What are Skin Ulcers?
A skin ulcer is an open sore normally assumed to be caused by poor blood flow (Ref 1).
Actually, poor blood flow is not the only reason. In a diabetic patient, the reason behind the slow healing of ulcers is the presence of high level of blood glucose that modifies the nascent collagen into a glycosylated collagen. Glycosylation is one of the post-translational modifications of a protein. Once when the collagen is glycosylated, it inhibits the natural collagen maturation by chemical cross-linking through enzymes like lysyl-oxidase.
Causes of Skin Ulcer
1. Diabetes
The slow healing of skin ulcers in a diabetic patient is the result of high level of blood glucose that not only affects the nerves (Neuropathy) and reduces the much-needed blood flow (Arterial and Venous insufficiency, Fig 2) but also impedes the natural maturation of the healing (granulation) tissue.
2. Atherosclerosis
Atherosclerosis, or arteriosclerosis, occurs as a result of fat buildup called plaque in the arteries resulting in blocked or narrowed blood vessels. With diabetes, the chances of developing atherosclerosis increases.
Arterial insufficiency will eventually reduce the blood supply much needed for tissue formation. Without enough blood flow, tissues will break down resulting in an open sore or ulcer.
3. Venous insufficiency
Venous insufficiency impedes the blood flow from the veins in your leg to your heart ultimately resulting in clogged veins. It is primarily caused by varicose veins and blood clots. The blood pooled inside the veins will exert pressure on the skin and cause venous ulcers.
4. Pressure
Constant pressure as result of unchanged position is not good for the blood vessels as it will squeeze the blood supply to the tissue eventually causing ulcer.
Types of Skin Ulcers:
Diabetes is one of the major inducers of different types of ulcers as follows
- Neuropathic Ulcer
- Venous Ulcer
- Arterial Ulcer
- Pressure Ulcer
The slow healing of the ulcers induced by Diabetes is the result of high level of blood glucose that not only affects the nerves (Neuropathy) and reduces the much-needed blood flow (Arterial and Venous insufficiency) but also impedes the natural maturation of the healing (granulation) tissue.
1.Neuropathic Ulcer
Neuropathic foot ulcers are caused by damaged nerves and narrowed arteries. Approximately, it affects about 15 percent of people with diabetes (Ref 2).These ulcers commonly affect the pressure points of the foot such as
- Heels
- Toes
- Soles
2.Venous Ulcer
Venous ulcers are caused by impeded blood circulation in the veins of the leg. They usually affect the calf muscles or the region between the knee and ankle. It has been estimated that 80-90% of leg ulcers are caused by venous insufficiency (Ref 3).
3. Arterial Ulcer
Arterial ulcer also known as ischemic ulcer is caused by blocked arteries resulting in poor blood flow. The commonly affected areas are:
- Lower leg
- Feet
- Heels
- Toes
- Exterior side of ankles
4.Pressure Ulcer
Pressure ulcers/Pressure sores are caused by non-stop friction or pressure on the skin. These ulcers commonly affect the bony areas as exert additional pressure on the skin as opposed to the external pressure.
It may also affect the following regions:
- Back
- Hips
- Buttocks
- Ankles
- Heels
Symptoms of Skin Ulcer
Appearance:
- Normally, a skin ulcer may appear as an open sore with a small diameter on the surface of the skin.
- The ulcer perimeter might be thick, elevated and slightly discolored.
- As the condition gets worse, the ulcer may resemble a crater.
- Exudate or a clear fluid will seep from the wound bed.
Other notable symptoms
- Redness
- Swelling
- Itchiness
- Tenderness
- Changes in Skin Texture
- Pain
- Pus due to an Infection
- Skin Discoloration
Diagnosis of Skin Ulcer
The following are the common methods of diagnosing a skin ulcer
- Medical history: It can help you understand the underlying root cause of the ulcer
- Physical exam: The size and depth of the sore will be examined. Excretion of blood, fluid, or pus will also be noted.
- Blood test: In case of an infection, the body’s defending response could be understood with a blood panel. Moreover, a blood test can help narrow down the root cause of the problem.
- Tissue or fluid culture: The causative agent (like type of bacteria) of an infection can be determined with this test. Based on the results, proper antibiotics will be administered.
- Imaging tests: In case of severe chronic ulcer that extends up to the bone, an X-ray, MRI or CT scan will help reveal the degree of ulceration.
Treatment of Skin Ulcer
Skin ulcer treatment can be categorized into at-home treatment and clinical management
1.At-home treatment
At-home treatments are suggested for mild skin ulcers. The following remedies are not advisable in cases of chronic skin ulcer
- Compression socks: Compression socks may help reduce leg swelling by directing the blood flow to the heart. However, just compressing the wound region might not suffice in certain cases. Under such circumstances, it is better to compress the swollen, wounded region with a biological skin substitute to aid in tissue formation and faster wound healing.
- Saline solution: Mild skin ulcers can be treated with a sterile combination of salt in water called saline. The same is not advised for a severe ulcer and proper medical assistance must be sought.
2.Clinical Treatment
At-home remedies might not aid in complete wound healing. Chances of recurrence and infection are bound to increase if the underlying cause of the ulcer is not properly dealt with. Following are the clinical treatments advised for chronic skin ulcers.
- Dressing: Purpose of a dressing is to protect the ulcer by maintaining a moist environment, hydrating the cells surrounding the wound and boosting the tissue granulation process. Commonly used dressings include hydrogels, moist dressings; collagen wound dressings, antimicrobial dressing and hydrocolloids.
- Antibiotics: Antibiotics must be administered if the wound is infected. Oral administration is the not the only option of treating an infected ulcer. Using an antimicrobial dressing can also help control the invasion of microbes on the site of infection. Use of a fenestrated membrane is not advised if the ulcer is infected.
- Pain medication: Frequent change of dressing will increase the pain and affect the underlying granulation process. A pain medication may be administered on replacement of dressing every 48 h.