Ulcers: is a non-traumatic disruption of continuity in epithelial surface of the skin or
mucous membrane.
• It may either follow molecular death of the surface epithelium or its traumatic removal.
Characteristics Ulcers are characterised by their shapes, margins or edges, floor, and base.
• Edge: This gives clue to the diagnosis of an ulcer and condition of an ulcer.
o There are five common types of ulcer edge:
Undermined edge: Mostly seen in ulcers caused by Mycobacterium (e.g.
mycobacterium tuberculosis causing tuberculous ulcer or mycobacterium ulcerans
causing buruli ulcer).
Punched out edge: Mostly seen in gummatous ulcers (syphilitic) or in deep
trophic ulcer.
Sloping edge Mostly seen in healing traumatic or venous ulcer.
Raised and pearly white beaded edge: A feature of basal cell carcinoma (rodent
ulcer).
Rolled out everted edge: Is a characteristic feature of squamous cell carcinoma or
an ulcerated adenocarcinoma.
• Floor
o This is the exposed surface of the ulcer.
o Pale and smooth granulation indicates a slowly healing ulcer.
o A trophic ulcer penetrates down even to the bones.
• Base
o It is the site on which the ulcer rests.
o Hardness of the base is an important feature of carcinomatous lessions.
Clinical Classification • There are two ways of classifying ulcers
o Clinically
o Pathologically .
Clinical Classification of Ulcers • Spreading (acute phase)
o Surrounding skin is inflamed and the floor is covered with profuse offensive slough
without any evidence of granulation tissues.
o The ulcer is inflammed, oedematous and ragged edges; it is a painful ulcer.
o Draining lymphnodes are inflamed, enlarged and tender and may be suppurated with
abscess formation.
• Healing
o The floor is covered with pinkish or red healthy granulation tissue.
o The edges are reddish with granulation, while the margin is bluish with growing
epithelium and the discharge is slight and serous.
• Callous (chronic phase)
o The ulcer shows no tendency towards healing.
o The floor is covered with pale granulation tissue; sometimes shows typical washleather slough in gummatous.
o Discharge is scanty or absent.
• Tropical
o Common feature of this ulcer is callousness and they develop through three stages
Stage One: A pustule, or neglected cut, containing microorganisms (typically
penicillin-sensitive).
Stage Two: Progression of the cut or pustule to form an acutely painful ulcer with
a raised, thickened, and slightly undermined edge. This ulcer grows rapidly for
several weeks. A bloody discharge covers the grey slough on its floor, the skin
around it is dark and swollen, and muscle, bone, and tendon occasionally lie
exposed in its base. After about a month, the pain, swelling, and discharge
improve, and it either heals, or it goes on to the next stage.
Stage Three: It becomes chronic, and resembles any other long-standing indolent ulcer.
Pathological Classification • Pathologically an ulcer may be:
o Nonspecific
o Specific (tuberculous or syphilitic)
Non-Specific Ulcers
• Traumatic
o Mechanical: e.g. Dental ulcers of the tongue from jagged tooth, from pressure of a
splint
o Physical: From electrical or X-ray burn
o Chemical: From application of caustics
o These types of ulcers heal quickly and do not become chronic unless supervened by
infection or ischaemia.
• Trophic Ulcers
o Arterial (ischaemic), as in Atherosclerosis (hardening & narrowing of the vessels)
o Venous
Typically situated on the medial aspect of the lower third (1/3) of the lower limb
often associated with varicose veins in upper third (1/3) of the lower limb
Occur as a complication of Deep Venous Thrombosis (DVT)
Presents with eczema and pigmentation around ulcers, slightly painful in the
beginning, but gradually the pain settles down
o Associated with other diseases
Gout
Diabetic Mellitus- may be precipitated by ischeamia due to diabetic
atherosclerosis, infection or diabetic peripheral neuropathy; toes and feet are
commonly affected
Anaemia
Avitaminosis
Rheumatoid arthritis
o Neurogenic trophic
Trophic ulcers are due to impairment of nutrition of the tissues, which depends
upon an adequate blood supply and a properly functioning nerve supply
Ischaemia and loss of sensation do cause these ulcer
In the leg, painful ischaemic ulcers occur around the ankle or on the dorsum of the
foot
These ulcers have punched out edge with slough in the floor thus resembling
gummatous ulcer
Bed sores and perforating ulcers are typical examples of trophic ulcers.
Specific Ulcers • Tuberculous: Caused by mycobacteria tuberculosis
• Buruli ulcer: Caused by mycobacteria ulcerans
• Syphilitic ulcer: There are primary, secondary, tertiary stages in syphilis
o In primary- a hard chancre or hunterian chancre is seen. This chancre usually
develops at site of entry of tryponema in about three or four weeks after exposure.
Sites of the ulcers are the genitalia, lip, tongue, nipple, and perianal region. These
types of ulcer are single, usually painless and have a characteristic indurated base
which feels like a button.
o In secondary- ulcers may develop in form of mucous patches, snail track ulcers –these
are multiple small, round and superficial erosions which coalesce to form narrow,
curved shallow ulcers. They are mostly found in the mouth. Condylomalata are fleshy
wart like growths which are seen in the angles of the mouth anus, vulva.
o In tertiary- gummatous ulcers occur in (late stage) syphilis. It is a result of obliterative
endarteritis, necrosis and fibrosis, usually seen over the bones (e.g. tibia, sternum,
ulna and skull), in the scrotum in relation to the testis, upper part of the leg etc.
The most characteristic feature is punched-out indolent edge and yellowish grey
gummatous tissue in the floor. Pain and tenderness are absent. Lymphnodes are
seldom involved unless secondarily infected.
• Malignant Ulcers
o Squamous cell carcinoma (Marjolin’s ulcer)
A squamous cell carcinoma (SCC) arising from a long standing benign ulcer or
scar.
The most common ulcer to become malignant is a longstanding venous ulcer.
The scar which may show malignant change is an old burn scar.
It’s a slow growing and less malignant SCC.
Edges are not raised and everted as do the typical SCC ulcers.
o Epithelioma (squamous cell carcinoma or basal cell carcinoma)
Arises from layer of the skin, so can arise anywhere in the body.
Commonly seen on the lips, cheek, hands, penis, vulva and old scars.
Mostly seen after 40 yrs as a small nodule, enlarges and gradually the centre
becomes necrotic and sloughs out to develop an ulcer.
In early stages it’s mobile, but later on becomes fixed to the deeper structure.
o Malignant melanoma
A malignancy of pigment producing cells (melanocytes) located predominantly in
the skin, but also found in eyes, ears, GIT, leptomeninges, oral and genital mucous
membranes.
Clinically it presents like a mole which increases in size and changes colour but in
some cases the colour does not change. Lesions that do not change colour are
known as amelanotic melanoma.
Ulceration of the mole can lead to bleeding.
Enlarged regional lymph nodes indicate that there is metastasis.
Malignant melanoma is not painful, although it often itches.
o Basal Cell Carcinoma
Common in the trunk in black population
Presents with raised rolled out edges
Regional lymphadenopathy indicate metastasis {rare}
Principles of Management of Ulcers • Identification of the exact aetiology of the ulcer is important so as to have a successful
treatment of the ulcer.
o History and clinical physical findings are important.
o Biopsy of the lesion is extremely important to determine the exact nature of the ulcer.
o A clear ulcer with healthy granulation tissue exuding serous discharge should be
dressed once a day, and if there is copious discharge more frequent dressings are
needed.
o Ulcers can be cleaned safely with normal saline solution.
o The ideal dressing should be one that is soft, absorbent, non-adherent, and nonallergenic.
o Topical antibacterials may be administered, e.g. Povidone Iodine, Metronidazole
cream.
o Systemic antibiotics are prescribed to manage specific bacterial infection.
o Management of melanoma is complicated; it is mainly by surgical excision of the
lesion and later regional lymphnodes excision depending on the site of the melanotic
lesion.
o Management of squamous cell carcinoma ulcers is surgical by wide excision of the
ulcer followed by skin graft which is done at the district hospital. Finally the patient
should be referred for radiotherapy.