A skin ulcer is a break in the continuity of skin with loss of tissue often without a tendency to heal spontaneously [1]. The ulcer may be superficial involving only the epidermis or can be deep involving layers of the epidermis and the dermis. Acute onset ulcers e.g. surgical wounds tend to heal in a predictable manner - inflammation is followed by granulation, re-epithelialization, and remodeling [2]. Chronic ulcers, however, have a prolonged phase of inflammation [3]. Chronic skin ulcers can be classified based on their etiology as arterial, hematologic, hypertensive, infectious, malignant, neurotropic, venous or drug related e.g. chemotherapy agents [1] [4] [5].

A skin ulcer can have variable presentations. Acute onset skin ulcers present as painful wounds; ulcers in diabetic patients present as a non-painful, long-standing often discharging wound usually in the lower extremity and decubitus (pressure) ulcers may be noted incidentally in bed-ridden patients. Secondary bacterial colonization of the skin ulcer can lead to foul-smelling discharge which can progress to osteomyelitis and gangrene. Discharging skin ulcers are often associated with contact or irritant dermatitis due to the discharge or the dressing material used to treat the ulcer. Lower extremity skin ulcers and decubitus ulcers limit patient mobility while chronic non-healing ulcers can lead to psychological issues like isolation and depression.

• Chronic Dermatitis

  However, radiation exposure induces acute or chronic dermatitis, depending on the radiation dose, interval, tissue volume, or irradiated area of the body. [ncbi.nlm.nih.gov]

Diagnosis of a skin ulcer, especially a chronic non-healing ulcer necessitates consultation with several medical specialists e.g. internist to diagnose the medical comorbidities, dermatologist, and surgeons [6]. The workup begins with a detailed history about the ulcer onset, duration, progression, aggravating and relieving factors and associated medical comorbidities like diabetes, varicosities, autoimmune/infectious diseases and malignancy.

A comprehensive physical examination focusing on the ulcer and its surrounding area should be carried out. In the case of lower extremity ulcers, one must examine peripheral pulses, sensations and look for varicosities. Skin ulcers can be often be identified based on their characteristic appearance: thrombotic ulcers have eschar and areas of necrosis; pyoderma gangrenosum have violaceous, undermined borders while a reddish yellow plaque around the ulcer is suggestive of necrobiosis lipoidica diabeticorum (NLD), an ulcer associated with diabetes [6].

Laboratory workup should include complete blood count, urinalysis, metabolic panel, and tests to diagnose underlying autoimmune causes of skin ulceration. A wound swab from the ulcer has to be obtained for microbiology and antibiotic sensitivity testing. Radiological tests like simple X-rays, bone scan or magnetic resonance imaging may be required in deep ulcers to detect osteomyelitis and doppler studies may be necessary for thrombotic/venous ulcers to detect vascular problems. Biopsy of a chronic skin ulcer has to be performed, especially if there is a suspicion of malignant transformation e.g. Marjolin's ulcer.

We initiated antiangiogenic treatment with pazopanib. [ncbi.nlm.nih.gov]

Fertram Sigurjonsson, the chief executive of Kerecis, told Good Health: 'Around 50 people in Britain have had the treatment. Our product is the standard treatment in Iceland for wounds that fail regular wound treatment.' [dailymail.co.uk]

Adamsen and Thomsen, {Reimar Wernich}", note = "Keywords: Adult; Aged; Aged, 80 and over; Clinical Audit; Clinical Competence; Delayed Diagnosis; Denmark; Duodenal Ulcer; Female; Humans; Male; Middle Aged; Peptic Ulcer Perforation; Preoperative Care; Prognosis [sundaldring.ku.dk]

Healing prognosis Some people suffer from venous leg ulcers for many years, but the healing prospects are also good - around 90% percent of all venous leg ulcers can be healed using some of the treatment procedures available today. [mediusa.com]

Helicobacter pylori-negative duodenal ulcers: Prevalence, clinical characteristics and prognosis - Results from a clinical trial with 2 year follow-up. AJG 2001; 96:1409-1416. (8) Rosenstock SJ, Jorgensen T, Bonnevie O, Andersen LP. [dsgh.dk]

Prognosis for early-stage PUs is excellent with timely, appropriate treatment, but healing typically requires weeks. After 6 mo of treatment, > 70% of stage II PUs, 50% of stage III PUs, and 30% of stage IV PUs resolve. [merckmanuals.com]

Chronic skin ulcers can be classified based on their etiology as arterial, hematologic, hypertensive, infectious, malignant, neurotropic, venous or drug related e.g. chemotherapy agents. A skin ulcer can have variable presentations. [symptoma.com]

[…] due to the underlying etiology. [icd10data.com]

The etiology is unknown, although recent reports have associated it with the Epstein-Barr virus. [scielo.br]

Etiology Pressure ulcers are accepted to be caused by three different tissue forces: Prolonged pressure: In most cases, this pressure is caused by the force of bone against a surface, as when a patient remains in a seated or supine position for an extended [woundsource.com]

Medical Device Related Pressure Injury: This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. [npuap.org]

PURPOSE OF REVIEW: This article provides an overview of the biology, epidemiology, clinical features, diagnostic tests, and treatment of Haemophilus ducreyi infection, with special reference to the decline of chancroid and the recent emergence of H. ducreyi [ncbi.nlm.nih.gov]

Epidemiology United States statistics Pressure injuries are common among patients hospitalized in acute- and chronic-care facilities. [emedicine.medscape.com]

PATHOPHYSIOLOGY Predisposing factors (4Ps) pressure +/- shear poor perfusion poor healing poor ‘padding’ / prominence’s Development of pressure ulcers can develop within 2-6 hours most vulnerable areas are the heels, coccyx, sacrum, femoral trochanter [lifeinthefastlane.com]

The severity of chronic venous diseases con be classified according to CEAP: C = Clinic (clinical findings) E = Etiology (causes / trigger of the disorder) A = Anatomy (anatomical localisation) P = Pathophysiology (pathological dysfunction) CEAP stages [medi.de]

Back to Top Pathophysiology Neurotrophic Ulcers The development of neurotrophic foot ulcers in patients with diabetes mellitus has several components, including neuropathy, biomechanical pressure, and vascular supply. [clevelandclinicmeded.com]

(See Pathophysiology and Etiology .) [emedicine.medscape.com]

While healing you will also be asked to keep the legs elevated, again to prevent blood from pooling. Prevention of Leg Ulcers Venous leg ulcers can be prevented from occurring or reoccurring with the use of compression stockings. [embarrassingissues.co.uk]

Covering the wound as early as possible can prevent infection and shorten the course of treatment. [ncbi.nlm.nih.gov]

Prevention There are a variety of ways you can prevent venous skin ulcers through lifestyle changes, diet or medication. [webmd.com]

Can skin ulcers be prevented? There are different strategies for preventing the different types of skin ulcers. Many can be prevented. [patient.info]

The following statements have been noted as preventative skin care steps for pressure ulcer preventions: Cleansing To prevent bacterial growth and to keep skin free of outside elements, clean the skin with a gentle and mild agent. [byebyedoctor.com]

1. Greer N, Foman NA, MacDonald R, et al. Advanced Wound Care Therapies for Non-Healing Diabetic, Venous, and Arterial Ulcers: A Systematic Review. Washington (DC): Department of Veterans Affairs, 2012; VA Evidence-based Synthesis Program Reports
2. Frank C, Bayoumi I, Westendorp C. Approach to infected skin ulcers. Can Fam Physician. 2005 Oct 10; 51 (10): 1352 -1359
3. International Wound Bed Preparation Advisory Board, Canadian Chronic Wound Advisory Board. Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage. 2003;49(11):23–51.
4. Huljev D. Contemporary management of leg ulcer. Acta Med Croatica 2012; 66(5):387-95
5. D'Epiro S, Salvi M, Luzi A, et.al. Drug cutaneous side effect: focus on skin ulceration. Clin Ter. 2014; 165(4): e323-329.
6. Panuncialman J, Falanga V. Unusual causes of cutaneous ulceration. Surg Clin North Am. 2010 Dec; 90(6): 1161 -1180