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

2. Types of Ulcers  Pressure  Venous  Arterial  Neurotrophic Diabetic  Special Cases

3. Pressure Ulcer: Definition  “Decubitus” vs. Pressure Ulcer

4. Pressure Ulcer

5. Stage 1  Non-blanchable erythema.  Not a trivial lesion.  Subdermal tissue is more vulnerable to pressure/ischemic damage.

6. Stage 2  Epidermis disrupted  Blister or shallow ulcer.  Important to check elsewhere (heels).

7. Stage 3  Extension into subdermal tissues.  Undermining or tunneling common.  Measurement may underestimate size.

8. Stage 4  Bone or tendon often colonized/infected.

9. Stage 4 Ulcers

10. Ulcer treatment  Managing tissue loads  Managing bacterial colonization/infection  Nutritional support  Local wound care  Operative repair  “Why did this happen?”

11. Wound Healing

13. Granulation Tissue

14. 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.

15. 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.

16. 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

17. Local Ulcer Care  Debridement  Cleansing Avoid antiseptics which may be cytotoxic  Dressings  Be consistent, be familiar with preferred treatments.

18. 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?

19. 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

20. 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

21. 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

22. Leg Ulcers  Venous Insufficiency: 80-90% See N Eng J Med 2006;355:488-98  Arterial Insufficiency: 5%  Neurotrophic Ulcers: 2%

23. Venous leg ulcers  Medial malleolus is typical  Stasis dermatitis, hyperpigmentation, hemosiderin deposits  Chronic edema, will not diurese  Tender to palpate  Varicose veins?

24. 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.

25. Leg Vein Anatomy

26. Leg Vein Valves

27. Valve Function

28. Calf Muscle Vein Pump

29. Bergan J et al. N Engl J Med 2006;355:488-498 Action of the Musculovenous Pump in Lowering Venous Pressure in the Leg

30. Factors for Venous Ulcers  Overload CHF, obesity  Obstruction Clot, tumor  Pump malfunction Stroke, MS, inactivity

31. Bergan J et al. N Engl J Med 2006;355:488-498 Clinical Manifestations of Chronic Venous Disease

32. 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.

33. Compression Stocking

34. 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.

35. Leg Artery Anatomy

36. 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.

37. ABI and Survival

38. Buerger’s Disease  Thrombangiitis obliterans.  Occurs in smokers, often young.  Hands and feet.  Associated thrombophlebitis (arrows)  Treatment: quit smoking.

39. 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.

40. Treatment of Arterial Ulcers  Same cleansing, debridement and dressing principles as pressure ulcers.  External compression is detrimental.  Smoking cessation.  Revascularization.  Skin graft.  Amputation.

41. Neurotrophic Ulcers  Plantar aspect of foot or toes is typical.  Prominent callus formation.  Caused by peripheral neuropathy, usually diabetic.

42. Screening for Neuropathy

43. The Charcot Foot

44. 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).

45. Total Contact Cast

46. Platelet-derived growth factor

47. Some Less Common Ulcers  Skin Cancer Basal Cell Carcinoma Squamous Cell Carcinoma  Pyoderma Gangrenosum

48. Basal Cell Carcinoma  Most common skin cancer.  “Heaped up” or rolled edges.  Usually sun-exposed surfaces.  Does not metastasize.

49. Squamous Cell Skin Cancer  May occur as a complication of previously benign ulcer.  May metastasize, check regional lymph nodes.  If in doubt, biopsy.

50. Pyoderma Gangrenosum  Margins are serpiginous and elevated.  Edges have blue or purple hue.  Pustule or blister precedes.  Assoc’d with inflammatory bowel, RA, leukemia.

51. Common Leg Ulcers