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Although no two wounds are truly alike, they are often categorized by the underlying cause. Diabetes, pressure, arterial, and venous stasis are terms often associated with commonly occurring wounds. Wounds or ulcers are not limited to these categories:
Diabetic Ulcers
The complications from diabetes are numerous and extensive. Often, a combination of factors associated with diabetes, such as decreased circulation, loss of sensation, structural foot deformities and loss of skin integrity, will create the conditions for the formation of a non-healing wound. This type of wound is often referred to as a “diabetic ulcer”. A diabetic ulcer can be a simple break in the skin which does not heal in a timely and orderly fashion, or a wound that extends to deep structures and bone. They are often the entry points for bacteria and fungal organisms to invade the body, and the cause of limb and life threatening infection. Incredibly, diabetic foot ulcers are often painless.
Blood sugar which remains elevated, greater than 110 mg/dl, for extended periods of time, may result in irreversible effects within the body of a diabetic. Small blood vessels in the eyes, kidneys and feet may be damaged with a result in decreased blood flow and oxygen to each area.
In the feet, decreased ability to sense light touch or pain as a result of an associated symptom known as peripheral neuropathy puts diabetics at a greater risk for developing diabetic foot ulcers. Neuropathy may also be related to elevated blood glucose over time.
It is all too common for diabetics to step on sharp objects such as glass or nails, or to develop blisters, without ever feeling the pain associated with such trauma. Inspection of the feet, at least once daily, can be a critical measure in the prevention of diabetic foot ulcers and for the long term well being of the person with diabetes
Pressure Ulcers
Also known as bedsores, decubitus ulcers or pressure sores. Prolonged pressure over a bony prominence result in a decrease blood flow and oxygen to the skin and underlying structures. When cells are deprived of oxygen, they die, resulting in destruction of the tissue they are structurally a part of. Cell and tissue death may occur as quickly as thirty minutes, possibly faster in an individual with compromised circulation.
Individuals who are at risk for developing pressure ulcers are those who may not be able to re-position themselves while in bed or a chair, or who may not feel the body’s warning signal to shift bodyweight when in one position for an extended period.
The risk factors for developing pressure ulcers are many. The greater the number of factors a person has, the greater the risk. Among the risk factors for developing pressure ulcers are the following:
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confinement to bed or a chair (ill, injured, post surgical),
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diabetes
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circulatory disease (arterial and venous)
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partial or whole body paralysis
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decrease in mental awareness (due to Alzheimer’s disease, medication, alcohol, anesthesia after surgery)
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poor nutrition or dehydration (poor fluid intake)
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loss of bowel or bladder function
Venous Stasis Ulcers
Ulcers that result from an underlying disease of the veins are known as venous ulcers or venous stasis ulcers. Venous stasis is a common condition that occurs due to a deficiency within the valves of the deep veins in the legs. Blood tends to pool near the ankle as gravity pulls fluid and blood downward while diseased veins inefficiently return blood to the heart and lungs. Prolonged swelling of the legs and ankles causes pressure to increase and blood flow and oxygen to the skin to be reduced, usually near the ankles, with breakdown in the skin resulting in ulcer formation.
Venous ulcers are typically located near the ankles, or the “gaiter” region. They are often painless when elevated, but may be painful when the leg is down (dependent). Skin surrounding the ulcer often appears brown or reddish in color, a permanent staining of the skin. The border of a venous ulcer is often smooth, with drainage also a very common finding. The surface of venous ulcers is often red in appearance, the result of blood within the region, but not moving efficiently. Ulcer formation may be triggered by injury to the ankle or leg, such as bumping into an object (coffee table leg or car door, for example), after extended periods of standing, lack of exercise, or any condition that may result in excess fluid collection in the body and legs.
Symptoms of chronic venous stasis disease may include any or all of the following:
• swelling in legs and ankles, skin discoloration (brown, red or bluish)
• dry scaly itchy skin
• aching or feeling of tiredness in legs that is relieved by elevating legs
• prominent superficial veins
• skin ulcer (usually above the ankle on inside surface of the leg)
Arterial Ulcers (Ischemic Ulcers)
Individuals afflicted with arteriosclerosis, (also referred to as arterial disease, Peripheral vascular disease, PVD, Peripheral arterial disease, PAD, or “hardening of the arteries”) are at risk for developing arterial or ischemic ulcers. Ischemia is a term that refers to a lack of oxygen and resultant tissue death. Diabetics, smokers and persons with kidney disease often suffer from calcification, injury or destruction of arteries. Damage to arteries results in decreased blood and oxygen to tissue and cells. This type of ulcer is among the most difficult to treat successfully unless blood flow is restored to the leg by way of surgical by pass procedure (if adequate vessels remain) or with medication.
Arterial ulcers are typically extremely painful and are often seen first in the toes and feet, where blood vessels are smallest. They are often described as “punched out” in appearance with clearly defined borders. These ulcers may appear as black “scabs”, also known as eschar. Ulcers with black eschar may be referred to as “dry gangrene”.
Persons with arterial disease may exhibit warning signs such as:
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cramping in the calf when walking which is relieved with rest (intermittent claudication)
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pain in buttocks region, red discoloration of legs and feet when in down position (dependent rubor) relieved with elevation of legs
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bluish discoloration (cyanosis, due to lack of oxygen) of feet and legs
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Need to sleep with legs dangling from side of bed (to assist gravity in supplying blood to the legs and feet)
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Need to sleep with sitting up/pillows behind back (also to assist gravity in bring blood to the lower part of the body)
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