LOWER EXTREMITY ULCERS: CLASSIFICATION

Ulcers are depressed lesions which appear on feet with a changeable affectation, they can be from the most superficial layer of the skin (epidermis), to osseous structures on a necrotic process and with a common feature, the difficulty of cicatrization or impromptu cure. Classification according to its etiopathogeny:

• Neuropathic ulcer (45 – 60%).
• Neuroischemic ulcer (40 – 55%).
• Ischemic ulcer:
• Chronic arterial obstruction (arteriosclerosis) 90 – 95%.
• Thromboangiitis obliterans (Buerger’s disease) 5%.
• Vasospastic diseases (Raynaud’s disease) 10%.
• Infected ulcer (neuropathic or neuroischemic), (cellulitis, necrotizing infection and osteomyelitis).

Groups of risk

• Backgrounds of previous ulcerations.
• With peripheral neuropathy.
• With ischemic vascular disease.
• With osseous deformities to preventive surgery.
• Alcoholism backgrounds.
• With social isolation.

Types of ulcers

• Vascular ulcers: they make up continuity solutions with loss of epithelium-conjunctive substances, due to a pathological tissular process with a vascular origin and a chronic evolution. There are two types: ischemic or stasis arterial or venous. They are always a result of a vascular pathology, of a chronic nature and relapsing. The most frequent ulcers are venous or stases, they represent between 60 and 80%. The arterial ulcers represent between 10 and 25%, although they can be mixed. The venous ulcers are more frequent in women and the arterial ulcers are more frequent in men.
  • Risk factors: tobacco, diabetes, hypertension, obesity, sedentary lifestyle.
  • The diagnosis of venous ulcers includes appearance at internal supramalleolar region; of a variable size, they can be only or numerous; rounded or oval shape; with soft margines, a little high, red purplish color and bright; the fundus has different features, it depends on the state of the ulcer, it can be red or yellow or it can show purulent secretion. Moderate or nonexistent pain, when it appears is due to the infection.
  • However, the diagnosis of the arterial ulcers includes pain caused by the ischemia and the ulcer, searing and well located, aggravated by the dressings and the decubitus. It relieves with the leg in pendular position; coldness by the decrease of blood supply; paleness which when time goes by develops to cyanosis; intermittent abandonment; muscular pain; functional impotence; acute arterial occlusion by a sudden obstruction and a lack of pulse. The ulcer is located among the toes or on the tip of toes, articular heads of phalanges, heel, outer malleolus. Among diabetic people, it is located in the zone of the metatarsi heads and the planta pedis. The ulcers are characterized by a small size, well-defined margines, a great depth where you can see the bone, blackish or necrotic tissue without hemorrhages, because they are dry. There are changes associated in the leg or foot, like a thin, bright and dry skin, thick nails, a lack of hair, temperature variations, paleness, periulcerous edema, etc.
• Neuropathic ulcers: they are caused by a deficit of sensitivity which will cause the ulceration in points of friction or deformation of foot. It is located in any point of the planta pedis, where there will be a kept extrinsic pressure. They are round shape ulcerations which show periulcerous hyperkeratosis. They are painless.

• Ulcers by pressure: they are located zones of necrosis which they usually appear when the soft tissue is compressed between two plane zones. The normal pressure in the cutaneous capillaries ranges between 16 and 33 mm Hg. When the weight exceeds such pressure, appears local ischemia and erosion in the skin, causing the ulcer. The risk factors which keep up its appearance are cutaneous lesions; disorders in the transportation of oxygen; deficiencies in the diet; immunological disorders; alterations of the state of awareness; motorial deficiencies and sensorial deficiencies.
  • Its etiopathogeny includes:
  • Pressure: it is a strength which works perpendicularly to the skin as a consequence of gravity, causing a crush between two plane zones.
  • Friction: it is a tangential strength which works parallel to the skin, causing rubbings by movements or drags.
  • Stength of vascular trapping: it combines the effects of pressure and friction.

Treatment: It is a multidisciplinary, long and complex treatment, therefore, it will be fundamental to establish a differential diagnosis among the different kinds of ulcers. The local cure must go with the correction of the original cause, crucial in the treatment, as well as to avoid the recidivation (discharge templates). It is very important to keep the perilesion skin very clean and moisturized. We must avoid the abuse of aggressive antiseptics on the skin, because they can make it very dry.