Leg Ulcers 5p6u56

Tropica ulcers Aden ulcer," "Jungle rot," "Malabar ulcer," and "Tropical phagedena

ULCERS-Gradual and progressive loss in the continuity epithelial or mucosal lining TROPICAL ULCERS A tropical ulcer is an ulcer common in third world countries commonly in the tropics and it occurs on the lower extremities of the leg.

Epidemiology Careful research in Uganda has clarified the etiology. The ulcers occur at all ages, being recorded from age 5 to 70 years old. In children the sex incidence is equal, but in adults in most countries they are more common in men; this reflects the higher probability of trauma to the male leg. Ninety percent develop below the knee, affecting the front and outer side of the leg and the ankle region particularly. . Tropical ulcer has been described as a disease of the 'poor and hungry', and it may be that slowly improving socioeconomic conditions and nutrition for its decline. Urbanization of populations is another factor, as tropical ulcer is usually a rural problem. More widespread use of shoes and socks also provides protection from initiating trauma.

MARERA DOMNIC KAMPALA INTERNATIONAL UNIVERSITY WESTERN CAMPUS. GRAND ROUND PRESENTATION HELD ON

JANUARY,13,2011 AT MAKERERE UNIVERSITY CONFERENCE HALL

ETIOLOGY • • • •

FUSIFORM BACTERIA=Vincent's organism FLY FRICTION FOOD

• GENERAL PRESENTATION • A small discoloured patch, usually on the lower leg, develops rapidly over 5-6 days into a pustule of more than 1cm. • When this ruptures foul smelling blood-stained pus exudes • Considerable tissue damage is apparent at this stage as full thickness epidermal tissue has been destroyed to reveal an ulcer. • The ulcer is regular round/oval in shape, with a sloughy wound bed and a clearly defined edge. The edge will not be significantly undermined. • Ulcers are most frequently seen on lower legs but may occasionally be seen on thighs and arms

• Oedema exists around the ulcer along with hyperpigmentation which can last a significant amount of time after the ulcer has healed. • Generally there is some growth over the first 2-3 weeks (the acute phase) and the maximum size is reached at 6 weeks. • Initially, in the acute phase, the wound will be painful. If the wound does not heal and moves into a chronic phase it stops being painful. • If the wound is treated promptly in the acute phase it may heal and not progress to the chronic ulcerative phase. On some occasions the wounds will heal spontaneously without treatment however this may take months or years and leaves a heavy fibrotic scar. •

TYPES – Acute tropical ulcer • • • • •

It has short hx of less than 1 month It is very painful It discharges pus The patient is febrile means systemic infection On culture and sensitivity of pus specific macroorganism fuss form bacteria are found • On x-ray there is no sign of bone infection • There is bleeding at times • Foul smelling

– Chronic tropical ulcers • Takes more than 1 months • Not painful • There is no discharge or bleeding • No systemic infection • The patient is not febrile • The edges of the ulcer is irregular • The surrounded tissues are hyperpigmented.

• • • • •

DDX Diabetic gangrene marjolin’s ulcer Rodent ulcer Venous ulcers

• MANAGEMENT • Treatment of uncomplicated chronic tropical ulcer comprises three main aspects; • 1-control of infection • 2-control of any factors hindering healing • 3-provision of robust epithelial cover which will protect against further ulceration and malignant change. • -For control of infection patients require systemic treatment with antibiotics, chosen on the basis of laboratory determined sensitivities. • -Excision of indolent granulation tissue, areas of dense fibrosis, and severely scarred depigmented skin may be essential to achieve ultimate healing. Contractures and bone deformity will usually need to be corrected before the ulcer is covered. Bone infection must be controlled

• Epithelial cover is usually achieved by applying a split-thickness skin graft to the granulating bed of the ulcer or after excision of the ulcer. • Management of underlying condition leading to ulceration.

• COMPLICATIONS Septicaemia Malignancy Osteomyelitis Chronic ulcers Contractures Gangrene Pathological fracture Loss of function