Updated: 12/10/2019

Wounds

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  • A 50-year-old man presents for a routine checkup with his primary care physician. He has no complaints. He has a past medical history of diabetes with his last HbA1c of 14%, coronary artery disease, and thyroid disease. He is currently being treated with insulin but has trouble with adherence. On physical exam, his physician finds an ulcer on the plantar metatarsal head on the left side. The ulcer is 1 cm in diameter with undermined borders. It is mildly erythematous. His physician is concerned and refers him to a specialized center. (Diabetic foot ulcer)
Ecthyma Gangrenosum 
  • Clinical definition
    • ulcerative form of impetigo resulting from Pseudomonas aeruginosa infection and extends deep into the dermis 
      • typically occurs in immunocompromised patients
  • Pathogenesis
    • this ulcer usually occurs in the setting of bacteremia with bacterial invasion in the arteries and veins causing secondary ischemic necrosis
  • Presentation 
    • painless red macules that rapidly become pustules or bullae and then gangrenous “punched-out” ulcers with yellow crust and raised violaceous borders (all within 24 hours) 
      • commonly affects anogenital and axillary region
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • antibiotics
    • good wound care
Venous Ulcers
  • Clinical definition
    • ulcer resulting from chronic venous insufficiency, which can be caused by deep vein thrombosis or incompetence of valves
  • Pathogenesis
    • development of venous hypertension from venous insufficiency, leading to increased vascular permeability and release of inflammatory cells that cause skin changes and ulceration
  • Presentation
    • often presents between the knee and the ankle
    • erythematous beefy red wound with granulation tissue
    • surrounding skin is eczematous with scaling, weeping, and crusting
      • pruritus
      • typically not painful
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • good wound care
    • compression therapy, leg elevation, and leg exercises
    • aspirin
Pressure Ulcers
  • Clinical definition
    • ulcer resulting from vertical pressure
      • risk factors include elderly age, immobilization, and incontinence
  • Pathogenesis
    • enough pressure can prevent delivery of important nutrients and oxygen to tissue, resulting in accumulation of waste products and free radicals
    • muscles are most susceptible to damage, followed by subcutaneous fat and then dermis
    • moisture from sweat or urine can cause skin maceration and predispose the area to ulceration
  • Presentation 
    • commonly located over bony prominences
    • based on stage 
      • pre-ulcer stage with erythematous skin, often nonblanchable
      • more advanced ulcers can range from partial to full-thickness loss of skin and necrosis/eschar
      • may extend to the muscle and bones
    • edges of wound can be undermined
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • good wound care with a moist wound environment
      • debridement if necrotic tissue is present
    • position and re-position to relieve pressure or using support surfaces 
    • antibiotics if infected
Diabetic Foot Ulcers
  • Clinical definition
    • ulcer resulting from sequelae of diabetes
  • Pathogenesis
    • multifactorial etiology, including diabetic neuropathy (preventing sensation of pain in areas of trauma), vascular insufficiency, and autonomic dysfunction
  • Presentation
    • commonly on plantar metatarsal heads
    • ulcer with undermined borders
    • foot often has hyperkeratotic callouses
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • good wound care
      • debridement is often necessary
    • negative pressure wound therapy
    • mechanical offloading with methods like cast walkers and wedge shoes
    • improved glycemic control 
Ischemic Ulcers
  • Clinical definition
    • ulcer resulting from ischemia
    • also known as arterial insufficiency ulcer
  • Pathogenesis
    • arterial obstruction that causes inadequate perfusion to tissue
      • atherosclerosis, small vessel vasculitis, or thromboangiitis obliterans
  • Presentation
    • pain at rest
    • pain with elevation
    • sharply demarcated “punched-out” wound with little or no granulation tissue and minimal exudate
    • surrounding skin is shiny and tight and may have alopecia
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • good wound care with debridement if needed
    • revascularization if needed
Hypertensive Ulcers
  • Clinical definition
    • ulcer resulting from hypertension
      • uncommon
  • Pathogenesis
    • medial calcification that obliterates the small vessels, leading to decreased tissue perfusion and ulcer formation
    • a type of nonuremic calciphylaxis
  • Presentation
    • commonly located in the supramalleolar region or Achilles tendon
      • often bilateral
    • red patch that becomes cyanotic and forms an ulcer
    • painful
  • Making the diagnosis
    • diagnosis is made clinically
  • Treatment
    • treatment of hypertension
    • good wound care

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