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CASE

• Name : Vasudevan
• Age :62/M
• Address :Atukkal

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Presenting Complaints

An ulcer on the medial side of left foot – 3mth


- with oozing of watery thin fluid, & blood
- Severe burning sensation.
- Oversensitive to touch with pain
< walking
> rest

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History of Presenting Complaints

An ulcer appear on the medial aspect of the ankle


1yr back. Took allopathic treatment & got temporaary
relief. Now the ulcer reappered on the the same site. First
appeared as a papule, with itching, then its size
increased, & burst, & form an ulcer.

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Past History

Nothing Particular

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Family History

No Relevant h/o illness in the family

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Personal History

• Place of Birth : Mellemod


• Educational Status : Illeterate
• Economic Status :Low
• Occupational status : Manual labour
• Nutritional status :low
• Marital status : Married,
1 daughter

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Personal History

• Occupation : Tea shop worker


• Food : Non Veg,
• Domestic relationship : Good
• Thermal relationship : chilly

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Physical Generals

• Appt : Good
• Thirst : Good
• Food desires & aversions – Nothing Particular
• Sleep :disturbed due to burning sensation in foot

• Stool : regular
• Urine : Nothing particular
• Sweat : Not charecteristic
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Physical Examination

• Built : Moderate
• Complexion:Dark Pulse :72/mt,
• Temp :afebrile RR :18/ mt
• Anaemia :No pallor BP :138/86 mm of Hg
• Cyanosis :Absent
• Jaundice : not icteric
• Clubbing :absent
• Oedema :nill
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Local Examination of Ulcer
Inspection
Shape : Oval
Number : Single
Position : Above medial malleolus, Lt. ankle
Floor : covered with slough
Edge : Inflammed with oedema
Discharge : Profuse, purulent
Surrounding area : Oedematous, blackish
discolouration, rough dry skin

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Palpation

Tenderness : Present, Increased temperature.


Base : Slight induration
Edge : Inflamed, sloping edge.
Surrounding skin : Oedematous, blackish
discolouration, rough dry skin
Regional Lymph Node: Inguinal Lymph node
enlarged & tender
Peripheral Pulses : Normal

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Diagnosis of Disease

Provisional Diagnosis : Venous ulcer

Differential diagnosis : Arterial Ulcer


Infective Ulcer
Meleny’s Ulcer
Trophic Ulcer
Tropical Ulcer
Marjolins Ulcer

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Lab Investigations

• Hb: 13g%
• TC: 6700cells/mm3
• ESR: 71mm/Hr
• N55, L44,E11
• FBS; 84mg%
• S.cholestrol: 183mg%
• Urine, Albumin: nill
Sugar: nill
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Diagnosis Of The Patient

• Chilly patient
• Severe burning sensation < night
• Oversensitive to touch with pain
• Blakish discoloration of surrounding skin
• < walking
• > rest

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Remedy Given

12 -11-09
RX
Ars alb 0/3
C & D With Calendula Q

Patient is reviewed after 2 wks, by repeating Ars alb 0/3 at


the intervel of 5 days.

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Follow up

26/ 11/09
Burning pain slight relief
Bloody discharge occasional
Ulcer size remains same

Patient is reviewed after 2 wks, by repeating Ars alb 0/3 at


the intervel of once in week.

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Follow up

10/ 12/09
Burning pain >
Discharge occasional
Ulcer shows tendency to heel, Signs of granulation
tissue seen, size remains same.

Patient is reviewed after 2 wks, by repeating Ars alb 0/3 at


the intervel of once in week

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Follow up

17/ 12/09
Burning pain >
No discharge
Ulcer is heeling, size decreases

Patient is reviewed after 2 wks, by repeating Ars alb 0/3 at


the intervel of once in week

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Follow up

24/ 12/09
Burning pain >
Ulcer is heeling

Patient is reviewed after 2 wks, by repeating Ars alb 0/3 at


the intervel of once in week

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An ulcer is is the break in the continuety of the
covering epithelium, skin or mucus membrane.

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The life history of an ulcer consists of 3 phases

1) Extension - During this stage the floor is covered with


exudates and sloughs while the base is indurated. The
discharge is purulent and even blood stained

2) Transition - Transition stage prepares for healing. The floor becomes cleaner, sloughs separate, indurations of the base diminishes and the
discharge becomes more serous. Small reddish area of granulation tissue appear on the floor and these link up until the whole surface is covered.

3. Repair - Stage of repair consists in 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 at a rate of 1mm. Per day. The healing edge consists of three zones- the outer epithelium, which
appears white, the middle one bluish in color (granulation tissue covered by a few layer of epithelium) and inner reddish zone of granulation tissue covered by a
single layer of epithelial cells.

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The life history of an ulcer consists of 3 phases

1) Extension - During this stage the floor is covered with exudates and sloughs while the base is indurated. The discharge is purulent and even blood
stained

2) Transition - Transition stage prepares for


healing. The floor becomes cleaner, sloughs separate,
indurations of the base diminishes and the discharge
becomes more serous. Small reddish area of granulation
tissue appear on the floor and these link up until the whole
surface is covered.
3. Repair - Stage of repair consists in 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 at a rate of 1mm. Per day. The healing edge consists of three zones- the outer epithelium, which
appears white, the middle one bluish in color (granulation tissue covered by a few layer of epithelium) and inner reddish zone of granulation tissue covered by a
single layer of epithelial cells.

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The life history of an ulcer consists of 3 phases
1) Extension - During this stage the floor is covered with exudates and sloughs while the base is indurated. The discharge is purulent and
even blood stained
2) Transition - Transition stage prepares for healing. The floor becomes cleaner, sloughs separate, indurations of the base diminishes and
the discharge becomes more serous. Small reddish area of granulation tissue appear on the floor and these link up until the whole surface
is covered.

3. Repair - Stage of repair consists in 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 at a rate of 1mm. Per day.
• The healing edge consists of three zones- the outer epithelium,
which appears white, the middle one bluish in color
(granulation tissue covered by a few layer of epithelium) and
inner reddish zone of granulation tissue covered by a single
layer of epithelial cells.

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Pathophysiology
Blood Flow in veins – In the direction of heart

Superficial – Perforating – Deep

Effect Of Gravitational Pressure on Venous Pressure

Venous HTN in both Superficial & Deep veins results from


• Valve Dysfunction
• Venous Obstruction
• Deep Vein thrombosis
• Failure of Calf muscle pump
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Classification of ulcer
Clinical Classification Pathological classification
1) Spreading ulcer 1) Non specific ulcers
2)Callous or Chronic Traumatic ulcer
Arterial ulcer
ulcer Venous ulcer
Neurogenic/Trophic ulcer
Asso. With malnutrition
Ulcers asso. With other d/s
Other types,
Bazin’s ulcer
martorell’s ulcer
2) Specific ulcers
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SPREADING CALLOUS / HEALING ULCER
ULCER CHRONIC ULCER

No Granulation Pale Granulation Red Granulation


tissue tissue tissue

Plenty of Discharge Serous discharge Minimal Serous


discharge

Excessive slough Slough present Slough absent

Surrounding area red Induration at base, Signs of inflamation


& inflamed edge & surrounding minimal
area
Purulant smell Smell can be present Smell absent
present
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Spreading Ulcer

• Surrounding skin is inflamed,


• floor is covered with proffuse & offensive slough,
• No evidence of granulation tissue
• painful
• draining lymphnodes are inflamed, enlarged,& tender

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Callous ulcer / Chronic ulcer

• Shows no tendancy towerds healing


• floor covered with pale granulation tissue
• Scanty discharge
• Base indurated

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Traumatic ulcer

• Site – Where skin is close to the body


• Single
• Painful
• Heal quickly,
• Do not become chronic unless supervened by
infection

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Specific ulcers

• Tuberculous ,
• syphillitic ,
• Soft sores,
• Actinomycosis.
• Malignant ulcers
• Epithelioma,
• Marjolins ulcers,
• Rodent ulcers.
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Venous ulcer
• Abnormal venous
hypertension on the lower
third of leg.
• Follow many years after
venous disease,
• So patients are around age
group of 40-60.
• lower part of leg on medial
side, above medial malleolus.
• Never seen above middle and
upper third of leg
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Venous ulcer
• Edge is sloping.
• Margin is thin and blue of growing
epithelium
• Floor is formed by pale
granulation tissue.
• Usually shallow, never penetrates
the deep fascia.
• Surrounding skin shows signs of
chronic venous Hypertension.
• Squamous cell carcinoma from
long standing venous ulcer -
Marjollins ulcer.
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Arterial ulcer ( Ischaemic ulcer)
• Rare when compared to
venous ulcer.

• Due to peripheral vascular


disease and poor
peripheral circulation.

• Episodes of trauma and


infection of destroyed
skin over limited area
of leg and foot.
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Arterial ulcer ( Ischaemic ulcer)

• Sites: anterior and outer


aspect of leg below
medial malleolus.
• Pain, history of intermittent
claudication , rest pain
seen
• character: punched out ulcer
with destruction of
deep fascia , expose
tendon at the base.
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ARTERIAL ULCER VENOUS
ULCER
Location Tip of toes Medial / lateral
side of leg

Pain Painful Painless

Number Numerous Single


Shape Irregular Oval
Depth Deep, penetrates fascia Superficial

Pigmentation Absent Present

Nature of blood Peripheral pulse absent, Peripheral pulse


Vessels Veins not dilated normal, Veins
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Diabetic ulcer

Three factors play to produce


diabetic ulcer
1.Diabetic neuropathy –> Loss
of sensation –> Trophic ulcer
2.Glucose laden tissue ->
susceptible to infection –>
spreading ulcer
3. Diabetic atherosclerosis ->
causing ischaemia –> arterial
ulcer

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Trophic ulcer /Neuropathic ulcer
• Develops in an anesthetic
limb.
• Causes Repeated trauma,
Follows Spinal d/s,
leprosy, Transeverse
myelitis, nerve injury,
Diabetic neuropathy
• Punched out edge and
slough in the floor
resembling gummatous
ulcers.
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Trophic ulcer /Neuropathic ulcer

• bed sores are typical


examples.

• Common site – on
pressure points - heel and
ball of foot

• Also called perforating


ulcer
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Erythrocyanoid ulcer
• Associated with diseases of young
women “erythrocyanosis
frigida”
• Abnormal amount of sub
cutaneous fat with thick ankles
combined with poor arterial
supply are the predisposing
factors.
• Starts as nodule and breaks to form
ulcer which are small and
multiple
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Martorelles ulcer / Hypertensive ulcer.

• old age

• associated with
hypertension,
atherosclerosis

• site: outer side of calf


muscle, may be bilateral

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Martorelles ulcer / Hypertensive ulcer.
• punched out ulcer.

• severe pain.

• peripheral foot pulses are


present

• features of arterial ulcer,

• may take months to heal


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Infective ulcer:

• staphylococcus ulcer may occur at any age

• Multiple small red scabbed sores on legs and ankles.

• Due to constant reinfection as a result of unclean


habit,poor hygiene and inadequate dressing

• Anaemia and poor nutritional status are the predisposing


factors
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Tropical ulcer / Phagedenic ulcer

• This ulcer seems to be due to


infection by vincent’s organism

• Charater of ulcer: commences


as a papule-pustule with a zone of
surrounding inflammation and
induration

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Tropical ulcer / Phagedenic ulcer

• Pustules burst in 2-3 days


forming ulcers whose edges are
undermined and raised. ulcer
become indolent and refers to heal
even for months and years

• Pain with lymphadenitis is the


important symptom

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Meleney’s ulcer

• Seen in post operative wounds

• Site-commonly in abdomen, thorax, rare in legs and


dorsum of hand.

• It is a spreading ulcer which is very painful with signs


of toxaemia

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Meleney’s ulcer

•Character of ulcer - undermined edge as it destroys


tissues at the depth with lot of granulation tissue in
the floor.

• Ulcer is surrounded by deep purple zone which in turn


is surrounded by outer zone of erythema

• General condition deteriorates without treatment

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Tuberculous ulcer

• Results from bursting of


caseous lymph nodes.
• ulcer is slightly painful.
• Common site - neck,axilla,groin
according to frequency
• Edge undermined ,thin reddish
blue
• Regional lymph nodes,non
tender and matted
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Lupus vulgaris

• A form of cutaneous
tuberculosis.

• Usual victims – Children,


young adultss

• Occurs commonly in face


and hands.

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Lupus vulgaris

•single or multiple
cutaneous nodules gradually
turns into small superficial
ulcerations on the skin.

• Ulcer active at periphery,


spreads outward & heal at
the centre gradually

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Syphilitic ulcer:
1) Primary stage - Hard Chancre on the external
genitalia,painless with indurated base.

2) Secondary Stage - Mucus Patches & Condylomas seen in


the mucocutaneous junctions associated with painless
lymphadenopathy. small round superficial transient
erosions particularly in the mouth which form snail track
ulcer.

3) Gummatous ulcer - indicate tertiary syphilis. These ulcers


are results of obliterative endarteritis, necrosis and fibrosis.
seen in the subcutaneous bones,Scrotum,upper part of leg
Feature – Punched out edge, Floor wash leather slough. 57
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Soft chancre or sore

• These are multiple painful acute ulcers

• These are seen on external genitalia.

• Caused by H. Ducrey

• These ulcers generally appear 3 days after infection

• The regional lymph nodes show the picture of acute


lymphadenitis with tendency towards suppuration.
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Marjolins ulcer:

• This is squamous cell


carcinoma arising from long
standing benign ulcer or scar.
• Edge is not always raised and
everted.
• Absolutely painless.
• Unlike squamous ca it is radio
resistant it is relatively avascular
and there is extensive fibrosis.

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Rodent ulcer

• Malignant, Exposure to
sun light or UV rays

• Hard reddish brown


nodule, painless, capillary
network

• Raised pearly – white


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Rodent ulcer

• Confined to upper part of


face, above the line joining
the angle of mouth to the
lobule of ear,

• Frequent site – inner


canthi of eye

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Clinical Features
• Aching pain
• Heaviness
• Leg Tiredness
• Cramps
• Itching, Burning & Swelling
• Discomfort and tenderness of the skin
• Pigmentation, eczema
• < Standing
• > Elevation of Leg

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Location of the Ulcer

• Arterial ulcer – tip of toes, dorsum of foot


• Long saphinous varicose ulcer – medial side of leg
• Short saphinous varicose ulcer – lateral side of leg
• Perforating ulcer – Over pressure points – soles
• Non healing ulcer – over shin & medial maleolus

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Floor of the ulcer

This is the part of ulcer which is exposed or seen

• Red Granulation tissue – Healing ulcer


• Necrotic tissue, slough – Spreading ulcer
• Wash - leather slough – Gummatous ulcer
• Part of the Bone – Neuropathic ulcer
• Nodular – Epithelioma
• Black tissue – Malignant melanoma

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Discharge from the Ulcer

• Serous discharge – Healing ulcer


• Purelent discharge – Spreading ulcer
• Bloody discharge – Malignent ulcer
• Discharge with bony spicules – Osteomyelitis
• Greenish discharge – Pseudomonas infection

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Edge, Margin of Ulcer
Edge - This is between floor of ulcer & margin
Margin - junction between normal epithelium & ulcer
These are the areas of maximum activity
• Sloping edge - Healing ulcer – traumatic & venous ulcer
• Punched out edge - Gummatous ulcer & trophic ulcer
• Undermined edge - Tuberculous ulcer
• Raised edge - Rodent ulcer
• Everted edge - Squamous cell ca.
On Palpation
• Induration (Hardness) – Squamous cell ca, C/c ulcers, Long
standing varicose ulcers
• Tenderness – infected ulcers, arterial ulcers
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Surrounding area

• Thick & pigmented – Varicose ulcer


• Thin & dark – Arterial ulcer
• Red & oedematous – Spreading ulcer
• Scar around ulcer – Marjolin’s ulcer

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Base

Area on which ulcer rests

• Induration at base – Squamous cell ca.


• Brawny induration – Abscess.
• Cyanotic induration – c/c venous congestion as in
varicose ulcer

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Palpation - Mobility

• fixed - Malignent ulcers


• Mobile - Benign ulcers

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Reginal Lymph nodes

• Tender & Enlarged – a/c secondary infection


• Non – tender & enlarged – c/c infection.
• Non tender & hard – Squamous cell ca.
• Non tender, large, firm, – Multiple melanoma.
multiple

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Spreading ulcer - Management

• Venous ulcers should be


debrided of necrotic and
fibrinous material to allow a
healthy granulation tissue
to develop.

• Hydrogen peroxide when


poured over the wound,
liberrates nasent o2 helps in
seperating slough.
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• Moistened saline gauzes may be appropriate for initial
management of all types of leg ulcers but moisture
retentive dressings are preferred.

• The latter help debride necrotic tissue, relieve pain and


reduce the frequency of dressing change

• The goal of wound dressings is to provide a warm,


moist environment that is free of external contamination.
Saline wet-to-dry dressings is effective
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Compression therapy
• Compression is applied using
elastic bandages or boots
specifically designed for the
purpose.

• Patients should wear as much


compression as is comfortable.

• The type of dressing applied


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Compression therapy

• Non-elastic, ambulatory, below


knee compression aggressively
counters the impact of reflux on
venous pump failure.

• Compression therapy is used


for venous leg ulcers and can
decrease blood vessel diameter and
pressure, which increases their
Application of a multilayer
effectiveness, preventing blood compression system
from flowing backwards. www.similima.com 76
Compression therapy

• Compression is also used to


decrease release of inflammatory
cytokines, lower the amount of
fluid leaking from capillaries and
therefore prevent swelling, and
prevent clotting by decreasing
activation of thrombin and
increasing that of plasmin

Application of a multilayer
compression system
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• Patients with venous insufficiency are advised to elevate their
legs above the heart level while sleeping, and to avoid standing for
long periods.

• The mainstay of venous ulcer management is compression to


achieve an external pressure between 30-40 mm Hg at the ankle,
this is required to prevent capillary transudate.

• For compression bandaging to be safely applied the ankle


brachial pressure index must be at least 0.8. (16,25)

• The bandages should be changed once or twice a week.


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Arterial ulcer management
• In daily wound care a sharp wound debridement is not
recommended.

• Compression therapy is contraindicated in arterial disease.

• The mainstay of treatment of arterial leg ulcers is surgical. The


aim is to restore blood supply to compromised limbs.

• An optimal control of associated predisposing factors, such as


hyperlipidemia, hypertension, and diabetes, as well as smoking
cessation and an exercise program should be Included in the
management plan.
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Preventing and treating infection

• A greater amount of exudate and necrotic tissue in a wound


increases likelihood of infection by serving as a medium for
bacterial growth away from the host’s defenses.

• Since bacteria thrive on dead tissue, wounds are often surgically


debrided to remove the devitalized tissue.

• Debridement and drainage of wound fluid are an especially


important part of the treatment for diabetic ulcers, which may create
the need for amputation if infection gets out of control.

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Maggot therapy
• Removing necrotic or devitalzed tissue is also the aim of,
Maggot therapy the intentional introduction by a health care
practitioner of live, disinfected maggots into non-healing wounds.

• Maggots dissolve only necrotic, infected tissue; disinfect the


wound by killing bacteria; and stimulate wound healing.

• Maggot therapy has been shown to accelerate debridement of


necrotic wounds and reduce the bacterial load of the wound, leading
to earlier healing, reduced wound odor and less pain.

• The combination and interactions of these actions make maggots


an extremely potent tool in chronic wound care.
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Treating ischemia and hypoxia

• Blood vessels constrict in tissue that becomes cold and


dilate in warm tissue, altering blood flow to the area.

• Thus keeping the tissues warm is probably necessary to


fight both infection and ischemia.

• Some healthcare professionals use ‘radient bandages’


to keep the area warm

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Surgery

• Surgical treatment to correct venous hypertension or


treating the ulcer itself by skin grafting is one treatment of
many that could be used.

• Other surgical procedures include superficial stripping


and excision of varices, subfascial perforating vein
interruption, excision and skin grafting, excision and free
flap coverage.

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Skin grafts
• Pinch grafts may be performed as an outpatient procedure
in patients with small ulcers.

• Small punch biopsies are taken from the patient’s thigh and
placed dermal side down on the ulcer bed. Split thickness graft
is used for large ulcers.

• The graft may be meshed to avoid build-up of exudate


underneath it. This procedure requires anesthesia and has the
disadvantage of creating a new donor site ulcer

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Artificial skin

• Artificial skin, made of collagen and cultured skin cells, is


also used to cover venous ulcers and excrete growth factors to
help them heal.

• Bilayer artificial skin, used in conjunction with compression


bandaging, increases the chance of healing a venous ulcer
compared with compression and a simple dressing.

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Hahnemann classified the ulcers of the skin in local
maladies under one sided disease of the large class of chronic
diseases.

In the homoeopathic concept no external malady can


arise, persist or even grow worse without some internal cause,
without the co-operation of the whole organism, which must be
in a diseased state.

So the treatment should be directed towards the


annihilation of the general malady by means of internal
remedies, selected on basis of totality of symptom, with which
the restoration of the health of the entire body along with the
disappearance of the external affection is effected.
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Miasm

Syphilitic miasm
Syphilitic miasm is predominant in open ulcers.
Ulcers which heal slowly with putrefaction of tissues.
Ulcerated skin with pus and blood represents syphilis.
Putridity, acridity, offencivenes of discharges

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Psora
small,sensitive painful non suppurating
boils,which may shed scurfy scales.
Itching without pus or discharge is characteristic
of psora.
Unhealthy dry skin with itching and burning.
Skin complaints are aggrevated by cold, winter.
Sycosis:
vesicular eruptions are generally sycotic.

Tubercular
Bleeding ulcers, varicose ulcer
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• Burning in interior of ulcer
• base of ulcer of blackish color, or lardaceous; foetid proud
flesh in the ulcer;
• pus copious, bloody, ichorous, or corrosive, putrid, thin and
watery;
• Phagedenic ulceration, ulceration extending in breadth (Sil.,
in depth);
• amel. from warmth (Sec., aggr. from warmth).
• Ulcers with offensive discharge.
• The ulcers burn like fire, pain even during sleep, discharge may
be copious or scanty, the base blue, black or lardaceous.—Nash

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• Ulcers resulting from cutaneous irritation; discharges
thin, offensive, with rapid loss of tissue, corroding every
part over which it passes.

• Induration is a strong feature; sometimes in glands, in


ulcers, in skin affections.

• Dropsical, spongy swelling of skin; ulcers with bleeding


or bloody discharges, with corrosive watery, yellow
discharge.-- Kent

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• Ulcers with intermittent pricking pain, high hard edges,
easily bleeding; shooting pains around ulcer;
• pus profuse, greenish, thin, offensive, even ichorous;
• ulcers turn black.
• Ulcers, particularly when affecting the bones, discharging
ichorous, thin and foetid pus; ulcerations from burns and
scalds, with great sensitiveness to suffering; intolerable
soreness around ulcer.
• Great sensitiveness to contact; in ulcers, especially
periosteal.
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• cadaverous-smelling and corroding, scanty secretion; mottled
appearance of skin around ulcer; flat, spreading ulcer of an
adynamic type, discharging thin, corrosive,ulcer in folds of
skin.
• Lividity is a common indication; indolent gangrene; varicose
veins of arms, legs, vulva, Varicose ulcers—Clarke
• Burning is generally a sensation that runs through the remedy.
burning in various parts of the skin. Often an internal burning
is attended by external coldness. .
• Elderly patients with indolent skin ulcers, with heart diseases,
weak, fainting.- Vitholkus
• General bruised soreness or heavy aching burning; in bones,
ulcers, etc.  
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• Slight pain, with severe ulceration or inflammation.
[Conium opposite.]
• Ulcers, with paroxysmal stitches; aggravated at night.
• Syphilitic ulcers, with cheesy, tenacious exudation.
• Punched-out, perforating ulcers, occurring on skin,
mucous membranes, and affecting bones—Clarke
• Ulcers; with dark dots, deep, perforating, round; look
punched out; septal; peptic; with overhanging edges or
thick crusts.-- Boger

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• Ulcers and wounds bleed profusely; even "small wounds bleed
much," wounds easily become gangrenous.
• flat ulcers, hard at circumference and very sensitive, with black
bottom, discharging very little pus, but easily bleeding; ulcers
sensitive to touch, with ichorous, offensive discharge,
• better from warmth; bedsores, with black edges; with
tendency to extend rapidly;
• burning pain only when touching the sore; smooth ulcers, with
jagged edges, surrounded by papillae or small ulcers, and of a
livid appearance.
• Boils, carbuncles, ulcers, with bluish, purple surroundings.  
• Blood decomposes, breaks down, haemorrhages; blood
uncoagulable;
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• Readily bleeding ulcers, with a lardaceous base,
• worse from heat of bed and hot and cold applications;
• spreading ulcers, exceedingly painful, and sensitive to
slightest touch; ulcers of a bluish or livid appearance, pus
scanty or copious, but never laudable.  
• Ulcers, irregular in shape, edges undefined.
• Ulcers, irregular, spreading, shallow, bleeding; with
cutting and proud flesh.--Boger

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• zigzag, irregular edges; base looks like raw flesh.
• which pains as if splinters were sticking in affected parts,
or burning, aggr. from cold water;
• syphilo-mercurial or scrofulous ulcers.
• fistulous ulcers difficult to heal; pus copious, bloody,
corroding, ichorous;
• rapid destruction of parts.
• This remedy is very often of curative value in angry, deep-
seated ulcers of a perforating character (Fluor-Ac., Kali-B.,
Sil.).--Lippe

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• Ulcers phagedenic, extending in depth;
• becoming black at base or edges, and bleeding; boring or
burning in edges and sensation of coldness in ulcer; deep or flat,
crusty ulcers; hard, fistulous or gangrenous ulcers; proud flesh in
ulcer, which is difficult to heal;
• Pus scanty, putrid, thin, watery, yellow; worse in open air, from
weather change, lying on painful side, or pressure;
• Unhealthy skin; every injury tends to ulceration.
• It seems to make no particular difference whether the
suppuration takes place in the soft or hard parts, for it is equally
efficacious in glandular or bony ulcerations.-- Nash

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• Burning ulceration

• The greatest general psoric remedy for almost every kind of itch,
sore, ulcer,

• Skin dry; rough; scaly; voluptuous itching - "feels so good to


scratch"; ecchymosis; chapping of the skin, esp. when it
ulcerates; chapping of the skin after being wet;

• The skin of a Sulphur patient ulcerates and suppurates easily; a


splinter under the skin will cause it to ulcerate; wounds heal
slowly and fester. -- Kent
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• Ulcers smelling like old cheese,
• edges very sensitive, with a pulsating sensation; stinging- pain
in the edges; jagged edges pus laudable or foetid, ichorous and
corroding.
• Putrid ulcers, surrounded by little pimples.

• But if pus is already formed, it will hasten the pointing and


discharge and help along the healing of the ulcer afterwards.
—Nash

• When handling the involved areas pain is felt as from sub-


cutaneous ulceration.--Lippe
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• Ulcers with bloody corrosive discharge; digging pain in ulcer,
aggr. by motion.

• Very characteristic is the great desire for sweets, the


splinter-like pains, and free muco-purulent discharge in
the inflamed and ulcerated mucous membranes.

• Cancer-like ulcers.

• Ulceration, with much yellow, bloody pus (Hep.).

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• Painful ulcers, < warmth, >cold, with copious discharge;
• varicose veins and ulcers on legs;
• burning pains on small spots on skin.

• Acts especially upon lower tissues, and indicated in deep,


destructive processes, bedsores, ulcerations, varicose veins,
and ulcers.

• Ulcer over tibia.


• Ulcers; red edges and vesicles.
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• Ulcers on heel from friction.

• Senile gangrene

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• Putrid flat ulcers with a pungent sensation,
• pain relieved by keeping limb elevated and from
outward pressure;
• pus white and putrid.

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• This nosode has proven a great remedy in epidemic
spleen diseases of domestic animals, and in septic
inflammation, carbuncles and malignant ulcers.

• Ulceration, sloughing and intolerable burning.

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• Ulcers, with sensitive areolae and easily bleeding, painful at
night, burning vesicles around ulcers; worse from rubbing or
scratching; linen sticks to ulcer, and when torn away it bleeds.
• Eruptions ulcerate and form thick scabs under purulent matter
exudes.
• Eruptions upon the legs and arms, on parts with poor circulation
as the ears, wrists, backs of the hands, skin eruptions followed by
ulcers; discharging a thick, white, offensive matter. - Kent
• Ulcer on leg with intense itching in surroundig skin and in scalp,
much agg. in warmth; with slight diarrhoea.- Clarke
• Deep, hard, painful ulcers; acrid pus, drying into crusts; agg.
touch and warmth.-- Boger 
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• Stinging, itching and painful ulcers, with foetid odor,
though covered with a crust;

• putrid ulcers, with burning pain or heat on edges;

• pus foetid and scanty.

• Carbuncles;

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• ulcers on toes, originating in blisters;
• feet tender and bathed in a foul moisture; ulcers with
stinging pain and proud flesh, often deep ulcers, with raised
edges;
• pus scanty, acrid, corroding; sanious and watery; worse from
cold in winter.
• Skin unhealthy; every injury tends to ulceration.

• The mucous membrane, or internal skin, has little patches of


ulcers, with induration about the patch, and hence Petr. is
useful in syphilitic ulcers. --Kent

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• Ulcers of a bluish color, bleeding easily, attended by
a bruised sensation in contiguous parts;

• results of contusions

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• Sycosis, flabby, lymphatic constitution;
skin destitute of pliability and elasticity; tetters.
Ulceration with sharp pains, piercing to scapulae.

• Cancer mammae even in ulcerative stage. Acute,


lancinating pain. Axillary glands swollen hard and
knotted.

• Ulcers, with fetid ichor

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• Deep ulcers affecting the bones;

• cancerous ulcers; mercurial ulcers;

• bluish-red, deep, fistulous, swollen and painful;

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• Useful in cases of burns, when the affected parts
ulcerate - Lippe

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• Congenital syphilis manifesting itself in ulcerating of
mouth and throat, caries and necrosis with boring
pains and heat in parts.

• Ulcers on the scalp with callous, hard edges.

• Indolent, fistulous ulcers, secreting thick, yellow pus.

• Indurations; of stony hardness; edge of ulcers,


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•Indolent ulcers, accompanying varicose veins.

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• Ulceration of the skin and ulcers bluish, burning,
cancerous, crusty,deep, corrosive, offensive with
yellow pus, fistulous, foul, indolent indurated,
stinging, and unhealthy.—Kent

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• Inflamed ulcers, painful as if beaten;

• excessive secretion of pus,

• phagedenic ulcers spreading in depth and width;

• weak, indolent, sloughing, varicose or haemorrhagic


ulcers, aggr. at night.

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• Ulceration and decomposition.

• Spongy ulcers, copper-colored eruption.

• Induration and bluish-red discoloration are often


present. Offensive, ichorous, acrid discharges exude
from ulcers and other skin defects; there is a tendency
to ulceration, gangrene, putrefaction.--Vithoulkus

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• Bleeding ulcers with blisters on the surrounding skin;
boring and burning in ulcers; burning on edges; pain
as if burnt;

• sensitive ulcers with pustules around them;

• phagedenic ulcers; varicose and fistulous ulcers on


hands, fingers and toes, corroding, thin, acrid, watery
discharge, with burning pain, amel. in damp weather
and from walking;

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• Old ulcers with foetid pus,
• skin not inclined to heal, cracks and fissures, easily
ulcerating;
• sensitive, sore, spongy ulcers, with a salty discharge;
crusty and scabby ulcers;
• pus bloody, watery, acrid and corroding, smelling like
herring-brine.
• It is of service in eczema, rhagades, excoriations and
ulcers of the skin that are characterized by a sticky,
glutinous discharge that is oozing out all the time.--
Blackwood

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• Cancer and cancerous state, before ulceration, when
pain is principal symptom.

• Lupus; ulcers, cancerous formations.

• Deep eating spreading ulcers upon the skin or mucous


membrane, with thick, viscid, yellow pus.—Kent

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• Haemorrhages, ulcerations, cancerous affections.

• This curious substance seems to act chiefly upon the


mucous membranes, producing profuse and offensive
secretions and ulcerations, with greatly depressed
vitality.

• This ulceration may be found in cancer of the uterus,


and then Kreosote will often be of great value.-- Nash

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• Syphilitic ulcers when perforation threatens.
 
• Covered with ulcerations.  

• Ulcerations of mouth have a gray membrane.  

• Mucous membranes broken down, ulcerated

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• Ulcers, with very offensive pus.

• Ulcers on the skin; carbuncles; warts; chilblains;


wens; corns with stinging and burning, and parts
become black; feeble circulation in the skin. --Kent

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• Swelled and easily bleeding gums, ulcerated.

• Little ulcer outside of large ones.

• Haemorrhage; vicarious; blood-streaked discharges of


ulcers, etc.--Boger

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• Veins in the forearm , hands are swollen. Shifting
pains ,

• >open air, chilly, aversion fatty food , warm food


and drink, worse from the letting the affected limb
hang down.

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• oozing blisters on legs, from small pustules,
increasing in size, with tearing pains;

• eruptions on instep, soon becoming thick, dirty, scaly,


suppurating, painful and itching, keeping him awake;
deeply penetrating, ichorous ulcers; crusty eruptions
all over;

• whole body has a filthy smell. 

• Indolent ulcers, slow to heal


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• Herpetic ulcers, extending in a circular form, forming
no crusts; red, granulated bases, white borders;
• Onychia, ulceration around ends of fingers, cutting
sensation under nails.
• Tetter on hands; ulceration around ends of fingers.
• Suitable in old syphilitics whose complaints have been
suppressed by Mercury; mind and body in a state of
prostration; paralytic weakness of the lower
extremities, no endurance; the heart palpitates on
exertion; suffocation on the least exertion; always tired;
ulcers here and there on the body; the skin is flabby and
full of distress at night. --Kent
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• Varicose ulcers. Burning sensation; better by cold;
wants parts uncovered, though cold to touch.
• The withered scrawny person with tendency to
ulcerations, unhealthy skin and aggravation from
heat, is striking in both acute and chronic states. –
Kent
• Ulcers that turn black; skin withered and gangrenous.
—Clarke
• Varicose ulcers wonderfully cured by the action of
this medicine.--Lippe

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• fistulous, gaping, angry ulcers in the mammae;

• pus sanious, ichorous, foetid and unhealthy.

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• Next to the Night agg., is Ulceration : and the ulcers
have greyish bases; - Clarke

• Non-healing ulcerations,

• fetid discharges from any part of the body,


• succession of abscesses, chronic throat symptoms,
falling hair, patchy alopacia, recurrent keratitis are
some of its field of application.

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• The root contains a crystalline solid, that stimulates
the growth of epithelium on ulcerated surfaces.

• Externally as a dressing for sores and ulcers and


pruritus ani.

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• Fistulous, deep and flat ulcers; spongy ulcers, with
itching or pricking;

• granulations exuberant, worse from bathing or


getting heated near the fire; pus scanty.

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• Deeply penetrating, malignant ulcers;

• gangrenous ulcers with hectic fever;

• ulcers surrounded with black pustules, which break


down into deep ulcers;

• no pus. merely oozing of foetid humor.

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• The greatest use of this medicine will be found in
nervous conditions, throbbings, jerking and
spasmodic condition of muscles, ulceration of the
skin and mucous membranes, and all this in such
patients as are tending towards a state of imbecility, a
state of confusion or weakness of mind.-- Kent

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• Phagedaenia ulcers.

• Black leg ulcer, running bloody, foul water; with


cutting, burning, itching and dyspnoea.- Boger

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• Hemorrhagic diathesis,

• right sided affection and intense prostration

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• Locally, for ulcers and rheumatic pains.

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• Hardening of tissues of tongue, rectum, uterus, etc.;

• ulcers with indurated base.

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• Flat ulcers, eating into the bones; abscess of ankle-
joint; spinal caries, aggr. after rubbing and in bed.

• Very painful ulcers, which affect the bone and extend


into the marrow of it--Lippe

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• Profuse discharge from granulating ulcers.

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• Eczema, with ulceration.
• As a stimulant to raw surfaces in indolent
ulcers, scabies, cracked nipples, rhagades, itch.

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• The clinical experience of Hering and his fellow-
provers has shown this to be highly useful remedy in
cracked and ulcerated nipples.

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• Old, putrid, spreading ulcers, with a history of liver
disease, or of a tubercular diathesis

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• Poisoned wounds, bites, phagedenic ulcers.

• Syphilitic ulcers on lower limbs, with hard swelling


around.

• Mercurio-syphilitic ulcers.

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• The ulcers are deep with hard edges, the
surrounding skins being covered with small
shining scales.

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• Very fiery red looking ulcer, Associated with ciliary
neuralgia and ulceration

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• Indolent ulcers, with hard, callous edges and foul,
ichorous discharge; old ulcers, appearing cancerous.

• Varicose ulcers.

• Ulcerative stage of carcinoma cutis when fissures


form.

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• Ulcers; gangrene.

• Acne, pustules on face and in the cruro-genital


region;

• ulcers look like chancre. 

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• Erysipelas and foul ulcers.

• Post-nasal catarrh with ulceration and fetor.


.
• Old tibial ulcers.

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• Typhoid when ulcers have eaten into tissues, and
black blood is discharged.

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• Foul, indolent ulcer, Pricking sensation followed by
painful aching

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• Very sensitive and oedematous mucous membranes
with ulceration.

• deep acrid ulcers, with intense itching and burning;


worse, touching the parts from washing.

• Eruption rough, scaly, smarting, and burning; when


scratched forms deep, ragged ulcers; skin where
ulcerated remains red.
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• old, torpid, indolent ulcers;
• ulcers turning black; insensible

• <morning, on getting heated near fire,


>from motion and walking.

• gangrene Ulcerating carcinoma and epithelioma of


the skin.

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• Has clinical confirmation of its use in cancerous
ulcers and nodulated tumors of the tongue.

• Favors healthy granulations on ulcerated surfaces.

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• Obstinate ulcers.

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• tertiary syphilis and Paralysis,

• Eczema, prurigo, old ulcers, leprosy, cancer of


glandular structures and bites of serpents.

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• Locally, applied to ulcers and unhealthy wounds.

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• phlegmonous inflammations, hastens suppuration;

• powerful antiseptic.

• Ulcerative tendency in all tissues.

• Said to act more powerfully than Hepar and Silica.

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• Chronic ulcers on lower parts of body, leg, foot, toe,
also breast, rectum.
• Painful ulcer, oozing offensive moisture on perineum.
• Haemorrhoids, fissures, ulceration of anus and
perineum, purple, covered with crusts.
• Ulcers below coccyx, around sacrum; varicose veins.
• Ulcers in general, from pressure, bedsores, etc.

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• The skin is covered with scales, which when they
drop off, leave white spots that may ulcerate.

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• Superficial ulcers and sores on lower extremities,
especially in females at climacteric.

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• Ulcers due to Radium burns, take a long time to heal.

• Necrosis and ulceration.

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• It has been employed extensively locally in powder
form or as an ointment, in old indolent ulcers,
pruritus and in tubercular and epithelimatous
conditions of the skin. - Blackwood

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• Thickened ulnar nerves. Neurofibromatosis-like
nodules.
• Loss of toes and fingers.

• Non-healing ulcers. Maggots. Gangrene.

• Thickened popliteal nerves. Wrists and feet drop.

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• It is useful in epithelioma of the skin and of cancer
especially of scrotum and uterus.

• It is also used for obstinate non-healing malignant


ulcers of the skin.

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• "Malignant erysipelas, particularly if attended by
large formation of pus, and destruction of parts. Non-
healing ulcers, livid appearance“ Clarke.

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• Venous congestion & passive haemorrhages,

• Varicose veins, ulcers

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• Strengthens the heart;

• blood purifier;

• useful in haematemesis, ulcers and is a good


expectorant

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• In ulcer It is an infallible remedy for any kind of
chronic ulcer particularly of the throat; cancer of the
throat; tongue with bad smelling saliva and
inflammation.
• Application of the pulp of cheroot substance as
mentioned above is useful in ulcer or gonorrhoea,
syphilis and wound of scabies.
• Gargling with the decoction (diluted with water) of
this drug relieves ulcer of the throat and tonsil.

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• Oozing of a fetid juice from the ulcer or wound;

• Affected part itches during menstrual flux which


some times become unbearable.

• Fever caused by septic ulcer;

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• It is also very effective for the dressing of the wounds
and ulcers.

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• Healing of whitlows and perforating ulcers and
gradual improvement of anaesthesia and muscular
atrophy are also said to occur.

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• Dry skin with scabies, aggravation at night;

• small pimples, carbuncle, skin disease, ulcers of the


diabetic patient.

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• Dry skin with scabies, aggravation at night;

• small pimples, carbuncle, skin disease, ulcers of the


diabetic patient.

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.
• Erysipelatous inflammation of skin. Lupus. Indolent
ulcers.

• disorders of the skin showing great cell growth,


lupoid conditions, epithelioma sloughing ulcers.

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• an extremely effective herb used to restore the
functioning of the circulatory system and improve
peripheral blood flow to the extremities.

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• known as a strong anti-inflammatory and pain
reliever,

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• Skin troubles worse from heat and better from cold.

• Ulcers due to impurity of blood

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• Old ulcers of skin.

• Diabetic ulceration.

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• can help to dilate and strengthen blood vessels.

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• For skin health, Natrium mur, Kali mur and Kali sulph
are three homeopathic ingredients hailed for their
ability to cleanse blood and lymph, help eliminate
waste in the blood and act as a natural anti-
inflammatory.

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• Furthermore, by providing essential oxygen to
inflamed or infected cells, Kali. sulph. effectively
assists healing, reduces inflammation and removes
infected or dead cells.

• Ferrum phos. is another well known biochemic tissue


salt to promote the supply of oxygen rich blood to all
cells of the body and will also prove helpful at the
first signs of an infection.

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1) Activate your calf muscles regularly by walking and
exercising.

1) Reduce the amount of fat in your food. Eat more


fruit and vegetables.

1) Sit with your legs raised whenever you have the


opportunity - above heart level if possible.

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4) Avoid sitting with your legs crossed. This impairs
blood circulation.

5) If your work requires a lot of standing or sitting, try


to vary your stance as much as possible. Walk about
from time to time, if you can.

6) If you have to stay seated for a long time, move your


feet up and down occasionally.
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• Leg ulcers are very common and physicians should
be familiar with the common methods used for their
diagnosis and management.

• Some laboratory investigations may be helpful and


can be ordered as part of the baseline work up.

• Unusual leg ulcers need more specific tests.

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