Ulcers of skin- a general outline
An ulcer is a discontinuity of an epithelial surface. There is usually progressive destruction of surface tissue, cell by cell.
The life history of an ulcer consists of 3 phases9

1. Extension- During this stage the floor is covered with exudates and sloughs while he base is indurated. The discharge is purulent and even blood stained

2. Transition- Transition stage prepares for healing. The floor becomes cleaner, sloughs separate, indurations of the base diminishes and the discharge becomes more serous. Small reddish area of granulation tissue appear on the floor and these link up until the whole surface is covered

3. Repair- Stage of repair consists in the transformation of granulation to fibrous tissue which gradually contracts to form a scar. The epithelium gradually extends from the now shelving edge to cover the floor at a rate of 1mm. Per day. The healing edge consists of three zones- the outer epithelium, which appears white, the middle one bluish in color (granulation tissue covered by a few layer of epithelium) and inner reddish zone of granulation tissue covered by a single layer of epithelial cells.

Clinical classification 8
i. Spreading ulcer
ii. Healing ulcer
iii. Callous or chronic ulcer

Spreading ulcer- surrounding skin is inflamed and the floor is covered with profuse and offensive slough without any evidence of granulation tissue. The edge is inflamed, edematous and ragged. It is painful ulcers drawing lymph nodes are painful and tender

Healing ulcer- floor covered with pinkish granulation tissue. Edge red with granulation. Margin is bluish with growing epithelium

Callous or chronic ulcer- no tendency towards healing. Floor covered with pale granulation tissue or show typical wash-leather slough in gummatous ulcer. Discharge is scanty or absent. Base and edges considerably indurated


Pathological classification of ulcers 8
i. Non specific
ii. Specific
iii. Malignant

Non-specific ulcers are classified into
1. Traumatic
2. Arterial
3. Venous
4. Neurogenic
5. Associated with malnutrition
6. Ulcers associated with other diseases
7. Certain other type of ulcers

A short description of different types of ulcer
1. Traumatic ulcer:
Traumatic ulcer can be either
i. Mechanical, e.g. Dental ulcer of the tongue from jagged tooth, from pressure of a splint etc. or
ii. Physical from electrical or x-ray burn or
iii. Chemical from application of caustics. This ulcer heals quickly unless supervened by infection or ischaemia, which may turn this ulcer to chronicity.

2. Arterial ulcer or ischaemic ulcer:
These are due to
i. Peripheral arterial diseases like atherosclerosis, Buerger’s disease and Raynaud’s disease. or
ii. Poor peripheral circulation

This condition is more often seen in older people. When it occurs secondary to Buerger’s disease, younger men between 20 and 40 years of age are affected. In this case patches of dry gangrene may be present along with arterial ulcer. Such ulcers tend to occur on the anterior and outer aspects of the leg, dorsum of the foot, on the toes or the heel. Pain is the main complaint of this disease. Arterial ulcer tends to occur below the medial malleolus. There is often a history of intermittent claudication and even rest pain in majority of cases. The tendons, bone or underlying joints ma be exposed in the floor of the ulcer with minimal granulation tissue. Peripheral pulses are always feeble or absent. Presence of ischaemic changes may be detected in the foot such as pallor, dry skin, loss of hair, etc.

3. Venous ulcer
Typically situated on the medial aspect of the lower third of the lower limb  i.e., above the medial malleolus. Ulcers are the complication of deep vein  thrombosis. Painful at the beginning but gradually pain settles down. Eczema  and pigmentation are often seen around the ulcers.

4. Trophic ulcer or neurogenic ulcer.
These ulcers have punched out edge with slough in the floor thus  resembling a gummatous ulcer. Bedsore and perforating ulcers are typical examples of trophic ulcers. These ulcers develop as a result of repeated trauma  to the insensitive part of the body. Commonly seen in the heel and the ball of the  foot in ambulatory patients and on the buttock and on the back of the heel in non- ambulatory patients. These ulcers starts with callosity under which suppuration  takes place, the pus comes out and the central hole forms the ulcer which  gradually burrows through the muscles and tendons to the bone. The resulting is  a callous ulcer with punched out corny edge. The surrounding skin has no  sensation. the cause may be spinal or leprosy or peripheral nerve injury, diabetic neuropathy, tabes dorsalis, transverse myelitis or meningomyelocele.

5. Ulcers associated with malnutrition or tropical ulcer :
Occurs in legs and feet of the people in the tropical countries. E.g. Infection  by Vincent’s organisms. The most important features of this ulcer is its callousness  towards heeling. Its edge is slightly raised and exudes copious serosanguinous  discharge. This ulcer may retain the same size for months or spread rapidly so as  to require amputation.

6. Ulcers associated with certain other diseases
i. Diabetic ulcer:
Three factors play o produce diabetic ulcer.
a) diabetic neuropathy- trophic ulcer,
b) diabetic atherosclerosis causing ischaemia- arterial ulcer and
c) Glucose laden tissue is quite vulnerable to infection and the ulcer is formed which is a type of spreading ulcer. blood and urine sugar estimation is performed to prove the diagnosis.

ii. Tuberculous ulcer:
This mostly occurs from bursting of a caseous lymph node.This type of  ulcer may develop when cold abscess from bopne and joint tuberculosis  breakes out on the surface. Usually seen in neck, axilla and groin. Edges are  tin reddish blue and undermined. Regional lymph nodes are enlarged non- tender and matted. The ulcer tends to be chronic.

iii. Lupus vulgaris :
It is a coetaneous tuberculosis occurring commonly in the face and hand usually in children and young adults. It starts superficially as multiple cutaneous nodules leading to ulcerations. These ulcers remain active at the periphery and spreads outwards whereas in the center they gradually heal. Due to its destructive nature at the peripohey it is called ‘lupus’.

iv. Syphilitic ulcers:
a. hard chancre appears on the external genitalia 3-4 weeks after the infection in the first stage of disease. It is painless and is having an indurated base which feels like a button . in the penis chancre is found commonly in the coronal sulcus and frenum. Lymph nodes are enlarged, mobile, firm,painless and descrete and show no tendency towards suppuration. extra genital chancres seen in nipple, lip, tongue , and anal canal are not often indurated and may be slightly painful.
b. mucus patches and condylomas seen in secondary stage of syphilis. There is small round , superficial , transient erosions in the mouth which coalesce to form snail track ulcers.
c.gummatous ulcers-occur intertiary syphilis. These ulcers are result of  obliterative endarterits, necrosis and fibrosis and are mostly seen over subcutaneous bones. The most characteristic feature is punched out indolent edge and yellowish gray gummatous tissue( wash-leather slough)in the floor. pain and tenderness are totally absent.

v. soft chancre- these are multiple painful acute ulcers with edematous edge and yellowish slough on the floor. These are seen on external genitalia.

vi. Meleney’s ulcer:
These ulcers are seen in post operative wounds either after operation for perforated viscous or for drainage of empyema thoracis

vii. Epithelioma:
It arises from prickle cell layer of the skin and hence may occur anywhere in the body. But it is more commonly seen on the lips , cheek, penis, vulva and old scars. it is mostly seen after 40 years of age . it begins as a small nodule which enlarges and gradually the center becomes necrotic and sloughs out and thus ulcer develops. The edge of the ulcer is raised and averted. Floor is covered by necrotic tumor, serum and blood. Base of the ulcer is indurated

viii. Marjolin’s ulcer:
This is squamous cell carcinoma arising from a long standing benign ulcer or scar.The commonest one to become malignant is a long standing venous ulcer.

7. certain other types of ulcers:
i. Bazin’s disease- erythrocaynoid ulcer- these ulcers are associated with erythrocyanosis frigida. Which is an exclusive disease of young women. Abnormal amount of subcutaneous fat with thick ankles combined with an abnormally poor arterial supply are the predisposing factors. The patient finds that the ankle skin is abnormally sensitive to temperature changes. small superficial painful nodules are formed which breakdown to form ulcers.

ii. Martorell’s ulcer-hypertensive ulcer- it is seen in old age and associated with atherosclerosis.A local patch of skin on the back or outer side of the calf suddenly necroses and sloughs away leaving a punched out ulcer extending down to the deep fascia. Characteristic severe pain is the prominent symptom.

iii. Ulcers complicating various diseases- gross anemia , polycythemia, leukemia, rheumatoid arthritis, paget’s disease, ulcerative colitis are the main conditions causing ulcers8.

HOMEOPATHIC APPROACH TO ULCERS

Samuel Hahnemann in his essay on ‘directions for curing radically old sores and indolent ulcers’ in the year 1784, mentions a good many useful observations on the management of the old ulcers. Absurdities of usual modes of treatment then in practice especially modern medicine were explained in this article with examples from his own experience. In this work he mentions about a certain ‘strengthening balsam’ for the treatment of old ulcers, whose composition he does not reveal, but which he offers to supply genuine to any one.7.

Concept in homoeopathy
Hahnemann classified the ulcers of the skin in local maladies under one sided disease of the large class of chronic diseases. In the homoeopathic concept no external malady can arise, persist or even grow worse without some internal cause, without the co-operation of the whole organism, which must be in a diseased state . so the treatment should be directed towards the annihilation of the general malady by means of internal remedies with which the restoration of the health of the entire body along with the disappearance of the external affection is effected. This is possible when all the changes, sufferings and symptoms observable in patients along with the exact character of the local affection is considered in the totality of symptoms and the remedy corresponding to the totality is selected10.

Miasmatic back ground
Syphilitic miasm is predominant in ulcers. Ulcers which heal slowly with putrefaction of tissues. Ulcerated skin with pus and blood represents syphilis.

Chapters
1. PATHOLOGICAL & CLINICAL TYPES
2. LOCATION
3. SENSATIONS
4. NATURE OF THE ULCER
  i. Appearance
  ii. Edges
  iii. Margin
  iv. Floor/base
  v. Surrounding areas
  vi. Discharge
5 . MODALITIES
  i. General
  ii. particular

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