Not All Ulcers Are Created Equal

To the general public an ulcer is just an ulcer. It’s merely a wound or sore needing treatment from our billion dollar wound care industry. However, did you know there are different types of ulcers? Ulcers, dependent on their distinctive pathologies, also require different treatments and thereby involve different standards of care. To avoid comparing apples to oranges, it is important to identify what type of ulcer is involved in your legal case.

Diabetic ulcers are usually located on lower extremities and caused by peripheral neuropathy associated to small or large vessel disease in chronic, uncontrolled diabetes. 

Ischemic ulcers are typically found on the distal lower extremities, such as the tips of the toes. These types of ulcers result from a decrease in blood flow to the tissues, which may be caused by coronary artery disease, diabetes, hypertension, hyperlipidemia, peripheral arterial disease or even smoking. 

Venous ulcers also develop in the lower extremities, but have yet another different and unique pathology. They are caused by venous hypertension from incompetent venous valves, post-phlebitic syndrome or venous insufficiency. These specific ulcers tend to be irregular in shape. 

A pressure ulcer is a localized injury to the skin or underlying tissue due to unrelieved pressure combined with shear or friction. These ulcers are typically found over bony prominences such as the shoulders, buttocks, hips, heels or elbows. Pressure ulcers are even further broken down and described by “stages.”

• A Stage I pressure ulcer describes intact skin that is red and non-blanchable. It may be painful, firm, soft, and warmer or cooler compared to surrounding skin. It is also an indicative sign of risk for further skin breakdown.
  
• A Stage II pressure ulcer is described as “partial thickness” loss of the dermis layer of skin. It resembles a shallow, open ulcer with a red, pink ulcer bed. It also may present as an intact or ruptured serum-filled blister. This stage does NOT describe skin tears, tape burns, maceration or excoriation. It also does NOT involve bruising or “slough” (necrotic tissue).
  
•  Stage III pressure ulcers are deeper ulcers involving subcutaneous tissue (the fatty layer of skin). It is a “full thickness” tissue loss. Bone, tender or muscle are NOT exposed in this stage.
  
• A Stage IV pressure ulcer is also “full thickness” tissue loss, however bone, tendon and/or muscle will be visible or directly palpable. It often involves undermining and tunneling (similar to a pocket hidden under the skin). 

It is important to note when attempting to stage a pressure ulcer that if “slough” or “eschar” is present in the ulcer bed, that the ulcer is “unstageable.” Until this dead tissue is removed to expose the base of the ulcer and a the true depth, a stage cannot be determined. 

The National Pressure Ulcer Advisory Panel (NPUAP) serves as an authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment. Keep an eye out, they will be announcing a new and updated pressure ulcer staging system in 2016.

This is a brief summary of ulcers; there are still many other types of ulcers caused by trauma and dermatologic disease. The nurses at Aguirre Legal Nurse Consulting can assist you in properly identifying which type of ulcer is involved in your legal case. We also know some of the best wound care experts available to provide testimony. Call us at (443) 598-2562 or email AguirreLegalNurseConsulting@gmail.com

Stay tuned for my next post on pressure ulcer prevention….