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Ulcers & skin infections

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Ulcers & skin infections

  1. 1. C ULCERS & SKIN INFECTIONS BY: R. Nandinii Group K1
  2. 2. Overview • Ulcers of the skin -Definition & Causes -Identification of an ulcer -Examinations -Investigations -Types of ulcer -Management • Skin Infections • Impetigo • Erysipelas • Cellulitis • Infections of the hair follicles • Life threatening skin & soft tissue infections
  3. 3. ULCER DEFINITION: • A break in the continuity of the covering epithelium- skin / mucous membrane. Causes: • venous disease: superficial incompetence; deep venous damage(post-thrombotic) • arterial ischaemic ulcers; • rheumatoid ulcers; • traumatic ulcers; • neuropathic ulcers (diabetes); • neoplastic ulcers (squamous cell carcinoma and basal cell carcinoma) Source: Bailey & Loves Short Practice of Surgery 25th ed
  4. 4. IDENTIFICATION OF AN ULCER INSPECTION • Size & Shape • Number • Position • Edge • Floor • Discharge • Surrounding area • Whole limb PALPATION • Tenderness • Edge & margin • Base • Depth • Bleeding • Relations with deeper structure • Surrounding skin Source: A manual on Clinical Surgery 9th ed
  5. 5. ## Size important to know  Determines time required for ulcer to heal. Source: A manual on Clinical Surgery 9th ed
  6. 6. Position Source: A manual on Clinical Surgery 9th ed
  7. 7. Edge Source: A manual on Clinical Surgery 9th ed , Pictures from Doctors Hangout
  8. 8. FLOOR Source: A manual on Clinical Surgery 9th ed
  9. 9. 9Source: A manual on Clinical Surgery 9th ed
  10. 10. PALPATION Source: A manual on Clinical Surgery 9th ed
  11. 11. Examinations: Source: A manual on Clinical Surgery 9th ed
  12. 12. Investigations: • Routine examination of the blood • Examination of the urine • Bacteriological examination of the discharge • Skin test • Chest X ray • Biopsy • X ray of bone & joint • Contrast radiography • Imaging technique Source: A manual on Clinical Surgery 9th ed
  13. 13. C TYPES OF ULCER
  14. 14. Venous ulcer • Abnormal venous hypertension in the lower part of the leg • Venous drainage of the ankle via ankle perforating veins  when valves of this vein are damaged  local venous hypertension  Aggravated by obstructed main deep veins  Post-canalization of thrombosed deep vein  Destruction of the valves of the deep vein. • Complication: Carcinoma (Marjolin ulcer) from the growing edge of ulcer • Follows many years of venous disease (age group 40-60 years) • F > M • Discomfort & tenderness of skin, pigmentation & eczema mths/ years before ulcer. • Ulcer painful in the beginning chronic: painless Source: A manual on Clinical Surgery 9th ed
  15. 15. Venous Ulcer • Edge: Sloping • Margin: thin & blue of growing epithelium • Floor: Pale granulation tissue • Ulcer: Shallow & flat & never penetrates the deep fascia • Discharge: seropurulent • Base: Fixed to deeper structures
  16. 16. Arterial Ulcer • Rare compare to venous ulcer • Due to peripheral arterial disease & poor peripheral circulation. • Seen in older people & are episodes of trauma & infection of the destroyed skin over a limited area of the leg/foot. • Anterior & outer part of the leg, dorsum of the foot on the toes / heel. • Hx of intermittent claudication & rest pain • Pain during when leg is elevated. Source: A manual on Clinical Surgery 9th ed
  17. 17. Arterial Ulcer • Ulcers are punched out with destruction of deep fascia. • Tendon, bones & underlying joints exposed in the floor • Covered with minimal granulation tissue. • Presence of ischaemic changes : pallor, dry skin, loss of hair, fissuring of nails.
  18. 18. Neuropathic Ulcer • 3 factors cause diabetic ulcer: - diabetic neuropathy - diabetic atherosclerosis causing ischaemia - glucose laden tissue vulnerable to infection • Soles, toes, heel • Early symptoms of neuropathy : paresthesia, pain, anesthesia of leg and foot • Punched out corny edge. Floor is covered with slough. Tendons & bones can be seen. Source: A manual on Clinical Surgery 9th ed
  19. 19. Malignant Ulcer • Usually squamous cell carcinoma • Most commonly seen on the lips, cheek, hands, penis, vulva & old scar. • Mostly seen after 40 years of age. • Begins as small nodule  enlarge  gradually centre becomes necrotic & sloughs out & ulcer develops. Source: A manual on Clinical Surgery 9th ed
  20. 20. Malignant Ulcer • Oval / circular in shape. • Edge: raised & everted • Floor covered with necrotic tumour, serum & blood • Some granulation tissue  pale & unhealthy • Can be fixed due to involvement of deeper structures. • Regional lymph nodes enlarged.
  21. 21. CONSERVATIVE TREATMENT • Use of interactive dressings that are typically occlusive dressings. • Venous ulcers : commonly treated with multilayer compression dressings that assist the return of pooled blood to the central circulation. • Chronic wounds : administer systemic antibiotics & topical methods (silver sulfadiazine) to encourage wound healing. 21
  22. 22. SURGICAL THERAPY • Debridement or incision of the affected tissue prior to grafting. • Split-thickness skin graft (STSG) • Pedicled and free flaps 22
  23. 23. 23
  24. 24. Pressure Ulcer • Tissue necrosis with ulceration due to prolonged pressure. • Pressure sore frequency in descending order : Ischium Greater trochanter Sacrum Heel Malleolus (lateral then medial) Occiput Source: Bailey & Loves Short Practice of Surgery 25th ed
  25. 25. Staging System of American National Pressure Ulcer Advisory Panel STAGE DESCRIPTIONS 1 Non-blanchable erythema without a breach in the epidermis 2 Partial-thickness skin loss involving the epidermis and dermis 3 Full-thickness skin loss extending into the subcutaneous tissue but not through underlying fascia 4 Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving muscle, bone, tendon or joint 25
  26. 26. Prophylaxis for At-Risk Patients: • Reposition every 2 h (more often if possible); • Massage areas prone to pressure ulcers while changing position of patient • Use interface air mattress to reduce compression. • Clean with mild cleansing agents, keeping skin free of urine and feces. • Maintain head of the bed at a relatively low angle of elevation (<30°). • Evaluate and correct nutritional status; consider supplements of vitamin C and zinc. • Mobilize patients as soon as possible. 26Source: Bailey & Loves Short Practice of Surgery 25th ed
  27. 27. Management • Stages I and II Ulcers i. Topical antibiotics under moist sterile gauze for early erosions. ii.Normal saline wetto-dry dressings for debridement. iii.Hydrogels or hydrocolloid dressings. • Stages III and IV Ulcers Surgical management: • debridement of necrotic tissue • bony prominence removal, flaps and skin grafts. i. Infectious Complications ii.Prolonged course of antimicrobial iii.surgical debridement of necrotic bone in osteomyelitis. 27Source: Bailey & Loves Short Practice of Surgery 25th ed
  28. 28. C SKIN INFECTION
  29. 29. SKIN INFECTIONS • Skin and soft-tissue infections  localised or spreading  necrotising or non-necrotising. • Localised or spreading non-necrotising infections  respond to broad-spectrum antibiotics. • Localised necrotising infections  surgical debridement and antibiotic therapy. • Spreading, necrotising soft-tissue infection constitutes a life-threatening surgical emergency, requiring immediate resuscitation, intravenous antibiotic therapy and urgent surgical intervention with radical debridement. Source: Bailey & Loves Short Practice of Surgery 25th ed
  30. 30. Depth of involvement in skin & soft tissue infection Source: Rajan, S., 2012. Skin & soft tissue infection: Classifying and treating a spectrum, Cleveland Clinic Journal of Medicine, 79:1(61).
  31. 31. Erysipelas • Sharply demarcated streptococcal infection of the superficial lymphatic vessels, • Usually associated with broken skin on the face. • The area affected  painful, well-defined, shiny, erythematous and oedematous plaques. • Palpation: skin is hot and tender • The patient  febrile and have a leucocytosis. • Prompt administration of broad-spectrum antibiotics after swabbing the area for culture and sensitivity is usually all that is necessary. Source: Bailey & Loves Short Practice of Surgery 25th ed
  32. 32. Impetigo • Superficial skin infection with staphylococci, streptococci or both. • Highly infectious and usually affects children. • Characterised by blisters that rupture and coalesce to become covered with a honey-coloured crust. • Tx: - directed at washing the affected areas - applying topical anti-staphylococcal treatments. *If streptococcal infection  broad-spectrum oral antibiotics Source: Bailey & Loves Short Practice of Surgery 25th ed
  33. 33. Cellulitis/lymphangitis • Bacterial infection of the skin and subcutaneous tissue that is more generalised than erysipelas. • Associated with previous skin trauma or ulceration. • Characterised by an expanding area of erythematous, oedematous tissue that is painful and associated with a fever, malaise and leucocytosis. • Erythema tracking along lymphatics may be visible (lymphangitis). • Causative organism is Streptococcus. • Blood and skin cultures for sensitivity should be taken • Before prompt administration of broad-spectrum intravenous antibiotics and elevation of the affected extremity. Source: Bailey & Loves Short Practice of Surgery 25th ed
  34. 34. Infections of the hair follicles
  35. 35. Folliculitis Furuncle Carbuncle Lesion distribution Any hair bearing region beard area, posterior neck, occipital scalp, axillae, Inguinal area, buttocks Lesion characteristics multiple small papules and pustules on an erythematous base that are pierced by a central hair, although the hair may not always be visualized.  • Initial firm tender nodule, red ,hot &tender • Nodule becomes fluctuant with abcess with or without central pustule • Same evolution like furuncle • Composed of multiple, adjacent furuncle • Multiple dermal &subcutaneous abcess, superficial pustule & necrotic plugs Symptoms Throbbing pain, tenderness Tender, throbbing pain Tender, throbbing pain and low grade fever
  36. 36. Management
  37. 37. I&D PROCEDURE 1. Make an incision directly over the center of the cutaneous abscess *Successful entrance into abscess cavity will show purulent drainage. 2. Extend the incision to create an opening large enough to ensure adequate drainage and to prevent recurrent abscess formation. 3. For culture : use a swab or syringe sample from the interior aspect of the abscess cavity 37 Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
  38. 38. 38 4. Allow pus drainage (spontaneously or use gauze or gentle press). 5. Use curved hemostats for further blunt dissection to break loculations and to allow the abscess cavity to be opened completely. 6. Gently irrigate the wound with normal saline to reach the interior of the abscess cavity. 7. Gently pack the abscess by starting in one quadrant & gradually working around the entire cavity (wound packing material with or without iodoform) Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
  39. 39. Aftercare: • Antibiotics is not required after most successful I&D procedures performed in healthy patients unless extensive cellulitis (+) beyond abscess area. • Cover the abscess wound with a sterile, non adherent dressing. • Check that the patient’s tetanus immunizations are up-to-date . • Remove packing material after 2-3 days. 39 Source: Fitch, M., et. Al, 2007. Abscess Incision & Drainage, The New England Journal of Medicine, 357:20 (1-6)
  40. 40. Life threatening Skin & Soft tissue Infections 1.Group A β-hemolytic streptococcal gangrene •Extremely rapid progressing skin and soft-tissue infection. • Causative organisms  hemolysins, streptolysins O and S (which are cardiotoxic), and leukocidins. •Gangrene  when the cutaneous blood vessels thrombose, finding is often associated with intense local pain. •The involved skin is initially erythematous and indurated but, if tx is delayed, quickly evolves to contain hemorrhagic blebs with focal necrotic zones •Therefore, prompt, aggressive tissue debridement and antibiotic therapy are necessary for a favorable outcome Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
  41. 41. FIG 1& 2: Strepto. gangrenous infection (so-called flesh-eater) of the arm, involving skin and subcutaneous tissues, that followed a minor penetrating traumatic event. Pic below: Close-up displaying obvious necrosis of superficial tissues. FIG 3: Streptococcal gangrene of the abdominal wall following an elective operative procedure. The incision can be seen in the umbilical area, with tape strips covering it. Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
  42. 42. 2.Clostridial myonecrosis (“gas gangrene”) • A destructive infectious process of muscle ass. with infections of the skin and soft tissues. • Often ass. with local crepitance and systemic signs of toxemia, caused by the anaerobic, gas-forming bacilli of the Clostridium genus. • Occurs after abd. operations on the GI tract; however, penetrating trauma, such as gunshot wounds and frostbite, can expose muscle, fascia, and subcutaneous tissues to these organisms. • Pt complaints sudden onset of pain at site of trauma or surgical wound, which rapidly increases in severity and extends beyond the original borders of the wound. • The skin initially becomes edematous and tense pale appearance progress to  magenta hue. Hemorrhagic bullae common (as is a thin, watery, foul-smelling discharge) • Examination of the wound discharge by Gram staining reveals abundant large, gram- positive rods with a paucity of surrounding leukocytes. Tx: debridement, IV antibiotic Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
  43. 43. FIG 4: Clostridial myonecrosis (“gas gangrene”) following emergent surgery for penetrating abdominal trauma. At debridement, all layers of the abdominal wall were involved. Source: Nichol, R. & Florman, S., 2001. Clinical Presentations of Soft-Tissue Infections and Surgical Site Infections, Clinical Infectious Diseases, 33:2 (S85-S86)
  44. 44. Necrotising fasciitis • Surgical emergency • Polymicrobial, synergistic infection – most commonly a streptococcal species (group A β-haemolytic) in combination with Staphylococcus, Escherichia coli, Pseudomonas, Proteus, Bacteroides or Clostridium; • 80% have a history of previous trauma/infection • Rapid progression to septic shock • Predisposing conditions include: diabetes; smoking; penetrating trauma; pressure sores; immunocompromised states; IV drug abuse; skin damage/infection (abrasions, bites and boils). Source: Bailey & Loves Short Practice of Surgery 25th ed
  45. 45. • Classical clinical signs include: - oedema stretching beyond visible skin erythema, - a woody hard texture to the subcutaneous tissues, - an inability to distinguish fascial planes and muscle groups on palpation, - disproportionate pain in relation to the affected area with ass. skin vesicles and soft-tissue crepitus. - Lymphangitis tends to be absent. • Patients may be febrile and tachycardic, with a very rapid progression to septic shock. • Radiographs may demonstrate air in the tissues, but diagnosis are made promptly on the basis of symptoms and signs without recourse to ‘screening radiography’ • Management: urgent fluid resuscitation, monitoring of haemodynamic status and administration of high-dose broad-spectrum intravenous antibiotics. • Mortality of between 30% and 50% can be expected even with prompt operative intervention.
  46. 46. C THANK YOU

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