Large Chronic Ulcers

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An ulcer or sore is a breach in the continuity of the skin and the underlying tissue. Large ulcers can cause a lot of morbidity and lead to serious complications. Predisposing and underlying disease needs to be investigated. Complications include deformity, ankylosis of joints,  osteomyelitis, cellulitis and malignant transformation of ulcers. Surgical treatment may be needed.

Cause

  • Infections and infestations e.g. Buruli ulcers, yaws ulcers, tuberculous ulcers, guinea worm ulcers
  • Non-specific ulcers e.g. pressure (decubitus), traumatic, venous, diabetic, sickle cell ulcers, ischaemic 
  • Malignant ulcers e.g. squamous cell carcinoma, melanoma, Kaposi’s sarcoma

Symptoms

  • Pain 
  • Loss of sensation at site of ulcer
  • Discharge, which may be offensive
  • Severe disfigurement 
  • Disability

Signs

  • Sloping edges (non-specific ulcers)
  • Undermined edges (buruli and tuberculous ulcers)
  • Punched out edges (yaws ulcers) 
  • Raised everted edges (malignant ulcers)
  • Loss of sensation in affected part (diabetes, leprosy, yaws or syphilis ulcers)
  • Deformity of affected part
  • Wound discharge (purulent or offensive) 
  • Gangrene of affected part (diabetes, peripheral vascular disease)
  • Darkening of affected area  (peripheral vascular disease, venous insufficiency)
  • Pink granulation tissue without slough (healthy wound)

Investigations

  • FBC, ESR
  • Sickling test
  • Fasting blood glucose
  • Wound swab for culture and sensitivity, Ziehl Nielsen staining
  • VDRL/RPR test 
  • X-ray of underlying bone

TreatmentTreatment Objectives

  • To deslough the ulcer and promote healthy granulation tissue formation
  • To promote healing
  • To identify and manage any underlying cause
  • To prevent complications

Non-pharmacological treatment

  • Change dressing daily
  • Use absorbent dressing for wounds that have profuse discharge
  • Deslough wounds that have adherent slough
  • Elevate lower limb on sitting
  • Adequate nutrition

Pharmacological treatment 

Evidence Rating: [C]

A. For non-antiseptic wound cleansing

  • Normal saline solution (Do not use Eusol)

B. For antiseptic wound cleansing

Evidence Rating: [C]

  • Chlorhexidine solution 4%, topical, 

Or 

  • Cetrimide 15%, topical,

Or

  • Povidone iodine solution 10%, topical,

C. Systemic antibiotic treatment for secondary bacterial infections

Specific antimicrobial treatment is guided by culture and sensitivity results.

Empiric antibiotic treatment may be initiated while awaiting culture and sensitivity results based on suspected or likely organisms.

Note: Avoid topical antibiotics as there is insufficient evidence for their effectiveness

Referral CriteriaRefer patients with ulcers failing to show signs of healing with above treatment, and patients who would require surgery either for skin grafting, wound excision or limb amputation to a surgical specialist. All ulcers suspected to be malignant should also be referred to a surgical  specialist.