This document provides an overview of ulcers, including their classification, clinical features, investigations, and management principles. Ulcers are classified based on duration (acute vs chronic), etiology (infectious, physical/chemical agents, circulatory impairment), and location (Wagner's classification for foot ulcers). Clinical features include characteristics of the site, size, shape, edges, floor, base, discharge, pain levels, and surrounding lymph nodes. Investigations may include hematological and biochemical tests, imaging, biopsies, and microbiological cultures. Management principles focus on determining the underlying cause, correcting comorbidities, adequate drainage and debridement, treating any infection, and using appropriate dressings to promote healing.

1. Ulcer
By
Dr Prashant Patil
MS ( gen Surgery)
Reader & HOD
Dept. of surgery

2. Ulcer
Breach in the
continuity of surface
epithelium ( skin /
mucus membrane )
due to molecular death
of tissue cell by cell

3. Classification
-
-- Acute < 12 wks -- healing
-- Chronic > 12 wks -- Non healing
Infection TB Sq. cell carcinoma
physical/ chemical agents Syphilis Melanoma
local irritation /Trauma basal cell CA ( rodent)
interference with circulation
- arterial / venous
Cropathic, Bazin’s, Martorells
Diabetic, Cortisol, Tropical
aetiological Duration healing
Non
specific
specific Malignancy

4. Classification
 Wagner’s Classification (foot ulcers)
 The Wagner scale is used to classify the severity of foot ulcers in
diabetics:
 Grade 0 Pre- or post-ulcerative site
 Grade 1 Superficial ulcer
 Grade 2 Penetration into tendon or joint capsule
 Grade 3 Involvement of deeper tissues
 Grade 4 Gangrene of the forefoot
 Grade 5 Gangrene involving more than two-thirds of the foot

5. Classification
 Classification Based on Pain
 Painful Ulcers
 Tuberculous
 Arterial
 Advanced Malignancy
 Painless Ulcers-

Syphilitic
 Trophic
 Early Malignancy

6. Ulcer - few concepts
 Trophic ulcer ( trophe’ Greek ; lack of nutrition ) occur due to the
impairment of tissue nutrition as a result of either ischemia or anesthesia .
 E.g. In the arm -- chronic vasospasm ( painful )
-- syringomyelia .( painless ) ulcer on fingertips .
 in the leg -- ischemic ulcers ( painful ) around ankle/ dorsum of foot .
 Neuropathic ulcer ( anesthesia )
 Perforating ulcer seen in – Diabetes
 -- Spina bifida
 -- Tabes dorsalis
 -- Leprosy
 -- peripheral nerve injury
 It starts as acorn / bunion  penetrate foot  suppuration  Bone / joint /along fascial
planes of calf .

7. Ulcer - few concepts
 Modes of Onset of Ulcer
 • Traumatic
 • Spontaneous-
 • Secondary changes on a Swelling-Tuberculous lymphadenopathy
 • From a Previous Scar-Marjolin’s Ulcer

8. Life history of Ulcer
 Extension Transition Repair
Covered with slough clearer granulation tissue
and exudate transforms to fibrous
tissue .
Indurated Induration decreases further decreases.
Purulent / even blood more serous serous
stained
absent small areas appear & epithelisation from
spread surrounding area
growth rate 1 mm/d
3 layers +ve
+++ ++ -- ve
Floor
Base
Discharge
Granulation
Pain

9. Ulcer – clinical features
 Site : Rodent ulcer (95%) on upper part of face .
CA affects lower lip while primary ulcer of syphilis occur
on upper lip .
Arterial ulcers occur at finger tips / toe .
Venous ulcers occurs around ankle .
Size: Variable , depends on length of history .
inflammation > CA > Rodent .
Shape: Irregular -- Infective / CA .
Circular -- Rodent / Gummatous
Sq area / straight edge -- dermatitis artefacta .

10. Ulcer - parts
Edge
Floor
slough
Base

11. Ulcer – clinical features
 Shelving (sloping) -- non sp.healing
ulcer
 Rolled & pearly -- Rodent ulcer
 Raised & everted -- Epithelioma
 Undermined & blueish -- Tuberculosis
 Punched out -- Syphilis
 Edge

12. Ulcer – clinical features ( cont. )
 Floor ( area seen by the observer )
Granulation -- non specific healing
Slough -- infected
Watery / Apple jelly Appearance -- tuberculus
Wash leather appearance -- gummatous
 Base ( part of an ulcer which is palpated )
Indurated -- malignancy
Attached to deep structures -- venous ulcer

13. Ulcer – clinical features ( con’t )
 Discharge : Purulent -- active infection
watery -- tuberculosis
blue – green -- pseudomonas
Blood stained -- extension phase of ulcer
 Lymph nodes : enlarged , tender -- infected
enlarged , hard , fixed -- CA
firm & shotty -- syphilitic chancre
enlarged submandibular LN – chancre on lip
not enlarged -- rodent ulcer

14. Ulcer – clinical features ( cont. )
 Pain
non sp ulcer in ext & ulcer in phase of repair
transition phase
Tuberculous ulcer on Tuberculous ulcer
tongue
Syphilitic Ulcer on anal Syphilitic ulcer
canal
Apthos ulcer
present absent

15. Ulcer – Regional examination
 Examination of draining LNs
Tender & enlarged – secondary infection
 Enlarged hard fixed – malignant ulcer
 Enlarged , firm , matted – tuberculous ulcer
 Enlarged and shotty – syphilis
 Examination for impaired circulation
 look for absent pulse/ weak pulse,
 trophic changes – thin limb, shiny skin, loss of hairs, brittle nails
 Look for varicose veins
 Neurological examination
 Sensation, motor power, reflexes

16. Ulcer – general examination
 Look for -- Aneamia , Malnutrition , Diabetes .
 Rule out -- Cardiac Failure .

17. Ulcer -- Investigations
 Haematological
 LFT / Protein
 Blood sugar -- fasting & post prandial
 Montoux test
 Serological tests for Syphilis
 Biopsy ( wedge/ Excision ) / scraping – histopath
 Swab -- culture / sensitivity
 Discharge – gm. staining, ZN staining for AFB, PCR for Koch.
 FNAC of enlarged LNs
 X-ray of affected part

18. Ulcer - principles of management
 Determine aetiology
 Accurate assessment of ulcer
 Identify and correct comorbid factors .
 Treat underlying cause
 Adequate drainage and desloughing .
 Avoid adherent dressings .

19. Ulcer -- treatment
local applications ( lotions / ointments ) -- treatment of cause
-- to separate slough -- correct Aneamia
-- hasten granulation -- treat metabolic
-- stimulate epithelisation disorders.
Na hypochlorite -- Antibiotics
0.5% AgNo3 early phase -- treatment of DM
Zinc Sulphate
Ointments ( mupirocin, soframycin , povidon iodine )
Vinegar ( 1: 6 ) for pseudomonas
Amnion ( fresh & cleaned with sodium hypochlorite
stored at 4*C
Silver Foil / SWD / Infra red
Hydrocolloids , Alginates ,Tegaderm
Recombinant epidermal growth factor
treatment
generallocal

20. Ulcer treatment - points to remember
 Determining exact aetiology is important - note the site & local characteristics
 - thorough history & physical assessment
 Detect & treat comorbid factors
 Biopsy of the lesion may be necessary sometimes for exact cause.
 Treat the underlying cause -- infection /DM / venous or arterial insufficiency .
 Adequate drainage & desloughing required – surgical excision is cost effective.
Antibiotic treatment is required for – infected ulcer / ulcer due to sp cause e.g. TB
 Clean ulcer should be dressed twice /day or more if copious discharge.
 Avoid adherent dressings .
 Wounds can be cleaned safely with normal saline solution.

21. Ulcer treatment – basic requirement of ideal dressing
 Maintain high humidity between wound & dressings.
 Absorbent , removes excess exudate.
 Non- adherent , allowing easy removal without trauma at changing
 Safe & acceptable to patients ( non allergic )
 Permit gaseous exchange but impermeable to micro- organisms .
 Cost - effective

22. Ulcer treatment ( Loco + Gen )
Healing
excision & curettage
AgN03 application
swab to r/o staph
coagulase + organism
pseudomonas
beta- hemo. Strepto .
clean with tetracycline treatment & confirm with swab
Loco + gen Treatment
Small ulcer Large ulcer
granulation Excessive granulation
(proud flesh )
Large area but granulation ++
+ ve- ve
SSG

23. Ulcer - factors causing delayed healing
 Aneamia
 Hypoproteinemia
 Absence of rest
 Malnutrition
 Diabetes
 Ureamia
 Irradiation
 Ischemia
 Neutropenia
 Active infection

24. Ulcer -- photo gallery

25. Ulcer -- photo gallery

26. References
 Bailey & love’s Short Practice of surgery 22nd & 24th edition
 Short cases in surgery - Bhattacharya
 Text book of surgery for dental students- Dr. Sanjay Marwah
 Clinical surgery – Hamilton Bailey
 Text book of Clinical Surgery – S Das

27. Thank You