The leg ulcer is a very common pathology associated with vascular disease (arterial or venous, usually). It is defined as a loss of chronic substance without spontaneous tendency to healing.
The diagnosis of ulcer is the crux of the management, conditioning therapy.
In this chapter, we distinguish the main types of ulcer from major clinical presentations allowing the practitioner to move rapidly.
GREAT CLINICAL PICTURES:
The main causes of ulcers are summarized in Box 1.
Box 1. Main causes of ulcers Frequently
– Superficial venous insufficiency (essential venous disease)
– Deep venous insufficiency (post-phlebitis illness)
– Arterial insufficiency
– Angiodermatitis necrotizing
– Mal rare piercing More
– Antiphospholipid syndrome (APS) primary or secondary
– General and connective Vasculitis – sensory neuropathy (diabetes, alcohol-deficiency, Thevenard’s disease, spinal abnormalities including spina bifida)
– Myeloproliferative, hyperviscosity, cryoglobulinemia
– Pyoderma gangrenosum
– Congenital haemolytic anemias (thalassemia, Minkowski-Chauffard, sickle cell anemia).
– Tertiary syphilis, leprosy, tuberculosis and atypical mycobacteria, deep mycoses, leishmaniasis
– Cytomegalovirus (CMV), AIDS
– Werner disease, progeria (exceptional)
Venous ulcer:
Diagnosis:
The venous ulcers characteristics criteria are:
– Single;
– Large;
– Shallow;
– Little painful;
– Serving mostly internally sub-malleolar.
Diagnosis is helped here by the presence of trophic changes on the skin around the ulcer (stasis dermatitis, sclerotic skin although limited, sometimes forming a true gaiter) and the association with varicose veins.
Classically, arterial examination is normal, but do not forget the possibility of mixed forms.
Obese women over 50 years is often reached. The research examined a history of venous thrombosis or superficial, possible venous éveinages.
The examination of the veins of the lower limbs by performing venous Doppler is to ask first line (superficial or deep reflux, deep obstructive syndrome).
Treatment:
The treatment is based primarily on the wearing of a suitable restraint (belt force varices II) and the elevation of the legs when resting.
Proper hygiene is essential, as well as the research and treatment of possible entry points for possible erysipelas (eg intertrigo interorteils). Weight loss and physical therapy (fight against the ankle ankylosis) are useful.
Sclerotherapy is preferred in the elderly and sick in the short reflux. Surgery is preferred in young patients and the reflux with significant varicose veins. The choice of treatment depends on the phlebotomist and the patient’s desire.
The rehabilitation of the ankle joint with fight against ankylosis (draining vein of the calf and the foot is fundamental).
The veinotonic (Daflon®) are discussed.
Spa treatments have a favorable psychological role.
Local treatments are detailed in the section Processing.
Arterial ulcer:
Diagnosis:
The characteristic signs of arterial ulcer are:
– Breakfast;
– Deep;
– Painful;
– Single or multiple;
– Suspended (or on the side edge of the foot);
– Digging;
– Often appearing in a male about 50 years with cardiovascular risk factors.
The peri-ulcerated skin is cold, white, popped.
The peripheral pulses were abolished.
Cardiovascular examination must be comprehensive, looking in particular a pulselessness, ischemic heart disease and heart failure signs. An eventual lameness is noted. Finally, the practitioner asks factors patient cardiovascular signs (age, family history, smoking, diabetes, hypertension, dyslipidemia, abdominal obesity).
The arterial Doppler ultrasound examination is the first line. The measurement of pressure at the ankle (distal pulses) is fundamental (posterior tibial pressure on brachial pressure ratio = Normal 1 to 1.3).
The abdominal aorta is examined in search of a possible aneurysm source of distal embolism.
A general assessment of atheromatous disease (échocardiaque, Doppler ultrasound of the supra-aortic trunks [TSA], electrocardiogram [ECG]) is always indicated.
The MR angiography or CT angiography dethroned conventional arteriography for surgery.
The MRA is interesting to study
the downstream bed, but may be impeded by a currently still early venous return. The multidetector scanner is against-indicated in patients with renal insufficiency or allergy to iodine, and avoid in diabetes on oral antidiabetic agents, or myeloma, embarrassed by the possible mediacalcosis.
Treatment:
The treatment is both:
– General: Fixed cardiovascular risk factors, suppression of tobacco, diabetes control, to develop walking collaterality;
– Medical:
– Aggregation inhibitors,
– Vasodilators: their relative inefficiency is offset by their safety,
– Surgery: unblocking, bypass surgery, stent, sympathectomy,
– Intravenous prostacyclin in severe ischemia with surgical indication-cons;
– Local: it is detailed in the section Processing.
Conventionally, the contention is against inappropriate.
Angiodermatitis necrotizing:
Diagnosis:
The necrotizing angiodermatitis the characteristics criteria are:
– Age and patient sex: over 60 year old woman;
– Hypertensive subject;
– Diabetes;
– Ulcer in the anterolateral aspect of the leg, very painful, beginning with purpuric or Livedoid plate, extending then necrosis with superficial ulcerations in geography card.
There is no sign of arterial insufficiency (distal pulses are present) or intravenously.
The land (hypertension, diabetes) is a guidance factor.
The venous and arterial échodopplers are normal (at most parietal blood infiltration, but without hemodynamic consequences).
We must carry out a complete clinical examination for inflammatory disease (vasculitis, connective) and minimal immunological tests (FAN [anti-nuclear factors], anti-DNA, Waaler-Rose latex, cryoglobulinemia, hepatitis B and C. )
Treatment:
Treatment is often difficult. It requires hospitalization. Skin grafts are often used in tablets (with Action on pain and increased healing rate).
Diabetic foot ulcer:
Diagnosis:
The plantar evil is characterized by hyperkeratosis on a bearing weight ulcerating, painless, sometimes with deep ulceration in diabetic.
The heel and metatarsal head in a diabetic, due to repetitive strain injuries are the most commonly affected areas.
The onset is suggestive context (poorly controlled diabetes, éthylocarentielle neuropathy, spinal abnormalities, family-type disease Thévenard neuropathy, etc.)
Radiography in search of bone injuries is imperative.
Treatment:
Diabetes must be better balanced (intravenous insulin by syringe pump [IVSE]). It will also carry a reminder of tetanus toxoid (TT) and local treatments.
Surgery is often necessary.
Preventive treatment involves appropriate footwear, hygiene and care to a rigorous feet.
Ulcers due to general vasculitis:
Ulcers caused by vasculitis occur in general an evocative context. Include polyarteritis nodosa, Wegener’s disease or connective such as lupus, antiphospholipid syndrome.
Ulcers caused by Klinefelter syndrome:
Ulcers can also occur in a patient with Klinefelter syndrome (great man, gynecomastia, microwave orchidie and micropenis, XXY karyotype).
The treatment is the same.
Ulcer in a young patient:
Besides the presence of antiphospholipid syndrome (APS) primary or secondary, and the possible infl ammatory general disease underlying this possibility should be investigated congenital corpuscular hemolytic anemia (hereditary spherocytosis, sickle cell disease, thalassemia).
Myeloproliferative disorders (polycythemia vera, essential thrombocythemia) and dysglobulinémies (cryoglobulinemia) can cause ulcers rheological disturbances they cause (state hyperviscosity).
Ulcers due to chronic infections:
Chronic infections can cause ulcers:
– Necrotic ulcers small edges in inflammatory, painful, dirty in a subject debility ecthyma;
– Gums tertiary syphilis, leprosy, atypical mycobacteria, tuberculosis;
– Leishmaniasis, tropical mycoses in an individual returning from endemic areas;
– Virus in immunocompromised patients (HIV, organ transplanted, long-term corticosteroid).
These ulcers are the domain of the specialist. The patient is sent to treat the underlying infectious disease.
Pyoderma gangrenosum:
The ulcer begins with an ulcerating pustule and then to the state phase-edged ulcer, with edges as drawn with compass, inflammatory, with perforated edges of hutches pus, ranging from fast centrifugally.
The context is very evocative with in two thirds of cases underlying systemic disease to detect, if it is not known: blood disease, rheumatoid arthritis, inflammatory bowel disease Crohn’s disease, ulcerative colitis or kind (RCH), monoclonal gammopathy . The patient is assigned to a specialist hospital (general or local corticosteroid doses, research the general underlying disease).
STANDARDISED APPROACH:
The examination and clinical examination plays an important role.
Review of ulcer:
Initially the ulcer itself is examined:
– Location:
– Single or multiple,
– Ankle, anterolateral aspect of legs, internal;
– Size;
– Manifestation or not of pain;
– Deep or superficial aspect;
– Background: clean, budding, dirty, superinfected, sluggish, necrotic;
– Edges (flexible, at the same level or below the ulcer, hard or raised).
Examination of the skin around the ulcer:
Secondly, peri-ulcer skin
is examined:
– Reflecting the underlying vascular disease:
– White skin, stiff f, d shaved: arterial,
– Evocative trophic disorders venous insufficiency;
– Eczema lesions, erythematous, scaly, itchy, and can spread to the rest of the leg;
– Brown cupboards (initially purplish red), large closets internal malleolus or the anterior tibia: stasis dermatitis;
– Hair hairy back of the foot or ankle: hypertrophic capillaries;
– Whitish plaque, a trophic, irregular, small, possible telangiectasia: White atrophy, a tendency to ulceration;
– Big red leg, acute, febrile: hypodermitis acute or subacute (“jambite”). This is not erysipelas;
– Sclerotic zone diffuse pleating printing retractable spat: spat sclerotic. It appears from the outset or after several episodes of acute hypodermitis.
Vascular examination:
The vascular examination must be complete with a search:
– Cardiovascular risk factors (diabetes, high blood pressure [hypertension], dyslipidemia, smoking, abdominal obesity, etc.);
– Personal history (phlebitis, varicose veins surgery, pregnancies, myocardial infarction [IDM], stroke [stroke]) and family (phlebitis, venous insuffi growth, MI, stroke);
– Cramping pain at rest, Vesper edema;
– Intermittent claudication of the lower limbs (MI), rest pain;
– Pulse palpation and auscultation;
– Research Varicose veins MI.
Search aggravating factors:
We must also look aggravating factors:
– Ankylosis ankle joint;
– Osteoarthritis;
– Osteoarthritis;
– Deformation of the feet.
Search complications:
Are sought as complications:
– Hemorrhage: often spectacular (venous ulcers), a simple compression can deal with them.
– Squamous cell carcinoma:
– Chronic non-healing ulcer despite adequate treatment,
– Severe pain, local bleeding,
– Excessive budding,
– Multiple biopsies necessary;
– Vicious attitudes, difficult to correct, or shin osteoperiostitis leading to ankylosis of the ankle and making it difficult healing;
– Microbial infections:
– The presence of germs on an ulcer translated colonization and is not synonymous with infection (no systematic antibiotic treatment, especially as it may hamper the healing)
– Entrance possible infection (erysipelas, fasciitis, gas gangrene, tetanus [systematic prevention]);
– Eczematisation peri-ulcerative:
– Related to the ulcer itself or topical use, and vesicular pruritic erythema, initially located but extending secondarily
– Balsam of Peru, lanolin, neomycin, antiseptics are usually involved,
– The treatment is based on the judgment of topical and topical corticosteroids.
Treatment:
It is local and general.
General treatment:
The general treatment is essential to the improvement or healing of the ulcer and the prevention of recurrences.
In all cases, the correction is necessary aggravating factors:
– Weight loss;
– Diabetes control;
– Equilibration of dyslipidemia;
– Moderate physical activity;
– HTA;
– Stop smoking.
Venous ulcers:
General treatment of venous ulcers is based on:
– Stockings or bands fighting against edema by limiting the reflux by a mechanical effect;
– Walking rehabilitation, mobilization ankle joint to drain the venous pump and plantar venous sole;
– Proper treatment of thrombosis and restraint;
– Sclerotherapy: short reflux nonsurgical elderly patients;
– Surgery: long reflux, large varices in the elderly;
– Veinotonic (discussed);
– Cures.
Arterial ulcers:
General treatment of arterial ulcer is based on:
– Antiplatelet agents;
– Vasodilators (discussed);
– Prostacyclin analogues intravenously in hospital for chronic ischemia;
– Unblocking / bypass / sympathectomy: these techniques are the responsibility of the vascular surgeon. Recall the development of endovascular techniques.
Local treatment:
Local treatment consists of three phases: debridement, granulation, re-epithelialization.
The need for a competent nurse is important.
Cleansing:
– Cleaning of the ulcer. It is done by antiseptic (type aqueous chlorhexidine), just days because antiseptics impede wound healing, or in the case of secondary infection proven by extensive washing with saline.
– Removal of cellular debris and crusting at the surface of the ulcer. This gesture can be painful and then requires prior application of viscous Xylocaïne® (Xylogel®) 20 minutes before, an analgesic administration levels 2 or morphine. This move requires the use of compresses, scissors and knife.
– Installation of new dressings promoting debridement. If fibrin wound, the use of hydrogels (Urgo Gel®) is recommended, otherwise the use of hydrocolloids or hydrocellular (Comfeel®, Duoderm®). They must be left for 48 hours Vaseline remains a good tool (then change dressings every 24 hours).
– If bleeding occurs, alginates may be recommended. If superinfection occurs, dirty appearance and odor, coal may be used.
Budding:
– Cleaning with saline.
– Fat dressings with Vaseline effective and well
tolerated for 24 hours.
– Ydrocolloïdes H / 48 hours and hydrocellular
(Comfeel®, Duoderm®, etc.) promote budding.
Re-epithelialization:
– Idem.
– Transplant into pellets.
Treatment of peri-ulcer skin:
– Venous trophic disorders: ontention c ++.
– Eczema ulcer: topical corticosteroids.
– Inflammatory hypodermitis (“jambite”): + antibiotics contention.