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
·
= 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
·
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
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