cutaneous ulcer
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Introduction
A lesion on the surface of the skin or on a mucous surface that extends to the level of the dermis or deeper.
Etiology
- primary cutaneous disorders
- peripheral vascular disease
- venous stasis ulcer (70-80%)
- arterial ulcer (5-10%)
- risk fastors:: male, > 40 year, smoking, diabetes mellitus, dyslipidemia, hypertension, sedentary lifesyle[5]
- livedoid vasculitis
- Marjolin's ulcer
- infections - ecthyma
- bacterial
- septic lesions
- atypical mycobacterium
- fungus
- squamous cell carcinoma of the skin
- basal cell carcinoma
- systemic diseases
- legs & feet
- vasculitis (palpable purpura & livedo reticularis)
- hemoglobinopathies: sickle cell anemia
- cryoglobulinemia
- cholesterol emboli
- necrobiosis lipoidica & other neuropathic conditions (10%)
- vasculopathic conditions:
- vasculopathic lesions (thrombosis without vasculitis)
- hands & feet
- Raynaud's phenomenon
- generalized
- pyoderma gangrenosum
- infections (fungi, chronic Herpes zoster)
- lymphoma
- calciphylaxis
- 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
- venous
- less painful, shallow, irregular ulcers
- along the course of the long saphenous vein
- frequently over the medial malleolar region
- edema, dermatitis, hemosiderin deposition & varicosities
- aggravated by standing
- worse at end of day[5]
- arterial
- neuropathic
- pyoderma gangrenosum
- vasculitis
- neoplastic: rough-edged or exophytic lesions
- infectious:
- purulent ulcer
- furuncles, ecthyma or septic lesions from bacteria
- nodulo-ulcerative lesions of atypical mycobacteria & fungi
- vasculopathic: painful, punched-out, necrotic ulcers
Laboratory
- complete blood count (CBC)
- serum chemistries
- serology
- workup for hypercoagulable state
- wedge biopsy of ulcer margin & bed
- non-healing ulcers of > 3 months duration
- clinically atypical ulcers
- uclers associated with manifestations of vasculitis
- ulcers associated with nodules or cellulitis suggesting an infectious etiology
- unexplained associated systemic illness
Diagnostic procedures
- 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
- treatment directed at the underlying condition
- eliminate or control contributing factors
- debridement of necrotic tissue (except pyoderma gangrenosum)
- 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
- systemic antibiotics do NOT expedite healing of cutaneous ulcers
- avoid topical anesthetics & neomycin (common sensitizers)
- occlusion of wounds enhances re-epithelialization by preventing desiccation & does not result in a higher incidence of infection
- wet-to-dry dressings remove both regenerating as well as necrotic tissue
More general terms
More specific terms
- arterial ulcer
- genital ulcer
- livedoid vasculitis
- Marjolin's ulcer
- neuropathic ulcer
- painless cutaneous ulcer
- pressure ulcer (decubitus ulcer, bedsore)
- pyoderma gangrenosum
- venous stasis ulcer
Additional terms
References
- ↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 306
- ↑ 2.0 2.1 Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018.
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 327
- ↑ Onesti MG et al. Ten years of experience in chronic ulcers and malignant transformation. Int Wound J 2013 Jul 18 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23865503
- ↑ 5.0 5.1 5.2 5.3 5.4 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/24126647
- ↑ Kirsner RS, Vivas AC. Lower-extremity ulcers: diagnosis and management. Br J Dermatol. 2015 Aug;173(2):379-90. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26257052
- ↑ Rayala BZ. Skin ulcers: prevention and diagnosis of pressure, venous leg, and arterial ulcers. FP Essent. 2020;499:11-18. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33263972