Ulcers & skin infections
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Ulcers & skin infections
- 1. C ULCERS & SKIN INFECTIONS BY: R. Nandinii Group K1
- 2. Overview • Ulcers of the skin -Definition & Causes -Identification of an ulcer -Examinations -Investigations -Types of ulcer -Management • Skin Infections • Impetigo • Erysipelas • Cellulitis • Infections of the hair follicles • Life threatening skin & soft tissue infections
- 3. ULCER DEFINITION: • A break in the continuity of the covering epithelium- skin / mucous membrane. Causes: • venous disease: superficial incompetence; deep venous damage(post-thrombotic) • arterial ischaemic ulcers; • rheumatoid ulcers; • traumatic ulcers; • neuropathic ulcers (diabetes); • neoplastic ulcers (squamous cell carcinoma and basal cell carcinoma) Source: Bailey & Loves Short Practice of Surgery 25th ed
- 4. IDENTIFICATION OF AN ULCER INSPECTION • Size & Shape • Number • Position • Edge • Floor • Discharge • Surrounding area • Whole limb PALPATION • Tenderness • Edge & margin • Base • Depth • Bleeding • Relations with deeper structure • Surrounding skin Source: A manual on Clinical Surgery 9th ed
- 5. ## Size important to know Determines time required for ulcer to heal. Source: A manual on Clinical Surgery 9th ed
- 6. Position Source: A manual on Clinical Surgery 9th ed
- 7. Edge Source: A manual on Clinical Surgery 9th ed , Pictures from Doctors Hangout
- 8. FLOOR Source: A manual on Clinical Surgery 9th ed
- 9. 9Source: A manual on Clinical Surgery 9th ed
- 10. PALPATION Source: A manual on Clinical Surgery 9th ed
- 11. Examinations: Source: A manual on Clinical Surgery 9th ed
- 12. Investigations: • Routine examination of the blood • Examination of the urine • Bacteriological examination of the discharge • Skin test • Chest X ray • Biopsy • X ray of bone & joint • Contrast radiography • Imaging technique Source: A manual on Clinical Surgery 9th ed
- 13. C TYPES OF ULCER
- 14. Venous ulcer • Abnormal venous hypertension in the lower part of the leg • Venous drainage of the ankle via ankle perforating veins when valves of this vein are damaged local venous hypertension Aggravated by obstructed main deep veins Post-canalization of thrombosed deep vein Destruction of the valves of the deep vein. • Complication: Carcinoma (Marjolin ulcer) from the growing edge of ulcer • Follows many years of venous disease (age group 40-60 years) • F > M • Discomfort & tenderness of skin, pigmentation & eczema mths/ years before ulcer. • Ulcer painful in the beginning chronic: painless Source: A manual on Clinical Surgery 9th ed
- 15. Venous Ulcer • Edge: Sloping • Margin: thin & blue of growing epithelium • Floor: Pale granulation tissue • Ulcer: Shallow & flat & never penetrates the deep fascia • Discharge: seropurulent • Base: Fixed to deeper structures
- 16. Arterial Ulcer • Rare compare to venous ulcer • Due to peripheral arterial disease & poor peripheral circulation. • Seen in older people & are episodes of trauma & infection of the destroyed skin over a limited area of the leg/foot. • Anterior & outer part of the leg, dorsum of the foot on the toes / heel. • Hx of intermittent claudication & rest pain • Pain during when leg is elevated. Source: A manual on Clinical Surgery 9th ed
- 17. Arterial Ulcer • Ulcers are punched out with destruction of deep fascia. • Tendon, bones & underlying joints exposed in the floor • Covered with minimal granulation tissue. • Presence of ischaemic changes : pallor, dry skin, loss of hair, fissuring of nails.
- 18. Neuropathic Ulcer • 3 factors cause diabetic ulcer: - diabetic neuropathy - diabetic atherosclerosis causing ischaemia - glucose laden tissue vulnerable to infection • Soles, toes, heel • Early symptoms of neuropathy : paresthesia, pain, anesthesia of leg and foot • Punched out corny edge. Floor is covered with slough. Tendons & bones can be seen. Source: A manual on Clinical Surgery 9th ed
- 19. Malignant Ulcer • Usually squamous cell carcinoma • Most commonly seen on the lips, cheek, hands, penis, vulva & old scar. • Mostly seen after 40 years of age. • Begins as small nodule enlarge gradually centre becomes necrotic & sloughs out & ulcer develops. Source: A manual on Clinical Surgery 9th ed
- 20. Malignant Ulcer • Oval / circular in shape. • Edge: raised & everted • Floor covered with necrotic tumour, serum & blood • Some granulation tissue pale & unhealthy • Can be fixed due to involvement of deeper structures. • Regional lymph nodes enlarged.
- 21. CONSERVATIVE TREATMENT • Use of interactive dressings that are typically occlusive dressings. • Venous ulcers : commonly treated with multilayer compression dressings that assist the return of pooled blood to the central circulation. • Chronic wounds : administer systemic antibiotics & topical methods (silver sulfadiazine) to encourage wound healing. 21
- 22. SURGICAL THERAPY • Debridement or incision of the affected tissue prior to grafting. • Split-thickness skin graft (STSG) • Pedicled and free flaps 22
- 23. 23
- 24. Pressure Ulcer • Tissue necrosis with ulceration due to prolonged pressure. • Pressure sore frequency in descending order : Ischium Greater trochanter Sacrum Heel Malleolus (lateral then medial) Occiput Source: Bailey & Loves Short Practice of Surgery 25th ed
- 25. Staging System of American National Pressure Ulcer Advisory Panel STAGE DESCRIPTIONS 1 Non-blanchable erythema without a breach in the epidermis 2 Partial-thickness skin loss involving the epidermis and dermis 3 Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fascia 4 Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon or joint 25
- 26. Prophylaxis for At-Risk Patients: • Reposition every 2 h (more often if possible); • Massage areas prone to pressure ulcers while changing position of patient • Use interface air mattress to reduce compression. • Clean with mild cleansing agents, keeping skin free of urine and feces. • Maintain head of the bed at a relatively low angle of elevation (<30°). • Evaluate and correct nutritional status; consider supplements of vitamin C and zinc. • Mobilize patients as soon as possible. 26Source: Bailey & Loves Short Practice of Surgery 25th ed
- 27. Management • Stages I and II Ulcers i. Topical antibiotics under moist sterile gauze for early erosions. ii.Normal saline wetto-dry dressings for debridement. iii.Hydrogels or hydrocolloid dressings. • Stages III and IV Ulcers Surgical management: • debridement of necrotic tissue • bony prominence removal, flaps and skin grafts. i. Infectious Complications ii.Prolonged course of antimicrobial iii.surgical debridement of necrotic bone in osteomyelitis. 27Source: Bailey & Loves Short Practice of Surgery 25th ed
- 28. C SKIN INFECTION
- 29. SKIN INFECTIONS • Skin and soft-tissue infections localised or spreading necrotising or non-necrotising. • Localised or spreading non-necrotising infections respond to broad-spectrum antibiotics. • Localised necrotising infections surgical debridement and antibiotic therapy. • Spreading, necrotising soft-tissue infection constitutes a life-threatening surgical emergency, requiring immediate resuscitation, intravenous antibiotic therapy and urgent surgical intervention with radical debridement. Source: Bailey & Loves Short Practice of Surgery 25th ed
- 30. Depth of involvement in skin & soft tissue infection Source: Rajan, S., 2012. Skin & soft tissue infection: Classifying and treating a spectrum, Cleveland Clinic Journal of Medicine, 79:1(61).
- 31. Erysipelas • Sharply demarcated streptococcal infection of the superficial lymphatic vessels, • Usually associated with broken skin on the face. • The area affected painful, well-defined, shiny, erythematous and oedematous plaques. • Palpation: skin is hot and tender • The patient febrile and have a leucocytosis. • Prompt administration of broad-spectrum antibiotics after swabbing the area for culture and sensitivity is usually all that is necessary. Source: Bailey & Loves Short Practice of Surgery 25th ed
- 32. Impetigo • Superficial skin infection with staphylococci, streptococci or both. • Highly infectious and usually affects children. • Characterised by blisters that rupture and coalesce to become covered with a honey-coloured crust. • Tx: - directed at washing the affected areas - applying topical anti-staphylococcal treatments. *If streptococcal infection broad-spectrum oral antibiotics Source: Bailey & Loves Short Practice of Surgery 25th ed
- 33. Cellulitis/lymphangitis • Bacterial infection of the skin and subcutaneous tissue that is more generalised than erysipelas. • Associated with previous skin trauma or ulceration. • Characterised by an expanding area of erythematous, oedematous tissue that is painful and associated with a fever, malaise and leucocytosis. • Erythema tracking along lymphatics may be visible (lymphangitis). • Causative organism is Streptococcus. • Blood and skin cultures for sensitivity should be taken • Before prompt administration of broad-spectrum intravenous antibiotics and elevation of the affected extremity. Source: Bailey & Loves Short Practice of Surgery 25th ed
- 34. Infections of the hair follicles
- 35. Folliculitis Furuncle Carbuncle Lesion distribution Any hair bearing region beard area, posterior neck, occipital scalp, axillae, Inguinal area, buttocks Lesion characteristics multiple small papules and pustules on an erythematous base that are pierced by a central hair, although the hair may not always be visualized. • Initial firm tender nodule, red ,hot &tender • Nodule becomes fluctuant with abcess with or without central pustule • Same evolution like furuncle • Composed of multiple, adjacent furuncle • Multiple dermal &subcutaneous abcess, superficial pustule & necrotic plugs Symptoms Throbbing pain, tenderness Tender, throbbing pain Tender, throbbing pain and low grade fever
- 36. Management
- 37. I&D PROCEDURE 1. Make an incision directly over the center of the cutaneous abscess *Successful entrance into abscess cavity will show purulent drainage. 2. Extend the incision to create an opening large enough to ensure adequate drainage and to prevent recurrent abscess formation. 3. For culture : use a swab or syringe sample from the interior aspect of the abscess cavity 37 Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
- 38. 38 4. Allow pus drainage (spontaneously or use gauze or gentle press). 5. Use curved hemostats for further blunt dissection to break loculations and to allow the abscess cavity to be opened completely. 6. Gently irrigate the wound with normal saline to reach the interior of the abscess cavity. 7. Gently pack the abscess by starting in one quadrant & gradually working around the entire cavity (wound packing material with or without iodoform) Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
- 39. Aftercare: • Antibiotics is not required after most successful I&D procedures performed in healthy patients unless extensive cellulitis (+) beyond abscess area. • Cover the abscess wound with a sterile, non adherent dressing. • Check that the patient’s tetanus immunizations are up-to-date . • Remove packing material after 2-3 days. 39 Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
- 40. Life threatening Skin & Soft tissue Infections 1.Group A β-hemolytic streptococcal gangrene •Extremely rapid progressing skin and soft-tissue infection. • Causative organisms hemolysins, streptolysins O and S (which are cardiotoxic), and leukocidins. •Gangrene when the cutaneous blood vessels thrombose, finding is often associated with intense local pain. •The involved skin is initially erythematous and indurated but, if tx is delayed, quickly evolves to contain hemorrhagic blebs with focal necrotic zones •Therefore, prompt, aggressive tissue debridement and antibiotic therapy are necessary for a favorable outcome Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
- 41. FIG 1& 2: Strepto. gangrenous infection (so-called flesh-eater) of the arm, involving skin and subcutaneous tissues, that followed a minor penetrating traumatic event. Pic below: Close-up displaying obvious necrosis of superficial tissues. FIG 3: Streptococcal gangrene of the abdominal wall following an elective operative procedure. The incision can be seen in the umbilical area, with tape strips covering it. Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
- 42. 2.Clostridial myonecrosis (“gas gangrene”) • A destructive infectious process of muscle ass. with infections of the skin and soft tissues. • Often ass. with local crepitance and systemic signs of toxemia, caused by the anaerobic, gas-forming bacilli of the Clostridium genus. • Occurs after abd. operations on the GI tract; however, penetrating trauma, such as gunshot wounds and frostbite, can expose muscle, fascia, and subcutaneous tissues to these organisms. • Pt complaints sudden onset of pain at site of trauma or surgical wound, which rapidly increases in severity and extends beyond the original borders of the wound. • The skin initially becomes edematous and tense pale appearance progress to magenta hue. Hemorrhagic bullae common (as is a thin, watery, foul-smelling discharge) • Examination of the wound discharge by Gram staining reveals abundant large, gram- positive rods with a paucity of surrounding leukocytes. Tx: debridement, IV antibiotic Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
- 43. FIG 4: Clostridial myonecrosis (“gas gangrene”) following emergent surgery for penetrating abdominal trauma. At debridement, all layers of the abdominal wall were involved. Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
- 44. Necrotising fasciitis • Surgical emergency • Polymicrobial, synergistic infection – most commonly a streptococcal species (group A β-haemolytic) in combination with Staphylococcus, Escherichia coli, Pseudomonas, Proteus, Bacteroides or Clostridium; • 80% have a history of previous trauma/infection • Rapid progression to septic shock • Predisposing conditions include: diabetes; smoking; penetrating trauma; pressure sores; immunocompromised states; IV drug abuse; skin damage/infection (abrasions, bites and boils). Source: Bailey & Loves Short Practice of Surgery 25th ed
- 45. • Classical clinical signs include: - oedema stretching beyond visible skin erythema, - a woody hard texture to the subcutaneous tissues, - an inability to distinguish fascial planes and muscle groups on palpation, - disproportionate pain in relation to the affected area with ass. skin vesicles and soft-tissue crepitus. - Lymphangitis tends to be absent. • Patients may be febrile and tachycardic, with a very rapid progression to septic shock. • Radiographs may demonstrate air in the tissues, but diagnosis are made promptly on the basis of symptoms and signs without recourse to ‘screening radiography’ • Management: urgent fluid resuscitation, monitoring of haemodynamic status and administration of high-dose broad-spectrum intravenous antibiotics. • Mortality of between 30% and 50% can be expected even with prompt operative intervention.
- 46. C THANK YOU
Notes de l'éditeur
- semilunar= half a moon Serpiginous= wavy/indented margin
- Rodent ulcer: skin lesion of nodular basal cell carcinoma with central necrosis and is a type of basal cell carcinoma (frequently near the inner canthus of the eye) Hunterian chancre:the primary sore of syphilis and occurs at the site of entry of the infection. This lesion is also known as a hard, Hunterian or true chancre. The chancre is a hard ulcer, characteristically painless, and highly infective. 90% of chancres are genital, the rest are mostly anal. Gummatous: tertiary sore of syphilis
- Edge: the area btwn the margin and floor of the ulcer -sloping: Ulcer is superficial/ shallow, has good chance in healing. Healthy granulation tissue usually is pinkish=good vascularity -punched out: There's rapid death over full thickness of tissue with minimal attempts of the body to repair it. Seen in neuropathic ulcer and ischemia ulcer. -raised: Tissues over edges are growing slowly, which is usually pale/pink in color, with telangiectasis seen over the pearly edges. An ulcer with rolled edges is almost diagnostic of a rodent ulcer of BCC
- Floor : exposed surface of the ulcer : usually made up of granulation tissues or slough tissues with underlying structures are exposed. : Any adherence to the floor. Wash-leather slough (like wet chamois leather) -Stasis ulcer moist granulating base that oozes venous blood when manipulated. -Ischaemic ulcer contains grayish, unhealthy-appearing granulation tissue with visible bones, tendons, periosteum. -Syphilitic ulcers slough tissue resembles a yellow-grey wash leather (gumma) dull red clean (primary stage) -Tuberculosis ulcers Unhealthy, soft-bluish granulation tissue. May appear yellow & caseous
- -Discharge: need to note the amount and smell -Serosanguineous 1 (of a discharge) thin and red. 2 composed of serum and blood.
- -Margin: the junction btwn normal epithelium & the ulcer (boundary of the ulcer) -Edge: the area btwn the margin and floor of the ulcer -Base: on which the ulcer rests (floor is the exposed surface within the ulcer n base is on which the ulcer rests) -Rel to deeper structure: a gummatous ulcer over a subcutaneous bone (tibia/ strernum) is often fixed. Malignant ulcers will obviously be fixed to deeper structure by infiltration -Induration:a n increase in the fibrous elements in tissue commonly associated with inflammation and marked by loss of elasticity and pliability : SCLEROSIS 2.: a hardened mass or formation
- Contrast radiography: arteriography to diagnose arterial/ischaemic ulcer Imaging technique: radioactive fibrinogen test - 125I-labelled fibrinogen in detecting DVT
- -Lipodermatosclerosis (LDS) is a condition that affects the skin just above the ankle in patients with long-standing venous disease resulting in chronic venous insufficiency. LDS literally means "scarring of the skin and fat" .Over time the skin becomes brown, smooth, tight and often painful. - Marjolin's ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized , [1] chronically inflamed, [2] or scarred skin. [3]:737[4] They are commonly present in the context of chronic wounds including burn injuries,venous ulcers, ulcers from osteomyelitis, [5] and post radiotherapy scars.
- Skin Graft : A skin graft is a procedure performed where healthy skin is removed from one area of the body, the donor site, and transplanted to another, the recipient site. The areas of the body that are most commonly used as donor sites for skin grafts are the leg, inner thigh, upper arm, forearm and buttocks. There are two main types of skin grafts and they are: Split or partial thickness graft – This is the most common type of graft. The epidermis (the top layer of the skin) and part of the dermis (the middle layer of the skin) are removed from the donor site and transplanted on the damaged area. It is possible that the graft can be spread over a mesh to increase the surface area covered. This type of graft heals relatively quickly but is quite fragile and not suitable for deep or infected wounds and the cosmetic result is often not good. Skin on the donor site can grow back from sweat glands and hair follicles. Full thickness graft – The entire epidermis and dermis are transplanted to the recipient site. Although the cosmetic effects can be good, full thickness grafts are only suitable for small areas. The donor site needs to either be closed with stiches, or have a partial thickness graft transplanted. Skin Flap: A skin flap is similar to a graft in that a transplantation of tissue occurs. The essential difference between the two is that a flap exists on it’s own blood supply. This means that much larger amounts of tissue can be transported, including muscle if required. There are many different types of surgical techniques used to create flaps, but they can be broadly classified into the following groups: Local flap – This is when the donor site is immediately adjacent to the recipient site. The required area of skin and tissue is moved without interrupting the blood supply. Distant flap – Distant flap is when a flap is from an entirely different area of the body, for example, a flap taken from the leg might be used for a wound on the neck. This may be achieved over the course of two or more operations depending on the complexity of the reconstruction. Free Flap – A Free flap is also a distant flap but the procedure is done in one stage using microsurgery to repair the blood and donor vessels establishing immediate blood flow. Pedicled/islanded flaps . The axial blood supply of these flaps means that they can be swung round on a stalk or even fully ‘ islanded’ so that the business end of the skin being transferred can have the pedicle buried (Fig 29.7). Free flaps . The blood supply has been isolated, disconnected and then reconnected using microsurgery at the new site (Fig. 29.8).
- Skin Flap: A skin flap is similar to a graft in that a transplantation of tissue occurs. The essential difference between the two is that a flap exists on it’s own blood supply. This means that much larger amounts of tissue can be transported, including muscle if required. There are many different types of surgical techniques used to create flaps, but they can be broadly classified into the following groups: Local flap – This is when the donor site is immediately adjacent to the recipient site. The required area of skin and tissue is moved without interrupting the blood supply. Distant flap – Distant flap is when a flap is from an entirely different area of the body, for example, a flap taken from the leg might be used for a wound on the neck. This may be achieved over the course of two or more operations depending on the complexity of the reconstruction. Free Flap – A Free flap is also a distant flap but the procedure is done in one stage using microsurgery to repair the blood and donor vessels establishing immediate blood flow. Pedicled/islanded flaps . The axial blood supply of these flaps means that they can be swung round on a stalk or even fully ‘ islanded’ so that the business end of the skin being transferred
- -a type of superficial cutaneous cellulitis with marked dermal lymphatic vessel involvement -painful, bright,red, raised, edematous, indurated plaque with advancing raised borders, sharply marginated from surrounding normal skin.
- -many of the features of erysipelas but extends to subcutaneous tissue -caused by group a streptococcus / staphy. aureus -diff from erysipelas: -cellulitis lesion are primarily not raised, -demarcation from uninvolved skin is indistinct - It commonly begins as a hot, red, edematous, sharply defined eruption and may progress to lymphangitis, lymphadenitis, and in severe cases, necrotizing fasciitis and gangrene. -Cellulitis usually occurs in the setting of local skin trauma from insect bites, abrasions, surgical wounds, contusions, and other cutaneous lacerations.
- -Folliculitis is a pyoderma that arises within a hair follicle. When this infection extends beyond the hair follicle, the process is known as a "furuncle" or "boil." -Any fluctuant nodules or masses should be incised and drained, and recurrent disease requires extended treatment.
- Mssa: Methicillin-sensitive Staphylococcus aureus mrsA: Methicillin-resistant Staphylococcus aureus -i&d: Cutaneous abscess (>5mm in diameter, accessible location) - If treatment of the uncomplicated localized processes caused by susceptible organisms requires intervention with antibiotics, oral agents, such as penicillinase-resistant penicillins or cephalosporins, could be used. - If a prompt response is not noted after parenteral antibiotic treatment has been administered, surgical exploration of the involved area may be indicated to rule out the presence of deeper necrotic or gangrenous tissue.
- Equipments : Universal precautions : gown, gloves, face mask with shield. Skin cleansing agents Sterile gauze 1% or 2% lidocaine with epinephrine; 5 to 10 cc syringe and 25- or 30- gauge needle for infiltration. Draping Scalpel blade (number 11 or 15) with handle Small curved hemostat Normal saline with a sterile bowl Large syringe with a splash guard or a needleless 18-gauge angiocatheter Culture swab Wound-packing material (plain or iodoform, ¼ or ½ inch), scissors, gauze, and tape Preparation: Inform the patient of procedure, potential severe complications, benefits, necessity of follow ups. Obtain informed consent. Wash hands with antibacterial soap and water. Wear gloves and a face shield at all times. Place equipments within reach, on a bedside table. Position the patient & adjust the lighting. Cleanse site & cover with drape. Anesthetize with 25-gauge or 30-gauge needle.
- Complications: Insufficient anesthesia Progression to surrounding cellulitis or lymphangitis, development of fever, or other signs of clinical worsening
- Gangrene: -change of color (pale, bluish purple n finally black) – loss of temperature, -loss of sensation, -loss of pulsation, loss of function
- - Common to all of these conditions is an environment containing tissue necrosis, low oxygen tension, and sufficient nutrients(amino acids and calcium) to allow germination of clostridial spores and production of the lethal a-toxin. Clostridia are gram-positive, spore-forming obligate anaerobes that are widely found in soil contaminated with animal excretia. - The definitive diagnosis of gas gangrene is based on the appearance of the muscle on direct visualization by surgical exposure, because many of the changes associated with such infections are not apparent when the tissue is inspected through a small traumatic wound. Initially, the muscle is pale, edematous, and unresponsive to stimulation. As the disease process continues, the muscle becomes frankly gangrenous, black, and extremely friable. This occurs, however, very late and is often accompanied by septicemia and shock.
- -Necrotizing soft tissue infection: necr. Cellulitis, necr. Fasciitis, myonecrosis -starts with erythema and painful induration of underlying soft tissues, rapid development of black eschar which transforms into liquefied black & malodorous necrotic mass.