Wednesday, August 5, 2009

Ulcer and Wound Care

WHAT'S THE PROBLEM?When using the term ulcer, we are generally referring to breaks in the normal integrity of the skin. Ulcers are skin wounds that are slow to heal and are classified in four stages, according to which layers of skin are broken through. Stage 1 ulcers are characterized by a reddening over bony areas. The redness on the skin does not go away when pressure is relieved.Stage 2 ulcers are characterized by blisters, peeling or cracked skin. There is a partial thickness skin loss involving the top two layers of the skin.Stage 3 ulcers are characterized by broken skin and sometimes bloody drainage. There is a full thickness skin loss involving subcutaneous tissue (the tissue between the skin and the muscle.)Stage 4 ulcers are characterized by breaks in the skin involving skin, muscle, tendon and bone and are often associated with a bone infection called osteomyelitis.HOW DOES IT FEEL?How an ulcer feels is dependent on the underlying cause of the ulcer. For example, one of the more common types of ulcers is seen in patients with diabetes, who have loss of sensation in their feet. In this type of ulcer, there is little if any pain, due to a condition called diabetic neuropathy. In fact, diabetics typically get this type of ulcer because they've lost their protective pain sensation. Another common ulcer is due to loss of arterial blood flow to the leg, resulting in ischemic ulcers that can be very painful. So you can see that it very important to have any break in the skin properly evaluated and the lack of pain is not always a good initiator as to the severity of the problem.LET'S DO A TEST!There are many different diagnostic tests that can be done in the course of treating an ulcer. If the ulcer appears to be infected, i.e., there is redness, and drainage, then a culture of the wound should be done. The reason for the culture is to identify the type of infection, so that you can be put on the appropriate antibiotic. If there is suspicion of the bone being infected under the ulcer, the doctor will do x-rays and/or a bone scan. If there is suspicion that the underlying reason for the ulcer is poor circulation, then a non-invasive vascular study can be done. This test is to see if you have enough oxygen getting down to the area to heal the ulcer. HOW DID THIS HAPPEN? Ulcers occur due to different reasons, so it is very important to determine the underlying medical problem that caused the ulcer. There are essentially four main reasons people get ulcers on the foot.Neuropathic: This is when a patient has loss of sensation in the feet. It is commonly seen in people with diabetes but it can be caused by other reasons such as chronic alcohol abuse. These ulcers are generally seen under weight bearing areas and often will begin as a callus or a corn.Arterial: This type of ulcer is due to poor blood flow to the lower extremity. This type of ulcer can be very painful and are usually found on the tips of toes, lower legs, ankle, heel and top of the foot. They can very easily become infected.Venous: This type of ulcer is due to compromised veins. Veins are the vessels that take fluid out of the legs and back up to the heart. Veins have small valves that allow blood to flow only one way, back up to the heart. The valves normally block the tendency for gravity to pull the blood back down to the legs. Sometimes the valves leak or cease to work at all. If the valves do not work, then the fluid pools down in the legs, causing swelling. This swelling leads to increase pressure in the venous system, producing discoloration of the leg and eventually this lead to ulceration. They are commonly seen around the inside of the ankle and are slow to heal.Decubitus: This type of ulcer is caused by excessive prolonged pressure on one area of the foot. The most common place to see this type of ulcer is in a person confined to bed and they occur on the backs of the heels.WHAT CAN I DO FOR IT? The best thing you can do for an ulcer is to have it looked at by your doctor, as soon as you can. The earlier that the ulcer is treated, the better chance you have at healing it.WHAT WILL MY DOCTOR DO FOR IT?The first thing that will be done is to inspect the wound. The doctor is looking for signs of infection, location of the wound, the color of the tissue in the wound. This is all done to determine the best treatment for that wound. Often the doctor will refer you to another specialist, such as a vascular doctor, to check your circulation. If you are a diabetic, he will want to consult with your diabetes doctor, to make sure that your blood sugar is under control. Once the cause of the ulcer is determined and all the necessary referrals are made, treatment of the ulcer can begin. The treatment will be tailored to the individual ulcer and it is often difficult to predict how long it will take an ulcer to heal. Ulcer care is best treated by a team approach, involving a few different types of doctors.CAN I PREVENT FROM IT HAPPENING AGAIN?Yes. The best prevention is treating the underlying cause of the ulcer. That means if you are a diabetic, check your blood sugar daily and inspect your feet every day. If the reason for your ulcer is due to swelling in the legs, then you need to wear support stockings and keep your feet elevated as much as possible.Ulcers can be a very debilitating problem, causing pain and disability. The best treatment is preventing the ulcer from ever occurring. If it does occur, have it checked immediately by your doctor.Give your Legs a RestELEVATE your feet above your heart while sleeping and at regular times during the day (elevate foot of bed or mattress).AVOID work that requires you to stand or sit with your feet on the ground for long periods. Change positions frequently.TAKE walks to help leg muscles "pump" fluid out of your legs.Give your legs SupportWEAR professionally made support stockings that apply pressure from ankle to knee or other compression devices (Dr. Thomajan can help you choose the kind that is right for you and send you to a professional who will properly measure your legs for correct stocking size).HAVE at lease two pairs of support stockings available so you can change them daily. After laundering, hang them up to dry. Do not put them in the dryer.ALWAYS put on support stockings early in the morning before fluid pools in lower legs WEAR support stockings all day and then remove in the evening when going to sleep. BUY new stocking every 6 months so their strength doesn't wear out. AVOID ACE bandages. It is extremely difficult to wrap them properly to provide the pressure you need.IF your doctor has prescribed the use of a compression pump, follow the instructions completely. It may take a little time to adjust to the pumping procedure.Take Care of Your SkinMAKE sure to wash your lower legs and feet regularly with mild soap and water. This will help to avoid a build-up of lotion. Do not soak your feet.USE moisturizing creams and emollients after washing. It is important not to use petroleum or lanolin based creams when wearing stockings which contain latex. Your doctor or pharmacist may suggest appropriate brands.BE particularly careful to avoid activities that are likely to cause injury to legs or feet. Prevention is very important.Watch for Skin ChangesPay particular attention to signs of progressive venous insufficiency.SWELLING that does not go away quickly when you lie downDISCOLORATION, especially brownish skin discoloration around ankles and lower legs.DRYNESS and/or itching in the same areas.ANY WOUND or bruise that doesn't go away within a week.GUIDELINES If Your Wound Doesn't Heal in One (1) WeekDON'T put off seeing your doctor. Any wound that doesn't heal in a week should be seen by your physician.REMEMBER You are a vital part of your treatment program and it is essential that you faithfully follow all medical directions.ALWAYS consult your physician before making any change to your healthcare routine, if you have questions or if your symptoms are becoming worse. GUIDELINES IF YOU HAVE A WOUND:KEEP IT CLEANKeep minor wounds clean and protect with a bandageAVOID strong antiseptics. Many antiseptics such as hydrogen peroxide, povidone-iodine (Betadine) and sodium hypochlorite (Dakin's solution) can damage skin and interfere with healing. DON'T stop wearing support stockings during your daily activities. If it is difficult to wear them over the bandage, put on a knee length nylon stocking first and wear the support stocking over it.WATCH the wound carefully. You will need to describe any changes to your doctor. Remember that any wound may turn into a chronic wound and early treatment has been shown to be beneficial.--Dr. Craig Thomajan is a podiatrist at Austin foot and Ankle Specialist located in Austin, Texas. If you would like to learn more about a variety of foot and ankle aliments, you may visit him online at Austin Foot and AnkleSource:

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