Examination of Ulcer

“An ulcer is a break in the continuity of the

covering epithelium — skin or mucous membrane.
It may either follow molecular death of the surface
epithelium or its traumatic removal”.
Parts of an Ulcer:

• Margins: is the junction between normal

epithelium and the ulcer, so it is the boundary
of the ulcer. It may be regular or irregular. It
may be Rounded or oval in shape.
• Edges: is the area between the margin and
the floor of the ulcer. Marked induration
(hardness) of the edge is characteristic feature
of a carcinoma, be it a squamous-celled
carcinoma or adenocarcinoma. A certain
degree of induration or thickness is expected
in any chronic ulcer, whether it is a
gummatous ulcer or a syphilitic chancre or a
trophic ulcer. In healing ulcers Its inner part
is red because of red, healthy granulation
tissue, Its middle part is white due to
scar/fibrous tissue, Its outer part is blue due to
epithelial proliferation.
Different edges are:

Sloping edge: It is mostly seen in traumatic

healing or venous ulcers.

Undermined edge: is seen in tuberculous ulcer.

Disease process advances in deeper plane (in
subcutaneous tissue) faster than in skin. The
overhanging skin is thin, friable, reddish blue
and unhealthy.
Punched out edge: is seen in gummatous
(syphilitic) ulcer and trophic ulcer. It is due to
end arteritis. The edge drops down at right
angle to the skin surface as if it has been cut
out with a punch. The diseases which cause
the ulcers are limited to the ulcer itself and do
not tend to spread to the surrounding tissue.

Raised and beaded edge (pearly white): is seen

in rodent ulcer (BCC). Beads are due to
proliferating active cells. This type of edge
develops in invasive cellular disease and
becomes necrotic at the centre.
 Everted edge (rolled out edge): It is seen in
carcinomatous ulcer due to spill of the
proliferating malignant tissues over the
normal skin. It is characteristic feature of
squamous cell carcinoma or ulcerated
adenocarcinoma.

• Floor: It is the one which is seen. Floor may

contain discharge, granulation tissue, etc. It is
the exposed surface of an ulcer. Floor may
contain,
Red, granulation tissue Healing ulcer

Pale, scanty granulation tissue Tuberculous ulcer,

slow healing ulcer

Wash-leather slough (like wet chamois Gummatous ulcer

leather)

Black mass at the floor Malignant

melanoma

Necrotic tissue or slough Spreading ulcer

• Base: Base is the one where ulcer rests. It

may be bone or soft tissues. It is better felt
than seen. If an attempt is made to pick up the
ulcer between the thumb and the index finger,
the base will be felt. Slight induration of the
base is expected in any chronic ulcer but
marked induration (hardness) of the base is an
important feature of squamous-celled
carcinoma and Hunterian chancre.
Classification:
Clinical classification:
Spreading ulcer Here edge is inflamed and oedematous.
Healing ulcer Edge is sloping with healthy pink/red
granulation tissue with serous
discharge.
Callous ulcer Floor contains pale unhealthy
granulation tissue with indurated edge/
base. Ulcer has no tendency to heal. It
lasts for many months to years.

Pathological classification:
Specific ulcers Meleney’s ulcer, Actinomycosis, Tuberculous,

(MATS) Syphlitic

Malignant ulcers Carcinomatous ulcer, Rodent ulcer,

Melanotic ulcer

Non-specific ulcers Traumatic, Trophic, Tropical, Arterial,

Venous, Infective, Diabetic, Cryopathic

(frostbite), Bazin’s ulcer, Martorell’s

hypertensive ulcer.
Wagner’s classification:
Grade 0 Healed ulcer.

Grade 1 Superficial ulcer (epidermis & dermis).

Grade 2 ulcer 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.

History:
Mode of onset (How has the ulcer developed—
following a trauma or spontaneously as a result of some
other diseases like Varicose vein or burn or pressure
ulcer etc. ), Duration (How long is the ulcer present
there? An acute ulcer will be present for a shorter
duration, whereas a chronic ulcer will remain for a long
period. In this context, one must also know the
incubation period, i.e. the time interval between the
exposure and the onset of the ulcer. In Hunterian
chancre (Syphilis) this incubation period is 3 to 4 weeks,
whereas in chancroid (soft sore) this period is about 3 to
4 days), Pain (Ulcer may be painful or painless. Often
ulcer is painless to begin with but may eventually
become painful like malignant ulcers due to secondary
bacterial infection or infiltration to deeper plane or
nerve ending. Some ulcers are painful to begin like
acute ulcer, but becomes painless once it turns to
chronicity- ask questions related to pain),
Discharge(character of the discharge, its amount and
smell), Multiplicity (numbers & other body areas
involved), Associated symptoms (fever, varicose veins,
associated diseases, etc.)
Discharge Character Ulcer

Serous Mostly clear or slightly yellow thin plasma Healing Ulcer

that is just a bit thicker than water.

Sero-sanguineous Discharge that contains both blood and a Tuberculous

discharge clear yellow liquid known as blood serum. It ulcer or a
is a thin and watery fluid that is pink in color malignant
due to the presence of small amounts of red ulcer.
blood cells.
Bloody discharge Touch to bleed. Malignant
ulcers
Purulent Pus, mostly foul smelling Spreading
discharge /Infective
ulcer
Greenish Pseudomonas
discharge infection

Inspection:
Site (Exact anatomical location of the ulcer is noted. It
is mentioned in relation to particular anatomical point
usually bony point), Size (Ulcer size should be
measured both vertically and horizontally using a
measuring tape. Tape may be placed over sterile gauze
covering the ulcer to measure), Shape, Margins (either
regular/irregular/well-defined/ill-defined), Edges (look
but not palpate at this level), Floor, Discharge,
Surrounding area (If the surrounding area of an ulcer
is glossy, red and oedematous, the ulcer is acutely
inflamed. Very often the surrounding skin of a varicose
ulcer is eczematous and pigmented. A scar or a
wrinkling in the surrounding skin of an ulcer may well
indicate an old case of tuberculosis), Whole limb.

Palpation:
Temperature of surrounding area as compared to
normal skin (Warmness over surrounding area signifies
acute inflammation),
Tenderness should be elicited over the edge, base and
surrounding area (Acute ulcers are tender. Chronic
ulcer is usually non-tender but can be tender if there is
secondary infection, involvement of deeper structures
like periostitis in venous ulcer. Malignant ulcer is
non-tender to begin with. It may only become tender in
later period when it infiltrates into deeper plane),
Edges (palpation should be done for tenderness and to
define characteristics),
Base (on which the ulcer rests and it is better felt than
seen. If an attempt is made to pick up the ulcer between
the thumb and the index finger, the base will be felt.
Base may be fascia, soft tissues or bone. If base is
formed by bone then ulcer is fixed and non-mobile.),
Bleed to touch,
Mobility/relation to deeper structures (it should be
checked in two perpendicular planes Ulcer is held firmly
at two opposite points over the margin and tried o move
over the base.),
Depth of Ulcer (Trophic ulcer is deep with bone as its
base. Depth is measured in mm, if possible),
Surrounding skin, Draining/regional lymph nodes
(e.g. for ulcer on foot palpate inguinal lymph nodes),
examine venous system of limb (rule out varcosities) ,
Arterial examination of limb (distal pulses),
Examine nerve lesion (Trophic ulcers develop as a
result of repeated trauma to an insensitive part of the
patient’s body. This is mostly seen in the sole, as this is
the weight bearing zone if there is sensory loss. It may
well lead to ulcer formation. So presence of trophic ulcer
indicates some neurological - particularly sensory -
disturbance, either in the form of tabes-dorsalis or
transverse myelitis or peripheral neuritis), Gait of the
patient for ulcers on foot (Gait of the patient should
be checked to find out the severity of loss of function due
to ulcer).