Ulcers
By SHO: BARAKA MANDRO(2020-01-00293), MUSAFIRI SIMBA(2020-01-00629), MUMBERE
MUSONGYA(2020-01-00448) on supervision of Mr OKEDI XAVIER
Leaning objectives and plan
 Definition
 Etiology
 Classification
 Pathophysiology
 Clinical presentation
 Work up
 Treatment
 Complication
 Reference
Figure Vasculitis –
multiple, punched out
ulcers on the leg of a
patient with rheumatoid
arthritis.
1. DEFINITION
A break in the continuity of the covering epithelium of the skin or mucous
membrane, it may either follow molecular death of the surface epithelium or its
traumatic removal
2. ETIOLOGY
 Traumatic causes (Mechanical, Physical - electrical, radiation, chemical)
 Vascular insufficiency (Arterial, Venous)
 Neoplastic conditions (Malignant melanoma etc)
 Metabolic diseases (diabetes mellitus)
 Malnutrition (Beriberi)
 Tropical ulcer (Burili ulcer)
 Inflammatory processes (cellulitis, Infective processes, TB, Syphilis, Fungal
infections)
 Neurogenic causes (Bed sores, Perforating ulcers, Cord Lesions, Peripher al
Neuropathies
 Other causes (Bazin ulcer, Martorell’s (hypertensive ulcer)
3. CLASSIFICATION OF ULCER
1. Etiologic classification.
 Traumatic ulcer.
 Vascular ulcer.
 Neoplasic ulcer.
 Metabolic
 Ulcer due to malnutrition,
 Inflammatory
 Infective ulcer
 Miscellaneaous ulcer

2. Clinical classification
 Spreading ulcer
 Healing ulcer
 Calleaous ulcer
3. Pathological classification
 Non specific ulcer
 Specific ulcer
 Malignant ulcer

Figure Mycosis
fungoides –
ulcerated
and
plaques
tumors on the
back
Figure Sickle cell anemia – lower leg ulcer in a black patient.
4. PATHOPHYSIOLOGY.
The natural history of an ulcer consist of three phases:
1. Extension phase:
 The floor is covered with exudates and sloughs
 The base is indurated
 The discharge is purulent or even blood stained
2. Transitional phase
 Prepares for healing
 The floor becomes cleaner and the slough separates
 The induration of the base diminishes
 The discharge become more serous
 Small reddish are
of granulation tissue appear on the floor
3. Repair phase
 Transformation of granulation to fibrous tissus
 The epithelium gradualy extend from the new shelving edge to cover the
floor
 The healing edge consists of three zone: outer zone, Mildle zone and
inner zone.
5. CLINICAL PRESENTATION
Composed of History and Physical examination
1. History
Note the following:
 Duration (i.e. how long is the ulcer present?)
 Acute: present for short time
 Chronic: present for long time
 Mode of onset (i.e. how has the ulcer developed?)
 Following trauma
 Spontaneously e.g. following- swelling
 Marjolin's ulcers are the malignant transformation of chronic wounds
 Pain (i.e. is the ulcer painful?)
 Painful: ulcers associated with inflammation
 Slight painful: tuberculous ulcer
 Painless eg syphilitic, neurogenic, malignant ulcers
 Discharge (i.e. does the ulcer discharge or not?)
If YES: note the nature of discharge- pus, bloody, serous
 Associated diseases which may lead to ulcer formation
e.g. Tuberculosis, syphilis, diabetes mellitus, nervous diseases
5.2. Physical examination
It’s has three part: General examination, Local examination and Systemic
amination, we will focus on local examination.
1.Local examination: Inspection, palpation, examination of lymph node,
examination of vascular insufficiency




Inspection
Site: gives clue to the diagnosis
 Varicose ulcer- lower limb on the medial malleolus
 Rodent ulcer-face
 Tuberculus ulcer-cervical
 Trophic ulcer – heal
 Malignant ulcer- anywhere
Shape:
 Tuberculus ulcer- oval in shape
 Syphilitic ulcer– circular in shape
 Varicose ulcer – vertically oval in shape
 Malignant – irregular in shape
Size: May determine the time of healing
E.g. the smaller the ulcer the shorter the time it will take to heal
Surrounding skin. E.g. red and edematous- acute inflammation
ex
 Floor/surface i.e. exposed part of the ulcer may give clue to the diagnosis, Eg
red granulation – healing ulcer, Black floor- malignant melanoma
 Number
Tuberculous ulcer
Gummatous ulcer
Varicose ulcer
Note
: the number of ulcers may be more than one
 Edge: five types:
 Sloping edge e.g. healing ulcer
 Punched out edge e.g. Gummatous ulcer, deep trophic ulcer
 Undermined edge e.g. tuberculous ulcer-destroy subcutaneous faster
the skin
 Raised edge e.g. Rodent ulcer
 Rolled out (everted)- e.g. Squamous Cell Carcinoma
 Discharge: the character of the discharge should be noted
e.g. -Healing ulcer- scant serous discharge
- Spreading ulcer- purulent discharge
- Tuberculus ulcer- serosanguinous
- Malignant ulcer- bloody discharge
 Whole limb: should be examined e.g. varicose veins
Palpation
 Tenderness:
 Tender- acutely inflamed ulcer
 Slightly tender- tuberculous ulcer, syphilitic ulcer
 Non-tender- malignant ulcer, chronic ulcer, neurogenic ulcer
 Edge and surrounding skin
 Hard induration- malignant ulcer
 Firm induration- chronic ulcer, syphilitic ulcer
 Base (i.e. on which the ulcer rest) Slightly induration (syphilitic ulcer) and
marked induration- malignant ulcer
 Depth: eg trophic ulcer may be deep to reach the bones
 Bleeding: easy bleed on touch is a feature of malignant
 Fixity to the deep structures. Eg malignant ulcers are usually fixed to deep
structures
Examination of lymph node: depends on the site of an ulcer
Examination of vascular insufficiency: depends on the site of an ulcer
6. WORK UP: Laboratory, Imaging, Histopathology
1. Laboratory investigations:
- Haematological: FBP & ESR, Haemoglobin levels,
- Microbiological: Gram staining, Culture and sensitivity
- Biochemical, Serum glucose
2.Imaging investigations: Plain X-rays: CXR,X-ray of the affected limb,
Doppler US, CT Scan, MRI
3. Histopathology: To confirm diagnosis
7.TREATMENT: Depends on the cause
Generally → treat the cause
1. Conservative treatment
- Dressing
- Treat infections: Bacteria, fungal, syphilis, TB etc
- Steroids
- Trace elements
- Topical antimicrobial agents
- Nutritional support
- Limb elevation
- Control blood glucose
- Compression bandage
7.2. Surgical treatment
- Surgical debridement
- Sloughectomy
- Skin grafting
- Flaps
- Limb amputation
8.COMPLICATIONS: not treated in time ulcer will cause: limb amputation,
chronic osteomyelitis, malignant change, septicemia, septic emboli, death
9. REFERENCE
1.Hutchison’s Clinical Methods,An integrated approach to clinical practice, Michael
Glynn MA MD FRCP FHEA, Consultant Physician and Gastroenterologist,, Barts and
the London NHS Trust;,and other, North East Thames Foundation School,London,
UK, 2012
2.Brown DL, Borschel GH. Michigan manual of plastic surgery. Baltimore,
MD: Lippincott, Williams & Wilkins, 2004.
3. Georgiade GS, Riefkokl R, Levin LS. Georgiade plastic, maxillofacial and
reconstructive surgery, 3rd edn. Baltimore, MD: Williams & Wilkins,1997.
4. McGregor AD, McGregor, IA. Fundamental techniques of plastic surgery,
10th edn. Edinburgh, Churchill Livingstone, 2000. Richards AM, MacLeod T, Dafydd
H. Key notes on plastic surgery. Oxford, Wiley-Blackwell, 2012.
5. Thomas S. An introduction to the use of vacuum assisted closure. World
Wide Wounds 2005; available from: www.worldwide-wounds.com. Westaby S.
Wound care. London: William Heinemann Medical Books Ltd, 1985.