Ulcer

Ulcer

Its discontinuity of the covering epithelium with progressive destruction of the epithelial surface.

Classification

1- Nonspecific which could be due to

     Traumatic, infective, neuropathic, iatrogenic, ischemic,

      physical, or chemical causes

 2- Specific due to specific infection like TB, Syphilis.

3- Malignant.

Clinical evaluation of ulcer

1- Site: 95% of Bcc occur in the upper part of the face. Venous ulcer mostly affect the medial malleuolus.

2- Size: its depend on the nature of the ulcer, inflammatory ulcer is rapidly progressing ,less rapidly is malignant one.

3- Shape: rodent (BCC)ulcer tend to be circular.

4- Edge:

A- Sloping edge found in healing ulcer.

                                                                                               

B- Undermined edge due to destruction of subcutaneous tissue more than the skin like

in TB or ulcer in a fatty area.

C- Punched out edge occur when there is a cut limit between pathological and normal cells like in ischemic, neuropathic and syphilitic ulcer.

D- Everted edge due to

 excessive growth of cells

 that sheds on the margin of the ulcer like in malignancy.

E- Rolled edge occur in less malignant ulcer like Bcc.

5- Floor: part of the ulcer that can be seen, it may show granulation, slough, exposed tendon or bone.

6- Base: part of the ulcer that can be palpated which may be indurated or attached to deep structure.

7- Discharge: puss mean infection, watery discharge in TB, or blood discharge. 

8- Pain: ischemic and inflammatory ulcers are painful while neuropathic ulcer is not.

9- Lymphatic drainage: painful lymph adenitis associated with inflammatory condition while painless lymph node is due to secondary  deposition.

10- Surrounding area: which may show sign of inflammation or invasion of malignancy.

  

Investigation

1- Culture and sensitivity in case of suspected infection.

2- Biopsy which could be

A- Incisional: where part of the ulcer is removed.

B- Excisional: where all the ulcer is removed

Management

1- General:

A- Control the causative factor like infection, ischemia, neuritis, malignancy.

B- Control the comorbed factor like DM, anemia, malnutrition.

C- antibiotic in infected ulcer

2- Local: 

A- desloughing and puss drainage.

B- Excision of the ulcer with primary suture or graft.

C- Dressing by using non adhesive non allergic cost effective material like hydrocolloid gel or micro porous polyurethane.