Derm Chapt 19 Ulcers

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Ulcers

Open wound that results from the loss of the epidermis **and part or all of the dermis**

etiologies of ulcers:Arterial occlusion

usually due to an embolus or thrombus that causes sudden severe pain in an extremity.

etiologies of ulcers:Arteriosclerosis

plaque formation causing gradual onset of pain with exertion and relieved by rest.

etiologies of ulcers:Venous stasis

lower leg heaviness, aching and swelling typically after long periods of standing or sitting

etiologies of ulcers:Neoplastic

often have a history of growth preceding ulceration

etiologies of ulcers:Factitial

suspected in patients with history of emotional disorders

etiologies of ulcers:Infective

suspect in patients with recent travel history, sexual history, or wildlife exposure

etiologies of ulcers:Drug side effect

allopurinol, barbituates, anticonvulsants and certain antibiotics may cause drug-induced epidermal necrolysis or vasculitis.

HPI for ulcers should include:

Onset- acute vs. chronic
Symptoms
Neoplasm
Family History
Social History
Travel
Medications

Physical Examination for ulcers should include

Size, shape, and color of ulcer
Location
Associated physical findings (surrounding skin, pulses, neurologic findings)

Vascular Studies for ulcers:Ankle:brachial index-

best screening tool to rule out PVD.

Vascular Studies for ulcers:Selective arteriography and/or arterial duplex ultrasonography

can be used to define extent of arterial obstruction

Vascular Studies for ulcers:Photoplethysmography

used to delineate venous and arterial pathologic and physiologic abnormalities or to determine cutaneous blood perfusion at margins of ulcer to predict potential for healing.

Vascular Studies for ulcers:Venous duplex Scan-

used to rule out venous insufficiency, DVT, and superficial thrombophlebitis

Blood Tests for ulcers:

ANA, RF, anti-DNA antibody, anti-phospholipid antibody and lupus anticoagulant are used to rule out connective tissue disease
Hematologic disorders including sickle cell anemia, spherocytosis, thalassemia and dysglobulinemia can be ruled out by various blood tests

Why Cultures for ulcers?

Necessary for diagnosing topical or unusual infections.
Routine _____ are generally polymicrobial
Antibiotics for ulcers that have become secondarily infected will not result in healing unless the underlying cause of the ulcer is corrected
If osteomyelitis is suspected diagnostic radiography is required

Biopsy of ulcer

Indicated for all chronic ulcers of unknown origin
Helpful to rule out neoplasm

Venous Insufficiency ulcers

Typical findings:
Lower leg edema, brawny induration, brownish discoloration, petechiae and dermatitis
Rarely occur below the level of the malleolus
Varicose veins may or may not be prominent
Treatment :
External compression is the most effective therapy
Treat initially with a compressive boot that is changed weekly.
After healing, knee-high medium pressure elastic compression stockings are used to prevent recurrence

Venous Insufficiency

Typical findings:
Lower leg edema, brawny induration, brownish discoloration, petechiae and dermatitis
Rarely occur below the level of the malleolus
Varicose veins may or may not be prominent
Treatment :
External compression is the most effective therapy
Treat initially with a compressive boot that is changed weekly.
After healing, knee-high medium pressure elastic compression stockings are used to prevent recurrence

Vasculitis

Typical Findings:
multiple small ulcers predominant on the lower extremities.
purpuric, hemorrhagic
and necrotic ulcer borders

Vasculitis

multiple*** punched out ulcers*** on the leg of a patient with RA.
Typical Findings:
multiple small ulcers predominant on the lower extremities.
purpuric, hemorrhagic
and necrotic ulcer borders

Neoplastic Ulcers

Picture is Mycosis Fungoides- ulcerated plaques and tumors on the back.
Typical Findings:
Individual or multiple cutaneous nodules that become ulcerated
Treatment:
Surgery, chemotherapy, and radiotherapy

Sickle Cell Disease

**25% chance of getting SS if both parents are carriers.**
lower leg ____ on African American patient
Typical Findings:
Ulceration of the lower third of the leg above the ankle in an African American adult can be a major manifestation of homozygous SS disease

Neuropathic Ulcer (mal perforans)

*Typically below the ankle*
Typical Findings:
Found in areas of pressure and trauma, particularly on an insensate foot
Commonly seen in patients with diabetes or leprosy
Frequently has significant softened, macerated cells
Treatment:
Prevention is key
Relieve pressure with mechanical devices (ie: orthotic shoes for a diabetic)

Factitial Ulcer

Typical Findings:
Ulcer will be geometric, bizarrely shaped, angular

Genital Ulcers

Highly suggestive of a venereal cause including: herpes simplex, syphilis, chancroid or granuloma inguinale

Decubitus Ulcers

Found in 3% of hospitalized patients
Bedridden or wheelchair bound patients at greatest risk
Patients are usually elderly and incontinent
Most common sites include sacral, coccygeal, ischial tuberosities and greater trochanter
Begin as irregular, ill defined, reddish, indurated areas that resemble abrasions
Full thickness skin defects develops with extension into the subcutaneous tissue and ultimate penetration into the deep fascia and muscle

Pyoderma Gangreosum

**Most commonly associated with connective tissue disorders*
Well defined borders
Typical Findings:
Rapidly developing, painful ulcer with undermined edge and gangrenous border
Usually occur on lower legs
Frequently associated with ulcerative and granulomatous colitis, RA, and myeloproliferative diseases
Correct or Treat Underlying Cause
Venous insufficiency- compression boot/stocking
Arterial insufficiency- surgery
Neoplasm- surgery, chemo, radiotherapy
Infection- antibiotics
Neuropathic or decubitis ulcer- remove pressure
Vasculitis or pyoderma gangrenosum- prednisone, dapsone, treatment of associated disease

Treatment for ulcers:Venous insufficiency

compression boot/stocking

Treatment for ulcers:Arterial insufficiency

surgery is treatment for what type of ulcer?

Treatment for ulcers:Neoplasm

surgery, chemo, radiotherapy are treatments for what types of ulcers

Treatment for ulcers:Infection

antibiotics are used to treat what type of ulcers?

Treatment for ulcers:Neuropathic or decubitis ulcer

remove pressure

Treatment for ulcers:Vasculitis or pyoderma gangrenosum

prednisone, dapsone, treatment of associated disease

General Treatment for ulcers:

Promote Wound Healing
Debridement- surgical, enzymes
Dressings- nonadherant, occlusive, or moist to dry
Infection control- antibiotics
Skin Grafting

Ulcers:Occlusive dressings

Made from various polymers
Keep ulcer moist >>> promoting epidermal repair through migration or epithelial cells over the ulcer
Large amounts of exudate form under the occlusive dressing, which remove the crust and necrotic debris through autolytic digestion
Change dressing every 2-3 days
Provide significant pain relief

When do you use and not use antibiotics in the treatment of ulcers

Use of oral and topical antibiotics is often ineffective due to development of resistant bacteria
Treatment with antibiotics is reserved for ____ that are complicated by cellulitis, lymphangitis, or septicemia

When do you treat ulcers with Surgical Intervention

Required in patients with peripheral vascular disease
Skin grafting is often necessary in venous ulcers that have failed to respond to conservative therapy

Complications of ulcers

Cellulitis
Lymphangitis
Septicemia
Osteomyelitis

Pathogenesis of ulcers

Cell Death:
Infection, toxic chemicals, physical injury, and loss of nutrition all cause cell death, tissue loss, and _____.
As long as cell death continues, the ___ will persist
___ Healing:
Healing is a complex process that requires intact vascular supply, inflammation, and proliferation of fibroblasts, endothelial cells, and keratinocytes.
Dermal integritiy depends synthesis of collagen, elastin, and proteoglycans by fibroblasts.
Epidermal repairs requires proliferation and migration of keratinocytes over a fibrin-fibronectin support matrix
Inflammation always is part of the healing process because the macrophage is the essential and most important cell.
Growth Factors (epidermal, platelet-derived, fibroblast, TGF-B) have a role in wound healing by enhancing reepithelialization and granulation tissue

A detailed history and physical examination (lab tests MAY be necessary)

What items are sufficient to establish a diagnosis of an ulcer?

arterial occlusion due to embolus or thrombus

The sudden appearance of severe pain in an extremity suggests what?

Intermittent claudication due to arteriosclerosis

The gradual onset of pain with exertion relieved by rest is characteristic of what?

Venous stasis

A history of lower leg heaviness, aching, and swelling, particularly after periods of inactive sitting or standing is typical of what?

Factitial ulcers

What type of ulcers are suspected in pts with hx of emotional d/o and overly dramatic and reactive behavior or indifference?

Tularemia, plague, or anthrax

Name 3 types of ulcers that are suspected in pts who have acute onset after wildlife exposure in pt with fever, chills, and malaise?

Lower leg edema, brawny induration, brownish discoloration, petechiae, and dermatitis

Venous insufficiency in the lower leg is characterized by what?

Vasculitis

Multiple small ulcers (0.5-2cm) **Punched out ulcers** occurring predominantly on the lower legs suggest what?

Homozygous sickle cell disease

Ulceration of the lower third of the leg above the ankle in an African-American adult pt is a major manifestation of what?

Neuropathic ulcer (mal perforans)

The type of ulcer that occurs mainly in pts with diabetes or leprosy is what?

Pyoderma gangrenosum (Frequently associated with ulcerative and granulomatous colitis, rheumatoid arthritis, and myeloproliferative diseases).

A rapidly developing, painful ulcer with an undermined edge and gangrenous border is characteristic of what type of ulcer?

Brachial index

What is the best screening test to rule out peripheral arterial disease?

Venous Duplex scanning

In order to rule out venous insufficiency, deep vein thrombosis, and superficial thrombophlebitis, what type of scanning would be necessary?

Biopsy, which is helpful in ruling out neoplasms

What is indicated for ALL chronic ulcers of unknown origin? What is this particularly useful for ruling out?

External compression (either boot for initial tx or compression stockings to prevent recurrence)

What is the most effective therapy for pts with venous diseased legs?

Moisture in the form of moisturized dressings (This moisture allows breakdown of exudate, crust, and debris from ulcer which build up in the dressings. Therefore, until healing begins, dressings must be changed every 2-3 days, after healing has begun 5-7 days is appropriate)

When treating an ulcer, what is one of the main features that promotes epidermal repair?

Cellulitis, lymphangitis, or septicemia

ONLY use antibiotic therapy when treating ulcers complicated by what three d/o's?

Peripheral Vascular disease

Surgical intervention (bypass graft or thromboendarterectomy) is required in pts with what disease?

Compression boot or stocking

What is the correct treatment for venous insufficiency?

surgery

What is the correct treatment for arterial insufficiency?

surgery, chemotherapy, radiotherapy

What is the correct treatment for neoplasm?

Antibiotics

What is the correct treatment for infectious ulcers?

remove pressure+ promote wound healing

What is the correct treatment for neuropathic or decubitus ulcer?

prednisone, dapsone, treatment of associated disease

What is the correct treatment for vasculitis or pyoderma gangrenosum?

Debridement, dressings, infection control, and skin grafting

Name 4 ways to promote wound healing of an ulcer?

Venous Insufficiency ulcers

Typical findings:
Lower leg edema, brawny induration, brownish discoloration, petechiae and dermatitis
Rarely occur below the level of the malleolus
Varicose veins may or may not be prominent
Treatment :
External compression is the most effective therapy
Treat initially with a compressive boot that is changed weekly.
After healing, knee-high medium pressure elastic compression stockings are used to prevent recurrence

Vasculitis

Typical Findings:
multiple small ulcers predominant on the lower extremities.
purpuric, hemorrhagic
and necrotic ulcer borders

Vasculitis

Typical Findings:
multiple small ulcers predominant on the lower extremities.
purpuric, hemorrhagic
and necrotic ulcer borders

Sickle Cell Disease

lower leg ____ on African American patient
Typical Findings:
Ulceration of the lower third of the leg above the ankle in an African American adult can be a major manifestation of homozygous SS disease if parents are carriers you have a 25% chance of inheriting the disease

Neuropathic Ulcer (mal perforans)

Typical Findings:
Found in areas of pressure and trauma, particularly on an insensate foot
Commonly seen in patients with diabetes or leprosy
Frequently has significant softened, macerated cells
Treatment:
Prevention is key
Relieve pressure with mechanical devices (ie: orthotic shoes for a diabetic)

Decubitus Ulcers

Found in 3% of hospitalized patients
Bedridden or wheelchair bound patients at greatest risk
Patients are usually elderly and incontinent
Most common sites include sacral, coccygeal, ischial tuberosities and greater trochanter
Begin as irregular, ill defined, reddish, indurated areas that resemble abrasions
Full thickness skin defects develops with extension into the subcutaneous tissue and ultimate penetration into the deep fascia and muscle

Decubitus Ulcers

Found in 3% of hospitalized patients
Bedridden or wheelchair bound patients at greatest risk
Patients are usually elderly and incontinent
Most common sites include sacral, coccygeal, ischial tuberosities and greater trochanter
Begin as irregular, ill defined, reddish, indurated areas that resemble abrasions
Full thickness skin defects develops with extension into the subcutaneous tissue and ultimate penetration into the deep fascia and muscle

Pyoderma Gangreosum

Typical Findings:
Rapidly developing, painful ulcer with undermined edge and gangrenous border
Usually occur on lower legs
Frequently associated with ulcerative and granulomatous colitis, RA, and myeloproliferative diseases

Factitial Ulcer

Typical Findings:
Ulcer will be geometric, bizarrely shaped, angular

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