Trophic ulcers: causes, symptoms, diagnosis, treatment

A tropical ulcer is a collective term used to refer to the different ulterior and clinical patterns of ulcers common to which are the climatic and geographical factors necessary for their origin and development in tropical and subtropical countries. At present, from the whole variety of tropical ulcers, the tropical ulcer, the tropicoid ulcer, the plague of the deserts and the coral ulcer, have the greatest clinical independence.

A tropical ulcer is a persistent and torpid peptic ulcer with a dominant localization on the skin in the ankle and less than the lower third of the shin, which occurs more often in children, young and middle-aged men living in tropical and subtropical climates. As synonyms, the tropical ulcer is sometimes referred to as the phagodenetic, crocheted, jungle, Madagascar, and others.

Epidemiology of tropical ulcers

The disease is a tropical ulcer found in most countries in a hot, tropical climate. In South America - this is Brazil, Guiana, Colombia, Ecuador, Argentina, Chile, etc. On the African continent, a tropical ulcer occurs with a relatively high frequency in almost all countries, especially in the east and south mainland. Many patients with tropical ulcers are registered in India, Sri Lanka, Nepal, less often in southern China and Indonesia. Rare cases have been observed in Iran, Turkey and other countries of the Middle East.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Causes of Tropical Ulcer

Despite numerous studies, the issues of etiopathogenesis of the tropical phagodenetic ulcer still remain unclear in many respects. Today there is a point of view that the causes of tropical ulcers are mixed strepto-staphylococcal infection with the mandatory presence of fusospirill in this association. English dermatologists proposed a theory of etiopathogenesis of tropical ulcers, described by four letters F: foot, fusobacteria, filth, friction. This indicates the primary lesion of the foot, the constant presence of fusobacterial ulcers in the mixed flora, the natural bacterial contamination of the tropic environment and a naturally high risk of traumatizing the skin of the lower extremities due to traditionally open footwear or none at all.

Predispose to the disease a tropical ulcer decrease in the protective properties and reactivity of the body as a result of the presence of various concomitant diseases, such as malaria, yaws, dysentery, helminthiases and other tropical infections and parasitosis. Often, tropical ulcers are observed in people suffering from alimentary dystrophies, as well as hypo- and avitaminosis.

The importance of vitamin deficiency in the pathogenesis of tropical ulcers is indicated by the dependence of the frequency of their occurrence on the time of year, i.e. Seasonality. It is known that tropical ulcers occur more often in the spring season, when the diet of the population of endemic zones is depleted of vitamins. Closer to the autumn, when the food ration became more diverse and enriched, the number of cases is decreasing.

Of the other factors contributing to the occurrence of tropical ulcers, one can point out the lack of respect for body hygiene, the late sanitation of skin injuries, including the places of bites of various insects, prickly prickly and especially poisonous plants, pollution by their soil, etc.

There is also a strong and well-founded view that a tropical ulcer is a disease of the poor that is a reflection of the low socioeconomic level of the developing third world countries, most of which belong to the tropical and subtropical regions.

[12], [13], [14], [15],

Symptoms of a tropical ulcer

Tropical ulcer is most often observed in adolescents and young men, less often - under the age of 40 years. This is explained, first of all, by the most frequent exposure of this contingent to injuries of the skin of the lower extremities. Usually, tropical ulcers are recorded as individual observations, but cases of small epidemics, in particular among prisoners of war, tea gatherers, jungle conductors, etc., are described.

In the overwhelming majority of cases, the typical localization of tropical ulcers is the lower extremities, especially the ankle region and the lower third of the shin, i.e. Places that are most often exposed in the tropics to injuries and pollution, as well as bites of various insects. As an atypical case, tropical ulcers can be localized on the skin of the upper limbs and other parts of the body.

In most patients, tropical ulcers are single and mostly unilateral. In the mechanism of rare cases of multiple ulcers, apparently, the phenomenon of autoinoculation can take place.

Symptoms of a tropical ulcer often begin acutely: from the formation of a bubble or flickens in size to a pea, surrounded by a distinctly pointed, inflammatory rim. When palpation, at the base of the fiction, a limited compaction is often determined. Often, the element from the very beginning causes pain to patients, increasing even with the slightest touch. Fast enough, already on the second day, the cover of the bladder bursts with the release of a small amount of purulent serous bloody liquid. The resulting erosion, which in a short time passes into an ulcer, is usually superficial at first, has round or oval outlines, a dirty-grayish bottom, and clear, slightly eroded edges. In the course of further evolution, the ulcer can slowly grow both deep inside and along the periphery.

Soon in the center of the ulceration, necrotic masses of ash-gray color begin to form, sometimes with some yellowish-green tinge. The scab is usually mildly doughy, produces an unpleasant odor, and when it is rejected at the bottom of the ulcer against the background of purulent-necrotic tissue decay, soft pinkish-gray granulation is found. Often, despite the development of granulations under the scab (especially in the center of ulcers), the process of disintegration of soft tissues in the area of the ulcer not only does not cease, but, on the contrary, continues, while capturing deep subcutaneous layers.

A very typical symptom of tropical ulcers is the so-called gravity phenomenon. It is expressed in the fact that the growth of the ulcer along the periphery proceeds mainly in the direction of gravity, i.e., with a predominantly vertical position, the ulcer "crawls" downward to the foot.

It should be noted that, despite the relatively sharp picture of the clinical course of the disease, especially pronounced at the onset of the development of the pathological process, the reaction from the lymphatic system usually is very weak, in particular, regional adenitis is extremely rare. Atypical and any expressed disturbances from the general condition of patients. The disease in the absence of treatment takes an indefinitely long time - many months and even years. Successful treatment of a tropical ulcer leads to its disappearance, less often the process ends with the formation of a smooth scar of various sizes and shapes. More or less typically some scarring of the scar, especially in the center, and the presence on its usually hypopigmented background of a sign of tissue paper. On the contrary, the peripheral zone of the rumen appears somewhat hyperpigmented.

In most cases, especially among residents of the African continent, prone to "keloid diathesis," one of the features of the functional state of their body is that scars can be subjected to keloidization.

The most common atypical forms of tropical ulcers are the so-called hypertrophic tropical ulcer. It is characterized by the fact that as a result of turbulent vegetation, developing at the bottom of the ulcers, warty growths, resembling an almost continuous and uneven conglomerate, clearly begin to appear above the general level of the skin.

Rarely, especially in patients who have been depleted by this or that disease, the ulcer can flow from the very beginning from the very beginning, can be of a lightning-like nature, can be malignant and lead to deep necrosis. In such cases, general phenomena are observed in the form of an increase in temperature to 38-39 C, as well as leukocytosis and an increase in ESR. The possibility of sepsis development is not ruled out.

Diagnosis of tropical ulcers

Tropical ulcers are differentiated most often with varicose and other trophic ulcers. It is important to remember that varicose ulcers usually develop against the background of a common varicose symptom complex, are noted much more often in women, and in the elderly, and are localized, usually in the lower third of the tibia. However, for the conditions of the tropics, the differential diagnostics of a tropical ulcer with ulcer Buruli, which is also endemic for these regions of the world, may be more relevant . Buruli ulcer is characterized by a multiplicity of skin lesions, a variety of localization, susceptibility to it of all age groups, more pronounced "creeping" and penetrating character with the formation of coarse scars.

The diagnosis of "tropical ulcer" is established exclusively in a typical clinical picture. Less important are the macroscopic and cultural methods of diagnosis, since it is possible to detect a variety of pathogens that are sometimes of a secondary nature.

[16], [17], [18], [19]

Treatment of tropical ulcers

Systemic treatment of a tropical ulcer usually involves the use of broad-spectrum antibiotics, often in the form of combined sequential or rotational therapy. This technique is dictated by the association of microbes underlying the etiopathogenesis of the disease, and participants often have different sensitivity and resistance to individual antibiotics. Sulfonylamide preparations are also administered inside and in the form of powders. Local treatment of a tropical ulcer consists of irrigation of ulcers with various disinfectant solutions, the use of antiseptic and anti-inflammatory ointments, including corticosteroids, better in combination with antibiotics. According to the indications resort to surgical intervention - removal of foci of necrosis (excision within healthy tissues) with subsequent application of a tile bandage from strips of adhesive plaster. In extreme cases, especially with extensive gangrenous decay and worsening of the general condition, amputation of the extremity is indicated.

How is a tropical ulcer prevented?

Tropical ulcers can be prevented by observing body hygiene, timely treatment of microtrauma of the skin of the lower extremities (wearing shoes). It is necessary to actively and probably early treatment of all skin lesions arising on the skin.

The prognosis of tropical ulcers is usually favorable and largely depends on the general condition of the body and its reactivity. In some cases, the process can lead to deep and rough cicatricial contractures and to disability; decreased ability to work can be observed and as a result of development of ankylosis ankle joint.