Ulcer (dermatology)

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Skin ulcer
Crohnie sores 4.JPG
Erythema nodosum - Skin ulcers that occur in some patients suffering from inflammatory bowel disease
Specialty Dermatology   Blue pencil.svg

An ulcer is a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue. Ulcers can result in complete loss of the epidermis and often portions of the dermis and even subcutaneous fat. Ulcers are most common on the skin of the lower extremities and in the gastrointestinal tract. An ulcer that appears on the skin is often visible as an inflamed tissue with an area of reddened skin. A skin ulcer is often visible in the event of exposure to heat or cold, irritation, or a problem with blood circulation. They can also be caused due to a lack of mobility, which causes prolonged pressure on the tissues. This stress in the blood circulation is transformed to a skin ulcer, commonly known as bedsores or decubitus ulcers. [1] Ulcers often become infected, and pus forms.

Dermis layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain

The dermis or corium is a layer of skin between the epidermis and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided into two layers, the superficial area adjacent to the epidermis called the papillary region and a deep thicker area known as the reticular dermis. The dermis is tightly connected to the epidermis through a basement membrane. Structural components of the dermis are collagen, elastic fibers, and extrafibrillar matrix. It also contains mechanoreceptors that provide the sense of touch and thermoreceptors that provide the sense of heat. In addition, hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels, nerves and blood vessels are present in the dermis. Those blood vessels provide nourishment and waste removal for both dermal and epidermal cells.

Infection invasion of a host by disease-causing organisms

Infection is the invasion of an organism's body tissues by disease-causing agents, their multiplication, and the reaction of host tissues to the infectious agents and the toxins they produce. Infectious disease, also known as transmissible disease or communicable disease, is illness resulting from an infection.

Pus

Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection of pus within or beneath the epidermis is known as a pustule, pimple, or spot.

Contents

Signs and symptoms

Skin ulcers appear as open craters, often round, with layers of skin that have eroded. The skin around the ulcer may be red, swollen, and tender. Patients may feel pain on the skin around the ulcer, and fluid may ooze from the ulcer. In some cases, ulcers can bleed and, rarely, patients experience fever. Ulcers sometimes seem not to heal; healing, if it does occur, tends to be slow. Ulcers that heal within 12 weeks are usually classified as acute, and longer-lasting ones as chronic.

Bleeding loss of blood escaping from the circulatory system

Bleeding, also known as a hemorrhage or haemorrhage, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vagina or anus, or through a wound in the skin. Hypovolemia is a massive decrease in blood volume, and death by excessive loss of blood is referred to as exsanguination. Typically, a healthy person can endure a loss of 10–15% of the total blood volume without serious medical difficulties. The stopping or controlling of bleeding is called hemostasis and is an important part of both first aid and surgery. The use of cyanoacrylate glue to prevent bleeding and seal battle wounds was designed and first used in the Vietnam War. Today many medical treatments use a medical version of "super glue" instead of using traditional stitches used for small wounds that need to be closed at the skin level.

Fever common medical sign characterized by elevated body temperature

Fever, also known as pyrexia and febrile response, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using values between 37.5 and 38.3 °C. The increase in set point triggers increased muscle contractions and causes a feeling of cold. This results in greater heat production and efforts to conserve heat. When the set point temperature returns to normal, a person feels hot, becomes flushed, and may begin to sweat. Rarely a fever may trigger a febrile seizure. This is more common in young children. Fevers do not typically go higher than 41 to 42 °C.

In medicine, describing a disease as acute denotes that it is of short duration and, as a corollary of that, of recent onset. The quantitation of how much time constitutes "short" and "recent" varies by disease and by context, but the core denotation of "acute" is always qualitatively in contrast with "chronic", which denotes long-lasting disease. In addition, "acute" also often connotes two other meanings: sudden onset and severity, such as in acute myocardial infarction (AMI), where suddenness and severity are both established aspects of the meaning. It thus often connotes that the condition is fulminant, but not always. The one thing that acute MI and acute rhinitis have in common is that they are not chronic. They can happen again, but they are not the same case ongoing for months or years.

Ulcers develop in stages. In stage 1 the skin is red with soft underlying tissue. In the second stage the redness of the skin becomes more pronounced, swelling appears, and there may be some blisters and loss of outer skin layers. During the next stage, the skin may become necrotic down through the deep layers of skin, and the fat beneath the skin may become exposed and visible. In stage 4, deeper necrosis usually occurs, the fat underneath the skin is completely exposed, and the muscle may also become exposed. In the last two stages the sore may cause a deeper loss of fat and necrosis of the muscle; in severe cases it can extend down to bone level, destruction of the bone may begin, and there may be sepsis of joints.

Tissue (biology) An ensemble of similar cells and their matrix with similar origin and function

In biology, tissue is a cellular organizational level between cells and a complete organ. A tissue is an ensemble of similar cells and their extracellular matrix from the same origin that together carry out a specific function. Organs are then formed by the functional grouping together of multiple tissues.

Blister small pocket of fluid within the upper layers of the skin

A blister is a small pocket of body fluid within the upper layers of the skin, typically caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled with a clear fluid, either serum or plasma. However, blisters can be filled with blood or with pus.

Fat one of the three main macronutrients, along with carbohydrate and protein. Fats, also known as triglycerides, are esters of three fatty acid chains and the alcohol glycerol

Fat is one of the three main macronutrients, along with carbohydrate and protein. Fats molecules consist of primarily carbon and hydrogen atoms, thus they are all hydrocarbon molecules. Examples include cholesterol, phospholipids and triglycerides.

Chronic ulcers may be painful. Most patients complain of constant pain at night and during the day. Chronic ulcer symptoms usually include increasing pain, friable granulation tissue, foul odour, and wound breakdown instead of healing. [2] Symptoms tend to worsen once the wound has become infected.

Pain type of unpleasant feeling

Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain's widely used definition defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"; however, due to it being a complex, subjective phenomenon, defining pain has been a challenge. In medical diagnosis, pain is regarded as a symptom of an underlying condition.

Venous skin ulcers that may appear on the lower leg, above the calf or on the lower ankle usually cause achy and swollen legs. If these ulcers become infected they may develop an unpleasant odour, increased tenderness and redness. Before the ulcer establishes definitively, there may be a dark red or purple skin over the affected area as well as a thickening, drying, and itchy skin.

Venous ulcer

Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs. They are the major occurrence of chronic wounds, occurring in 70% to 90% of leg ulcer cases. Venous ulcers develop mostly along the medial distal leg, and can be painful with negative effects on quality of life.

Ankle Region where the foot and the leg meet

The ankle, or the talocrural region, is the region where the foot and the leg meet. The ankle includes three joints: the ankle joint proper or talocrural joint, the subtalar joint, and the inferior tibiofibular joint. The movements produced at this joint are dorsiflexion and plantarflexion of the foot. In common usage, the term ankle refers exclusively to the ankle region. In medical terminology, "ankle" can refer broadly to the region or specifically to the talocrural joint.

Although skin ulcers do not seem of great concern at a first glance, they are worrying conditions especially in people suffering from diabetes, as they are at risk of developing diabetic neuropathy.

Ulcers may also appear on the cheeks, soft palate, the tongue, and on the inside of the lower lip. These ulcers usually last from 7 to 14 days and can be painful. [3]

Discharges

Different types of discharges from ulcer are: [4]

Causes

The wounds from which ulcers arise can be caused by a wide variety of factors, but the main cause is impaired blood circulation. Especially, chronic wounds and ulcers are caused by poor circulation, either through cardiovascular issues or external pressure from a bed or a wheelchair. [5] A very common and dangerous type of skin ulcers are caused by what are called pressure-sensitive sores, more commonly called bed sores and which are frequent in people who are bedridden or who use wheelchairs for long periods. Other causes producing skin ulcers include bacterial or viral infections, fungal infections and cancers. Blood disorders and chronic wounds can result in skin ulcers as well. [6] Venous leg ulcers due to impaired circulation or a blood flow disorder are more common in the elderly.

Rare causes of skin ulcers include pyoderma gangraenosum, lesions caused by Crohn's disease or ulcerative colitis, granulomatosis with polyangiitis, morbus Behçet, and infections that are usually seen in those who are immunocompromised, for example ecthyma gangraenosum. It is important to consider such causes if the skin ulcerations don't show improvement with antibiotic treatments, and when other systemic symptoms are present. It is advised to not use surgical procedures on ulcerations caused by Behçet or pyoderma gangraenosum, as those diseases usually exhibit pathergy.

Diagnosis

Grading

Wagner's grading of ulcer follows: [4]

GradeDescription
0Pre-ulcerative lesion or healed ulcer
1Superficial ulcer
2Ulcer deeper to subcutaneous tissue exposing soft tissue or bone
3Abscess formation underneath, osteomyelitis
4 Gangrene of part of tissues, limb or foot
5Gangrene of entire one area or foot

Management

Investigations

Some of the investigations done for ulcer are: [4] :19

Treatment

Skin ulcers may take a very long time to heal. Treatment is typically to avoid the ulcer getting infected, remove any excess discharge, maintain a moist wound environment, control the edema, and ease pain caused by nerve and tissue damage.

Topical antibiotics are normally used to prevent the ulcer getting infected, and the wound or ulcer is usually kept clear of dead tissue through surgical debridement.

Commonly, as a part of the treatment, patients are advised to change their lifestyle if possible and to change their diet. Improving the circulation is important in treating skin ulcers, and patients are consequently usually recommended to exercise, stop smoking, and lose weight.

In recent years, advances have been made in accelerating healing of chronic wounds and ulcers. Chronic wounds produce fewer growth hormones than necessary for healing tissue, and healing may be accelerated by replacing or stimulating growth factors while controlling the formation of other substances that work against them. [7]

Leg ulcers can be prevented by using compression stockings to prevent blood pooling and back flow. It is likely that a person who has had a skin ulcer will have it again; use of compression stockings every day for at least 5 years after the skin ulcer has healed may help to prevent recurrence.

See also

Related Research Articles

Gangrene serious and potentially life-threatening condition

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. Certain types may present with a fever or sepsis.

Mouth ulcer ulcer that occurs on the mucous membrane of the oral cavity

A mouth ulcer is an ulcer that occurs on the mucous membrane of the oral cavity. Mouth ulcers are very common, occurring in association with many diseases and by many different mechanisms, but usually there is no serious underlying cause.

Wound injury where the skin is torn

A wound is a type of injury which happens relatively quickly in which skin is torn, cut, or punctured, or where blunt force trauma causes a contusion. In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.

Pressure ulcer Decubitus ulcer is a chronic ulcer of skin where the ulcer is an ulceration of tissue deprived of adequate blood supply by prolonged pressure

Pressure ulcers, also known as bedsores, decubiti, decubitous ulcers, pressure injuries, and pressure sores, are localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction. The most common sites are the skin overlying the sacrum, coccyx, heels, and hips, though other sites can be affected, such as the elbows, knees, ankles, back of shoulders, or the back of the cranium.

Stasis dermatitis refers to the skin changes that occur in the leg as a result of "stasis" or blood pooling from insufficient venous return; the alternative name of varicose eczema comes from a common cause of this being varicose veins.

CREST syndrome syndrome characterized by calcinosis, Raynauds phenomeno, esophageal dysmotility, sclerodactyly and telangiectasia

CREST syndrome, also known as the limited cutaneous form of systemic sclerosis (lcSSc), is a multisystem connective tissue disorder. The acronym "CREST" refers to the five main features: calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.

Aphthous stomatitis stomatitis characterized by the repeated formation of benign and non-contagious mouth ulcers

Aphthous stomatitis is a common condition characterized by the repeated formation of benign and non-contagious mouth ulcers (aphthae) in otherwise healthy individuals. The informal term canker sores is also used, mainly in North America, although this may also refer to any mouth ulcers.

Proctitis Human disease

Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.

Dressing (medical) sterile pad or compress applied to a wound

A dressing is a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm. A dressing is designed to be in direct contact with the wound, as distinguished from a bandage, which is most often used to hold a dressing in place. Many modern dressings are self-adhesive.

Pyoderma gangrenosum condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs

Pyoderma gangrenosum is a condition that causes tissue to become necrotic, causing deep ulcers that usually occur on the legs. When they occur, they can lead to chronic wounds. Ulcers usually initially look like small bug bites or papules, and they progress to larger ulcers. Though the wounds rarely lead to death, they can cause pain and scarring.

A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. To overcome that stage and jump-start the healing process a number of factors need to be addressed such as bacterial burden, necrotic tissue, and moisture balance of the whole wound. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.

Corneal ulcer is an inflammatory or more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and the agrarian societies. In developing countries, children afflicted by Vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes, which may persist lifelong. In ophthalmology, a corneal ulcer usually refers to having an infectious cause while the term corneal abrasion refers more to physical abrasions.

An ulcer is a discontinuity or break in a bodily membrane that impedes the organ of which that membrane is a part from continuing its normal functions. According to Robins pathology, "ulcer is the breach of the continuity of skin, epithelium or mucous membrane caused by sloughing out of inflamed necrotic tissue." Common forms of ulcers recognized in medicine include:

Lipodermatosclerosis is a skin and connective tissue disease. It is a form of lower extremity panniculitis, an inflammation of the layer of fat under the epidermis.

Tropical ulcer

Tropical ulcer, more commonly known as jungle rot, is a chronic ulcerative skin lesion thought to be caused by polymicrobial infection with a variety of microorganisms, including mycobacteria. It is common in tropical climates.

Arterial insufficiency ulcer

Arterial insufficiency ulcers are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD).

Diabetic foot foot that exhibits any pathology that results directly from diabetes mellitus or any long-term complication of diabetes mellitus

A diabetic foot is a foot that exhibits any pathology that results directly from diabetes mellitus or any long-term complication of diabetes mellitus. Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome.

Chronic wound pain is a condition described as unremitting, disabling, and recalcitrant pain experienced by individuals with various types of chronic wounds. Chronic wounds such as venous leg ulcers, arterial ulcers, diabetic foot ulcers, pressure ulcers, and malignant wounds can have an enormous impact on an individual’s quality of life with pain being one of the most distressing symptoms.

Diabetic foot ulcer major complication of diabetes mellitus

Diabetic foot ulcer is a major complication of diabetes mellitus, and probably the major component of the diabetic foot.

References

  1. Kumar, Vinay; Fausto, Nelso; Abbas, Abul (2004) Robbins & Cotran Pathologic Basis of Disease (7th ed.). Saunders. Page 1230. ISBN   0-7216-0187-1.
  2. "Symptoms". Archived from the original on 2010-06-19. Retrieved 2010-06-16.
  3. "Ulcers Pictures and Descriptions" . Retrieved 2010-06-16.
  4. 1 2 3 Bhat, Sriram (2013). Srb's Manual of Surgery, 4e. Jaypee Brothers Medical Pub. p. 17. ISBN   9789350259443.
  5. "Symptoms". Archived from the original on 2010-06-19. Retrieved 2010-06-16.
  6. "What Causes Skin Ulcers?" . Retrieved 2010-06-16.
  7. "Treatments". Archived from the original on 2010-01-27. Retrieved 2010-06-16.
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