An ulcer is a loss of epithelial lining and is a kind of open wound. Ulcers can occur on the skin or mucous membranes like the surface of the stomach or inside the mouth.
Ulcers form when the surface of the skin or mucous membrane gets injured. This leads to necrosis of the top layer leaves an open wound called an ulcer.
There are many causes of ulcer
They can occur due to infection or due to pressure on the skin [pressure ulcers], due to burning of mucous membrane by acid [stomach ulcers]. Lack of blood supply, chemical burning and drug reactions are other causes.
Parts of An Ulcer
Parts of an ulcer are
- Margin- Line of demarcation between normal and abnormal
- Floor – The exposed part of an ulcer ( Inspection)
- Edge – Part between the margin and the floor of an ulcer
- Base-the structure on which the ulcer rests (Felt on palpation)
Base of the ulcer is different from floor of the ulcer and it is important to understand the difference. The floor is the exposed surface within the ulcer and base is on what the ulcer rests and it is better felt than seen. If an attempt is made to pick up the ulcer between thumb and the index finger,the base will be felt. Marked induration of the base is an important feature of squamous cell carcinoma and chancre.
Classification of Ulcers
An ulcer can be classified in many ways. It is important to know about these classifications to avoid confusion in understanding and communication.
Clinical Classification of Ulcer
An ulcer with surrounding inflammation
Slopping edge with red granulation tissue
Ulcer with no tendency to heal-with pale granulation tissue.
Pathological Classification of Ulcer
- Tuberculous – Infectio with mycobacteriae
- Syphylitic – Ulcer in syphilis disease
- Actinomycotic – Infection by actinomyces
Nonspecific ulcers are due to infection of wounds, or physical or chemical agents. Local irritation, as in the case of a dental ulcer, or interference with the circulation, e.g. varicose veins, are predisposing causes
Due to mechanical, physical or chemical trauma
Cryopathy is destruction of tissue by freezing and characterized by tingling, blistering and possibly gangrene. Ulcers associated with the condition are called cryopathic ulcers.
Associated with arterial disease leading to vascular insufficiency
Associated with venous stasis, as a in varicose veins
Neurogenic Ulcers or neuropathic ulcers
Neuropathic ulcers due to anaesthesia resulting from a neural disease (diabetic neuritis, spina bifida, tabes dorsalis, leprosy or a peripheral nerve injury). They are often called perforating ulcers
Impairment of the nutrition of the tissues, which depends upon an adequate blood supply and a properly functioning nerve supply. Ischemia and anesthesia therefore will cause these ulcers
Bazin’s Ulcer or Erythema Induratum
Erythema induratum is a panniculitis on the calves. It occurs mainly in women, but it is very rare now. It was also called as Bazin disease.
Post operative synergistic bacterial gangrene is a rare form of abdominal wall gangrene that develops following intra abdominal surgery in the immediate vicinity of the surgical wound.
These ulcers are associated with malignancies.
- Squamous cell carcinoma
- Basal Cell Carcinoma [also called rodent ulcer or Jacob’s ulcer]
Classification of Ulcer based on duration
Ulcers less than 12 weeks duration are called acute ulcers whereas ulcers > 12 weeks are called chronic ulcers.
Classification Based on Pain
- Advanced Malignancy
- Early Malignancy
Modes of Onset of Ulcer
- Secondary changes on a Swelling [Tuberculous lymphadenopathy]
- From a Previous Scar [Marjolin’s Ulcer]
Different Types of Discharges from Ulcer
It is seen in active infection of the ulcer. The color of the discharge may indicate the causative agents.
Like Yellow creamy – staphylococcal infection, bloody opalescent – streptococcal infection, greenish – pseudomonas ulcer.
Serous discharge is usually seen in healing ulcer and bloody discharge in malignant, usually seen in malignant ulcers and in healing ulcers with healthy granulation tissue
Serous with sulphur granules is seen in actinomycosis.
Causes of Chronic Ulcers
- Systemic Diseases (Diabetes)
- Arterial / Venous Disorders
- Neurological Disorders
- Chronic Irritation ( Dental Ulcers )
- Lack of rest to part ( Ulcer over a Joint )
Stages of Ulcer
The life history of an ulcer consists of three phases.
- During the stage of extension the floor is covered with exudate and sloughs, while the base is indurated. The discharge is exudative and can be blood stained.
- This stage prepares for healing. The floor becomes cleaner, the sloughs separate, induration of the base decreases and the discharge becomes more serous.
- Small, reddish areas of granulation tissue appear on the floor and these link up until the whole surface is covered.
- The stage of repair consists of the transformation of granulation to fibrous tissue, which gradually contracts to form a scar. The epithelium gradually extends from the now shelving edge to cover the floor.
- Edge of the healing ulcer has three zones
- Outer epithelium, which appears white, a middle one
- Bluish in color (where granulation tissue is covered by a few layers of epithelium)
- Inner reddish zone of granulation tissue
Examination of an ulcer
Following points should be noted
Many ulcers show predilection for the site and the site thus could be important clue to diagnosis. 95 per cent of rodent ulcers occur on the upper part of the face. Carcinoma typically affects the lower lip, while a primary chancre of syphilis is usually on the upper lip. Ulcers are on the lips,tongue,breast and penis are more likely to malignant.
Size and Shape
Tuberculosis ulcers are generally oval in shape but their coalescence may give an irregular crescentic border.
The size of an ulcer is important factor in healing of the ulcer. A bigger ulcer will take longer time to heal than smaller ulcer. Press a sterile gauze over ulcer to get the measurement.
How fast has an ulcer developed is an important historical information. A malignant ulcer extends more rapidly than benign.
A rodent ulcer is usually circular. A gummatous ulcer is typically circular, or serpiginous due to the fusion of multiple circles. An ulcer with a square area or straight edge is suggestive of dermatitis artefacta, a condition in which skin lesions are solely produced or inflicted by the patient’s own actions.
The edge of the ulcer are characteristic for some ulcers.
Edge In spreading ulcer the edges are inflammed and edematous.
In in a healing ulcer the edges, if traced from the red granulation tissue in the centre towards periphery,will show blue zone (due to thin growing epithelium) and a white zone (due to fibrosis of scar).
- Undermined edge – Mostly seen in tuberculosis.The disease causing the ulcer spreads in and destroys the subcutaneous tissue faster than it destroys the skin.The overhanging skin is thin friable,reddish blue and unhealthy.
- Punched out edges – it is mostly seen in gummatous ulcer or in a deep trophic ulcer.The edges drop down at right angle to the skin surface as if it has been cut out a punch.It is seen in diseases in which activity is limited to the ulcer itself and does not tend to spread to the surrounding tissues.
- Sloping edge – it is seen mostly in healing traumatic or venous ulcer.Every healing ulcer has a sloping edge,which is reddish purple in color and consists of new healthy epithelium. Raised and pearly white beaded edge is a feature of rodent ulcer which develops in invasive cellular diseases and becomes necrotic at the centre.
- Rolled (everted) edge – it is characteristic feature of squamous cell carcinoma or an ulcerated adenocarcinoma.This ulcer is caused by fast growing cellular disease,growing portion at the edge of the ulcer heaps up and spills over the normal skin to produce an everted edge.
The floor is the visible part of the ulcer which is seen by an observer, e.g. watery or apple-jelly granulations in a tuberculous ulcer, a wash-leather slough in a gummatous ulcer.
When floor is covered with red granulation tissue, the ulcer seems to be healthy and healing. Pale and smooth granulation tissue indicates a healing ulcer. Wash leather slough on the floor of ulcer is pathognomonic of gummatous ulcer.
A black mass at the floor suggests malignant melanoma.
The character of the discharge, its amount and smell should be noted. A healing ulcer will show scanty serous discharge,but the spreading and inflamed ulcer will show purulent discharge.
Palpation of Ulcer
An inflamed ulcer is very tender whereas chronic ulcer are slightly tender. Neoplastic ulcers are never tender.
Next the edge of ulcer is palpated to corroborate the findings of the inspection. After this one moves to base
The base is what can be palpated. It may be indurated as in a carcinoma or attached to deep structures, e.g. a varicose ulcer to the tibia.
An assessment regarding depth of the ulcer is noted.
Whether the ulcer bleeds on touch or not should be checked as it is a common feature of malignant ulcer.
The ulcer is made to move over the deeper structures to know whether it is fixed to any of these structures. A gummatous ulcer over a subcutaneous tissue or bone is often fixed to it. Malignant ulcer will be fixed to any of the deeper structure by infiltration.
Examination of Surrounding Area
Surrounding area If the surrounding area of an ulcer is glossy,red and edematous, the ulcer is acutely inflamed. Very often the surrounding skin of varicose ulcer is eczematous and pigmented. A scar or wrinkling in surrounding a skin of an ulcer may well indicate an old case of tuberculosis.
Examination of Lymph Nodes
Examination of draining lymphnodes should be done. In carcinoma, they may be enlarged, hard and even fixed. The inguinal nodes draining a syphilitic chancre of the penis are firm and shotty [small, often hard, lymph nodes] but the submandibular nodes draining a chancre of the lip are greatly enlarged.
Diagnosis of Ulcer
The ulcer is diagnosed by clinical examination and lab studies.
For example Pathological examinations, e.g. biopsy, will confirm carcinoma. The serological and Mantoux tests may be of value for syphilis and tuberculosis, respectively.
The actual set of investigations would vary from patient to patient. Here is a list of lab studies from which required can be chosen. It is essential to mention that not all the ulcers require extensive investigations.
- Complete blood count
- Erythrocyte sedimentation rate
- Blood sugar
- Lipid profile
- Renal function tests
- Liver function tests
Screening tests for vasculitis
- Hematuria, cylindruria
- Routine and immunohistopathology of skin biopsies
- Antinuclear antibodies,
- Rheumatoid factor
- Complement C4
- Circulating immune complexes
- Immunoglobulin fractions
- Antineutrophil cytoplasmic antibodies
- erological tests, and cultures for underlying infection
- Laboratory screening tests for clotting disorders
- Activated partial thromboplastin time
- Prothrombin time and thrombin time
- Factor V (Leiden) mutation
- Factor II (prothrombin) mutation
- Antithrombin III, protein C and protein S
- Lupus anticoagulant anticardiolipin
For Venous abnormaliteis
- Color duplex ultrasound scanning
- Bacterial culture from the discharge and deeper tissue
- Serology as appropriate
Biopsy of chronic ulcers
Treatment of Ulcers
The actual treatment protocol would vary with the type of ulcer and cause responsible for ulcer. For example in presence of infection, treatment of the infection is instituted. In case of trophic ulcers, the pressure is relieved from the part that has ulcer.
Similarly, In case of varicose ulcers, the varicose veins are treated.
Most of the ulcers start responding and heal after removal of the cause.
Local cleaning and dressing is required.
Some of them require debridement to facilitate granulation tissue formation.
Flap surgery may be required in resistant ulcers.
A dressing for ulcer should maintain a high humidity between the wound and the dressing, remove excess exudate and toxic compounds and permit gaseous exchange of oxygen, carbon dioxide and water vapor.
It should also provide thermal insulation to the wound surface and be impermeable to microorganisms.