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Skin Ulcers: Causes, Symptoms, Diagnosis, and Treatment

What is Skin Ulcers?

A skin ulcer is an open sore that forms when the outer layers of the skin (the epidermis and dermis) break down and do not heal normally. Ulcers can appear on any part of the body, but they are most common on the lower legs, feet, and pressure‑prone areas such as the heels or sacrum. The edges of an ulcer are usually raised, the base may be granulated (pink‑red) or covered with necrotic (dead) tissue, and the surrounding skin often appears reddened, warm, or swollen.

Ulcers differ from simple cuts or abrasions because they persist for weeks or months, showing delayed or absent healing. The underlying mechanisms may involve poor blood flow, chronic inflammation, infection, pressure, or systemic disease.

Common Causes

Many medical conditions and external factors can lead to skin ulcer formation. Below are the most frequently encountered causes:

• Venous stasis ulcers – Result from chronic venous insufficiency in the lower legs.
• Arterial (ischemic) ulcers – Caused by peripheral arterial disease (PAD) that reduces blood flow.
• Diabetic foot ulcers – Due to peripheral neuropathy and impaired wound healing in people with diabetes.
• Pressure (decubitus) ulcers – Develop over bony prominences in people who are immobilized.
• Infectious ulcers – Usually secondary to bacterial, fungal, or mycobacterial infections (e.g., Buruli ulcer, cutaneous leishmaniasis).
• Vasculitic ulcers – Result from inflammation of blood vessels in diseases such as granulomatosis with polyangiitis.
• Malignancy‑related ulcers – Skin cancers (e.g., squamous cell carcinoma) can ulcerate.
• Traumatic or chemical burns – Deep burns may evolve into chronic ulcers.
• Autoimmune disorders – Conditions like pyoderma‑gangrenosum or lupus can produce ulcerative lesions.
• Medication‑induced ulcers – Chronic use of corticosteroids or non‑steroidal anti‑inflammatory drugs (NSAIDs) can impair healing.

Associated Symptoms

Skin ulcers rarely occur in isolation. The following signs and symptoms often accompany them:

• Pain or burning sensation (sometimes absent in neuropathic ulcers).
• Swelling (edema) of the surrounding tissue.
• Redness or warmth around the ulcer – a possible sign of infection.
• Discharge: serous fluid, pus, or foul‑smelling odor.
• Changes in skin color—bluish (cyanosis) in arterial ulcers, brownish (hyperpigmentation) in venous ulcers.
• Visible blood vessels (telangiectasias) or hemosiderin staining near venous ulcers.
• Reduced sensation in the affected area, especially in diabetic foot ulcers.
• Fever, chills, or generalized malaise if infection spreads.

When to See a Doctor

While many small ulcers can be managed at home with proper wound care, you should seek professional medical evaluation promptly if you notice any of the following:

• The ulcer is larger than 1 cm in diameter or continues to enlarge.
• Increasing pain, swelling, or redness that spreads beyond the ulcer margins.
• Presence of purulent (pus‑filled) drainage, a foul odor, or black/gray necrotic tissue.
• Fever ≥ 38 °C (100.4 °F), chills, or feeling ill.
• Signs of peripheral arterial disease—cool, pale skin, or diminished pulses.
• Underlying conditions such as diabetes, immune suppression, or chronic venous disease that put you at higher risk of complications.
• Any ulcer that fails to show signs of healing within 2–3 weeks despite appropriate home care.

Diagnosis

Accurate diagnosis involves a combination of history taking, physical examination, and targeted investigations.

History and Physical Exam

• Duration, size, and progression of the ulcer.
• Associated systemic diseases (diabetes, heart failure, PAD, autoimmune disorders).
• Medication list and recent injuries.
• Assessment of peripheral pulses, capillary refill, and ankle‑brachial index (ABI) for arterial disease.
• Evaluation of edema, skin changes, and presence of varicose veins.

Laboratory and Imaging Tests

• Wound cultures – To identify bacterial, fungal, or mycobacterial infection.
• Complete blood count (CBC) and C‑reactive protein (CRP) – Detect systemic inflammation.
• Blood glucose/HbA1c – Screen for uncontrolled diabetes.
• Doppler ultrasound or ankle‑brachial index – Evaluate arterial flow.
• Duplex ultrasound or venography – Assess venous insufficiency.
• Biopsy – Required when malignancy, vasculitis, or atypical infection is suspected.
• X‑ray or MRI – Rule out underlying osteomyelitis (bone infection) when deep or recurrent ulcers are present.

Treatment Options

Treatment is individualized based on the ulcer’s cause, size, depth, and presence of infection. A multidisciplinary approach—often involving primary care, wound‑care nurses, vascular surgeons, endocrinologists, and infectious disease specialists—yields the best outcomes.

General Wound‑Care Principles

• Cleaning – Gentle irrigation with saline or sterile water; avoid harsh antiseptics that delay healing.
• Debridement – Removal of necrotic tissue using sharp, enzymatic, or autolytic methods.
• Moisture balance – Apply appropriate dressings (hydrocolloid, alginate, foam, or antimicrobial) to maintain a moist environment.
• Off‑loading – Use pressure‑relieving devices (e.g., specialized footwear, cushions) for foot and pressure ulcers.
• Infection control – Systemic antibiotics guided by culture results; topical antimicrobials for superficial colonization.

Cause‑Specific Treatments

• Venous ulcers – Compression therapy (graduated bandages or stockings), leg elevation, and treatment of underlying venous reflux (laser or surgical ablation).
• Arterial ulcers – Optimize cardiovascular risk factors, antiplatelet therapy, and revascularization (angioplasty or bypass) when indicated.
• Diabetic foot ulcers – Strict glycemic control, regular podiatric inspections, off‑loading with total contact casts, and possible use of growth‑factor dressings (e.g., becaplermin).
• Pressure ulcers – Frequent repositioning (every 2 hours), pressure‑relieving mattresses, and nutritional support (protein ≥ 1.2 g/kg/day, vitamin C, zinc).
• Infectious ulcers – Targeted antimicrobial therapy; for mycobacterial or atypical infections, prolonged multidrug regimens are required.
• Vasculitic ulcers – Systemic immunosuppression (corticosteroids, cyclophosphamide, or biologics) under rheumatology guidance.
• Malignant ulcers – Surgical excision, radiotherapy, or topical chemotherapy depending on tumor type and stage.

Adjunctive Therapies

• Negative‑pressure wound therapy (NPWT) for large, exudative wounds.
• Hyperbaric oxygen therapy for refractory ulcers, especially in diabetics.
• Skin substitutes (biologic or synthetic grafts) when granulation tissue is insufficient.
• Patient education on self‑inspection, foot care, and proper dressing changes.

Prevention Tips

Many skin ulcers are preventable with simple lifestyle changes and regular medical follow‑up:

• Manage chronic diseases – Keep blood pressure, cholesterol, and blood sugar within target ranges.
• Maintain good skin hygiene – Keep skin clean, moisturized, and free of cracks, especially on hands and feet.
• Inspect skin daily – Use a mirror or ask a caregiver to check hard‑to‑see areas.
• Wear properly fitted shoes – Orthopedic footwear or custom insoles for diabetics and those with peripheral neuropathy.
• Use compression stockings if you have chronic venous insufficiency (under physician guidance).
• Reposition immobile patients – Every two hours, and use pressure‑relieving cushions.
• Quit smoking – Improves peripheral circulation.
• Nutrition – Adequate protein, calories, vitamins A, C, and zinc support wound healing.
• Regular follow‑up – Annual vascular assessments if you have PAD, diabetes, or venous disease.

Emergency Warning Signs

Key Take‑aways

Skin ulcers are a common but serious problem that can stem from vascular disease, diabetes, pressure, infection, or malignancy. Early recognition, proper wound care, and treatment of the underlying cause are essential to prevent complications such as infection, cellulitis, or amputation. When in doubt, especially if the ulcer is painful, rapidly changing, or accompanied by systemic symptoms, consult a healthcare professional promptly.

References:

• Mayo Clinic. “Skin ulcer.” Accessed April 2024.
• American Diabetes Association. “Standards of Care in Diabetes—2024.” Diabetes Care.
• National Institute for Health and Care Excellence (NICE). “Chronic wound management.” 2023.
• CDC. “Pressure Ulcer Prevention.” Updated 2023.
• Cleveland Clinic. “Venous Ulcers: Diagnosis and Treatment.” 2024.
• World Health Organization. “Guidelines for the management of diabetic foot ulcers.” 2022.

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