SKIN ULCERS
SKIN ULCERS: Excerpt from Differential Diagnosis in Primary Care
The differential diagnosis of skin ulcers may be approached with
anatomy as the basic science, particularly if the ulcer is on one
of the legs. Beginning with the skin itself and applying the mnemonic
MINT, one can recall the following:
M—Malformations suggest sickle cell anemia.
I—Infection suggests syphilis, chancroid, lymphogranuloma,
actinomycosis, tularemia, and other infections.
N—Neoplasms suggest basal cell and squamous cell carcinomas.
T—Trauma suggests third-degree burns, unsutured lacerations, and
pressure sores (bedsores).
Now visualize the structure beneath the skin. The arteries
suggest arteriosclerosis and diabetic ulcers; the veins prompt the
recall of varicose ulcers or postphlebitic ulcers; the nerves
suggest trophic ulcers of tabes dorsalis, syringomyelia, and peripheral
neuropathy; and the bone suggests osteomyelitis (e.g.,
staphylococcal, tuberculosis) that penetrates the skin.
In contrast to the method described above, a somewhat more complete
differential diagnosis may be developed with the mnemonic
VINDICATE.
V—Vascular disorders suggest peripheral
arteriosclerosis, diabetic ulcers, and varicose ulcers.
I—Infections suggest syphilis, chancroid, yaws, and tularemia.
N—Neoplasm suggests carcinomas, sarcomas, and mycosis fungoides.
D—Degenerative disorders suggest ulcers
associated with degenerative and deficiency diseases, such as peripheral
neuropathy, syringomyelia, muscle atrophy, and peroneal muscular atrophy.
I—Intoxication suggests the ulcer of chronic dermatitis.
C—Congenital recalls the ulcers of sickle cell anemias.
A—Autoimmune brings to mind the ulcers of periarteritis nodosa,
pyoderma gangrenosum (associated with ulcerative colitis), and
Stevens–Johnson syndrome.
T—Traumaidentifies ulcers of burns and radiation secondary to
unhealed lacerations and decubitus ulcers.
E—Endocrine disorders suggest diabetic
ulcers.
I—Infections can be further elucidated by working from the
smallest organism to the largest.
Beginning with viruses,
herpes simplex, and lymphogranuloma is suggested. Bacteria remind
one of tuberculosis, tularemia, leprosy, and cutaneous diphtheria.
Spirochetes suggest syphilis and yaws. Parasites identify
leishmaniasis and amebiasis cutis. The rest are fungal and include
actinomycosis, blastomycosis, sporotrichosis, and cryptococcosis.
Approach to the Diagnosis
The approach to the diagnosis of a skin ulcer involves an assessment of
the vascular supply to the area, a neurologic examination, and a good
history (especially important is venereal disease). The laboratory can
support the diagnosis with a smear and culture, skin tests for tuberculosis
and fungi, and serologic tests.
An x-ray of the bone may reveal the cause. A biopsy may be necessary.
Radiographic and laboratory survey of other organs may be necessary if a
systemic disease (e.g., collagen disease or ulcerative colitis) is
suspected.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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