1. EXAMINATION OF ULCER
- JANMEJAY BANSODE
IV- I

2. Examinatin of ulcer
DEFINITION OF AN ULCER
—
AN ULCER IS DEFINED AS A BREAK IN THE CONTINUITY OF SURFACE E
PITHELIUM WITH
SUPERADDED INFECTION.

3. CLASSIFICATION OF ULCER

Clinical Classification of Ulcer
— Spreading- with surrounding inflammation
— Healing – Slopping edge with red granulation tissue
— Callous- Ulcer with no tendency to heal-with pale
granulation tissue.
Pathological Classification of Ulcer
— Specific- Tuberculous, Syphylitic,Actinomycotic
— Non specific- Traumatic( Mechanical,
Physical,Chemical)
Cryopathic, Arterial, Venous, Neurogenic, Trophic,
Tropical, Bazin’s, Martorell’s, Meleney’s ulcer
— Malignant- Squamous cell carcinoma, Basal Cell
Carcinoma, Melanom

4. INSPECTION:
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Size and shape:
Tuberculosis ulcers are enerally oval in shape but
their coalescence may give an irregular crescentic
border.
The size of an ulcer is important in deciding the
time which will be required for healing.Abigger ulcer
will definitely take longer time to heal than smaller
ulcer.
To record exactly the size and shape of an ulcer
sterile gauze may be pressed on to the ulcer to get
measurement.

5. 
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Number
Tuberculosis,gummatous,varicose and soft chancre
may be more than one in number.

6. 
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Position
It is very important and often gives clue to the
diagnosis.Rodent ulcer are usuall confined to the
upper part of the face above a line joining the angle
of the mouth to the lobule of the ear,occuring
frequentlynear the inner canthus of the eye.
Malignant ulcers are more commonly seen on the
lips,tongue,breast and penis.

8. 
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Edge
In spreading ulcer the edges are inflammed and edematous
whereas in a healing ulcer the edges,if traced from the red
granulation tissue in the centre towards periphery,will show
blue zone (due to thin growing epithelium) and a white zone
(due to fibrosis of scar).
Undermined edge – it is mostly seen in tuberculosis.The
disease causing the ulcer spreads in an d destroys the
subcutaneous tissue faster than it destroys the skin.The
overhanging skin is thin friable,reddish blue and unhealthy.
Punched out edges – it is mostly seen in gummatous ulcer or
in a deep trophic ulcer.The edges drop down at right angle to
the skin surface as if it has been cut out a punch.It is seen in
diseases in which activity is limited to the ulcer itself and does
not tend to spread to the surrounding tissues.

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Sloping edge – it is seen mostly in healing
traumatic or venous ulcer.Every healing ulcer has a
sloping egde,which is reddish purple in color and
consists of new healthy epithelium.
Raised and pearly white beaded edge – it is a
feature of rodent ulcer which develpos in invasive
cellular diseases and becomes necrotic at the
centre.
Rolled (everted)edge – it is characteristic feature of
squamous cell carcinoma or an ulcerated adenocarcinoma.This ulcer is caused by fast growing
cellular disease,growing portion at the edge of the
ulcer heaps up and spills over the normal skin to
produce an everted edge.

10. 
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Floor
This is the exposed surface of the ulcer.One must
be very careful to note what isthere at the floor of
an ulcer.
When floor is covered with red granulation tissue,
the ulcer seems to be healthy and healing.
Pale and smooth granulation tissue indicates a
healing ulcer.
Wash leather slough on the floor of ulcer is
pathognomonic of gummatous ulcer.
A black mass at the floor sugggests malignant
melanoma.

11. 
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Discharge
The character of the discharge should be noted,its
amount and smell.
A healing ulcer will show scanty serous
discharge,but the spreading and inflamed ulcer will
show purulent discahrge.
Serosanguineous discharge is often seen in a
tuberculoses ulcer or a malignant ulcer.

12. 
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Surrounding area
If the surrounding area of an ulcer is glossy,red and
edematous, the ulcer is acutely inflamed.
Very often the surrounding skin of varicose ulcer is
eczematous and pigmented.
A scar or wrikling in surrounding a skin of an ulcer
may well indicate an old case of tuberculosis.

13. PALPATION
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Tenderness
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An acutely inflamed ulcer is always exquisitely
tender.
Chronic ulcer are slightly tender.
Neoplastic ulcers are never tender.
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14. 
Edge
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In palpation different types of edge of the ulcer are
corroborated with the finding of the inspection.
Marked induration of the edge is characteristic
feature of a carcinoma.
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15. 
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Base
The student must understand the difference
between the floor( exposed surface within the
ulcer)and base(on which ulcer rests and it is better
felt than seen)
If an attempt is made to pick up the ulcer between
thumb and the index finger,the base will be felt.
Marked induration of the base is an important
feature of squamous cell carcinoma and chancre.

16. 
Depth
•
You should make assessment regarding depth of
the ulcer.It can be recorded in the examination
sheet in millimeters.

17. 
Bleeding
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Whether the ulcer bleeds on touch should be
checked as it is a common feature of malignant
ulcer.

18. 
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Relation with deeper structures
The ulcer is made to move over the deeper
structures to know whether it is fixed to any of these
structures.
A gummatous ulcer over a subcutaneous tissue or
bone is often fixed to it.Malignant ulcer will be fixed
to any of the deeper structure by infiltration.