Chapter 125

### Introduction

An ulcer, which occurring at any of the vital parts of the body secretes a copious quantity of pus and blood, and refuses to be healed, even after a course of proper and persistent medical treatment, is sure to have a fatal determination.

Sushruta-Samhita (5th century BC)

An ulcer is a localised break in the epidermal tissue of the surface of the skin or mucous membrane as a result of trauma, pressure, infection; they are associated with an underlying pathology. This applies particularly to leg ulcers. Ulcers are commonly found on the legs and feet, on areas exposed to the sun, and over bony prominences on the sacrum and heels. They may be clean, sloughy or necrotic.

The national morbidity survey (UK) showed that 2–3 per 1000 patients per annum consulted their GP with ‘chronic ulcers of the skin’.

Key facts and checkpoints1,2

• The great majority of leg ulcers are vascular in origin due to arterial insufficiency or venous hypertension or to a combination of the two i.e. mixed ulcers.

• If clinical findings don’t provide the diagnosis, ordering the ankle-brachial index (ABI) is essential if pulses are not palpable to exclude arterial disease. Duplex Doppler ultrasound is the key investigation for both venous and arterial disease.

• Most ulcers are multifactorial:

1. venous + obesity + immobility (often with osteoarthritis) + poor compliance, or

2. venous + arterial + trauma + infection

• Identify and treat any intrinsic or extrinsic factors impairing wound healing.

• High-stretch compression bandages are better than short-stretch compression bandages, which are mainly used in lymphoedema, and multilayer is best.

• Elastic bandages are better than non-elastic bandages.

• Venous surgery can improve outcomes—newer methods use non-surgical foam injections and lasers.

• A moist environment delivered by modern dressings provides a physiological environment for wound healing.

• Adequate wound debridement is essential to remove necrotic material and slough, and enable healing to commence and progress.

• It is important to consider biopsy as hypergranulation that does not respond quickly to topical treatment with hypertonic saline, silver nitrate and compression bandaging may be an SCC.

• Diabetic ulcers may be either neuropathic, which are mostly caused by pressure damage due to sensory neuropathy, or ischaemic due to loss of peripheral arterial circulation.

• Autoimmune diseases are the underlying cause of vasculitic wounds. They result from damage caused by circulating antibodies often seen in RA, lupus and scleroderma. They are very painful and difficult to heal without the use of immunosuppressants.

• Accurate diagnosis of the ulcer is vitally important for management decisions.

• Bacterial swabs are unhelpful because all chronic ulcers will become colonised with both Gram-positive and Gram-negative bacteria.

### The clinical approach

It is useful to keep in mind the various causes of ulcers (see Table 125.1). The commonest causes or types are venous and ischaemic ulcers of the leg, pressure ulcers (decubitus) and trauma. It is important ...

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