Examination of ulcers

The examination of an ulcer is a systematic clinical assessment that helps determine its type, cause, stage, and management.

Here is a comprehensive breakdown of the key steps in the examination of a skin ulcer, often remembered using mnemonics like the one below, which focuses on the local assessment:

Local Examination of an Ulcer

The main components of the local examination are Inspection (Look) and Palpation (Feel).

1. Inspection (Look)

Feature	Details to Note	Potential Significance (Examples)
Site/Position	Exact location on the body (e.g., medial malleolus, heel, over a bony prominence).	Venous ulcers (medial lower leg, "gaiter area"), Arterial ulcers (distal digits, lateral malleolus, pressure points), Neuropathic/Diabetic ulcers (pressure points on the sole/foot).
Size	Measure the length and width (or diameter) in centimetres.	Used to track healing progress.
Shape	Describe the outline (e.g., circular, oval, irregular, geographical).	Punched-out (Arterial, Gummatous), Irregular/Geographical (Venous).
Margin	The boundary between normal skin and the ulcer.	Well-demarcated (Punched-out), Ill-defined (Venous).
Edge	The area between the margin and the floor. The appearance of the edge is a critical diagnostic feature.	Sloping (Healing, Venous), Punched-out (Arterial, Trophic), Undermined (Tuberculous), Everted/Rolled-out (Malignant, e.g., Squamous Cell Carcinoma), Raised & Beaded (Malignant, e.g., Basal Cell Carcinoma).
Floor	The surface seen at the bottom of the ulcer.	Red/Pink Granulation Tissue (Healing), Pale/Unhealthy Granulation Tissue (Chronic, Callous), Wash-leather Slough (Gummatous), Black Necrotic Tissue (Arterial/Ischemic, Malignant Melanoma).
Depth	How deep the ulcer extends (e.g., superficial, deep to fascia/tendon/bone).	Deep involvement suggests a more serious pathology (e.g., neuropathic, severe arterial).
Discharge	Note the amount, color, and odor.	Serous (Clear, watery - usually healing), Purulent (Yellow/Green/Creamy - infection), Serosanguineous (Pink/Red-tinged - common).
Surrounding Area	Look for skin changes in the adjacent region.	Brawny skin, Hemosiderin pigmentation, Varicose eczema, Lipodermatosclerosis (Venous disease); Shiny, hairless, pale, cool skin, Trophic changes (Arterial disease); Callus (Neuropathic/Diabetic).

2. Palpation (Feel)

Palpation confirms the findings of inspection and assesses deeper tissues.

Feature	Details to Note	Potential Significance (Examples)
Tenderness	Test the ulcer and the surrounding area.	Painful (Arterial, Malignant, Infected, Pyoderma Gangrenosum), Painless (Neuropathic, Trophic).
Temperature	Compare with the surrounding skin and the opposite limb.	Increased warmth (Infection, Inflammation), Coolness (Arterial insufficiency).
Edge & Base	Gently palpate the edge and the base (the tissue the ulcer rests on) between the thumb and index finger to check for Induration (Hardness/Hardening).	Marked Induration (Malignant/Carcinomatous, Hunterian Chancre/Syphilis), Slight Induration (Expected in any chronic ulcer).
Relations	Assess if the ulcer is fixed to underlying structures (muscle, tendon, bone) by attempting to move them.	Helps determine the extent of tissue involvement.
Sensation	Especially for foot ulcers, test for Neuropathy using a 10g monofilament.	Loss of sensation is classic for Neuropathic/Diabetic ulcers.

3. General & Regional Examination

• Regional Lymph Nodes: Palpate for enlargement or tenderness. Enlargement can suggest infection or malignancy.

• Vascular Assessment: This is crucial for lower limb ulcers.

  • Pulses: Palpate distal pulses (dorsalis pedis, posterior tibial). Absent or weak pulses suggest Arterial disease. Use a Doppler if pulses are not palpable.

  • Ankle-Brachial Index (ABI): Measurement is recommended to objectively assess for peripheral arterial disease.

  • Signs of Venous Disease: Look for varicose veins, edema, and venous insufficiency signs in the whole limb.

• General Assessment: Look for signs of systemic diseases that can cause ulcers, such as:

  • Diabetes Mellitus (Neuropathic/Diabetic ulcers)

  • Atherosclerosis (Arterial ulcers)

  • Autoimmune/Inflammatory conditions (e.g., Pyoderma Gangrenosum, Vasculitis)

  • Malnutrition

  • Anemia (from chronic bleeding)

Key Takeaway

The characteristics of the edge (e.g., sloping, punched-out, everted) and the base/floor (e.g., healthy granulation, slough, black necrosis) are the most significant local findings that help a clinician differentiate between the various types of ulcers (Venous, Arterial, Neuropathic, Malignant, etc.).