Trophic ulcers: causes, types, diagnosis, and treatment

Causes (Etiology)

The development of trophic ulcers is associated with impaired local blood circulation, innervation, or general systemic disorders.

Main groups of causes:

Vascular (chronic): disturbances of venous (chronic venous insufficiency, post-thrombotic syndrome) or arterial (chronic arterial insufficiency, atherosclerosis) blood flow, lymphedema.
Traumatic: consequences of deep burns, frostbite, or extensive wounds.
Neurogenic: syringomyelia, nerve damage, tabes dorsalis (tabes dorsalis).
Metabolic: diabetes mellitus, vitamin deficiency.
Systemic and infectious: collagenoses, blood disorders, tuberculosis, syphilis, leprosy, erysipelas, deep mycoses.
Oncological: breakdown of a malignant tumor.

Classification and clinical presentation

The most common in surgical practice are vascular ulcers. The appearance and location of the defect depend on its cause.

Arterial (Atherosclerotic) Ulcers

Occur in elderly patients against the background of chronic arterial insufficiency. Located on the foot or the lower third of the leg. The defects are small, round-oval, with uneven, dense edges and pale granulations. Accompanied by severe limb ischemia.

Venous (Varicose and Post-Thrombotic Syndrome)

Varicose: Most frequently localized near the medial malleolus. Can be deep and extensive. Characterized by hyperpigmentation and sclerosis of surrounding tissues, mildly painful. Combined with varicose veins.
Post-thrombotic: Formed in post-thrombotic syndrome. Localization — medial malleolus. Can reach giant sizes (up to "gaiter" ulcers covering the entire lower leg). Edges are flat, granulations are sluggish. The surrounding skin is markedly thickened and edematous (indurative cellulitis).

Radiation Ulcers

A consequence of ionizing radiation. Preceded by skin atrophy, telangiectasias, and hair loss. Defects are deep (down to the bone), with uneven edges, surrounded by a zone of sclerosis.

Tumor Breakdown Ulcers

Form over a dense, fixed infiltrate. Edges are nodular, thickened, the base is covered with necrosis, and ongoing tumor tissue growth is noticeable at the periphery.

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Principles of treatment

The therapeutic approach is always comprehensive and includes three areas:

Pathogenetic treatment: elimination of the primary cause. For example, normalization of blood flow (removal of varicose veins, vascular surgery) or excision of scars.
Local treatment:
Cleansing: removal of necrosis and infection control (vacuum, enzymes, scalpel).
Regeneration: healing stimulation (physiotherapy, dressings with reparative agents) or skin grafting (autologous skin grafting).
General supportive therapy: vitamins, nutritional correction, stimulation of anabolism.

Briefly: answers to topical questions

What methods and groups of drugs are used for local cleansing of a trophic ulcer from necrotic masses?

For local cleansing of a trophic ulcer from necrotic masses, surgical excision, vacuum therapy, and proteolytic enzymes are used. Enzymes belong to biological antiseptics; they lyse necrotic tissues, fibrin, and pus, and also exert an anti-edematous effect. According to their origin, the following groups of proteolytic enzymes are distinguished:

Of animal origin — Trypsin, Chymotrypsin, Ribonuclease, Collagenase.
Of bacterial origin — Terrilytin, Streptokinase, Asperase (as well as the combination ointment Iruxol).
Of plant origin — Papain, Bromelain.

These drugs are used locally as a solution or powder applied directly to the ulcer.

What are the classic stages of the wound process distinguished in the course and healing of a trophic ulcer?

In the course and healing of a trophic ulcer, as in any wound process, three classic stages are distinguished. The healing pattern is universal, and the differences are only quantitative in nature:

Phase I — Inflammation (hydration) — combines the processes of alteration, exudation, and necrolysis; its essence lies in cleansing from necrotic tissues (clinically corresponds to a "black" or "yellow" wound).
Phase II — Proliferation (regeneration, dehydration) — formation and maturation of granulation tissue occurs (clinically this is a "red" wound).
Phase III — Healing (scar reorganization and epithelialization) — includes the maturation of scar tissue and epithelialization of the defect ("white" wound).

Class and exam questions

Why is a biopsy of a trophic ulcer necessary?

A biopsy is necessary for long-non-healing (calloused) ulcers to rule out malignant transformation (malignification) or to confirm a specific infection (e.g., tuberculosis).

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What else to study on this topic

Pathogenesis of microcirculatory disorders in chronic venous insufficiency and chronic arterial insufficiency
Methods for surgical closure of ulcer defects (autologous skin grafting)
Indurative cellulitis in post-thrombotic syndrome
Specific ulcers (tuberculous, syphilitic)
The role of proteolytic enzymes in wound cleansing

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Trophic ulcers