Chronic Skin Ulcer

Chronic skin ulcers are wounds on the skin that fail to heal through the normal process of tissue repair and regeneration over a period of time, typically longer than four to six weeks. Their management is a significant challenge in healthcare, often requiring multidisciplinary care.

Causes

  • Venous Insufficiency Ulcers: Caused by chronic venous insufficiency leading to increased pressure in the veins of the lower legs.
  • Arterial Ulcers: Result from poor blood circulation due to arterial disease.
  • Diabetic Ulcers: Common in individuals with diabetes, due to neuropathy and poor circulation.
  • Pressure Ulcers (Bedsores): Due to prolonged pressure, often in bedridden patients.
  • Infectious Ulcers: Caused by bacterial, viral, or fungal infections.
  • Traumatic Ulcers: Due to injury, especially in people with poor circulation or neuropathy.
  • Malignancy: Rarely, skin cancers can present as chronic, non-healing ulcers.

Diagnosis

  • Clinical Assessment: Detailed history of the ulcer, including duration, pain, and previous treatments.
  • Physical Examination: Assessing ulcer location, size, depth, and any signs of infection.
  • Ankle-Brachial Pressure Index (ABPI): To evaluate arterial blood flow in arterial ulcers.
  • Blood Tests: To assess for diabetes, infection, and nutritional deficiencies.
  • Biopsy: If there is suspicion of malignancy or atypical presentation.
  • Imaging: Doppler studies, arterial/venous ultrasound for vascular assessment.

Differential Diagnosis

  • Vasculitic Ulcers: Due to autoimmune conditions.
  • Pyoderma Gangrenosum: A rare, painful ulcerative condition often associated with systemic disease.
  • Martorell Ulcer: A Martorell ulcer is a very painful ulcer of the lower leg that develops in association with poorly controlled hypertension and/or diabetes.
  • Cutaneous Neoplasms: Like squamous cell carcinoma or melanoma.
  • Infectious Etiologies: Such as mycobacterial, fungal, or syphilitic ulcers.
  • Atypical Infections: In immunocompromised patients, consider unusual infectious agents.

Management

  • A2BC2D
    • Assessment of the wound – TIME
      • Tissue
      • Infection
      • Maceration
      • Epithelialisation
    • Assessment of the patient
    • Best dressing
    • Compression? – ABPI +/- Duplex
      • Graduated compression
    • Concerns of the patient 
    • Document
  • Debridement: Removing necrotic tissue surgically or using dressings.
  • Control of Infection: Topical or systemic antibiotics based on culture results.
  • Wound Care: Regular cleaning and dressing changes. Moist wound healing environment is often recommended.
  • Compression Therapy: For venous ulcers, using compression stockings or bandages.
  • Offloading: For pressure and diabetic ulcers, using special footwear or mattresses.
  • Optimizing Blood Flow: Vascular surgery or angioplasty for arterial ulcers.
  • Blood Sugar Control: In diabetic patients to promote wound healing.
  • Nutritional Support: Adequate protein and calorie intake as well as vitamins and minerals (Vitamin C, Vitamin D, Zinc and arginine)
  • Pain Management: Analgesics as needed.
  • Advanced Therapies: Such as skin grafting, growth factor therapies, or hyperbaric oxygen therapy.

Referral

  • Specialist Referral: To vascular surgeons, dermatologists, or wound care specialists for complex or non-healing ulcers.
  • Multidisciplinary Approach: Involving dietitians, diabetes educators, and physiotherapists as well as specialist wound care nurses

Conclusion

Chronic skin ulcers require a comprehensive and multidisciplinary approach to treatment, focusing on both local wound care and addressing underlying systemic conditions. Regular monitoring and timely intervention can prevent complications such as infection and promote healing.

Factors the negatively impact on wound healing

Wound healing is a complex process that can be adversely affected by a variety of factors. These factors can impede the normal stages of wound healing, leading to delayed or non-healing wounds. Understanding these factors is crucial for optimizing wound care and management. Here are the key factors that can negatively impact wound healing:

  1. Age: Older age can slow down the healing process due to decreased skin elasticity, reduced regenerative capabilities, and other age-related changes.
  2. Blood Flow and Oxygenation: Conditions that reduce blood flow and oxygenation to the wound area can significantly delay healing
    1. Peripheral arterial disease
    2. Chronic venous insufficiency
    3. Diabetic angiopathy
  3. Diabetes Mellitus: High blood sugar levels can impair blood flow, reduce immune function, and slow the wound healing process.
  4. Infection: Wound infections can impede healing by increasing local tissue damage and inflammation.
  5. Nutritional Status: Poor nutrition, especially deficiencies in protein, vitamins (such as vitamin C and D), and minerals (like zinc), can impair wound healing.
  6. Smoking: Smoking constricts blood vessels, reduces oxygen supply to the wound, and impairs immune function.
  7. Alcohol Abuse: Excessive alcohol consumption can impair immune function, nutrition, and liver function, all of which are important in wound healing.
  8. Obesity: Can reduce blood flow to the skin and increase the risk of infection, particularly in surgical wounds.
  9. Immune System Function: Immunosuppression, whether due to conditions like HIV/AIDS, cancer, or the use of immunosuppressive medications, can delay wound healing.
  10. Medications: Certain medications, such as corticosteroids and NSAIDs, can impair wound healing.
  11. Chronic Diseases: Diseases such as renal failure, heart failure, and liver disease can interfere with normal healing processes.
  12. Stress: Chronic stress can impair immune function and thus negatively impact wound healing.
  13. Wound Care and Environment: Inadequate wound care, poor hygiene, repeated trauma to the wound, excessive moisture, or dryness can all impede healing.
  14. Prolonged Pressure on the Wound Site: Such as from bedsores or pressure ulcers in immobile patients, can cause tissue ischemia and necrosis.
  15. Foreign Bodies in the Wound: Can cause chronic irritation and inflammation, leading to delayed healing.
  16. Excessive Scar Tissue Formation: Can interfere with the supply of nutrients and oxygen to the wound.

For optimal wound healing, it is important to address these factors through comprehensive medical and nursing care, proper nutrition, adequate blood glucose control, cessation of smoking, appropriate use of medications, and effective stress management. In complex cases, a multidisciplinary approach involving healthcare providers from different specialties may be required.