Skin Ulcers
David Spoelhof MDSt. Luke’s Hospital
Types of Ulcers Pressure Venous Arterial Neurotrophic
Diabetic Special Cases
Pressure Ulcer: Definition “Decubitus” vs.
Pressure Ulcer
Pressure Ulcer
Stage 1 Non-blanchable
erythema.
Not a trivial lesion.
Subdermal tissue is more vulnerable to pressure/ischemic damage.
Stage 2 Epidermis disrupted
Blister or shallow ulcer.
Important to check elsewhere (heels).
Stage 3 Extension into
subdermal tissues.
Undermining or tunneling common.
Measurement may underestimate size.
Stage 4 Bone or tendon often
colonized/infected.
Stage 4 Ulcers
Ulcer treatment Managing tissue loads Managing bacterial colonization/infection Nutritional support Local wound care Operative repair
“Why did this happen?”
Wound Healing
Wound Healing
Granulation Tissue
Managing Tissue Loads Pressure relief mattresses/overlays “zero tolerance” for continued pressure
over the wound Heels need special attention: heel
“protectors” often are ineffective Seated position
Especially difficult to reduce pressure on buttocks.
Bacterial colonization/infection All wounds are colonized, surface cultures
are worthless. Cleansing and debridement are key. Two week trial of topical antibiotic? Osteomyelitis: ESR, WBC, x-ray (69%
sensitivity if all 3 abnl). MRI? Sepsis, cellulitis, osteomyelitis require
systemic antibiotics, usually inpatient.
Nutritional Support Protein is key: 1.0-1.5 g/kg/day
Healing requires extra calories: 30-35 kcal/kg/day
Tube feeding does not seem helpful
Local Ulcer Care Debridement
Cleansing Avoid antiseptics which may be cytotoxic
Dressings
Be consistent, be familiar with preferred treatments.
Local care for stage 1 ulcer Debridement: none
Cleansing: nondrying soap and water
Dressing: None or polyurethane film
Central issues: Pressure relief Why did this happen?
Local Care for Stage 2 Ulcer Debridement: none.
Cleansing: Saline.
Dressing: Polurethane film, hydrocolloid wafer.
Central issues: provide moist wound bed keep surrounding skin dry
Local Care for Stage 3 Ulcer Debridement: if eschar or slough present
autolytic, wet-to-dry, enzymatic, sharp
Cleansing: saline Dressing: hydrocolloid, foam, hydrogel
may need packing if deep/undermined
Central issues: debride necrotic tissue protect granulation tissue
Local Care for Stage 4 Ulcer The same as stage 3.
Visible bone/tendon, even if superficially infected, does not mean it won’t heal.
Odor can be a problem metronidazole gel activated charcoal
Central issue: patience
Leg Ulcers Venous Insufficiency: 80-90%
See N Eng J Med 2006;355:488-98
Arterial Insufficiency: 5%
Neurotrophic Ulcers: 2%
Venous leg ulcers Medial malleolus is
typical Stasis dermatitis,
hyperpigmentation, hemosiderin deposits
Chronic edema, will not diurese
Tender to palpate Varicose veins?
Venous Ulcers There are two venous systems in the leg:
the deep system (high pressure) the superficial system (low pressure) connected by perforator veins
The low-pressure system is protected from the high pressure system by valves in the deep veins and perforators.
Leg Vein Anatomy
Leg Vein Valves
Valve Function
Calf Muscle Vein Pump
Bergan J et al. N Engl J Med 2006;355:488-498
Action of the Musculovenous Pump in Lowering Venous Pressure in the Leg
Factors for Venous Ulcers Overload
CHF, obesity
Obstruction Clot, tumor
Pump malfunction Stroke, MS, inactivity
Bergan J et al. N Engl J Med 2006;355:488-498
Clinical Manifestations of Chronic Venous Disease
Treatment of Venous Ulcers Same cleansing and debridement
principles as pressure ulcers.
Control of edema is essential. Restore venous return by way of external
compression (30-40 mm Hg @ ankle) Unna boot Compression hose Compression pumps “TED” socks provide ~ 18 mm Hg pressure.
Compression Stocking
Arterial Ulcers Circumscribed,
“punched-out” ulcers, often multiple.
Occur in areas least well perfused: lateral malleolus, tibial, feet/toes.
Shiny, hairless skin. Absent pulses. Claudication.
Leg Artery Anatomy
Ankle-Brachial Index (ABI) Normal is 1.0 or above. ABI below 0.8 causes claudication. ABI below 0.4 causes rest pain.
Peripheral arterial ischemia is a strong predictor of coronary and cerebral arterial disease.
ABI and Survival
Buerger’s Disease Thrombangiitis
obliterans. Occurs in smokers,
often young. Hands and feet. Associated
thrombophlebitis (arrows)
Treatment: quit smoking.
Allen Test
Occlude radial and ulnar arteries after making a fist to empty blood from the hand.
Open hand and release pressure over the ulnar artery.
Hand should refill with blood via ulnar artery, evidenced by return of pink color.
Positive = persistent pallor.
Treatment of Arterial Ulcers
Same cleansing, debridement and dressing principles as pressure ulcers.
External compression is detrimental. Smoking cessation. Revascularization. Skin graft. Amputation.
Neurotrophic Ulcers Plantar aspect of foot
or toes is typical.
Prominent callus formation.
Caused by peripheral neuropathy, usually diabetic.
Screening for Neuropathy
The Charcot Foot
Treatment of Neurotrophic Ulcers
The same cleansing, debridement and dressing principles as pressure ulcers.
Protection: footwear, total contact cast? Recombinant platelet-derived growth
factor (becaplermin)?
Good diabetic management. Beware of arterial insufficiency. Beware of infection (osteomyelitis).
Total Contact Cast
Platelet-derived growth factor
Some Less Common Ulcers
Skin Cancer Basal Cell Carcinoma Squamous Cell Carcinoma
Pyoderma Gangrenosum
Basal Cell Carcinoma Most common skin
cancer. “Heaped up” or rolled
edges. Usually sun-exposed
surfaces. Does not metastasize.
Squamous Cell Skin Cancer May occur as a
complication of previously benign ulcer.
May metastasize, check regional lymph nodes.
If in doubt, biopsy.
Pyoderma Gangrenosum Margins are
serpiginous and elevated.
Edges have blue or purple hue.
Pustule or blister precedes.
Assoc’d with inflammatory bowel, RA, leukemia.
Common Leg Ulcers
Venous/Stasis Ulcer
V a rico se V e insE cze m a
P ig m e n ta tion
S u p e rfic ia lO ften la rge
M e d ia l m a lle o lus
N o rm al P u lsesN o rm al S e nsa tion
Arterial Ulcer
C o ld to esT h ick n a ilsH a ir lo ss
D e e p u lce rP a in fu l
L a te ra l m a lle o lusT ib iaD ig its
A b se n t F o ot P u lses
Neurotrophic Ulcer
D ia be tes
C a llo s ityP a in le ss
P re ssu re P o in tP la n ta r Fo o t
R e du ced S e n sa tion
S ite o f u lce rF o o t P u lsesS e nsa tion