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cutaneous ulcer

A lesion on the surface of the skin or on a mucous surface that extends to the level of the dermis or deeper. Etiology: 1) primary cutaneous disorders 1) peripheral vascular disease - venous stasis ulcer (70-80%) - risk factors: old age, obesity, DVT, phlebitis [5] - arterial ulcer (5-10%) - risk fastors:: male, > 40 year, smoking, diabetes mellitus, dyslipidemia, hypertension, sedentary lifesyle [5] b) livedoid vasculitis c) Marjolin's ulcer d) infections - ecthyma - bacterial - septic lesions - atypical mycobacterium - fungus e) squamous cell carcinoma of the skin f) basal cell carcinoma 2) systemic diseases a) legs & feet - vasculitis (palpable purpura & livedo reticularis) - leukocytoclastic vasculitis - rheumatoid arthritis - systemic lupus erythematosus (SLE) - Wegener's granulomatosis - hypersensitivity vasculitis - antiphospholipid antibody syndrome - hemoglobinopathies: sickle cell anemia - cryoglobulinemia - cholesterol emboli - necrobiosis lipoidica & other neuropathic conditions (10%) - neuropathic ulcer, diabetic foot ulcer (diabetic neuropathy) - vasculopathic conditions: - vasculopathic lesions (thrombosis without vasculitis) - atrophie blanche - hypercoagulable states: - protein C deficiency - protein S deficiency - antiphospholipid antibody syndrome b) hands & feet - Raynaud's phenomenon c) generalized - pyoderma gangrenosum - infections (fungi, chronic Herpes zoster) - lymphoma - calciphylaxis d) mucosal - Behcet's syndrome - erythema multiforme - primary blistering disorders - lupus erythematosus - inflammatory bowel disease Epidemiology: - prevalence of chronic leg ulcers is 0.5-1% Pathology: - results from loss of epidermal dermal tissue, usually with inflammation - a wound with superficial loss of tissue from trauma is not primarily an ulcer, but may become ulcerated if infection occurs Clinical manifestations: 1) venous a) less painful, shallow, irregular ulcers b) along the course of the long saphenous vein c) frequently over the medial malleolar region c) edema, dermatitis, hemosiderin deposition & varicosities d) aggravated by standing e) worse at end of day [5] 2) arterial a) more painful, punched out necrotic ulcer b) atrophic skin bordering ulcer c) generally over bony prominence [5] d) other signs of arterial insufficiency 3) neuropathic a) minimally painful b) punched out ulcer with surrounding callous over sites of pressure 4) pyoderma gangrenosum a) necrotic purulent-appearing ulcer b) raised & undermined borders 5) vasculitis a) palpable purpura b) livedo reticularis 6) neoplastic: rough-edged or exophytic lesions 7) infectious: a) purulent ulcer b) furuncles, ecthyma or septic lesions from bacteria c) nodulo-ulcerative lesions of atypical mycobacteria & fungi 8) vasculopathic: painful, punched-out, necrotic ulcers Laboratory: 1) complete blood count (CBC) 2) serum chemistries a) serum glucose b) serum albumin & total protein c) serum iron & total iron-binding capacity (TIBC) 3) serology a) antinuclear antibodies (ANA) b) rheumatoid factor (RF) c) cryoglobulins d) cryofibrinogen e) hepatitis B serology, hepatitic C serology 4) workup for hypercoagulable state a) anti-phospholipid antibodies b) serum protein C & serum protein S c) factor V Leidin mutation d) serum protein electrophoresis 5) wedge biopsy of ulcer margin & bed a) non-healing ulcers of > 3 months duration b) clinically atypical ulcers c) uclers associated with manifestations of vasculitis 1] palpable purpura 2] livedo reticularis d) ulcers associated with nodules or cellulitis suggesting an infectious etiology 1] bacterial stains 2' fungal stains e) unexplained associated systemic illness Special laboratory: - systolic blood pressure in the ankle using doppler flowmeter (ankle-brachial index) Radiology: - doppler ultrasound of deep & superficial veins if indicated Differential diagnosis: - wound - malignant neoplasm Management: 1) treatment directed at the underlying condition 2) eliminate or control contributing factors a) hypertension b) hyperlipidemia c) tobaccoism 2) debridement of necrotic tissue (except pyoderma gangrenosum) 3) control infection - infection impairs healing [2] - use Silvadene for wounds with > 1 million CFU/g tissue or any infection with beta-hemolytic Streptococci - consider topical antibiotic for clean wounds that are not healing after 2-4 weeks of optimal care - systemic antibiotics for signs of spreading infection, cellulitis, or osteomyelitis - systemic antibiotics do NOT expedite healing of cutaneous ulcers - may result in infection with resistant organisms 4) avoid topical anesthetics & neomycin (common sensitizers) 5) occlusion of wounds enhances re-epithelialization by preventing desiccation & does not result in a higher incidence of infection 6) wet-to-dry dressings remove both regenerating as well as necrotic tissue

Related

mucosal ulcer

Specific

arterial ulcer genital ulcer livedoid vasculitis Marjolin's ulcer neuropathic ulcer painless cutaneous ulcer pressure ulcer (decubitus ulcer, bedsore) pyoderma gangrenosum venous stasis ulcer

General

skin lesion ulcer wound

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 306
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018.
  3. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 327
  4. Onesti MG et al. Ten years of experience in chronic ulcers and malignant transformation. Int Wound J 2013 Jul 18 PMID: 23865503
  5. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  6. Greer N, Foman NA, MacDonald R et al Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review. Ann Intern Med. 2013 Oct 15;159(8):532-42 PMID: 24126647
  7. Kirsner RS, Vivas AC. Lower-extremity ulcers: diagnosis and management. Br J Dermatol. 2015 Aug;173(2):379-90. Review. PMID: 26257052
  8. Rayala BZ. Skin ulcers: prevention and diagnosis of pressure, venous leg, and arterial ulcers. FP Essent. 2020;499:11-18. PMID: 33263972