Introduction

Skin ulcers are a common presentation to general practice – affecting 2-3 patients per 1000 per year, and can have several important causes:

• Venous ulcers
  • Due to venous blood stasis
• Arterial ulcers
  • A manifestation of peripheral vascular disease
• Mixed, venous and arterial ulcers
• Pressure sores and diabetic ulcers
  • Typically the result of excessive pressure to an area of skin, due to lack of sensation in this area from diabetic nephropathy
  • Also seen in immobile patients

Other rare causes can include:

• Autoimmune vasculitis – e.g. associated with rheumatoid arthritis, SLE
• Tropical disease
• TB
• Skin cancers
• Insect / spider bites

It is also important to differentiate between leg and foot ulcers as the causes are often very different:

• Leg ulcers
  • 65% are venous
  • 15% are arterial
  • 20% are other causes
• Foot ulcers
  • 70% are arterial
  • 5% are venous
  • 25% are other causes

Most ulcers are multifactorial, and important factors are obesity and sedentary life-style.

Treatment requires a multi-faceted approach. Regular wound dressings, and removal of dead sloughed tissues aids recovery. The use of moist dressings is important to create a physiological environment for healing. Wound swabs are often not useful as all chronic ulcers will become colonised with gram positive and gram negative bacteria.

Compression bandages are important in both treatment as prevention as they help to reduce venous stasis and promote blood flow.

Consider skin cancer, particularly SCC in any ulcer that fails to respond to treatment.

History

• Factors that make peripheral vascular disease (arterial ulcers) more likely:
  • Smoker or ex-smoker
  • Known cardiovascular disease (e.g. previous CVA or MI, history of coronary artery disease, angina)
  • History of claudication
• Past medical history
  • PVD
  • Diabetes
  • Rheumatoid arthritis, SLE or inflammatory bowel disease
• Drug history
  • Beta-blockers – can reduce peripheral blood flow
  • Steroids and NSAIDs – can reduce skin healing

Examination

• The most important part of the examination is checking the peripheral pulses!
  • Strong pulses throughout, indicate that arterial disease is unlikely
  • Absent pulses suggest arterial disease
• Ulcer location
  • Inside of the ankle and calf – likely venous ulcer
  • Areas of pressure – likely diabetic ulcer
  • Lateral foot and lower leg – likely arterial ulcer
  • Sun exposed areas – think about risk of skin cancers
• Appearance of the ulcer
  • Look at the wedge of the ulcer, and the base of the ulcer
  • A “punched out” ulcer refers to one that has clean straight edges and base – more likely arterial
  • An “undermined” lesion refers to a wide base of the ulcer, relative to the ulcer opening. Suggest pressure sores or diabetic ulcer
  • Lesions with raised edges suggest skin cancers (usually SCC or BCC)
  • Dry base of ulcer – suggests arterial disease
  • Moist base of ulcer – suggests venous disease

Venous vs arterial

Table adapted from a table in Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt

Pressure sores

Can be graded by severity:

• I – non-blanching erythema
• II – partial thickness ulceration
• III – full thickness ulceration
• IV – deel full thickness with extensive skin and tissue loss

Features:

• Slough at base
• Edges are “undermined” – i.e. the base is wider than the skin defect
• Can expand rapidly
• Often at sites of pressure – e.g. sacrum in bed bound patients, on sole of feet in mobile patients

Appearance

Arterial	“Punched out” Location: distal to ankle Surrounding skin often mottled to evidence of varicose veins and varicose eczema Painful – especially at night Associated PVD and / or risk factors
Venous	Location: proximal to ankle Surround skin might show haemosiderin deposition, varicose eczema or varicose veins May be infected (yellowish foul smelling discharge) Painless
Diabetic / neuropathic ulcer	Location: Pressure points – often on heel, tip of toes, between toes Painless Appearance often somewhat similar to arterial, but may lack other signs associated with PVD (e.g. pale cold foot, reduced pulses – may be normal)

Investigations

• Blood
  • FBC
  • U+Es
  • CRP
  • HbA1c or blood glucose
• Consider swab for MC+S
  • Useful in acute stages
  • In chronic ulcers – will often grow a variety of colonisation but not infective organisms
• Consider ABPI
  • ABPI – ankle-brachial pressure index
  • If <0.9 suggests arterial disease
• Doppler USS

Pathology

Arterial ulcers

• Insufficient arterial blood supply due to peripheral vascular disease
• Management is aimed at improving peripheral arterial blood supply

Venous disease

• Typically due to thrombophlebitis – venous inflammation and clots
• Associated with venous stasis – poor blood flow through the veins
• May have a history of DVT or varicose veins
• Causes chronic venous hypertension, which may lead to skin discolouration – dark, copper coloured skin – as a result of hyperpigmentation
• Often very slow to heal – especially if treated without compression
• Usually not painful
  • If they are associated with pain, this can often be relieved by raising the legs

Management

Arterial ulcers

• This should involve treating the underlying arterial insufficiency
• Usually this would be a referral to a vascular surgeon, for work-up for treatments to re-establish blood flow
• For more info, see management of peripheral vascular disease

Venous Ulcers

Ulcer heal better when occluded, and kept in a moist environment.

Principles of management

• Nursing care:
  • Regular dressing changes
  • Removal of slough and necrotic tissue
  • Keep wound moist
  • AVOID the use of anti-septics, which are toxic to cells and slow healing
    • Wash iff any antiseptics after 5 minutes
  • Cleaning should beamingly performed with saline
  • Dressings – are complicated – loads of different types, for slightly different purposes. Ask the nurse!
• Antibitoics
  • Are usually not indicated
  • Only useful if there is surrounding cellulitis
• Compression
  • Use a firm, elastic compression bandage
  • From the base of the toes to just below the knee
• Elevation
  • Elevate the affected limb
  • Aim for 60 minute BD, plus elevation overnight
  • Above the level of the heart
  • Aids venous drainage
• Medication review – avoid drugs that can affect healing
  • Steroids
  • NSAIDs
  • Beta-blockers
  • Smoking!
• Exercise
  • Encourage early ambulation and exercise
  • Helps to improve the pump action of the calf muscle which aids venous return
• Severe cases
  • May need surgery to treat varicose veins
• Prevention
  • Continue to use compression
  • Regular exercise
  • Use of emollients for varicose eczema
  • If BMI >25, then encourage weight loss
  • Smoking cessation

Pressure sores

• Management
  • Relieve the pressure!
  • Daily wound cleaning with saline and dressings
  • Vitamin C 500mg BD
  • Antibiotics
    • Are usually not indicated
    • Only useful if there is surrounding cellulitis
  • Negative pressure therapy
    • May be useful for non-healing wounds
  • Optimise nutritional status
  • Surgical wound debridement may be required in some cases
• Prevention
  • Particularly important in hospitals and residential care homes
  • Turning of patients every 2 hours
  • Daily skin checks for areas of pressure
  • Special mattresses – e.g. air filled – which may periodically change pressure in the mattress to change the areas of pressure on the patient
  • Control urinary and feral incontinence
  • Good general hygiene

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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