| Malum perforans | |
|---|---|
| Other names | Neurotrophic ulcer and Trophic ulcer |
 | |
| Diabetic foot ulcer | |
| Specialty | Dermatology  |
Malum perforans is a long-lasting, usually painless ulcer that penetrates deep into or through the skin, usually on the sole of the foot (in which case it may be called malum perforans pedis). It is often a complication in diabetes mellitus and other conditions affecting the nerves. [1]
These ulcers have punched-out edge and slough in floor, resembling gummatous ulcer. Surrounding area might have loss of sensation This is due to the fact that the nerves are no longer working properly.
This condition results from denervation of areas exposed to day-to-day friction of bony prominences. The denervation may be result of any of the following diseases:[ citation needed ]
Normal pressure and pain sensations are essential for protecting the foot from excessive and prolonged pressures over bony prominences. In insensitive foot, such as in diabetic neuropathy, soft tissues are exposed to excessive pressures without knowledge of the individual. In other words, by nerve damage in the feet, the patients get no feedback on the impact of the feet when walking. These ulcers start with callosity under which suppuration takes place. The pus comes out and a hole forms under which the lesion grows deeper. This leads to punched-out, painless ulcers usually under metatarsal heads, tip of toe, or proximal interphalangeal joint of a hammertoe or on the heel. [3] In non-ambulatory patients, these ulcers are found on buttocks and back of the heel.[ citation needed ]
Diagnosis is clinical. Sensation is tested using graded monofilament. [3]
The underlying cause of the neuropathy is first treated. Necrotic portions of the wound are removed and the wound is kept moist at all occasions. Infected ulcers are administered antibiotics.
Skin grafting is one option. It has been shown that ultrasound may increase the acceptance of a graft at trophic ulcer sites. [4]
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.
A callus is an area of thickened and sometimes hardened skin that forms as a response to repeated friction, pressure, or other irritation. Since repeated contact is required, calluses are most often found on the feet and hands, but they may occur anywhere on the skin. Some degree of callus, such as on the bottom of the foot, is normal.
Diabetic neuropathy is various types of nerve damage associated with diabetes mellitus. Symptoms depend on the site of nerve damage and can include motor changes such as weakness; sensory symptoms such as numbness, tingling, or pain; or autonomic changes such as urinary symptoms. These changes are thought to result from a microvascular injury involving small blood vessels that supply nerves. Relatively common conditions which may be associated with diabetic neuropathy include distal symmetric polyneuropathy; third, fourth, or sixth cranial nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; and autonomic neuropathy.
Peripheral neuropathy, often shortened to neuropathy, is a general term describing damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerves are affected. Neuropathy affecting motor, sensory, or autonomic nerves result in different symptoms. More than one type of nerve may be affected simultaneously. Peripheral neuropathy may be acute or chronic, and may be reversible or permanent.
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised 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.
Neuropathic arthropathy, also known as Charcot joint after the first to describe it, Jean-Martin Charcot, refers to progressive degeneration of a weight-bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity due to loss of sensation. Onset is usually insidious.
Tarsal tunnel syndrome (TTS) is a nerve entrapment syndrome causing a painful foot condition in which the tibial nerve is compressed as it travels through the tarsal tunnel. This tunnel is found along the inner leg behind the medial malleolus. The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel. Inside the tunnel, the nerve splits into three segments. One nerve (calcaneal) continues to the heel, the other two continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.
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.
Dysesthesia is an unpleasant, abnormal sense of touch. Its etymology comes from the Greek word "dys," meaning "bad," and "aesthesis," which means "sensation". It often presents as pain but may also present as an inappropriate, but not discomforting, sensation. It is caused by lesions of the nervous system, peripheral or central, and it involves sensations, whether spontaneous or evoked, such as burning, wetness, itching, electric shock, and pins and needles. Dysesthesia can include sensations in any bodily tissue, including most often the mouth, scalp, skin, or legs.
Small fiber peripheral neuropathy is a type of peripheral neuropathy that occurs from damage to the small unmyelinated and myelinated peripheral nerve fibers. These fibers, categorized as C fibers and small Aδ fibers, are present in skin, peripheral nerves, and organs. The role of these nerves is to innervate some skin sensations and help control autonomic function. It is estimated that 15–20 million people in the United States have some form of peripheral neuropathy.
People with diabetes have a greater chance of developing neuropathy, vascular disease, and infections, especially in the legs, so socks and footwear that reduce or eliminate pressures or hot spots is important. A diabetic sock is a non-restrictive, but close fitting sock which is designed to alleviate pressures on the foot or leg. Typically sufferers of diabetes are the most common users of this type of sock. Diabetes raises the blood sugar level, which can increase the risk of foot ulcers. Diabetic socks are made to be non-restrictive to circulation, but if inclusive of Medical Grade, FDA regulated gradient compression, they may include venous compression for enhanced blood circulation.
Pallesthesia, or vibratory sensation, is the ability to perceive vibration. This sensation, often conducted through skin and bone, is usually generated by mechanoreceptors such as Pacinian corpuscles, Merkel disk receptors, and tactile corpuscles. All of these receptors stimulate an action potential in afferent nerves found in various layers of the skin and body. The afferent neuron travels to the spinal column and then to the brain where the information is processed. Damage to the peripheral nervous system or central nervous system can result in a decline or loss of pallesthesia.
Diabetic shoes are specially designed shoes, or shoe inserts, intended to reduce the risk of skin breakdown in diabetics with existing foot disease and relieve pressure to prevent diabetic foot ulcers.
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).
Immersion foot syndromes are a class of foot injury caused by water absorption in the outer layer of skin. There are different subclass names for this condition based on the temperature of the water to which the foot is exposed. These include trench foot, tropical immersion foot, and warm water immersion foot. In one 3-day military study, it was found that submersion in water allowing for a higher skin temperature resulted in worse skin maceration and pain.
A diabetic foot disease is any condition that results directly from peripheral artery disease (PAD) or sensory neuropathy affecting the feet of people living with diabetes. Diabetic foot conditions can be acute or chronic complications of diabetes. Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome. The resulting bone deformity is known as Charcot foot.
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 is a breakdown of the skin and sometimes deeper tissues of the foot that leads to sore formation. It may occur due to a variety of mechanisms. It is thought to occur due to abnormal pressure or mechanical stress chronically applied to the foot, usually with concomitant predisposing conditions such as peripheral sensory neuropathy, peripheral motor neuropathy, autonomic neuropathy or peripheral arterial disease. It is a major complication of diabetes mellitus, and it is a type of diabetic foot disease. Secondary complications to the ulcer, such as infection of the skin or subcutaneous tissue, bone infection, gangrene or sepsis are possible, often leading to amputation.
Total contact casting (TCC) is a specially designed cast designed to take weight off of the foot (off-loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking weight off the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU. Furthermore, the five-year post-amputation mortality rate among diabetics is estimated at 45% for those with neuropathic DFUs.
Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.