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How to Examine Ulcers

Definitions
An ulcer is a break in the continuity of an epithelium
Chronic ulcers are those that persist for more than 4 weeks

What prevents an ulcer to heal?


What are the causes of chronic ulcers?

Ch. Venous Ins.


Infection
Non
Specific
Osteomyelitis

Specific
TB
Syphilis

Ischemia

Localized destructive
D/s
TB
Gamma

Repeated /Persistent
trauma

Malignancy

Denervation
Peripheral nerve lesions
DM, Nerve injury, Leprosy

Spinal cord lesions

History
Duration
Cause

Main
symptom
Course

More than 4 weeks is considered chronic


e.g. Minor trauma

Pain, Discharge,.
Increasing in size or depth
Became painful (infected?)
Discharging (infected?)
Recurrent (healing & breaking down)

Similar ulcer (same site or elsewhere)

Examination
Site

Shape

Size

Floor
Depth
Edge
Discharge
Skin (or tissues) around
Relations (adherent to deeper tissues)

Draining LNs

Floor
Edge

Examination
Site
Some ulcers have characteristic locations
e.g. Venous ulcer situated in the gaiter area of
the leg

Shape
Size
Are important in follow up of ulcer healing

Examination
Shape

Site

Solid brownish or blackish tissue indicates full thickness skin death

Size

Floor
By inspection you may notice:
Granulation tissue
Sloughs

Gamma 3ry syphilis. Sloughs (wash-leather)

Gangrenous tissue
Deeper tissues as tendon or bone

Sloughs in ischemic foot ulcer

Healthy granulation tissue. The red colour reflects good vascularity

Gangrenous tissue & tendons in ischemic ulcer

Examination
Site

Shape

Size

Floor

Depth
Neuropathic ulcers are deep

Venous ulcers are superficial

Examination
Site

Shape

1- Sloping

Size

Floor
Depth

Edge (5 types)

The ulcer is shallow & the epithelium is


growing in from the edge in an attempt to
heal

Examination
Edge (5 types)
1- Sloping

Gamma of 3ry
syphilis

2- Punched-out

or square cut: It results from rapid death


& loss of the whole thickness of the skin
with minimal attempt of healing

Leprosy

Neuropathic ulcer in the


sole of foot

Examination

3- Undermined edge

Edge (5 types)
1- Sloping

When infection is affecting the subcutaneous


tissue more than the skin, the edge becomes
undermined

2- Punched-out

Undermined edge in diabetic foot infection

Tuberculous ulcer

Undermined edge in
Pyoderma gangrenosa

Pressure bed sore in


the buttock.
Subcutaneous fat is more
susceptible to pressure
than the skin

Examination

4- Rolled

Edge (5 types)
1- Sloping
2- Punched-out
3- Undermined

Develops when there is slow growth of


tissue in the edge of the ulcer

Basal cell carcinoma (rodent ulcer):


Pale pink edge with clumps & clusters of cells visible through the
paper thin superficial covering of squamous cells

Examination

5- Everted edge

Edge (5 types)
1- Sloping
2- Punched-out
3- Undermined
4- Rolled

Develops when the tissue in the edge of the


ulcer is growing quickly and spilling out of
the ulcer to overlap the normal skin.
This edge is typical of carcinoma at any site

Malignant transformation in
a chronic venous ulcer
Marjulin ulcer

Malignant ulcer colon


carcinoma

Examination
Site

Shape

Size

Floor
Depth
Edge

Discharge
May be: serous, sanginous,
serosanguinous or purululent
A dry discharge forms a scab
that covers the ulcer

Dry scab covering the ulcer

Purulent discharge from


infected bed sore
Serosanguinous
discharge from infected
diabetic foot ulcer

Examination
Site

Shape

Size

Floor
Depth
Edge
Discharge

Cellulitis around the ulcer

Skin (or tissues) around


Pigmentation around
venous ulcer

Hyperpigmentation of ch. Recurrent infection

Examination
Site

Shape

Size

Floor
Depth
Edge
Discharge
Skin (or tissues) around

Relations (adherent
to deeper tissues)

It is important to know if the


ulcer is adherent to the
deep structures

Examination
Site

Shape

Size

Floor
Depth
Edge
Discharge
Skin (or tissues) around
Relations (adherent to deeper tissues)

Draining LNs

The draining LNs may be


enlarged 2ry to infection or
2ry to tumour deposits.
Infected LNs may be
tender