23. Ulcers

1. Definition

• Ulcer → defect of skin or mucosa with loss of epithelium, slow healing and little tendency to heal spontaneously
• Erosion → loss of epithelium only, heals without scar
• Chronic wound → no healing after 6 weeks

2. Aetiology: causes

Vascular

• Venous → chronic venous insufficiency, varicose veins, post-thrombotic syndrome; 70% of leg ulcers
• Arterial → peripheral arterial disease, atherosclerosis
• Mixed arterial and venous
• Lymphoedema
• Vasculitis → rheumatoid arthritis, lupus
• Hypertensive (Martorell) ulcer

Neuropathic (trophic)

• Diabetic neuropathy → plantar ulcers
• Leprosy, spinal cord injury, spina bifida, alcohol, syringomyelia

Pressure

• Pressure ulcers → immobile patients over sacrum, heels, hips

Traumatic, physical, chemical

• Burns, frostbite, radiation, chemicals

Infective

• Tuberculosis, syphilis (gumma), Buruli ulcer, fungal

Neoplastic

• Basal cell carcinoma (rodent ulcer), squamous cell carcinoma, melanoma
• Marjolin's ulcer → squamous cell carcinoma in a chronic scar or ulcer

Other

• Pyoderma gangrenosum → inflammatory bowel disease
• Haematological → sickle cell disease
• Self-inflicted (artefact)

3. Pathological characteristics

• Poor blood supply, oedema, fibrosis around the ulcer
• Chronic inflammation, bacterial colonisation, biofilm
• Granulation tissue → pale, flabby, poor quality
• Wound bed stuck in the inflammatory phase → high protease levels, senescent fibroblasts
• Surrounding skin → induration, pigmentation (venous), atrophy (arterial)

4. Evolution of an ulcer

1. Spreading stage → inflamed edge, slough, purulent discharge, pain
2. Stage of cleansing (transition) → slough separates, red granulations appear
3. Healing (repair) stage → healthy granulation tissue, bluish line of epithelium at the edge, wound contraction
4. Callous ulcer → stuck stage; pale granulations, thick indurated edge, no healing

5. Clinical manifestations: examination of an ulcer

History

• Duration, pain, previous ulcers, trauma, varicose veins, deep vein thrombosis, diabetes, smoking

Local examination

• Site → gaiter area (venous), toes and pressure points (arterial), sole (neuropathic)
• Size, shape, number
• Edge:
  • Sloping → healing, venous ulcer
  • Punched out → arterial, neuropathic, syphilitic
  • Undermined → tuberculosis, pressure ulcer
  • Rolled (pearly) → basal cell carcinoma
  • Everted → squamous cell carcinoma
• Floor → granulation tissue, slough, bone, tendon
• Base → induration, fixation to deep structures
• Discharge → serous, purulent, blood-stained
• Surrounding skin → pigmentation, eczema, lipodermatosclerosis, hair loss, shiny skin
• Regional lymph nodes → infection or malignancy
• Pulses, sensation (monofilament), ABPI

6. Main types compared

A. Venous ulcer

• Medial malleolus, gaiter area
• Large, shallow, sloping edge, moderate pain relieved by elevation
• Haemosiderin pigmentation, varicose eczema, lipodermatosclerosis
• Pulses present, ABPI > 0.8

B. Arterial ulcer

• Toes, heel, shin, pressure points
• Small, deep, punched out, very painful, worse with elevation and at night
• Cold, pale, hairless skin; absent pulses; ABPI < 0.5

C. Neuropathic ulcer

• Sole, under metatarsal heads, heel
• Painless, punched out, surrounded by callus
• Loss of sensation, warm foot, bounding pulses (if no arterial disease)

D. Pressure ulcer

• Sacrum, heels, greater trochanter, occiput
• Graded 1–4 (European Pressure Ulcer Advisory Panel):
  1. Non-blanching erythema, intact skin
  2. Partial-thickness skin loss, blister
  3. Full-thickness skin loss, subcutaneous fat visible
  4. Full-thickness tissue loss with bone, tendon or muscle exposed

7. Diagnosis

Laboratory

• Full blood count, glucose, HbA1c, CRP
• Swab → only if clinically infected

Investigations

• ABPI → before compression
• Duplex ultrasound → venous reflux, arterial disease
• Angiography → arterial ulcers before revascularisation
• X-ray, MRI → osteomyelitis
• Biopsy → atypical ulcer, raised or rolled edge, no healing after 3 months (exclude malignancy)

8. Principles of treatment

General

• Treat the cause
• Control diabetes, nutrition, stop smoking
• Treat anaemia, oedema
• Analgesia

Local

• Cleaning, debridement of slough and necrotic tissue
• Moist wound healing → appropriate dressings
• Treat infection → systemic antibiotics for cellulitis
• Negative pressure wound therapy
• Skin grafts, flaps → clean ulcer bed

By type

• Venous → multilayer compression bandaging (ABPI > 0.8), elevation, exercise; treat superficial venous reflux (endovenous ablation, surgery)
• Arterial → revascularisation (angioplasty, bypass); no compression; amputation if not salvageable
• Neuropathic → offloading (total contact cast, special footwear), debridement of callus, foot care
• Pressure → relieve pressure (turning every 2 h, pressure-relieving mattress), nutrition, debridement, flap reconstruction
• Malignant → wide excision, Mohs surgery, radiotherapy

9. Complications

• Infection, cellulitis, osteomyelitis
• Haemorrhage
• Contracture, deformity
• Marjolin's ulcer
• Amputation