1. د .علي كاظم الحيدر

2. Ulcers :
An ulcer is a break in the continuity of an epithelial surface . It's characterised by progressive destruction of the surface epithelium and a granulating base .
Ulcers are classified as ( non specific , specific and malignant ulcers ) . Non specific ulcers are due to infection of wounds or physical or chemical agents . Local irritation , interference with circulation and sensation are predisposing factors .

3. Classifications of common types of ulcers :
Non-specific : peptic ulcers , pressure sores , Ischemic ulcers venous insufficiency , traumatic ulcers , secondary infective Neuropathic ulcers ( DM , leprosy , tabes , dorsalis ) . Iareogenic , Aphthaus ulceration , Demnatitis artefacta .
Specific : Primary infective-herpes simplex , T.B. , fungal , syphilis .
Malignant : G.I.T and skin ( ulcerative gastric ca , basal cell ca. , squamous cell ca . ) .

4. Clinical features :
An ulcer may be acutely inflamed surrounded by area of cellulitis , or it chronically inflamed with adherent slough weak ulcers are covered ny granulation tissue .
Clinical examination of an ulcers : includes
Local exam .
Reginal exam .

5. Local exam : A. Inspection :
Site : e.g. 95% of rodent ulcers occurs on the upper part of the face , while carcinoma affect the lower lip .
Size :
Shape . e.g. rodent ulcer is usually circular .
Edges : - slopping Healing .
Inflammatory .
- Punched – our edge syphilis
- undermined Tuberculosis .
- Rolled edge Basal cell carcinoma
- Everted edge epithelioma
S.C.carc.

6. Floor : that which is seen , contain - infected granulation tissue ( yellow )
- clean granulation tissue ( pink )
- sloughs or dead tissue .
Base : that which can be palpated
indurated – carcinoma
Discharge : - Purulent : infective
- blue green : infection with pseudomonas
- watery – in T.B.

7. Reginal exam : 1. Reginal lymph nodes . Rodent ulcer not enlarged
S.C.C enlarged .
2. Pulse : above and below ulcerated area .
3. Tenderness : viral ulcer ( e.g. )
4. Sensory exam and reflexes .
5. Muscle power .
General exam : anemia , debility , cardiac failure , jumdice and D.M.
Pathological exam : biopsy will confirm ca.
Marjolin's ulcer : Carcinomatous change occurring at the edge of a chronic venous ulcer and long standing benign ulcer .

8. Trophic ( Ischemic ) ulcer : Occur's in
In Ambulent patient , pressure areas ( heel of the feets , tips of toes ) .
In bed ridden patients , pressure areas e.g. Back of the heel lateral side of the feet .
Causes of trophic ulcers :
Obliteration of large arteries ( atherosclerosis , embolism )
Obliteration of small arteries ( Raynaud's , Burger's dis D.M.
Physical agents : pressure necrosis , Trauma radiation .

9. Neuropathic ulcers : Peripheral lesions ( DM , injury , leprosy )
Neuropathic ulcers : Peripheral lesions ( DM , injury , leprosy ) . Spinal lesions ( spina bifeda , tabes dorsalis ) Chronic ulcers : Due to infections , Trauma , ischemia , oederna , denervation .

10. Basic requirements of the ideal ulcer dressing .
Management of ulcers :
Principles :
Determine etiology and comorbid factors ( e.g. anemia ) could be infection , venous or arterial insufficiency or D.M should be treated .
Accurate assessment of ulcer , adequate drainage and desloughing essential for healing . removal ( excision ) of dead Tissue .
Identify and correct comorbid factors .
Antibiotics not used in healthy granulating wounds but used when ulcer is infected and surrounded by cellulites .
Avoid adherent dressings and antiseptic solutions that impair capillary circulation .
Basic requirements of the ideal ulcer dressing .
- Maintain high humidity between wound and dressing .
- Absorbent , removes excess exudate
- Non adherent , allowing easy removal without trauma at dressing .
- Safe and acceptable to patient ( non-allergic )
- Permit gaseous exchange but impermeable to micro-organisms .
- Cost-effective .