Ulcers

Ulcers

Venous Stasis Ulcers

·        70 – 90% of ulcers on lower extremities are due to venous insufficiency (eg varicose veins)

·        Below the knee, never on the sole of the foot, usually around the malleoli

·        Unlike ulcers due to arterial insufficiency, will have good peripheral pulses and no peripheral neuropathy

·        Usual isolates: S aureus and/or various G –ive bacilli (including Pseudomonas aeruginosa and other aerobic G-ive‟s)

·        Treatment: in absence of extensive surrounding cellulitis or systemic signs, there is no role for systemic antibiotics

Pressure Ulcers

·        = Skin necrosis and ulceration as a result of pressure induced ischaemia

·        Incidence over a 3 week period of bed and chair bound patients is about 8 %

·        Critical factors in their development:

o   Pressure: Muscle and subcutaneous tissue are more vulnerable than epidermis. Pressure leads to venous, arteriolar and lymphatic occlusion. Especially over bony prominences 

o   Shearing: Sliding of adjacent surfaces (eg sacral skin on underlying bone) ® ­ vulnerability to pressure induced obstruction 

o   Frictional forces: Eg from being pulled across sheets ® intra-epidermal blisters

o   Moisture: eg urinary incontinence, also sweat and faeces.  ­Risk of pressure sores 5 times

·        Risk factors: age (loss of blood vessels, epidermal atrophy etc) and immobility

·        Staging:

o   1: irregular, ill-defined are of soft tissue swelling, induration and heat.  Reversible 

o   2: Plus inflammatory and fibroblastic response. Extends through dermis and into subcutaneous fat. Reversible 

o   3: Plus undermining of edges

o   4: Plus underlying muscle and bone 

·        Infection. All pressure areas become contaminated. Impairs healing. Can lead to bacteraemia (usually polymicrobial) with high mortality

·        Site: most at the sacrum, heel, ischial tuberosities and greater trochanter

·        Management:

o   Prevention (responsibility of all involved professionals)

o   Decreasing pressure: change of positioning, padding, alternating air cell mattresses 

o   ¯Friction: appropriate bed clothes, no particles in bed (eg food)

o   ¯Moisture: Pads, catheters, reduced sweating

o   ¯Shearing: avoid shearing positions (eg propped up in bed) 

o   Established sores: Good nutrition, oral vitamin C, ?topical antibiotics (but ­resistance), saline dressings + variety of preparations/dressings. If stage 3 or 4 then consider debridement or skin grafts

Other Ulcers

·        Ischaemic ulcers:

o   Large artery disease: usually lateral side of the leg, pulses absent

o   Small vessel disease (eg vasculitis): palpable purpura 

·        Malignant ulcer: eg basal cell carcinoma (pearly translucent edge), squamous cell carcinoma (hard everted edge), etc 

·        Neuropathic ulcer: painless penetrating ulcer on the sole of the foot due to peripheral neuropathy (eg diabetes, leprosy)

·        Underlying systemic disease: Diabetes, pyoderma gangrenosum, rheumatoid arthritis, lymphoma