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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:

1. M—Malformations suggest sickle cell anemia.
2. I—Infection suggests syphilis, chancroid, lymphogranuloma, actinomycosis, tularemia, and other infections.
3. N—Neoplasms suggest basal cell and squamous cell carcinomas.
4. 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.

SKIN ULCERS

In contrast to the method described above, a somewhat more complete differential diagnosis may be developed with the mnemonic VINDICATE.

1. V—Vascular suggests peripheral arteriosclerosis, diabetic ulcers, and varicose ulcers.
2. I—Infections suggest syphilis, chancroid, yaws, and tularemia.
3. N—Neoplasm suggests carcinomas, sarcomas, mycosis fungoides, and so forth.
4. D—Degenerative suggests ulcers associated with degenerative and deficiency diseases, such as peripheral neuropathy, syringomyelia, muscle atrophy, and peroneal muscular atrophy.
5. I—Intoxication suggests the ulcer of chronic dermatitis.
6. C—Congenital recalls the ulcers of sickle cell anemias.
7. A—Autoimmune brings to mind the ulcers of periarteritis nodosa, pyoderma gangrenosum (associated with ulcerative colitis), and Stevens–Johnson syndrome.
8. T—Trauma identifies ulcers of burns and radiation and secondary to unhealed lacerations and decubitus ulcers.
9. E—Endocrine suggests diabetic ulcers.
10. I—Infections can be further elucidated by working from the smallest organism to the largest. Beginning with viruses, herpes simplex and lymphogranuloma are suggested.
11. Bacteria reminds one of tuberculosis, tularemia, leprosy, and cutaneous diphtheria.
12. 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.

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• 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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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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