Ulcer management
Ulcer
• Definition
• Classification
• Malignant ulcer
• Management
• Dressing
• Flap and graft
Definition
• break in the continuity
epithelium either skin or
mucous membrane due to
molecular death of surface
epithelium or traumatic
removal
Classification
Etiology Clinical Pathological
1)Spreading 1)Non specific
1)Traumatic 2)Healing 2)Specific
2)Vascular 3)Callous 3)Malignant ulcer
3)Neoplastic -squamous cell carcinoma
4)Metabolic -basal cell carcinoma
5)Infection (rodent ulcer)
6)Inflammatory -malignant melanoma
6)Neurogenic
7)Malnutrition
Malignant ulcer
Treatment squamous cell carcinoma
• Surgical excision
• Mohs micrographic
surgery
• Radiation therapy
• Chemotherapy
Clinical picture
• history
-duration :acute(<12w),chronic(>12w)
-mode onset:traumatic,spontaneous(follow swelling/burn)
-pain:
*painful:inflammation
*slight painful:TB
*painless:syphilis,neurogenic,malignant
-discharge:
*purulent:spreading
*serous:healing
*blood:malignant
Local Examination
1)Inspection
• site:
varicose vein-lower limb
rodent ulcer-face
tuberculous-cervical
trophic ulcer-heel
malignant ulcer-anywhere
• shape
oval:TB
circular:syphilis
vertical oval:varicose
irregular:malignant
• size
-small,faster heal
• skin surrounding
• floor
-black:melanoma
-red granulation:healing
• number
-TB,syphilis
• edges
2)Palpation
• tenderness
*tender:inflamed ulcer
*slight tender:TB,syphilis
*non tender:malignant,chronic,neurogenic
• edges
*hard induration:malignant ulcer
*firm induration:chronic ulcer,syphilis
• depth
*trophic ulcer deep to reach the bone
• base
*slight induration:syphilis
*marked induration:malignant
• bleeding
• fixed to deep structure
3)Examination LN(dep on site of ulcer)
tender enlarge:secondary infection
enlarge,firm,matted LN:TB
enlarge,hard,fixed LN:malignant ulcer
4)Examination of vascular(dep on site of ulcer)
-absence/weak pulse
-trophic changes-shiny skin,thin limb,loss hair,brittle skin
Laboratory investigation
-FBC,ESR
-swab /tissue C+S
-serum glucose
-LFT/protein
-CRP
-biopsy(wedge/excision)
Imaging
• X ray
-gas shadow in soft tissue
• US
• CT scan-evaluate soft
tissue/bony invasion/LN
• MRI-evaculate perineural
invasion/intracranial
invasion
Treatment
1)Conservative
2)Surgical
Conservative
• identify cause and treat
• correct anemia and deficiency
• blood transfusion if needed
• control pain and infection(steroid,antimicrobial agent)
• Nutritional support
• Limb elevation
• Control blood glucose
• dressing
Surgical
• Surgical debridement
• Skin graft
• Skin flap
• Limb amputation
Dressing
Type of dressing 2)Modern
• Film
1)Conventional
• Hydrogel
• non antiseptic(normal
• Hydrocolloid
saline,water for irrigation)
• Calcium alginate
• Antiseptic(chlorhexidine,su
peroxidised • Foam(TEHO,duoderm
solution,polyhexamethylen ,aquacell)
e biguanide) • Hydrofiber
• Others(povidone,hydrogen • Charcoal
peroxide) • Silver
• polymem dressing
Vaccuum assisted closure(NPWD)
• Def:creation of intermittent negative pressure of -125mmHg to promote
formation of healthy granulation tissue
• Negative pressure
-reduce edema
-clear interstitial fluid
-improve perfusion
-increase cell proliferation
-promote healing
• Once ulcer granulate well,flap cover or skin graft is done
Surgical
• Surgical debridement
• Skin graft
• Skin flap
• Limb amputation
Reference
• https://onlinelibrary.wiley.com/doi/full/10.1002/app.47738
• Wound care manual, Ministry of Health Malaysia
• https://www.medscape.com/answers/460282-200671/what-are-
diabetic-foot-ulcers
