Skin Ulcers Overview ppt

Skin Ulcers Overview powerpoint presentation

1. SKIN ULCERS OVERVIEW DR OKOYE C.

2. Outline Introduction Epidemiology Characteristics of an ulcer Classification Specific ulcers Non-Specific Ulcers Management History Examination Investigation Treatment Complications Follow-up Conclusion References

3. Introduction An ulcer is the loss of continuity of the surface epithelium. The underlying tissues may be affected. There are several causes of an ulcer but necrosis or death of the cells is the immediate cause

4. Epidemiology It accounts for about 25-30% of general plastic surgery visits in industrialized countries In developing countries it constitutes about 35-40% of plastic surgery clinic About 80% of the ulcers are in the lower third of the leg In the industrialized countries the commonest cause are venous, diabetic trauma In developing countries the common causes are infection, trauma, venous

5. Characteristics of an ulcer EDGE It is where the healthy skin (epithelium )begins. S loping in a non-specific ulcers U ndermined in a Tuberculous ulcers Raised in Malignant Punched out in syphilis

6. Ulcer edges Sloping Undermined Raised Punched out

7. FLOOR : It is what is seen. S loughing with a profuse , offensive, yellowish discharge R ed granulation with a thin serous discharge Nodular

8. BASE : It is what is palpated . It may be indurated or hard (malignant or longstanding callous ulcer )

9. Classification of Ulcers A . Specific ulcers: Tropical ulcers. Tuberculous ulcers. Buruli ulcers. Syphilitic ulcers. Yaws ulcers.

10. B. Non-specific ulcers: Traumatic ulcers. Pyogenic ulcers. Ulcers of vascular origin: ( i ) Venous (gravitational) ulcers. (ii) Arterial ulcers.

11. Neurotropic (trophic) ulcers : ( i ) Leprosy . (ii ) Diabetic neuropathy . (iii ) Cord lesions. (iv) Peripheral neuropathies. (v) Syringomyelia .

12. C . Neoplastic ulcers Squamous cell carcinoma. Rodent ulcer. Malignant melanoma . Kaposi's sarcoma. Penetrating malignant tumour . C .

13. Specific Ulcers TROPICAL ULCER A cute ulcerative cutaneous lesion caused synergistically by the anaerobic Fusobacteria ( Bacteriodes fusiformis ) and the aerobic Borrelia vincenti . Starts as a Painful septic blister which sloughs to form an ulcer .

14. Predisposing Factors M ales Poor personal hygiene M alnutrition W alking barefooted

15. Pathology Painful septic blister or vesicle containing sero-sanguinous fluid surrounded by oedematous inflamed skin R uptures after a few days to expose a foul-smelling, ragged, yellowish brown , grey or black slough of the skin and subcutaneous tissues Lymphadenitis or lymphangitis Can affect deeper structures such as muscles and tendons causing them too to slough off

16. Blood vessels, if affected get thrombosed . G angrene may result if it is an end artery. Bones ------- periostitis . The slough with time liquefies, discharges offensive pus and separates. A circular ulcer about 4-l0cm in diameter then forms

17. TB ULCER Irregular outline and the edges are thin, blue and undermined F loor is covered with pale granulations and the discharge is thin and watery. The base is soft. There may be satellite sinuses and enlarged lymph nodes. There m ay be a tuberculous focus in the lung or bone.

18. BURULI ULCER Mycobacterium ulcerans T emperatures lower than central body temperature- 30- 32 C . This toxin is thought to be responsible for the necrosis of the dermis and subcutaneous tissues seen in typical lesions.

19. Clinical classification A. Pre-ulcerative disease B. Ulcerative disease PRE-ULCERATIVE Papule Nodule PAINLESS Plaque Oedematous lesions Mixed lesions PAINFUL

20. ULCERATIVE Necrotic stage; typical white central plug of necrotic fat, i f not interfered with forms a necrotic slough. Organising Stage : the slough separates leaving an ulcer with edematous base and undermined edges. Healing Stage: the ulcer at this stage is fairly clean and healing starts.

21. SYPHILITIC (GUMMATOUS) ULCER It is now uncommon. It follows breakdown of a subcutaneous gumma especially around the knee. I t has a serpiginous outline because as it heals in some parts it spreads in others .

22. YAWS S tarts as a small erythematous macule which becomes an enlarging papule up to 5cm wide. The skin often ulcerates and exudes a serous fluid. It heals spontaneously. Ulceration and secondary infection may occur. Resembling syphilitic ulcers, they are punched out with sloughing base. They heal spontaneously after a few weeks, the skin over them often becoming depigmented . The regional lymph nodes are enlarged

23. B. Non-Specific Ulcers Skin ulcers go through the following phases. 1 . Acute or Infective phase : U lcer is painful . The sloughing floor is covered with purulent discharge in which different types of bacteria may be identified. T he edge is sharp and surrounded by damaged cells. The surrounding skin is oedematous , warm and tender

24. 2. Transition phase : The slough separates, the pus drains , infection subsides, granulation tissue grows and the floor becomes clean and red . The edge , which is sloping, has a thin bluish-white layer of young epithelium growing inwards. The surrounding skin is slightly hyperaemic or normal.

25. 3. Reparative or healing phase; The ulcer is now painless. The healthy granulation tissue fills the floor and the epithelium grows from the edge.

26. 4. Chronic, indolent or callous phase: Some ulcers may remain unhealthy for a long time The edges are then ragged, the floor greyish or creamy pink with profuse offensive discharge, and the surrounding skin warm and oedematous .

27. TYPES OF NON-SPECIFIC ULCERS 1. TRAUMATIC ULCERS 2. PYOGENIC/INFECTIVE ULCERS 3. VASCULAR ULCERS 4. PRESSURE ULCERS 5. NON -SPECIFIC ULCERS ASSOCIATED WITH METABOLIC OR SYSTEMIC DISEASE 6. NEOPLASTIC ULCERS

28. MANAGEMENT HISTORY Onset and course Symptoms Medical History Family History Drug History Personal Habits PHYSICAL EXAM General Peripheral neuropathy Peripheral pulses Regional LNs

29. 2. Clinical Examination (a) Ulcer: ( i ) Number:- Multiple ulcers may be due to Kaposi’s sarcoma , yaws, spherocytosis, ulcerative colitis or self inflicted injuries (ii) Anatomical site: - An ulcer near the medial malleolus may be venous, traumatic or due to SCDx One in the groin or neck is probably tuberculous .

30. (iii) The size. (iv) The shape; whether round, oval, irregular or serpiginous (syphilitic). (v) Edge:-This is the most important part of the ulcer. Sloping edge - non-specific ulcer. Raised and everted -malignant ulcer. Raised and rolled - rodent ulcer. Undermined - tuberculous or Buruli ulcer. Punched out – syphilitic or yaws .

31. (vi) Floor - whether sloughy and discharging; clean and pink (healing) or nodular (malignant). Type of discharge is also noted. (vii) Base - whether slightly indurated as in chronic nonspecific ulcer or indurated and fixed as in carcinoma or callous non-specific ulcer .

32. ( viii ) The surrounding skin - whether it is inflamed or pigmented. (ix) The state of local circulation - presence of dilated veins. Oedema of tissues, temperature and colour of skin or toe nails. (x) State of innervation - any loss of sensation or motor function. ( xii ) Regional lymph nodes - this is important especially in carcinomatous ulcers. If enlarged, tender or mobile

33. INVESTIGATIONS BLOOD VDRL RBS HB GENOTYPE FBC MANTOUX EUCr SERUM PROTEIN / ALBUMIN

34. BACTERIOLOGY– Wound swab & biopsy HISTOPATHOLOGY- WEDGE BIOPSY ANKLE BRACHIAL PRESSURE INDEX RADIOLOGY DUPLEX DOPPLER SCANNING CHEST XRAY CT MRI

35. TREATMENT (Specific ulcers) Acute Tropical Admit Antibiotics Sloughectomy [surgical or non-operative] .TT,SPLINTING,PHYSIO Chronic Tuberculous Antituberculous regimen Syphilitic Penicillin Burul i Medical Antituberculous drug Heat treatment Surgical Pre-ulcerative – nodulectomy , wide excision Ulcerative –debridement, split skin graft/flap

36. TREATMENT (Non -specific ulcers) Acute Admit, bed rest and elevate affected limb Broad-spectrum antibiotics and Antitetanus . W ound dressings The affected limb is splinted in the position of function to prevent formation of contracture. Physiotherapy is started early to prevent wastage of muscle and contractures. Once the ulcer becomes healthy, it is covered appropriately Chronic Wide excision Skin graft/flap

37. Others Trauma Wound debridement Regular wound dressing Medication: antibiotics , analgesics, antitetanus Skin wound c losure Infective Appropriate antibiotics Wound debridement

38. Venous Conservative Elevation Compression-compression stocking, supportive bandage Surgical Superficial vein stripping Ligation of incompetent valves/perforators Arterial Trans-luminal angioplasty Endarterectomy Arterial grafting

39. Neuropathic: Regular wound dressing Treat underlying condition, if treatable Diabetic Control diabetes Give antibiotics to prevent infections Wound dressing with sugar/honey Skin graft Haemoglobinopathy Difficult to treat Bed rest Exchange blood transfusion , folic acid Anti-malarial drugs Prevent precipitating factors Malignant Treat underlying cause

40. Complications Recurrence Septicemia Wasting Osteomyelitis Periostitis Gangrene Tetanus Contracture Non healing

41. Follow up 1. the patient is advised to protect the affected skin for example- the legs and feet by wearing comfortable socks and shoes. 2. Farmers are advised to wear protective clothing and boots. 3. A dvised about proper foot hygiene. 4. Where there is extensive scarring, the patient is advised to continue wearing medical stocking or crepe bandage. 5. To seek prompt attention for any abrasion or laceration to the affected skin.

42. Conclusion Management of patients with skin ulcers has to be multidisciplinary. Should include detailed history, physical examination, investigations, basic and newer treatment modalities. While educating patients on issues of correct skin care and the importance of seeking early medical advice.

43. References O. Amir, A. Liu, and A. L. S. Chang, “Stratification of highest-risk patients with chronic skin ulcers in a Stanford retrospective cohort includes diabetes, need for systemic antibiotics, and albumin levels,” Ulcers, vol. 2012, Article ID 767861, 7 pages, 2012 . C. K. Sen , G. M. Gordillo , S. Roy et al., “Human skin wounds: a major and snowballing threat to public health and the economy,” Wound Repair and Regeneration, vol. 17, no. 6, pp. 763–771, 2009 . Oluwatosin OM. Wounds and Wound Healing.In Oluwatosin OM ed. Methods of Repair.Abeokuta.Sagaf Publishers 2007. 6thedition.

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