APPROACH TO ULCERS

PRESENTER: DR SINKALA YIZUKANJI

LAYOUT
• INTRODUCTION
• ANATOMY AND PHYSIOLOGY OF THE SKIN
• PARTS OF AN ULCER
• FEATURES OF AN ULCER
• CLASSIFICATIONS
• STAGES OF AN ULCER
• GRADING OF AN ULCER
• INVESTIGATIONS
• CLINICAL APPROACH TO ULCERS
• MANAGEMENT OF ULCERS
• An ulcer is break in the continuity of epithelial surface such as skin or
mucous membranes.
• It occurs as a result f microscopic death of tissue.
• They differ from wounds which are as result of external traumatic
force
PARTS OF AN ULCER
• Margin:- the junction between normal epithelium and an ulcer
• It may be regular or irregular and round or ovoid.
• Edge:- the area between the margin and the floor of an ulcer.
• This can be slopping, undermined, punched out or everted.
• Floor:- the exposed surface of an ulcer.
• It can contain a discharge like pus, sometimes granulation tissue and
sometimes slough
• Base: is where an ulcer rests. It can be soft tissue or bone
FEATURES OF AN ULCER
• INDURATION:- is a clinical palpatory sign which means specific type of
hardness in diseased tissue most observed in carcinomatous ulcer and
long standing ulcers with underlying fibrosis
• GRANULATION:-Proliferation of new capillaries, fibroblasts
intermingles with white and red blood cells with a thin fibrin covering
over it. This is a typical of health granulation tissue and a marker of
progressive and healthy healing. However there exists variants of
granulation tissue that is unhealthy and signals poor healing or
worsening ulcer. Unhealthy granulation includes pallor, presence of
sloughand inflamed edges
CLASSIFICATION OF ULCERS
1. CLINICAL
2. PATHOLOGICAL
CLINICAL CLASSIFICATION-
HEALING STATUS
• Spreading ulcer:- has inflamed
edges that are irregular and
oedematous.it is an acute and
painful ulcer and its floor does
not contain healthy tissue and
granulation tissue is absent. It
may contain pus discharge or
slough. There is involvement of
local draining lymph node
• Healing Ulcer:- has slopping edges
with pink/red heathy granulation
tissues with minimal or scanty
serous or serous discharge on the
floor. There is no pus discharge or
slough.
• It shows no sign of inflammation
nor induration.
• Regional lymph node may or may
not be involved.
Zones Observed In Healing Ulcers
1. Innermost zone: red/pink zone of granulation tissue
2. Middle zone:- bluish/dark(blacks) zone of growing epithelium
3. Outer zone:- zone of fibrosis or scar formation and is usually whitish
• None healing ulcer:- usually chronic ulcers. There edges will
determined by the cause.
• Edges will be punched out if trophic, undermined if tuberculous,
rolled out if carcinomatous and beaded if a rodent ulcer.
• The floor may contain unhealth granulation tissue or slough and
sometimes with serosanguinous discharge, purulent or bloody
discharge.
• Regional lymph nodes are enlarged and non-tender.
• Callous Ulcer:- Its floor contains pale unhealth granulation tissue with
indurated and hyperpigmented edges.
• It does not show the tendency to heal and can last from month to
years. Tissue destruction is more and only minimal regeneration.
• It often has copious amount of serosanguinous fluid
• Enlarged, firm/hard regional lymph nodes that are non tender.
CLINICAL CLASSIFICTION -
BASED ON DURATION
• Acute ulcer < 2 weeks
• Chronic ulcer > 2weeks
PATHOLOGICAL CLASSIFICATION
– SPECIFIC ulcers

• Tuberculous:- Thin undermined edges with n irregular outline with the

floor covered by pale granulation tissue and a watery discharge. Its base
is soft. There may be satellite sinuses and enlarged lymph nodes and
sometimes muted. There can be a tuberculous focus in the lungs or bone.
• Syphilitic ulcer:- has punched out edges, deep with wash leather slough
at the floor with an indurated base.
• Actinomycosis ulcer: pus filled ulcers caused by dental disease or surgery
• Meleney’s ulcer:- floor covered by eschar with gangrenous margins
following surgery or minor trauma
PATHOLOGICAL CLASSIFICATION-
MALIGNANT ULCERS
• Carcinomatous ulcer
• Rodent ulcer
• Melanotic ulcers
PATHOLOGICAL CLASSIFICATION-
NON SPEIFIC
• Traumatic ulcers:- following mechanical or physical trauma with chemical
being the commonest.
• Arterial Ulcers:- associated with critical limb ischaemia( peripheral
arterial disease) for example atherosclerosis and TAO. Tend to be deep
• Venous ulcers:- Associated with poor venous drainage and usually occurs
on the mid leg. They tend to be shallow.
• Infective ulcer:- pyogenic ulcer
• Diabetic ulcers:- associated with neurovascular complications of diabetes
• And an endless list that includes bazin ulcers, Martorell’s ulcer and
cortisol ulcers, pressure sores
WAGNER CLASSIFICATION OF
ULCERS
CLASSIFICATION OF PRESSURE
SORES(ULCERS)
INVESTIGAIONS ULCERS
• Pus swabs for microscopy, culture and sensitivity and AFB in suspicion
of tuberculous ulcers.
• Cytology: for analysis of malignant cells
• Wedge biopsy: taken from the edge which contains multiplying cells.
At least two biopsies must be taken. Biopsies taken from the centre
may be inadequate because of central necrosis.
• FNAC of regional lymph nodes
• HB(FBC/DC), ESR, serum protein estimation(albumin)
• RBS/FBS
Others
• X ray f the part for bone involvement
• Chest x rays if tuberculous ulcer is suspected
• CT angiography for arterial ulcers
CLINICAL APPROACH
• History:- duration, progression and setting of occurrences. Risk
factors and comorbidities such as HTN, DM, PVD, Venous
insufficiency, immune suppression and stroke/bedridden.
• Examination:- edges, margins, floor base, granulation, slough,
discharge, size, tenderness, location and grading and classification.
Asses for the 6Ps if ulcers occurs on the lower limp( Pain, paralysis,
paraesthesia, pallor, pulses or if perishingly cold). RBS, BP in absence
of these comorbidities in history.
• Investigate:- And establish definitive diagnosis and proceed to
manage as such.
MANAGEMENT/ TREATMENT
• Establish and eliminate the cause
• Correct anaemia and nutritional deficiencies such as proteins and
vitamins.
• Analgesia
• Control infections: wound care, debridement, and antibiotics. And in
some instance, amputations.
• Rest, immobilization, elevation and avoidance of repeated trauma.
Ulcer care
• Ulcer cleaning, debridement and dressing.
• Removal of slough mechanically(cutting) or chemically(hydrogen peroxide
and acriflavine, Eusol)
• Iodine use is controversial.
• Ulcer cleaning and dressing daily, twice daily.
• Normal saline is ideal for ulcer cleaning.
• Dressing after cleaning minimises reinfection.
• Large ulcers will require debridement in theatre
• Vacuum assisted closure therapy(25-200mHg)
• Maggot debridement therapy