Skin ulcers on limbs – Types, diagnosis and treatment

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An ulcer is defined as a break in continuity of the skin or mucous membrane. An example of mucous membrane is the inside of the mouth.

An ulcer can occur due to various causes ranging from trauma to specific illnesses like diabetes and tuberculosis.

Skin ulcers on limbs – Types, diagnosis and treatmentComponents of an ulcer

An ulcer consists of an edge, a floor and a base. The edge of an ulcer gives a clue to the cause, the floor is the raw tissue within the edge and the base is what tissue the ulcer rests on; for example, muscle or bone. The floor and edge are visible while the base of the ulcer has to be felt.

Types of skin ulcer

The simplest classification of ulcers is based on their case. We broadly divide ulcers into three groups:

  • Non-specific ulcers
  • Specific ulcers
  • Malignant ulcers

Non-specific skin ulcers include:

  • Traumatic ulcer - It results due to physical, chemical or mechanical trauma. Examples of these are an electrical burn, burn from an acid or an ulcer of the tongue due to friction against a jagged tooth.
  • Infective ulcer - Due to infection by bacteria or other organisms leads to pus formation causing an abscess which may burst resulting in an ulcer.
  • Arterial ulcer - These occur in parts of the limbs which undergo repeated trauma and pressure for e.g. the outer parts of the leg, upper part of the feet and heels. They are due to improper blood circulation to the skin commonly as a result of peripheral arterial disease and atherosclerosis (narrowing and hardening of the arteries). They are common in the elderly as they have poor circulation to the limbs and hence healing is affected.
  • Venous ulcer - This is the most common cause of an ulcer on the leg and occurs due to varicose veins or other medical conditions leading to increased blood pressure of the veins of the legs.
  • Neurogenic ulcer - When the nerves that sense pain are affected, the person may repeatedly injure a certain part of the body and may not be aware of the injury due to the lack of pain. These conditions include diabetes, due to alcohol, nerve injury or paraplegia (paralysis of both lower limbs). A bedsore is a trophic ulcer which occurs due to decreased blood supply, nerve problems and lack of proper nutrition. Bedsores must be avoided by shifting the patient’s position frequently and keeping the areas dry. Bedsores are difficult to heal and are extremely uncomfortable; so preventing them is the best option.
  • Tropical ulcer - Like the name suggests, these ulcers occur in people in the tropical countries generally on the feet and legs. A bacterial infection in a raw patch of skin is responsible. Other kinds of tropical ulcers are due to anaemia, malnutrition and lack of essential vitamins.
  • Diabetic ulcer - Diabetics are at a high risk of ulcers especially on the feet and legs. This is because even a slight injury may lead to infection which heals slowly due to excessive blood sugar. Also the nerves and blood vessels may be affected aggravating the problem. It is important for these patients to inspect their feet daily and follow a foot care regimen.

Specific ulcers

Prime examples in this group are tuberculosis and syphilis. Actinomycosis is a fungal infection included in this group.

Tuberculosis ulcer

Tuberculosis may lead to the formation of a cold abscess in bones, joints, intestine or lymph nodes. When the cold abscess bursts it forms typical oval shaped shallow ulcers which may be painful and discharge a liquid. When tuberculosis affects the skin, an ulcer is seen on the face or hands. This is called lupus vulgaris. This ulcer is peculiar in that the centre heals while the edges are active causing the ulcer to spread.

Syphilitic ulcer

Syphilis consists of three classical stages; primary, secondary and tertiary. Different types of ulcers are seen in all the stages. Most syphilitic ulcers are painless and are seen near the genitals, anus, mouth or nipples.

Actinomycosis

Multiple ulcers discharging pus are noticed. The skin around the ulcers will be bluish.

Diagnosis of skin ulcers

A thorough history including diabetes, tuberculosis and syphilis in the present or past as well as any injury before the ulcer was noticed is important. The physician will examine the ulcer and take a swab of the discharge if any and send it to the laboratory.

Investigations to diagnose skin ulcers

Examination of the pus or discharge gives a clue.

Other tests depend on the individual case, for example blood sugars are done if the person is diabetic or VDRL is done if syphilis is suspected.

Treatment of skin ulcers

Any underlying condition like varicose veins, tuberculosis or actinomycosis must be addressed. Local ointments such as an antibiotic steroid combination may be required to speed up healing.

In the next article we shall discuss malignant ulcers.

Photograph via sxc.hu

Written by Dr Nisreen Nakhoda, General Physician

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