Ulcers

Published on 05/03/2015 by admin

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Last modified 05/03/2015

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86

Ulcers

An ulcer is defined as a wound with loss of the entire epidermis plus dermal tissue, sometimes extending as deep as the subcutis.

The most common types of leg ulcers – venous, arterial, and neuropathic – as well as pressure ulcers, lymphedema, and an approach to wound healing are reviewed (see below); additional physical, inflammatory, infectious, metabolic, and neoplastic causes of leg ulcers are outlined in Fig. 86.1.

Features to consider in the history and physical examination of patients with a leg ulcer are presented in Table 86.1, and routine laboratory testing often includes a CBC, ESR, and blood glucose and serum albumin levels; microbial cultures, evaluation for hyperco­agulability (see Table 18.5), and additional studies depend on the clinical setting.

Ulcers with atypical features or a lack of response to appropriate therapy should be re-evaluated, with expansion of the DDx and consideration of a skin biopsy (preferably including the ulcer margin and bed) to exclude less common etiologies, such as SCC, vasculitis, and fungal or mycobacterial infections (via tissue culture).

Venous Ulcers

Venous hypertension and insufficiency represent the most common causes of chronic leg ulcers.

Prevalence increases with age, and risk factors include female sex, obesity, pregnancy, prolonged standing, and family history of venous insufficiency; hypercoagulability can be a contributing factor, especially in patients with a history of deep vein thrombosis or livedoid vasculopathy (Fig. 86.3; see Chapter 18).

Ulcers tend to have irregular borders and a yellow fibrinous base, with a predilection for the area above the medial malleolus

(Fig. 86.4); the ulcers can become large but are often fairly shallow, with granulation tissue evident upon debridement.

Surrounding skin has signs of venous hypertension such as yellow-brown discoloration due to hemosiderin deposits, pinpoint petechiae, stasis dermatitis, lipodermatosclerosis, and, occasionally, acroangiodermatitis (Fig. 86.5).

Other findings include varicosities and edema > lymphedema of the lower extremities (Fig. 86.6); swelling and aching of the legs is worsened by dependency (e.g. prolonged standing) and improved by leg elevation and the use of compression therapy; other dependent sites, such as a large pannus, can develop similar clinical changes (Fig. 86.7).

DDx: see Fig. 86.1; coexistent arterial insufficiency (see below) or uncompensated congestive heart failure should be excluded before initiating compression therapy.

Evaluation and Rx: an approach to the patient with a chronic venous ulcer is presented in Fig. 86.8.

Compression represents a mainstay of therapy.

Graduated compression stockings