Leg ulcers

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I- Introduction :

L’leg ulcer is defined as a loss of chronic skin substance with no spontaneous tendency to scarring. He is not’not act’a disease in itself but a complication of’an underlying vascular disease, often long-standing or severe, which regulates prognosis and therapeutic management.

II- Epidemiology :

prevalence 1 at 1,3 %.
The risk increases with age and there is a peak prevalence around 70 years.
Women are more affected than men.

III- pathophysiology :

A- venous ulcer :

→ The pathophysiology of’pure venous leg ulcer is ambulatory venous hypertension which can be secondary to :

  • reflux of the superficial and perforating veins (essential venous disease).
  • Reflux and / or obstruction in the deep veins (postthrombotique etiology).
  • A deficiency of the calf muscle pump.

→ L’ambulatory venous hypertension leads to microcirculation abnormalities and tissue pain.
→ On these integuments, a simple little trauma can be’origin of’ulcer.

B- arterial ulcer :

→ The skin lesions observed are directly related to’ischemia by default of arterial perfusion of the limb.

IV- Diagnostic :

It is based on a careful clinical examination :

1- Ulcer :

L’Clinical examination determines :
→ The number of’ulcers
→ The size ;
→ Seat and united character- or bilateral ;
→ The background
→ L’importance of’exsudare
→ L’edge appearance

2- Skin ulcer perished :

It is rarely normal. It reflects cutaneous vascular complications of underlying disease.

Artériopathie : The skin is white or cyanic, cold, shiny and depilated.

Venous insufficiency : manifested by :

  • edema : initially Vesper, aggravated by’orthostatism before becoming permanent with the’age of injuries.
  • dermo-epidermal lesions : plaques erythémato-squameuses, CASTROTHEODORICIENS, often starting in the internal malleolar region and may’extend to the rest of the leg. They are varicose éaalementappeléeseczéma.
  • Capillary damage :

– The stasis dermatitis which forms large closets, an early purplish red then brown due to indelible deposits of’hemosiderin.
– The White atrophy : is in the form of plates and atrophic ivoirinesparfoisparcouruesdefinestélangiectasies.
– Hypertrophic capillaries which have an aspect capillary hairy malleolar or back of the foot.

  • Lesions of’hypodermite

– L’acute or subacute hypodermitis which is manifested by a large red and painful leg,
– the Lipodermatosclérose (hypodermite scléreuse) : the skin is sclerotic, often pigmented and impossible to pinch.

Nb : In the same patient, several types of lesions can’associate.

3- vascular examination :

All leg ulcers justify a complete vascular clinical examination.

Examination : He's looking for :

  • Signs of’venous insufficiency : crampy pain at rest, Evening edema.
  • Signs of’arteriopathie : claudication intermittente, pain decubitus.
  • Personal or family history of varicose veins, deep vein thrombosis.
  • The obstetric history
  • vascular risk factors : diabetes, hypertension, metabolic disorder, smoking, …

Physical examination : He understands

  • Palpation of peripheral pulses
  • Auscultation of the arteries of the limbs and neck ;
  • The search for varicose veins and their location.
  • The search for telangiectasias and reticular veins of the ankle and foot.

4- Assessment of degree of locomotor disabilities :

→ Patients disabled by a stiff ankle, hip osteoarthritis, knee osteoarthritis, orthopedic foot deformities, have less chance of successful treatment and functional recovery.

5- GENERAL REVIEW SOMATIC :

Examination :

  • Specify treatment history (taking oral contraceptives).
  • Clarify the patient's occupation, which in the case of’prolonged orthostatism can worsen venous insufficiency.
  • Appreciate the’sport activity or patient sedentary lifestyle.

Physical examination :

  • Look for signs of heart failure, renal or hepatic.
  • Take blood pressure and weight.
  • Look for systemic pathologies that may worsen the’skin hypoxia: anemia, chronic respiratory failure.

After this examination fivefold, it will be possible to’discuss the main causes of’ulcer.

V- Etiology :

The causes remain dominated by vascular causes : l’chronic venous insufficiency : 60-70 %, etiologies arterial : 10% and mixed : 20%

A- Venous Ulcer :

1- Clinique :

→ The characters of l’ulcer are suggestive. It is most often :

  • Unique
  • Superficial
  • Large size
  • The edges are foam
  • Failure cleans background, fibrin or conversely red and burgeoning.
  • bit painful, s’there are pains, they appear most often during’orthostatisme, and are relieved by the elevation of the legs
  • From perimalleolar seat, overlying internal or external malleolus

→ The skin around the ulcer is the seat of trophic characteristics complications : dermo-epidermidis, panniculitis capillarity or more or less associated (see above).

→ L’vascular examination shows varicose veins while the’arterial examination is normal.

2- To-clinique :

Will complete the assessment of venous disease.

Ultrasound Doppler : only necessary and sufficient examination, can highlight the following :

  • Superficial reflux syndrome, signing the presence of varicose veins.
  • A deep reflux syndrome, synonymous with post-phlebitis syndrome.
  • A deep obstructive syndrome sign of’an acute phlebitis.

other exams : phlebographies, l’CT or nuclear magnetic resonance imaging (NMR), the capillaroscopie, l’venous endoscopy is not methods of’current use.

B- ARTERIAL ULCERS :

1- Clinique :

→ Classically, he s’acts of patients over 45 years who complain of intermittent claudication for months, even years, characterized by the onset of cramps in the calves or thighs after a certain distance walked.

→ When the’arteriopathy is more advanced, the, are rest pain.

→ L’aspect and topography of the’ulcer are characteristic :

  • Single or multiple ulcers often
  • digging
  • The edges are steep, often with one cyanotic edge
  • The sluggish background, without budding trend
  • The pain is usually intense, difficult to control pain, improved when the legs are dangling off the bed or when the patient is standing.
  • Suspended or distal topography (toes).

→ The skin around the ulcer is pale, dried, popped and atrophic. Generally cold in the perfusion defect by palpation, or rarely see normal heat increased in diabetics with hyper-vascularization distal

→ L’vascular examination shows an abolition of’one or more peripheral pulses.

2- To-clinique :

Additional tests will allow us to take stock of arterial disease.

L’Doppler ultrasound : it will show the level and type of injury

angiography : it specifies the seat of the’obliteration, has a length, detects atherosclerotic plaques likely to’ernboliser and will be essential to the operational decision.

The measurement of transcutaneous P02 : it reflects’skin oxygenation. Its measurement is taken into account in the decision and the level of a possible amputation.

Other : The most common cause of arterial ulcers is represented by atheromatous disease that requires balance is doubled :

  • A study of the distribution of arterial disease (electrocardiogram [ECG], Doppler of the supra-aortic trunks)
  • A study of the contributing factors (diabetes, HTA, Dyslipidémie …)

NB : In a significant number of cases, the two causes are highlighted simultaneously, making bet’mixed arterial and venous ulcer.

C- OTHER CAUSES VASCULAR :

1- L’necrotic angiodermal ulcer :

→ It occurs mostly in women after 60 years and on a field of’old and treated high blood pressure and / or diabetes.

2- Ulcers vasculitis :

D- CAUSES NO VASCULAR ULCERS :

1- Ulcers of’infectious origin :

→ L’impetigo, in deep variety (l’ecthyma) will perform a necrotic ulceration small, often at elevated inflammatory edges, painful.

→ Chronic infections can cause ulcers by’gum intermediate.

2- Ulcers of’hematological origin :

→ Myeloproliferative disorders (polycythemia vera, thrombocytémie…)

→ The dysglobulinémies.

→ Hemolytic anemia Congenital : sickle cell disease, thalassémie…

→ The coagulation disorders.

3- Other :

Syndrome de Klinefelter, ulcers’neurological origin, …

WE- Evolution- Prognosis :

a- venous ulcer :

→ L’Varicose ulcer treated properly progresses, in good standing, favorably but with a risk of recurrence and chronicity.

→ L’post-thrombotic ulcer is more rebellious,

b- arterial ulcer :

→ It can heal if an etiological treatment is possible (bridging, dilatation…).

→ In advanced tables or following acute ischemic events, the decision of’limb amputation is sometimes necessary.

VII- Complications :

1- Contact dermatitis :

→ They are common due to the large number of topical products.

→ They are limited at the beginning to the zone d’application of the product but which can broadcast remotely secondarily.

2- microbial superinfection :

→ The presence of germs on an ulcer is not a pathological phenomenon (colonization)

→ In some cases, l’ulcer may represent the gateway’entry d’a clear skin infection,

Think about it before :

  • Increased local pain.
  • Inflammation of the edges.
  • lymphangitis.
  • Fever.

3- musculoskeletal injuries :

→ They are very common : splints and osteoperiostitis =>ankylosis ankle.

4- Haemorrhage :

→ It often occurs as part of’venous ulcers : show but usually controlled by a simple prolonged compression.

5- squamous cell carcinoma :

→ Its occurrence is rare but not exceptional. .

→ Think about it before :

  • The chronicity of’ulcer without any improvement despite a well-managed treatment
  • L’onset of pain
  • A local hemorrhage
  • Excessive granulation

VIII- Treatment :

A- GENERAL TREATMENT :

→ Update tetanus vaccinations.

→ Treat pain depending on the cause and prescribe painkillers if needed.

→ Personal health :

  • Treating risk factors and / or comorbidities : smoking cessation, balance of’diabetes, adapted physical activity (physiotherapy if necessary).

B- LOCAL TRAITEMVIENT ULCER :

I includes three phases :

1- The phase of debridement :

→ Its objective is to’remove cellular and crusty debris accumulated on the surface of the’ulcer.

→ It is primarily mechanical.

→ Systematic use of’antiseptics n’is not indicated in l’absence d’declared infection.

2- Phase budding :

→ It appeals to’use of three types of products

  • The fat dressings
  • Hydrocolloids and hydrocellular.
  • Les alginates de calcium

→ In case of excessive budding l’use of dermocorticoid or nitrate d’money helps reduce budding

3- The stage réépithélialisasation :

→ It uses the same type of products as before.

→ It can be proposed to the patient achieving skin grafts that will have a powerful analgesic effect and allow to shorten the healing time / The use of growth factors (EGF) or skin substitutes is also useful.

C- THE SKIN TREATMENT PERI-ULCERATIVE :

→ Trophic complications of’venous insufficiency systematically justifies the wearing of an elastic compression.

D- THE TREATMENT ETIOLOGICAL :

It is essential when taking charge of’an ulcer.

1- Venous ulcers :

  • Elastic support
  • sclerotherapy.
  • Surgery’veins
  • The gait training.
  • the veinotonic.
  • crenotherapy (Spa treatment)

2- The arterial ulcer :

  • Medical treatment : vasodilators.
  • Surgical treatment

3- Ulcer mixed predominantly venous :

  • Take charge l’obliterating arteriopathy of the lower limbs.
  • Change compression under specialist medical supervision.

E- RELAPSE PREVENTION AND PREVENTION ULCER :

1- Relapse prevention :

  • Surgery’superficial venous insufficiency and the wearing of’a contention.

2- Prevention of’ulcer :

  • Prevention of’ulcer is that of post-phlebitic disease : correct treatment of thrombosis, Recognition of those at risk, …

IX- Conclusion :

  • In front of a leg ulcer, it should make a careful clinical examination not only of the ulcer, périulcéreux of integument affected limb, but also the general context.
  • We can use additional examinations to clarify the’etiology which remains largely dominated by vascular causes.
  • The local processing means must be tailored to three successive evolutionary phases of ulcer : debridement, budding, epithelialization.

Course of Dr MANSOUL Tarek – Faculty of Constantine