General management

The specific treatment of an ulcer is dependent on the subtype; there are several steps which may be applicable to all ulcers:

• determination of aetiology:
  • accurate description can aid diagnosis - see submenu
  • complete physical examination can largely aid in diagnosis e.g. state of nutrition, arterial disease, neuropathy
  • investigations:
    • FBC to exclude anaemia
    • dipstix urine to exclude diabetes mellitus
    • albumin; index of nutrition
    • biopsy edge of ulcer if suspicion of malignancy or aetiology is still unknown; can be done at endoscopy for gastrointestinal lesions. No indication that biopsy increases the risk of spread.
    • radiology: if suspicion of spread of infection from deeper focus
• correct dressings, frequently changed. Not applicable to gastrointestinal ulcers.
• ensure adequate drainage and desloughing:
  • slough inhibits the functioning of granulation tissue
  • drainage should be encouraged by surgical or chemical desloughing of ulcer base
• antibiotics are only indicated for infected ulcers in which:
  • there is evidence of spread around the margin e.g. a cellulitic rim
  • there may be ongoing systemic infection e.g. syphilis, tuberculosis
• correction of specific abnormalities e.g.:
  • malnutrition
  • myxoedema
  • excessive steroid use
• for large deficits or prolonged ulcers with little evidence of healing, further surgical intervention may be indicated e.g. skin grafts and rotational flaps.