• vascular: venous-lymphatic insufficiency and / or blood,
• Bacterial: leprosy, Buruli ulcer (Mycobacterium ulcerans) phagedenic ulcer (fusobactérie), yaws, syphilis,
• parasitic: dracunculiasis (guinea worm), leishmaniasis,
• metabolic: diabetes,
• traumatic: it is often a trigger associated with another underlying cause.
– The history of the disease and a complete clinical examination (such as neurotoxicity, seeking a peripheral neuropathy caused by leprosy or diabetes) are used most often ask the etiological diagnosis.
– Any ulcer may be complicated by secondary infection locoregional (abscesses, lymphangitis, adenitis, osteomyelitis, erysipelas, pyoderma), General (septicemia), tetanus and after long years of evolution of skin cancer.
Daily local treatment:
– Leg bath for 10 to 15 minutes with NaDCC or chloramine and rinse with boiled water.
– Removal of necrotic areas (black) and fibrinous (yellowish) with a compress or excision with a scalpel.
– Then apply:
• own little oozing ulcer: 10% povidone iodine and vaseline;
• dirty little oozing ulcer: silver sulfadiazine;
• oozing ulcer: 10% povidone iodine alone;
• multiple or extended ulcers, especially in children: gentian violet in case of seepage and silver sulfadiazine in the absence of seepage. Do not use povidone iodine (risk of transcutaneous absorption of iodine).
– Cover with a sterile dry dressing.
General treatment:
– Analgesic treatment for pain: class, dosage and dose adapted to each patient.
– General antibiotic therapy in case of:
• secondary infection (see Bacterial skin infections).
• phagedenic ulcer (in the early stages, antibiotics may be helpful and is often ineffective in the chronic stage.)
PPF (or procaine benzylpenicillin) IM: one injection per day (if necessary give half the dose in each buttock)
Children: 100 000 IU / kg / day for 7 days
Adult: 4 million IU / day for 7 days
In case of allergy to penicillin:
erythromycin PO
Children: 50 mg / kg / day in 2 divided doses
Adult: 2 g / day in 2 divided doses
or
doxycycline PO (except in children under 8 years and pregnant or lactating women)
Children over 8 years: 4 mg / kg / once daily
Adult: 200 mg / once daily
or
metronidazole PO
Children: 30 mg / kg / day in 3 divided doses
Adult: 1.5 g / day in 3 divided doses
After 7 days of treatment, if antibiotic treatment is effective, take over oral phenoxymethylpenicillin PO at the same doses (or continue treatment with doxycycline or erythromycin or metronidazole the doses indicated above). The duration of treatment depends on the clinical course.
– Treatment of the cause.
– Additional measures:
• Elevate the legs in case of venous insufficiency and / or lymph.
• Tetanus Prevention.
• Skin grafting 1 so extensive ulcer, clean, red and plan. The wide surgical excision of infected tissue followed by skin grafting is often necessary for healing in phagedenic ulcer Buruli ulcer.
1* For skin grafting technique, refer to the guide Minor surgical procedures in remote areas, MSF.