This is a detailed tutorial about how to diagnose a patient with ulcer. This approach leads you to reach a final diagnosis and to put the plan of management.
Note especially the following points:
1.Duration : This is short in acute ulcers and long in chronic ulcers. In venereal ulcers, inquire about the incubation period : 3-4 weeks in syphilitic chancre and 3-4 days in soft sore (chancroid).
2. Mode of onset: Inquire whether the ulcer has followed trauma (wound or burn) or has arisen in a previous local lesion. (.g. papule, Jump, callosity or patch of dermatitis.
3. Pain: Acute ulcer and tuberculous ulcers are painful whereas syphilitic ulcers and trophic ulcers are entirely painless.
Pain in absent in the early stages of rodent ulcer and epithelioma.
4. Discharge: Whether serum, pus or blood.
5. Progress: Whether spreading, stationary, healing or showing remissions and exacerbations. Inquire about any constitutional symptoms, such as fever and rigor, and about the effect of any treatment so far received.
6. Past history : Inquire about any history of specific in-fection (syphilis or tuberculosis), constitutional disease (diabetes or nephritis), peripheral vascular disease (varicose veins or intermittent claudication) or neurological disease.
- Always examine the urine for sugar and albumin.
- Particularly in elderly people, look for signs of cardiovascular disease and in trophic ulceration carry out a full neurological examina-tion.
- In tuberculous ulcers search for other tuberculous lesions in the skeleton, lymph nodes and viscera. When syphilis is suspected look for syphilitic stigmata, viz. saddle nose, perforat-ed palate, Hutchinson's teeth, wrinkling of the forehead, ptosis of the eyelids, absence of tendon reflexes and bone sense, Argyll-Robertson pupil and sensory ataxia (Rombergism).
Proceed systematically as follows:
- Number: Most ulcers are solitary but tuberculous and syphilitic ulcers may be multiple or recurrent.
- Site: Certain ulcers have a predilection for specific Parts of the body. Varicose ulcers are commonest in the lower third of the inside of the leg, perforating ulcers in the sole of the foot and gummatous ulcers in the upper third of the leg. Most rodent ulcers occur on the upper part of the face while 'Tithelioma is common on the lower lip and extragenital chancre on the upper. Tuberculous ulcers are comaxonly found on le neck and soft and hard chancres usually over the genetalia.
- Size: Note the size of the ulcer in relation to its duration. A CarCit1011111 spreads more rapidly than a rodent ulcer but more solwly than a septic ulcer.
- Shape: The contour may be round, oval, elong-ated, irregular or serpigi-nous, Tuberculous ulcers are oval with an irregular crescent is border. Gum ma toils ulcers are typically circular or semilunar but may unite to form a serpiginous ulcer. A rodent ulcer is more regular than a carcinoma.
- Floor: This is the visible area denuded of epithelium. Note its depth, the presence of sloughs and the type of tissue present ; whether necrotic material, granulations or t um our tissue.
- Edge: The edge is usually sloping or terraced in septic ulcers ; undermined in tuberculous and sarcomatous ulcers ; punched out in callous and syphilitic ulcers ; rolled-in and beaded in rodent ulcers and raised, nodular and everted in carcino-matous ulcers.
- Margin: This is the region between the edge and the normal surface around. it may be healthy or the seat of con-gestion, utdema, inflammation, etrzyma, pigmentation, indura-tion or outlying nodules. if there is a healing sear, note whether healthy, thin and papery or thick and keloidal.
- Discharge: Not elltin mount , roimititom!o, polour and smell.
- Base: This is the zone of tissue on which the ulcer is situated. It is invisible as it lies beneath the ulcer and around its edge. It should be palpated for warmth, tenderness, consistency and mobility. Slight indursition of the base may be Present in any chronic ulcer but marked induration is characteristic of carcinoma.
- Regional lymph nodes: They should be palpated for tenderness or enlargement. If enlarged, note their number, size, consistency and mobility. The glands are not affected in rodent and gummatous ulcers. They are markedly inflamed in acute ulcers ; discrete, firm and shotty in Hunterian chancre ; and stony hard in epitheliomatous ulcers.
- Local circulation: Examine the part thoroughly for any impairment of the arterial supply or venous drainage.
- Nerve supply: The sensations should always be tested in the surrounding skin and if a nerve lesion is suspected the nervous system should be thoroughly examined.
Types and shapes of ulcer
- Urine: Should always be examined for sugar and albumin.
- Blood: Special tests are carried out as indicated, e.g. blood sugar for diabetes, sedimentation rate for tuberculosis and W.A. for syphilis.
- Bacteriological examination : The discharge is examined for specific organisms, such as spirochxtes (dark-ground illumi-nation), tubercle bacilli (Ziehl-Neelsen stain, culture and animal inoculation) orpyogenic organisms (culture and antiobiotic sensitivity).
- Biopsy: doubtful cases. a wedge biopsy should be taken from the edge of the ulcer under local anmsthesia.
- X-ray examination: Plain radiography is carried out if raphy if peripheral the ulcer is fixed to a bone or joint and angiog vascular disease is suspected.
Defferential Diagnosis of Ulcer
1. Simple ulcers are due to direct destruction of the skin by trauma, heat or chemicals, supplemented by infection with pyogenic organisms. The clinical features of the ulcer depend ()1 its pathological state, i.e. whether spreading, healing or callous.
- a) A spreading ulcer is acute and painful. The floor is covered with sloughs, the discharge is profuse and the sur-r2unding tissues are acutely inflamed.
- b) A healing ulcer is painless, clean and covered with urn-form pink granulations. The discharge is slight and serous and the edge is sloping with a thin iris of bluish-white epithelium creeping over the floor.
- c) A callous ulcer has been present for a long time in an unhealed state. The granulations are pale and scanty and the base is indurated and fibrous and often adherent to the under-lying fascia or bone. The edges arepunched out and the surrounding skin is often pigmented and scaly.
2. Varicose ulcer: A callous ulcer typicall situated on the medial side of the lower third of the leg (ulcer-bearing area) and surrounded by pigmentation, eczema and dermatitis. The Presence of varicose veins in the leg and thigh confirms the diagnosis.
3. Trophic ulcers: are due to prolonged pressure on denervated or devitalized skin. They occur most often on the back of bed-ridden patients (bedsores) and the soles of ampulant Patients (Perforating ulcers).
- a. Bedsores (Decubitus ulcers) are Particularly common in paraplegic patients. They usually involve the pressure points over the sacrum, ischial tuberosities greater trochanters, and scapulae. The skin becomes swollen, shiny and congested and soon breaks down with severe inflammation and extensive sloughing. The ulcer often extends superficially to involve a wide area of skin and penetrates deeply to expose the muscles and bones.
- b. Perforating ulcers: occur most com monly in association with peripheral neuritis, tabes dorsalis, poliomyelitis, spina bifida and peripheral nerve injuries and less often with peripheral vascular disease, diabetes mellitus or nephritis, particularly in senile patients. The lesion starts as a thick callosity under the heel or the head of the first metatarsal. An adventitious bursa develops beneath the callosity and becomes infected to form an abscess which discharges through a small sinus in the horny layer. The condition is entirely painless and the patient continues to walk about on his foot so that the ulcer burrows deeply to involve the flexor tendons, bones or joints. Examination reveals a very deep ulcer with a punched out edge surrounded by the thick callosity and the anaesthetic skin.
4. Tuberculous ulcers: may develop in relation to any tuberculous structure, such as a lymph node, a bone or a joint. The ulcers aro small, painful and irregular. Their edges are thin, bluish and undermined and the floor is pale and covered with feeble granulations. The base is soft and the discharge is thin and watery with flakes of caseous material.
5. Syphilitic ulcers may occur in any stage of the disease.
- (a) Hard chancre appears initially 3.4 weeks after exposure to infection. It is a painless superficial ulcer usually oval in shape with sloping edges and serosanginous discharge. The floor is covered with pink granulations and the base is indurated and feels like a buried button. The nearest lymph nodes are invariably enlarged and "shotty" being small, discrete and painless with no tendency to softening or suppuration. However, Extragenital chances are usually not indurated and the regional lymph nodes are always considerably enlarged.
- (b) Mucous patches and NI;ail track ulcers occur on the mucous surfaces of the mouth or fames in the secondary stage of the disease. The former show as white patches of sodden thickened epithelium and the latter as superficial spreading ulcers, glistening from adherent mucus. Fissures with edematous edges also occur in the moist areas around the mouth and anus, usually in association with condylomata. There is often generalized enlargement of lymph nodes ; the epitrochlear and suboccipital groups are particularly involved.
- (c) Gummatous ulcers: arise from breaking down of cutaneous or subcutaneous gurnmata. They occur most often over the subcutaneous bones (sternum, ulna and skull), testis, upper part of the leg and sternomastoid. They are circular in shape with punched out edges and the floor is first covered with a yellowish-grey -wash -leather" slough which slowly exposing characteristic fiery red granulations. Lymph nodes are not involved unless secondary infection is present. Frequently, several gummata coalesce to form a serpiginous ulcer. Such ulcers tend to heal and break down again. The scars of healed ulcers are dead white, thin and papery and usually circular or crenated in outline.
6. Soft chancre (sore) : A venereal disease due to the bacillus of Ducrey. After a short incubation period (3 or 4 days), a vesicle appears and breaks down to form an ulcer about a week after infection. The ulcers are multiple and painful with oedematous edges, yellowish slough and copious purulent discharge. The regional glands are enlarged and inflamed with extensive suppuration and periadenitis (buboes).
7. Oriental sore : A specific granuloma of the skin due to Leishmania tropica which is transmitted by the sand fly. The ipcubation period is variable and may extend up to several months after exposure. The lesions may be multiple or solitary and usually occur on exposed parts of the body. A small itching nodule appears, grows slowly and ultimately ulcerates. The ulcer slowly enlarges, discharg-ing a scanty serous fluid which becomes inspissated to form a crust beneath which the sore extends. Diagnosis is estab-lished by puncture at the margin ; Leishrnania Donovani bodies will he found inside large macrophages.
8. Rodent- ulcer occurs usually on the upper part of the face in middle-aged subjects, especially males. It arises as a firm red papule which breaks down to form a rounded ulcer with a red granular floor, an indurated base and a regular clearly-cut or rolled in beaded edge. The ulcer extends slowly and erodes the underlying tissues including car-tilage and bone. The lymph glands are never affected by metastases but may be en-larged from secondary infection.
9. Carcinomatous ulcer (epithelioma) often develops on the top of a longstanding precancer-
ous lesion such as an ulcer, burn scar or wart. It may take the form of an elevated crater or a deep excavation. The ulcer has an irregular contour with raised everted nodular edges and an irre-gular floor composed of necrotic material or haemorrhagic tumour tissue. The base is typically hard and indurated and is often fixed to the deeper structures. Involved lymph nodes are hard and mobile and later fixed to the deeper structures.
10. Sarcomatous ulcer is due to stretching and pressure necrosis and not to neoplastic invasion so that the ulcer lies on the top of a bulky fleshy vascular tumour mass. The floor consists of fungating tumour tissue and the edges are thin and undermined and not indurated. The surrounding skin is congested and the seat of dilated veins is not adherent to the underlying tissues so that a probe can be inserted between the skin and the tumour mass at the edge of the ulcer. The regional glands are not affected but distant metastases are common.
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