An ulcer is a loss of epithelial lining and is a kind of open wound. These can occur on the skin or mucous membranes like the surface of the stomach or inside the mouth.
These are formed when the surface of the skin or mucous membrane gets injured. This leads to necrosis of the top layer leaves an open wound.
There are many causes of sores.
They can occur due to infection or due to pressure on the skin , due to the burning of the mucous membrane by acid [stomach ]. Lack of blood supply, chemical burning, and drug reactions are other causes.
Parts of An Ulceration
- Margin- Line of demarcation between normal and abnormal
- Floor – The exposed part of an ulceration ( Inspection)
- Edge – Part between the margin and the floor
- Base-the structure on which the ulceration rests (Felt on palpation)
The base is different from the floor and it is important to understand the difference. If an attempt is made to pick up the sore between the 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
Clinical Classification
Spreading
An ulceration with surrounding inflammation
Healing
Slopping edge with red granulation tissue
Callous
Ulceration with no tendency to heal-with pale granulation tissue.
Pathological Classification
Specific
- Tuberculous – Infection with mycobacteria
- Syphylitic – In syphilis disease
- Actinomycotic – Infection by actinomyces
Non-specific
These are due to infection of wounds, or physical or chemical agents. Local irritation, as in the case of a dental sore, or interference with the circulation, e.g. varicose veins, are predisposing causes.
Traumatic
Due to mechanical, physical or chemical trauma
Cryopathic
Cryopathy is the destruction of tissue by freezing and characterized by tingling, blistering and possibly gangrene. Ulcerations associated with the condition are called cryopathic.
Arterial
Associated with arterial disease leading to vascular insufficiency
Venous
Associated with venous stasis, as in varicose veins
Neurogenic or neuropathic
Neuropathic ulcerations due to anesthesia resulting from a neural disease (diabetic neuritis, spina bifida, tabes dorsalis, leprosy or a peripheral nerve injury). They are often called perforating ulcerations.
Trophic
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 ulcerations.
Tropical
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.
Meleney’s
Postoperative 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.
Malignant
These are associated with malignancies.
- Squamous cell carcinoma
- Basal Cell Carcinoma [also called rodent or Jacob’s ulcer]
- Melanoma
Classification Based on the duration
- < 12 weeks duration – acute
- > 12 weeks are called chronic
Classification Based on Pain
Painful
- Tuberculous
- Arterial
- Advanced Malignancy
Painless
- Syphilitic
- Trophic
- Early Malignancy
Based on Modes of Onset
- Traumatic
- Spontaneous
- Secondary changes on a Swelling [Tuberculous lymphadenopathy]
- From a Previous Scar [Marjolin’s]
Different Types of Discharges from Ulceration
Discharge means there is an active infection. The color of the discharge may indicate the causative agents.
- Like Yellow creamy – staphylococcal infection
- Bloody opalescent – streptococcal infection
- Greenish – pseudomonas.
Serous discharge is usually seen in healing lesion and bloody discharge in malignant, usually seen in malignant and in healing ulcerations with healthy granulation tissue
Serous with sulfur granules is seen in actinomycosis.
Causes of Chronic Ulcerations
- Malnutrition
- Anemia
- Immunosuppression
- Systemic Diseases (Diabetes)
- Arterial / Venous Disorders
- Neurological Disorders
- Infection
- Chronic Irritation ( Dental )
- Lack of rest to part ( over a Joint )
- Malignancy
Stages of Ulcer
The life history of an ulceration consists of three phases.
Extension
- 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 bloodstained.
Transition
- 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.
Repair
- 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 ulceration 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
Inspection
Following points should be noted
Site
Many show a predilection for the site and the site this could be an important clue to diagnosis. 95 percent of rodent ulcerations 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. Ulcerations are on the lips, tongue, breast, and penis are more likely to malignant.
Size and Shape
Tuberculous ulcers are generally oval in shape but their coalescence may give an irregular crescentic border.
The size is an important factor in the healing. A bigger one will take the longest time to heal than the smaller.
How fast has ulceration has developed is important. A malignant one extends more rapidly than benign.
A rodent and gummatous ulceration are circular, or serpiginous due to the fusion of multiple circles. An ulceration 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.
Edge
The edge is characteristic of some ulcerations
Edge In spreading lesion are inflamed and edematous.
In in a healing lesion, the edges, if traced from the red granulation tissue in the center towards the periphery, will show blue zone (due to thin growing epithelium) and a white zone (due to fibrosis or scar).
- Undermined edge – Mostly seen in tuberculosis. The disease-causing the sore 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 ulceration or in a deep trophic sore. The edges drop down at a 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 sore itself and does not tend to spread to the surrounding tissues.
- Sloping edge – it is seen mostly in healing traumatic or venous ulceration. Every healing sore has a sloping edge, which is reddish purple in color and consists of a new healthy epithelium. Raised and the pearly white beaded edge is a feature of rodent ulcer which develops in invasive cellular diseases and becomes necrotic at the center.
- Rolled (everted) edge – it is a characteristic feature of squamous cell carcinoma or an ulcerated adenocarcinoma. This ulceration is caused by fast-growing cellular disease, a growing portion at the edge of the ulceration heaps up and spills over the normal skin to produce an everted edge.
Floor
The floor is the visible part of the ulceration which is seen by an observer, e.g. watery or apple-jelly granulations in a tuberculous sore, a wash-leather slough in a gummatous sore.
When the floor is covered with red granulation tissue, the ulceration seems to be healthy and healing. Pale and smooth granulation tissue indicates a healing ulceration. Wash leather slough on the floor of ulceration is pathognomonic of the gummatous ulceration.
A black mass on the floor suggests malignant melanoma.
Discharge
The character of the discharge, its amount and smell should be noted. A healing lesion will show scanty serous discharge, but the spreading and inflamed one will show purulent discharge.
Palpation
An inflamed lesion is very tender whereas chronic ones are slightly tender. Neoplastic sores are never tender.
Next, the edge is palpated to corroborate the findings of the inspection. After this one moves to the base.
Base
The base is what can be palpated. It may be indurated as in a carcinoma or attached to deep structures.
An assessment regarding the depth is noted.
Whether the ulceration bleeds on touch or not should be checked as it is a common feature of the malignant ulceration.
Deeper Structures
Move the sore over the deeper structures to know whether it is fixed to any of these structures. A gummatous ulceration over a subcutaneous tissue or bone is often fixed to it. Malignant one will be fixed to any of the deeper structure by infiltration.
Examination of Surrounding Area
If the surrounding area of is glossy, red and edematous, the ulceration is acutely inflamed. . A scar or wrinkling in surrounding the skin may well indicate an old case of tuberculosis.
Examination of Lymph Nodes
Examination of draining lymph nodes 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
The ulceration 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 ulcerations require extensive investigations.
Blood investigations
- Complete blood count
- Erythrocyte sedimentation rate
- Blood sugar
- Lipid profile
- Renal function tests
- Liver function tests
Screening tests for vasculitis
- Urine
- Hematuria, cylindruria
- Routine and immunohistopathology of skin biopsies
- Antinuclear antibodies,
- Rheumatoid factor
- Complement C4
- Circulating immune complexes
- Paraproteins
- Immunoglobulin fractions
- Antineutrophil cytoplasmic antibodies
- Serological 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 abnormalities
- Venography
- Color duplex ultrasound scanning
Infections
- Bacterial culture from the discharge and deeper tissue
- Serology as appropriate
Biopsy
Treatment
The actual treatment protocol would vary with the type and cause. For example in presence of infection, treatment of the infection is instituted. In the case of trophic sore, the pressure is relieved from the part that has sore.
Similarly, In case of varicose ulceration, the varicose veins are treated.
Most of the sores start responding and heal after removal of the cause.
Local cleaning and dressing are required.
Some of them require debridement to facilitate granulation tissue formation.
Flap surgery may be required in resistant lesions.
A dressing should maintain a high humidity between the wound and the dressing, remove excess exudate and toxic compounds and permit the gaseous exchange of oxygen, carbon dioxide, and water vapor.
It should also provide thermal insulation to the wound surface and be impermeable to microorganisms.