3. DEFINITION
A break in the continuity of the covering
epithelium of the skin or mucous
membrane
It may either follow molecular death of the
surface epithelium or its traumatic
removal
10. Spreading ulcer
Surrounding skin is inflamed
Floor is covered by slough
No evidence of granulation tissue
Purulent discharge
11. Healing ulcer
Surrounding skin not inflamed
Floor covered with granulation
tissue
Edges show bluish outline of the
growing epithelium
Slight serous discharge
12. Callous ulcer
Pale granulation tissue in the floor
Considerable induration at the base,
edge and surrounding skin
Show no tendency towards healing
14. Non-specific ulcers
These include:-
Traumatic ulcers
Arterial ulcers due to ischemia eg gangrene
Venous ulcers e.g. Varicose ulcer
Neurogenic ulcers (trophic ulcer)
Ulcers associated with malnutrition
Ulcers associated with other diseases e.g. Anemia,
Avitaminosis, Gout, Rheumatoid arthritis
Miscellaneous ulcer
15. Specific ulcers
These include:-
Infective ulcers e.g. syphilitic ulcers,
Tuberculous ulcer, fungal ulcers, Buruli
ulcer (a neglected tropical disease
caused by infection with Mycobacterium
ulcerans)
17. PATHOPHYSIOLOGY
The natural history of an ulcer
consists of three phases:-
Extension phase
Transition phase
Repair phase
18. Extension phase
The floor is covered with exudates
and sloughs
The base is indurated
The discharge is purulent or even
blood stained
19. Transition phase
Prepares for healing
The floor becomes cleaner and the
slough separates
The induration of the base
diminishes
The discharge become more serous
Small reddish area of granulation
tissue appear on the floor
20. Repair phase
Transformation of granulation to fibrous tissue,
which gradually contracts to form scar
The epithelium gradually extends from the new
shelving edge to cover the floor (at a rate of
1mm/day)
The healing edge consists of three zones:-
Outer zone
This is white in color
Middle zone
bluish in color, granulation tissue covered by few layers of
epithelium
Inner zone
Reddish in color, a zone of granulation tissue covered by a
single layer of epithelial cells
The red granulation tissue is due to increased density of
new capillaries (neo-angiogenesis)
22. History
Note the following:-
Duration (i.e. how long is the ulcer present?)
Acute: present for short time
Chronic: present for long time
Mode of onset (i.e. how has the ulcer
developed?)
Following trauma
Spontaneously e.g. following- swelling e.g.
ulcerating lymph node in Tuberculosis or a scar of
burn Marjolin’s ulcer
Marjolin's ulcers are the malignant transformation
of chronic wounds
23. History………
Pain (i.e. is the ulcer painful?)
Painful: ulcers associated with inflammation
Slight painful: tuberculous ulcer
Painless eg syphilitic, neurogenic, malignant ulcers
Discharge (i.e. does the ulcer discharge or
not?)
If YES: note the nature of discharge- pus, bloody,
serous
Associated diseases which may lead to ulcer
formation
e.g. Tuberculosis , Syphilis, Diabetes Mellitus,
nervous diseases
27. Inspection
Site: gives clue to the diagnosis
Varicose ulcer- lower limb on the
medial malleolus
Rodent ulcer-face
Tuberculus ulcer-cervical
Trophic ulcer – heal
Malignant ulcer- anywhere
28. Inspection……….
Shape:
Tuberculus ulcer- oval in shape
Syphilitic ulcer– circular in shape
Varicose ulcer – vertically oval in shape
Malignant – irregular in shape
Size:
May determine the time of healing
E.g. the smaller the ulcer the shorter the time
it will take to heal
29. Inspection……….
Surrounding skin
E.g. red and edematous- acute inflammation
Floor/surface i.e. exposed part of the ulcer may
give clue to the diagnosis
Eg red granulation – healing ulcer
Black floor- malignant melanoma
Number
Tuberculous ulcer
Gummatous ulcer
Varicose ulcer
Note: the number of ulcers may be more than one
30. Inspection……….
Edge: five types:-
Sloping edge e.g.
healing ulcer
Punched out edge
e.g. Gummatous
ulcer, deep trophic
ulcer
Undermined edge
e.g. tuberculous
ulcer-destroy
subcutaneous faster
the skin
Raised edge e.g.
Rodent ulcer
Rolled out (everted)-
e.g. Squamous Cell
Carcinoma
31. Inspection……….
Discharge: the character of the
discharge should be noted e.g.
Healing ulcer- scant serous discharge
Spreading ulcer- purulent discharge
Tuberculus ulcer- serosanguinous
Malignant ulcer- bloody discharge
Whole limb: should be examined
e.g. varicose veins
33. Palpation……….
Base (i.e. on which the ulcer rest)
Slightly induration- syphilitic ulcer
Marked induration- malignant ulcer
Depth:
eg trophic ulcer may be deep to reach the
bones
Bleeding
easy bleed on touch is a feature of malignant
Fixity to the deep structures
Eg malignant ulcers are usually fixed to deep
structures