Ulcers

Abstract

Ulcers have multiple causes, including vascular diseases, neoplasms, hematologic disorders, drug-induced, connective tissue diseases, neurologic disorders, infections, physical etiologies, and idiopathic. The history and physical may point to the cause. However, laboratory testing is frequently necessary to confirm the diagnosis. Treatment is focused on removing the underlying cause of the ulcer along with good wound care that promotes healing.

Key Points

1.

Ulcers have many causes
2.

Good wound care promotes healing
3.

Cure requires resolution of the underlying etiology

Definition

An ulcer is an open sore that results from loss of the epidermis and part or all of the dermis ( Fig. 19.1 ). Ulcers have numerous causes ( Table 19.1 ). A detailed history and physical examination are often sufficient to establish a diagnosis; however, laboratory tests may be necessary to confirm the initial clinical impression.

Table 19.1

Etiology of Ulcers

Vascular

●

Venous stasis
●

Arteriosclerosis
●

Thromboangiitis obliterans
●

Vasculitis
●

Embolic – tumor, infections (SBE)
●

Hypertension
●

Calciphylaxis

Alpha-1-antitrypsin deficiency
Erythema induratum
Livedoid vasculopathy

Neoplastic

●

Carcinoma – cutaneous or metastatic
●

Lymphoma – mycosis fungoides
●

Sarcoma – Kaposi’s sarcoma

Hematologic

●

Hemoglobinopathy – sickle cell anemia, spherocytosis, thalassemia
●

Dysglobulinemia – cryoglobulinemia, macroglobulinemia
Hypercoagulopathic disorders

Drug-related

●

Methotrexate
●

Bleomycin
●

Ergot
●

Coumarin
●

Heparin
●

Iodine
●

Bromine
Illicit drug use

Connective tissue disease

●

Rheumatoid arthritis
●

Lupus erythematosus
●

Scleroderma
●

Dermatomyositis

Neurologic

●

Neuropathic – diabetes, syringomyelia, tabes dorsalis, leprosy, trigeminal trophic syndrome
●

Factitial

Infectious

●

Bacteria – atypical mycobacteria, tuberculosis, diphtheria, anthrax, tularemia, chancroid, granuloma inguinale, syphilis
●

Fungi – blastomycosis, histoplasmosis, chromomycosis, sporotrichosis, cryptococcosis, coccidioidomycosis, aspergillosis
●

Protozoa – leishmaniasis, amebiasis
●

Virus – herpes

Physical

●

Chrome
●

Coral
●

Beryllium
●

Radiation
●

Trauma
●

Cold
●

Heat
●

Pressure (decubitus)
●

Bites (brown recluse spider)

Unknown

●

Pyoderma gangrenosum
●

Necrobiosis lipoidica
●

Aphtous ulcers
●

Behceťs disease
●

Crohn’s disease

SBE, Subacute bacterial endocarditis.

Incidence

An ulcer is the chief complaint in 0.5% of the authors’ new patients. The frequency of different types of ulcer depends in part on the circumstances of the patient population. For example, decubitus ulcers are a common problem in bedridden patients, whereas leprosy might be considered in a patient from a tropical environment.

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