsides, granulation tissue grows and the floor
becomes clean and red.
– The edge, which is sloping, has a thin bluish-white
layer of young epithelium growing inwards.
– The surrounding skin is slightly hyperaemic or
normal.

26. • 3. Reparative or healing phase;
– The ulcer is now painless. The healthy granulation
tissue fills the floor and the epithelium grows from
the edge.

27. • 4. Chronic, indolent or callous phase:
– Some ulcers may remain unhealthy for a long
time
– The edges are then ragged, the floor greyish or
creamy pink with profuse offensive discharge, and
the surrounding skin warm and oedematous.

28. TYPES OF NON-SPECIFIC ULCERS
• 1. TRAUMATIC ULCERS
• 2. PYOGENIC/INFECTIVE ULCERS
• 3. VASCULAR ULCERS
• 4. PRESSURE ULCERS
• 5. NON-SPECIFIC ULCERS ASSOCIATED WITH
METABOLIC OR SYSTEMIC DISEASE
• 6. NEOPLASTIC ULCERS

29. MANAGEMENT
HISTORY
• Onset and course
• Symptoms
• Medical History
• Family History
• Drug History
• Personal Habits
PHYSICAL EXAM
• General
• Peripheral
neuropathy
• Peripheral pulses
• Regional LNs

30. 2. Clinical Examination
• (a) Ulcer:
• (i) Number:- Multiple ulcers may be due to
Kaposi’s sarcoma, yaws, spherocytosis, ulcerative
colitis or self inflicted injuries
• (ii) Anatomical site: - An ulcer near the medial
malleolus may be venous, traumatic or due to
SCDx
• One in the groin or neck is probably tuberculous.

31. • (iii) The size.
• (iv) The shape; whether round, oval, irregular or
serpiginous (syphilitic).
• (v) Edge:-This is the most important part of the ulcer.
– Sloping edge - non-specific ulcer.
– Raised and everted -malignant ulcer.
– Raised and rolled - rodent ulcer.
– Undermined- tuberculous or Buruli ulcer.
– Punched out – syphilitic or yaws.

32. • (vi) Floor - whether sloughy and discharging;
clean and pink (healing) or nodular
(malignant). Type of discharge is also noted.
• (vii) Base - whether slightly indurated as in
chronic nonspecific ulcer or indurated and
fixed as in carcinoma or callous non-specific
ulcer.

33. • (viii) The surrounding skin - whether it is inflamed or
pigmented.
• (ix) The state of local circulation - presence of dilated
veins. Oedema of tissues, temperature and colour
of skin or toe nails.
• (x) State of innervation - any loss of sensation or
motor function.
• (xii) Regional lymph nodes - this is important
especially in carcinomatous ulcers. If enlarged,
tender or mobile

34. INVESTIGATIONS
• BLOOD
– VDRL
– RBS
– HB GENOTYPE
– FBC
– MANTOUX
– EUCr
– SERUM PROTEIN/ ALBUMIN

35. • BACTERIOLOGY– Wound swab & biopsy
• HISTOPATHOLOGY- WEDGE BIOPSY
• ANKLE BRACHIAL PRESSURE INDEX
• RADIOLOGY
– DUPLEX DOPPLER SCANNING
– CHEST XRAY
– CT
– MRI

36. TREATMENT (Specific ulcers)
• Acute
– Tropical
– Admit
– Antibiotics
– Sloughectomy [surgical or non-operative].TT,SPLINTING,PHYSIO
• Chronic
– Tuberculous
– Antituberculous regimen
– Syphilitic
– Penicillin
– Buruli
– Medical
– Antituberculous drug
– Heat treatment
– Surgical
– Pre-ulcerative –nodulectomy, wide excision
– Ulcerative –debridement, split skin graft/flap

37. TREATMENT (Non-specific ulcers)
• Acute
– Admit, bed rest and elevate affected limb
– Broad-spectrum antibiotics and Antitetanus.
– Wound dressings
– The affected limb is splinted in the position of function to
prevent formation of contracture.
– Physiotherapy is started early to prevent wastage of muscle
and contractures.
– Once the ulcer becomes healthy, it is covered appropriately
• Chronic
– Wide excision
– Skin graft/flap

38. Others
 Trauma
• Wound debridement
• Regular wound dressing
• Medication: antibiotics, analgesics, antitetanus
• Skin wound closure
 Infective
◦ Appropriate antibiotics
◦ Wound debridement

39.  Venous
◦ Conservative
 Elevation
 Compression-compression stocking, supportive bandage
◦ Surgical
 Superficial vein stripping
 Ligation of incompetent valves/perforators
 Arterial
◦ Trans-luminal angioplasty
◦ Endarterectomy
◦ Arterial grafting

40.  Neuropathic:
◦ Regular wound dressing
◦ Treat underlying condition, if treatable
 Diabetic
◦ Control diabetes
◦ Give antibiotics to prevent infections
◦ Wound dressing with sugar/honey
◦ Skin graft
 Haemoglobinopathy
◦ Difficult to treat
◦ Bed rest
◦ Exchange blood transfusion, folic acid
◦ Anti-malarial drugs
◦ Prevent precipitating factors
 Malignant
◦ Treat underlying cause

41. Complications
• Recurrence
• Septicemia
• Wasting
• Osteomyelitis
• Periostitis
• Gangrene
• Tetanus
• Contracture
• Non healing

42. Follow up
• 1. the patient is advised to protect the affected
skin for example- the legs and feet by wearing
comfortable socks and shoes.
• 2. Farmers are advised to wear protective
clothing and boots.
• 3. Advised about proper foot hygiene.
• 4. Where there is extensive scarring, the patient
is advised to continue wearing medical stocking
or crepe bandage.
• 5. To seek prompt attention for any abrasion or
laceration to the affected skin.

43. Conclusion
• Management of patients with skin ulcers has
to be multidisciplinary.
• Should include detailed history, physical
examination, investigations, basic and newer
treatment modalities.
• While educating patients on issues of correct
skin care and the importance of seeking early
medical advice.

44. References
• O. Amir, A. Liu, and A. L. S. Chang, “Stratification of highest-risk patients
with chronic skin ulcers in a Stanford retrospective cohort includes
diabetes, need for systemic antibiotics, and albumin levels,” Ulcers, vol.
2012, Article ID 767861, 7 pages, 2012.
• C. K. Sen, G. M. Gordillo, S. Roy et al., “Human skin wounds: a major and
snowballing threat to public health and the economy,” Wound Repair and
Regeneration, vol. 17, no. 6, pp. 763–771, 2009.
• Oluwatosin OM. Wounds and Wound Healing.In Oluwatosin OM ed.
Methods of Repair.Abeokuta.Sagaf Publishers 2007. 6thedition.

47. •THANK YOU.