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Skin Ulcer

Skin Ulcers

A skin ulcer is a generic term used to describe a break in the skin with associated loss of tissue. The ulcer can have an acute onset or can be chronic. It can either be superficial or deep, involving layers of the epidermis and the dermis. Skin ulcers cause pain, inflammation and can get secondarily infected leading to patient morbidity and even amputation.


Presentation

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.

Foul Smelling Discharge
  • Secondary bacterial colonization of the skin ulcer can lead to foul-smelling discharge which can progress to osteomyelitis and gangrene.[symptoma.com]
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]

Workup

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.

Suppression
  • This effect might be brought about by the suppression of PG metabolism, especially in platelets.[ncbi.nlm.nih.gov]
Thrombocytosis
  • […] platelet basal iPGE levels were significantly decreased by PGE1 (P less than 0.025); (5) The plasma and platelet linoleic acid levels were significantly higher than before PGE1 treatment (plasma: P less than 0.05, platelets: P less than 0.025); (6) Thrombocytosis[ncbi.nlm.nih.gov]
Gram-Positive Bacteria
  • In addition, 23 isolates were Gram-positive bacteria, mainly comprising Staphylococcus aureus and Enterococcus faecalis.[ncbi.nlm.nih.gov]

Treatment

  • We initiated antiangiogenic treatment with pazopanib.[ncbi.nlm.nih.gov]
  • Results were as follows: (1) in all cases, complete healing of skin ulcers was observed; (2) In most cases, skin temperature increased during PGE1 treatment; (3) Platelet aggregation was higher during PGE1 treatment than before and was higher in PRP than[ncbi.nlm.nih.gov]
  • Hyperbaric oxygen therapy has been suggested as a treatment for delayed radiation injury with soft tissue and bony necrosis.[ncbi.nlm.nih.gov]
  • METHODS: Three men and four women were simultaneously treated with hyperbaric oxygen at 2 absolute atmospheric pressures for 90 minutes daily and spray treatment of basic fibroblast growth factor to the ulcer bed daily for an average of 2.6 months.[ncbi.nlm.nih.gov]
  • Treatment for venous ulcers and chronic wounds can be frustrating and take a great deal of time. The goals of treatment are usually: Keep the ulcer or wound infection-free, usually through topical antibiotics. Absorb any excess discharge.[web.archive.org]

Prognosis

  • Prognosis is excellent for early-stage ulcers; neglected and late-stage ulcers pose risk of serious infection and are difficult to heal. Treatment includes pressure reduction, avoidance of friction and shearing forces, and diligent wound care.[merckmanuals.com]
  • […] ul·cer ( dē-kyū'bi-tŭs ŭl'sĕr ) Focal ischemic necrosis of skin and underlying tissues at sites of constant tissue pressure, recurring friction, and inadequate perfusion in patients confined to bed or immobilized by illness; malnutrition worsens the prognosis[medical-dictionary.thefreedictionary.com]

Etiology

  • 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]
  • Figure 1: Superficial pressure ulcer, stage 2 development Figure 2: Stage 2 pressure ulcer (partial-thickness skin loss) Etiology Pressure ulcers are accepted to be caused by three different tissue forces: Prolonged pressure: In most cases, this pressure[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]
  • B 8 , 27 , 28 Etiology Pressure ulcers are caused by unrelieved pressure, applied with great force over a short period (or with less force over a longer period), that disrupts blood supply to the capillary network, impeding blood flow and depriving tissues[aafp.org]

Epidemiology

  • 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]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
Sex distribution
Age distribution

Pathophysiology

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

Prevention

  • 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]
  • Introduction The early detection of systemic sclerosis (SSc) patients at high risk of developing digital ulcers could allow preventive treatment, with a reduction of morbidity and social costs.[ncbi.nlm.nih.gov]
  • The early detection of SSc patients who are at high risk to develop digital ulcers could allow a preventive treatment of these complications with reduction of morbidity and social costs.[ncbi.nlm.nih.gov]

References

Article

  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

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Last updated: 2017-08-09 17:54