Skin Ulcers David Spoelhof MD St. Luke’s Hospital.

Skin Ulcers

David Spoelhof MDSt. Luke’s Hospital

Types of Ulcers Pressure Venous Arterial Neurotrophic

Diabetic Special Cases

Pressure Ulcer: Definition “Decubitus” vs.

Pressure Ulcer

Pressure Ulcer

Stage 1 Non-blanchable

erythema.

Not a trivial lesion.

Subdermal tissue is more vulnerable to pressure/ischemic damage.

Stage 2 Epidermis disrupted

Blister or shallow ulcer.

Important to check elsewhere (heels).

Stage 3 Extension into

subdermal tissues.

Undermining or tunneling common.

Measurement may underestimate size.

Stage 4 Bone or tendon often

colonized/infected.

Stage 4 Ulcers

Ulcer treatment Managing tissue loads Managing bacterial colonization/infection Nutritional support Local wound care Operative repair

“Why did this happen?”

Wound Healing

Wound Healing

Granulation Tissue

Managing Tissue Loads Pressure relief mattresses/overlays “zero tolerance” for continued pressure

over the wound Heels need special attention: heel

“protectors” often are ineffective Seated position

Especially difficult to reduce pressure on buttocks.

Bacterial colonization/infection All wounds are colonized, surface cultures

are worthless. Cleansing and debridement are key. Two week trial of topical antibiotic? Osteomyelitis: ESR, WBC, x-ray (69%

sensitivity if all 3 abnl). MRI? Sepsis, cellulitis, osteomyelitis require

systemic antibiotics, usually inpatient.

Nutritional Support Protein is key: 1.0-1.5 g/kg/day

Healing requires extra calories: 30-35 kcal/kg/day

Tube feeding does not seem helpful

Local Ulcer Care Debridement

Cleansing Avoid antiseptics which may be cytotoxic

Dressings

Be consistent, be familiar with preferred treatments.

Local care for stage 1 ulcer Debridement: none

Cleansing: nondrying soap and water

Dressing: None or polyurethane film

Central issues: Pressure relief Why did this happen?

Local Care for Stage 2 Ulcer Debridement: none.

Cleansing: Saline.

Dressing: Polurethane film, hydrocolloid wafer.

Central issues: provide moist wound bed keep surrounding skin dry

Local Care for Stage 3 Ulcer Debridement: if eschar or slough present

autolytic, wet-to-dry, enzymatic, sharp

Cleansing: saline Dressing: hydrocolloid, foam, hydrogel

may need packing if deep/undermined

Central issues: debride necrotic tissue protect granulation tissue

Local Care for Stage 4 Ulcer The same as stage 3.

Visible bone/tendon, even if superficially infected, does not mean it won’t heal.

Odor can be a problem metronidazole gel activated charcoal

Central issue: patience

Leg Ulcers Venous Insufficiency: 80-90%

See N Eng J Med 2006;355:488-98

Arterial Insufficiency: 5%

Neurotrophic Ulcers: 2%

Venous leg ulcers Medial malleolus is

typical Stasis dermatitis,

hyperpigmentation, hemosiderin deposits

Chronic edema, will not diurese

Tender to palpate Varicose veins?

Venous Ulcers There are two venous systems in the leg:

the deep system (high pressure) the superficial system (low pressure) connected by perforator veins

The low-pressure system is protected from the high pressure system by valves in the deep veins and perforators.

Leg Vein Anatomy

Leg Vein Valves

Valve Function

Calf Muscle Vein Pump

Bergan J et al. N Engl J Med 2006;355:488-498

Action of the Musculovenous Pump in Lowering Venous Pressure in the Leg

Factors for Venous Ulcers Overload

CHF, obesity

Obstruction Clot, tumor

Pump malfunction Stroke, MS, inactivity

Bergan J et al. N Engl J Med 2006;355:488-498

Clinical Manifestations of Chronic Venous Disease

Treatment of Venous Ulcers Same cleansing and debridement

principles as pressure ulcers.

Control of edema is essential. Restore venous return by way of external

compression (30-40 mm Hg @ ankle) Unna boot Compression hose Compression pumps “TED” socks provide ~ 18 mm Hg pressure.

Compression Stocking

Arterial Ulcers Circumscribed,

“punched-out” ulcers, often multiple.

Occur in areas least well perfused: lateral malleolus, tibial, feet/toes.

Shiny, hairless skin. Absent pulses. Claudication.

Leg Artery Anatomy

Ankle-Brachial Index (ABI) Normal is 1.0 or above. ABI below 0.8 causes claudication. ABI below 0.4 causes rest pain.

Peripheral arterial ischemia is a strong predictor of coronary and cerebral arterial disease.

ABI and Survival

Buerger’s Disease Thrombangiitis

obliterans. Occurs in smokers,

often young. Hands and feet. Associated

thrombophlebitis (arrows)

Treatment: quit smoking.

Allen Test

Occlude radial and ulnar arteries after making a fist to empty blood from the hand.

Open hand and release pressure over the ulnar artery.

Hand should refill with blood via ulnar artery, evidenced by return of pink color.

Positive = persistent pallor.

Treatment of Arterial Ulcers

Same cleansing, debridement and dressing principles as pressure ulcers.

External compression is detrimental. Smoking cessation. Revascularization. Skin graft. Amputation.

Neurotrophic Ulcers Plantar aspect of foot

or toes is typical.

Prominent callus formation.

Caused by peripheral neuropathy, usually diabetic.

Screening for Neuropathy

The Charcot Foot

Treatment of Neurotrophic Ulcers

The same cleansing, debridement and dressing principles as pressure ulcers.

Protection: footwear, total contact cast? Recombinant platelet-derived growth

factor (becaplermin)?

Good diabetic management. Beware of arterial insufficiency. Beware of infection (osteomyelitis).

Total Contact Cast

Platelet-derived growth factor

Some Less Common Ulcers

Skin Cancer Basal Cell Carcinoma Squamous Cell Carcinoma

Pyoderma Gangrenosum

Basal Cell Carcinoma Most common skin

cancer. “Heaped up” or rolled

edges. Usually sun-exposed

surfaces. Does not metastasize.

Squamous Cell Skin Cancer May occur as a

complication of previously benign ulcer.

May metastasize, check regional lymph nodes.

If in doubt, biopsy.

Pyoderma Gangrenosum Margins are

serpiginous and elevated.

Edges have blue or purple hue.

Pustule or blister precedes.

Assoc’d with inflammatory bowel, RA, leukemia.

Common Leg Ulcers

Venous/Stasis Ulcer

V a rico se V e insE cze m a

P ig m e n ta tion

S u p e rfic ia lO ften la rge

M e d ia l m a lle o lus

N o rm al P u lsesN o rm al S e nsa tion

Arterial Ulcer

C o ld to esT h ick n a ilsH a ir lo ss

D e e p u lce rP a in fu l

L a te ra l m a lle o lusT ib iaD ig its

A b se n t F o ot P u lses

Neurotrophic Ulcer

D ia be tes

C a llo s ityP a in le ss

P re ssu re P o in tP la n ta r Fo o t

R e du ced S e n sa tion

S ite o f u lce rF o o t P u lsesS e nsa tion