A skin ulcer is a break in the skin with loss of the epidermis and dermis that fails to heal promptly. Ulcers may result from vascular disease, neuropathy, pressure, infection, or systemic illness. They are common in older adults and those with diabetes, and they carry risks of infection, pain, disability, and in some cases, malignancy (Marjolin’s ulcer).

🧬 Pathophysiology

🔴 Ischaemic ulcers: inadequate arterial perfusion ➝ tissue necrosis.
🔵 Venous ulcers: venous hypertension ➝ capillary leak ➝ oedema ➝ tissue breakdown.
🟢 Neuropathic ulcers: loss of protective sensation (diabetes, leprosy) ➝ repeated trauma ➝ ulceration.
⚪ Pressure ulcers: prolonged pressure ➝ local ischaemia ➝ necrosis, common over bony prominences.
🦠 Infective ulcers: primary (tropical ulcers, leishmaniasis) or secondary infection of chronic ulcers.

📊 Common Types of Ulcers

Type	📍 Location	🔎 Features	💊 Management
🔵 Venous (stasis) ulcer	Gaiter area (medial malleolus)	Shallow, sloping edges, exudative, granulating base. Associated with varicose veins, oedema, haemosiderin staining, lipodermatosclerosis, atrophie blanche.	Compression therapy (if ABPI >0.8), elevation, wound care, venous surgery if severe.
🔴 Arterial (ischaemic) ulcer	Toes, heels, lateral malleolus, pressure points	Punched out, well-defined edges, painful, cold limb, pale skin, absent pulses, shiny skin, hair loss.	Risk factor modification (smoking, diabetes, statins, antiplatelets), vascular imaging, angioplasty/bypass if feasible, wound care.
🟢 Neuropathic ulcer	Pressure points (plantar surface of foot, metatarsal heads)	Painless, surrounded by callus, often deep. Sensory loss on monofilament testing. Often infected.	Strict glycaemic control, off-loading with special footwear, wound care, antibiotics if infected, vascular assessment.
⚪ Pressure ulcer (decubitus)	Bony prominences (sacrum, heels, hips)	Staged I–IV (erythema ➝ blister ➝ full-thickness necrosis ➝ exposure of bone/tendon). Risk ↑ with immobility, malnutrition.	Pressure relief (repositioning, mattresses), optimise nutrition, wound care, antibiotics if infected.
🦠 Infective ulcers	Variable (leg, exposed sites)	May be tropical (e.g., Buruli ulcer, leishmaniasis) or superinfection of chronic ulcer.	Antibiotics/antiparasitics depending on cause, wound debridement.
⚠️ Malignant ulcer (Marjolin’s)	Chronic non-healing wound, burn scar	Raised, everted edges, bleeding, resistant to healing.	Biopsy to confirm SCC, surgical excision, oncological management.

❓ Clinical Evaluation

🧾 History: duration, pain, risk factors (diabetes, smoking, vascular disease), mobility, nutrition.
👀 Examination: site, size, edge, base, discharge, surrounding skin, pulses, neurological assessment.
🚩 Look for systemic features: fever, weight loss, anaemia, malignancy signs.

🔬 Investigations

🧪 Bloods: FBC, U&E, glucose/HbA1c, CRP/ESR, albumin, clotting profile.
📏 ABPI (ankle-brachial pressure index) – venous compression contraindicated if <0.8.
📊 Doppler/duplex ultrasound of arteries/veins.
🖼️ Angiography (CT/MR/DSA) if revascularisation considered.
🧫 Wound swab / deep tissue culture if infected.
🔬 Biopsy of non-healing ulcer to exclude malignancy.

🛠️ Management Principles

⚖️ Treat the underlying cause (arterial ➝ revascularise, venous ➝ compression, neuropathic ➝ off-loading, pressure ➝ repositioning).
🧴 Local wound care: cleansing, dressings (hydrocolloid, alginate, foam), debridement of necrotic tissue.
🦠 Antibiotics only if clinical infection (not for colonisation).
🥗 Optimise nutrition (protein, vitamins, micronutrients).
🚭 Smoking cessation, glycaemic control, CV risk reduction (statins, antiplatelets).
🔍 MDT care: vascular surgeons, diabetologists, podiatrists, tissue viability nurses.

⚠️ Complications

Cellulitis, osteomyelitis.
Sepsis.
Amputation in advanced ischaemia or uncontrolled infection.
Malignant transformation (SCC in chronic ulcers).

📌 Exam Pearls

“Punched-out painful ulcer on toes” = arterial.
“Shallow, exudative ulcer near medial malleolus” = venous.
“Painless ulcer under metatarsal head with callus” = neuropathic (diabetes).
“Non-healing ulcer in burn scar” = Marjolin’s ulcer (SCC).
Always measure ABPI before starting compression therapy.
Biopsy any atypical or non-healing ulcer.

Venous Ulcer

Neuropathic Ulcer

Arterial Ulcer

Pressure Ulcer

📚 References

Cases

Case 1 — Venous Ulcer: A 72-year-old woman with a history of varicose veins develops a shallow ulcer above the medial malleolus, with surrounding haemosiderin staining and lipodermatosclerosis. Pulses palpable. Plan: Duplex scan to confirm venous insufficiency, compression bandaging, elevation, emollients for skin, and secondary infection management if present.
Case 2 — Arterial Ulcer: A 68-year-old smoker with peripheral vascular disease presents with a painful punched-out ulcer on the lateral malleolus, cold shiny skin, and absent dorsalis pedis pulse. Plan: Urgent vascular referral, ankle–brachial pressure index (ABPI), optimise cardiovascular risk factors, and consider revascularisation; avoid compression until arterial flow restored.
Case 3 — Neuropathic Ulcer: A 58-year-old man with poorly controlled type 2 diabetes develops an ulcer on the plantar surface under the first metatarsal head, surrounded by callus, with reduced sensation on monofilament testing. Plan: Multidisciplinary diabetic foot team, offloading with specialist footwear, optimise glycaemic control, screen for infection/osteomyelitis, and regular podiatry follow-up.

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Skin Ulcers