Management of cutaneous ulcers by Dr. Terdoo M.I .pptx

Ulcer are a major public health problem, affecting all age groups. Diabetes been the most common cause of chronic ulcers in Nigeria

1. MANAGEMENT OF ULCERS By Dr. Iorhemba , Terdoo Martins B.Sc., MB;BS, M. Sc., MPH(In View) 4/22/2024 Management of Ulcers by Dr. Terdoo 1

2. OUTLINE Introduction Classification of ulcers Characteristics of an ulcer Clinical classification of ulcers Management of ulcer Management of specific ulcer Phases of healing of non-specific ulcer Management of non-specific ulcer F actors affecting wound healing Complications of ulcers Prevention of ulcers Conclusion References 4/22/2024 Management of Ulcers by Dr. Terdoo 2

3. INTRODUCTION An ulcer is the loss of continuity (break or integration) of an epithelium, internal or external and usually follows a gradual cell by cell death (necrosis) of the constituent cells which may result in dysfunction of the affected organ. Epidemiology- A major public health challenge with a prevalence range of 1.5% to 20.3%, affects all age groups, no gender disparity, commonly affects lower limbs, DM is the commonest cause according to Akaa et al.; (2017) 4/22/2024 Management of Ulcers by Dr. Terdoo 3

4. CLASSIFICATION OF ULCERS SPECIFIC ULCERS Tuberculous ulcers Buruli ulcers Syphilitic ulcers Yaws Trepomema perteune ulcers Mycobacterium leprae ulcers 4/22/2024 Management of Ulcers by Dr. Terdoo 4

5. B. NON-SPECIFIC ULCER Traumatic ulcers 5. Metabolic or systemic Dx associated ulcers Pyogenic ulcers -DM ulcer Ulcers of vascular origin: -Haemoglobinopathies ulcers Venous (Gravitational) ulcers -UC ulcers Arterial ulcers - Spherocytotic ulcer Decubitus ulcers Pressure sores 4. Neutropic (Trophic) ulcers: Leprosy DM neuropathy Peripheral neuropathies Syringomyelia 4/22/2024 Management of Ulcers by Dr. Terdoo 5

6. C. NEOPLASTIC ULCERS SCC Rodent ulcer Malignant Melanoma Kaposi’s sarcoma Penetrating malignant tumors 4/22/2024 Management of Ulcers by Dr. Terdoo 6

7. CHARACTERISTICS OF AN ULCER Edge- Refers to where the healthy skin begins. Sloping in non-specific ulcers, undermined in a tuberculous ulcer, raised in a malignant ulcer and punched out in a syphilitic ulcer. Floor- Is what is seen. Maybe sloughing with a profuse, offensive, yellowish discharge or consist of pinkish red granulation with a thin serous discharge suggestive of healing. Nodular for malignancy. Base- Is what is palpated. Maybe indurated or hard 4/22/2024 Management of Ulcers by Dr. Terdoo 7

8. CLINICAL CLASSIFICATION Specific Ulcers- Caused by specific organisms e.g M. ulcerans bacilli, T. pallidium . Has characteristic edge type for each. Non- Specific ulcers- Has sloping edges but different etiologies. Most common ulcers Malignant Ulcers- Neoplastic in origin, some chronic ulcers can become neoplastic e.g chronic Buruli ulcers, chronic burn ulcers to Marjolin’s ulcer. Edge is raised, floor maybe nodular and indurated base. 4/22/2024 Management of Ulcers by Dr. Terdoo 8

9. MANAGEMENT OF ULCERS HISTORY Mode of onset Duration Pain Progress of the ulcer Painful regional lymph nodes Symptoms or past medical Hx : DM, SCDx , DVT, PADx , varicose viens , Neuropathies, Syphilis 4/22/2024 Management of Ulcers by Dr. Terdoo 9

10. 2. CLINICAL EXAMINATION Ulcer b. General examination- Pallor, hepatosplenomegaly, artherosclerosis Number Anatomical site Size Shape Edge Floor Base Discharge Surrounding skin State of local circulation State arterial pulses of the limbs State innervation Regional lymph nodes 4/22/2024 Management of Ulcers by Dr. Terdoo 10

11. 3. INVESTIGATIONS Urine- urinalysis and albumin Blood: VDRL FBG, RBG Hb Electrophoresis PCV, FBC Plasma protein levels Mantoux test ESR 4/22/2024 Management of Ulcers by Dr. Terdoo 11

12. INVESTIGATIONS CONT’D 3. Bacteriology 4. Radiology Plain films to see bone changes and calcifications Duplex Doppler scanning CXR for TB, malignancies 5. Biopsy of ulcer for histology 6. Other tests as indicated eg lepromin for leprosy 4/22/2024 Management of Ulcers by Dr. Terdoo 12

13. MANAGEMENT OF SPECIFIC ULCERS TUBERULOUS ULCER Usually seen in skin over discharging tuberculous abscess especially neck and groin. Outline is irregular, thin edge, blue and underlined. Floor is covered with pale granulations, discharge is thin and watery. Base is soft, there may be satellite sinuses and enlarged lymph nodes. Lungs and bones can be tuberculous focus. Investigations- AFB Bacilli in culture, wound Biopsy Tx- Anti-TB, wound care 4/22/2024 Management of Ulcers by Dr. Terdoo 13

14. BURULI ULCER Discovered by Sir Albert Cook in Uganda 1897, a devasting dx caused by M. ulcerans which produces heat-labile toxin called mycolacton (has cytotoxic and immunosuppressive ppts) causes necrosis of dermis and subcut . Though has low mortality but high morbidity and disability rates. Mode of transmission not known Investigations- AFB on ZN stain, Swabs culture on Lowenstein-Jensen medium, wound biopsy, PCR, FBC Tx- Anti-TB drugs, wound care 4/22/2024 Management of Ulcers by Dr. Terdoo 14

15. SYPHILITIC (GUMMATOUS) ULCERS Uncommon now, it follows breakdown of a subcut . Gumma especially around the knee. It has a serpiginous outline, edge is punched out, floor covered with yellowish slough, discharge is thin and fowl smelling. Dx- VDRL, Biopsy TX- A course of pencillin 4/22/2024 Management of Ulcers by Dr. Terdoo 15

16. PHASES OF HEALING OF NON-SPECIFIC ULCERS Acute or infective phase- Initial phase, ulcer is painful and histology similar to abscess. Slough floor covered with purulent discharge bacteria maybe identified. Edge is sharp and surrounded by damaged cells. Surrounding skin is edematous, tender and warm. Transition phase- Slough separates, pus drains, infection subsides, granulation tissues grows, floor becomes pinkish red. Reparative or healing phase- Painless with healthy granulation tissue fills floor, edges grows at the rate of 1mm/day to cover the floor. Chronic, indolent or callous phase- Ulcer may enter chronic phase and wound remain unhealthy tissues commonly due to systemic compromise. 4/22/2024 Management of Ulcers by Dr. Terdoo 16

17. MANAGEMENT OF NON-SPECIFIC ULCERS FOR ACUTE ULCERS Admit for bed rest and elevate limb Wound swab for Gram stain and M/C/S Broad spectrum antibiotics and review after sensitivity result is available TT booster dose Wound irrigation with N/Saline Dressing with povidone and firm creppe bandage to improve venous return Splint affected limb Early physiotherapy Once ulcers becomes healthy, graft with split skin graft Where infected slough, sloughectomy , use of maggots etc 4/22/2024 Management of Ulcers by Dr. Terdoo 17

18. FOR CHRONIC ULCERS These ulcers are excised and then grafted with split-skin graft or covered with a flap. 4/22/2024 Management of Ulcers by Dr. Terdoo 18

19. FACTORS AFFECTING WOUND HEALING Local factors 2. Systemic Factors Mechanical injury Age Infection Nutrition Edema Trauma Topical agents Metabolic Dx Ionizing radiation Immunosuppression Necrotic tissue Connective Tissue disorders Low oxygen tension Alcohol and smoking Foreign bodies 4/22/2024 Management of Ulcers by Dr. Terdoo 19

20. COMPLICATIONS Septicemia Lymphangitis Lymphadenitis Wasting Tetanus Lymphoedema Periostitis/Osteomyelitis Malignant change Deformities/Disabilities Social problems Psychological issues etc 4/22/2024 Management of Ulcers by Dr. Terdoo 20

21. MANAGEMENT OF NEOPLASTIC ULCER Multi-disciplinary approach consisting of; Oncologist, Dermatologist, plastic surgeon, Histopathologist etc. Surgical excision and repair Radiotherapy Chemotherapy Immunotherapy Adjuvant and neoadjuvant therapy 4/22/2024 Management of Ulcers by Dr. Terdoo 21

22. PREVENTION OF ULCERS Foot hygiene Use of pressure dressing and stockings after discharge Use of protective and comfortable foot wears Prompt medical attention following lacerations or abrasions BCG vaccines 4/22/2024 Management of Ulcers by Dr. Terdoo 22

23. CONCLUSION Ulcer forms a major public health and financial burden on the patients, families, communities and healthcare system. Prompt hospital presentation, early diagnosis and institution of management will help reduce the mortality and morbidity for the disease. 4/22/2024 Management of Ulcers by Dr. Terdoo 23

24. References Baja’s Principles and Practice of Surgery including Pathology in the Tropics, 5 th edition 2015, vol. 1, Ghana Publishing Corporation, ISBN(s): 978-9988-2-2289-5 Akaa PD; Agada E.; Ahachi C.N.; Inunduh P.; Eke B.A.; The Epidemiology of Classification of Chronic Cutaneous Ulcers in Tertiary Health Institutions in Makurdi, Nigeria. Highland Med Res J 2017;17(2):104-107 4/22/2024 Management of Ulcers by Dr. Terdoo 24

25. THANK YOU FOR YOUR ATTENTION 4/22/2024 Management of Ulcers by Dr. Terdoo 25