Review of Answer Choices (Correct Answer in Green):
A. Shallow ulcers with irregular borders and fibrinous, yellow exudate and surrounding hyperpigmentation and atrophe blanche.
B. Deep, poorly defined ulcers with evidence of lymphangitis
C. Well-demarcated edges with overlying necrotic eschar, with surrounding erythema and hyperpigmentation.
D. “Punched-out” appearance with a surrounding callous.
Explanation:
Evaluation of an ulcer: 5 Keys
- Size – note the size of the ulcer to track if it increases or decreases over time
- Bed – note the presence of granulation tissue and slough. Granulation tissue is pink, healthy tissue on a wound bed and indicates wound healing. Note whether the tissue is friable or bleeds easily, as properly healing wounds should not. Slough is moist host tissue that may be attached firmly or loose, and varies in colour (i.e. yellow, tan, cream) depending on the level of moisture.
- Edge – note the overall edge appearance. Examples are not exhaustive:
a) Punched out: seen in arterial or surgical etiology (i.e. arterial ulcer or surgical punch biopsy)
b) Undermined: tissue on wound’s edge is eroded, resulting in pocket underneath wound’s edges. This may occur in infections or pyoderma gangrenosum.
c) Ill-defined: seen in venous insufficiency - Exudate – note the type, amount, and additional characteristics
a) Arterial – dry; little exudate
b) Venous – lots of exudate
c) Trauma – sanguineous (contains blood)
d) Diabetic – more walking results in more exudate - Peri-wound skin – note if any dermatitis, sun damage, or venous insufficiency changes are present
A. Shallow ulcers on bilateral anterior shins with irregular borders and fibrinous, yellow exudate and surrounding hyperpigmentation and atrophie blanche: This provides the most comprehensive description, commenting on the location, demarcation, colour, shape, and surrounding skin features. Atrophe blanche is seen in up to 40% of patients with chronic venous insufficiency, and presents as sclerotic, indurated, and ivory-white plaques that may be surrounded by pigment changes and telangiectasias.
B. Deep, poorly defined ulcers on bilateral anterior shins with evidence of lymphangitis: The lesions here appear shallow, not deep. Lymphangitis is an infection or inflammation of the lymphatic channels, most often caused by skin and soft tissue infections. It presents as an erythematous line on the skin along the lymphatic channel, which we do not observe here.
C. Well-demarcated edges with overlying necrotic eschar: An eschar is a patch of dead, necrotic tissue that can be described as a black scab. It is common after a burn injury or a deep wound, and suggestive of the loss of nutritional and oxygen supply from the arterial blood. We observe no necrotic tissue in Mr. Ali.
D. “Punched-out” appearance with a surrounding callus: “Punched-out” appearance is classically associated with arterial ulcers and neuropathic ulcers. You can see surrounding callous in neuropathic ulcers.