Examination of Ulcer
Inspection
✔Size & Shape: Measure in two dimensions using a measuring tape.
✔Number: Single or multiple ulcers.
✔Location (characteristic sites):
Varicose ulcer – Medial lower third of the leg.
Rodent ulcer – Face, above a line from the angle of the mouth to the earlobe.
Tuberculous ulcer – Neck, over tuberculous lymphadenopathy sites.
Trophic/neuropathic ulcer – Weight-bearing areas (heels, sacrum, bony points
in bedridden patients).
Arterial/ischemic ulcer – Dorsum of the foot & toes.
✔Margin (transitional skin border):
Healing ulcer – Three distinct zones:
o Outer white – Newly cornified epithelium.
o Middle blue – Growing squamous epithelium (appears blue due to lack of
cornification).
o Inner red – Granulation tissue with a transparent epithelial layer.
Spreading ulcer – Red, inflamed, irregular margin with inflamed surrounding
skin.
Chronic non-healing ulcer – Thick, fibrotic, white margins without the blue zone
of growing epithelium.
✔Edge (junction of margin & floor):
Sloping edge – Healing ulcer. Granulation tissue is slightly below the skin
surface with gradual thinning of skin.
Punched-out edge – Trophic ulcer. Equal destruction of all layers from skin to
bone, forming a deep ulcer with vertical edges.
Undermined edge – Tuberculous ulcer. More destruction in the subcutaneous
plane than skin, causing the skin to overhang at the edges. Demonstrated by
passing a pin under the margin.
Raised & everted edge – Malignant ulcer. Rapid growth causes the tissue to
overhang the skin margin, particularly at the lower border.
Raised but not everted edge – Rodent ulcer. Slow-growing malignancy with
nodular, rolled edges and tissue destruction near the nasal area.
Inspection of the Floor & Surrounding Skin
✔Floor (exposed surface of the ulcer):
Healthy ulcer – Healthy granulation tissue, no slough, minimal serous discharge.
Spreading/infected ulcer – Unhealthy granulation tissue, areas of slough.
Chronic non-healing ulcer – Pale, flat granulation tissue, does not bleed easily.
Hypertrophic granulation tissue ("proud flesh") – Rises above skin surface,
excessive serosanguinous or purulent discharge.
✔Surrounding Skin:
Spreading/infected ulcer – Shiny, red, edematous skin due to cellulitis.
Varicose ulcer – Dark pigmentation & eczema.
Tuberculous ulcer – Multiple scars & puckering of surrounding skin.
Non-healing ulcer – Hypopigmentation of surrounding skin.
Marjolin’s ulcer – Ulcer within a large scar (e.g., post-burn scars from
childhood).
Palpation of Ulcer
✔Surrounding Skin
Temperature – Use the back of fingers, compare with the opposite side.
Tenderness – Warmth & tenderness suggest inflammation (spreading/infected
ulcer).
✔Ulcer Edge & Floor (palpate with a gloved hand)
Edge:
o Healing ulcer – Barely distinguishable.
o Non-healing ulcer – Firm due to fibrosis.
o Malignant ulcer – Hard edge.
Floor:
o Healthy granulation – Pinpoint hemorrhagic spots.
o Malignant ulcer – Profuse bleeding.
o Slough – Note if loosely or firmly attached.
✔Base of Ulcer (tissue on which ulcer rests)
Small ulcer – Pinch & palpate between fingers.
Large ulcer – Feel base through floor with gloved fingers.
Firm base – Common in chronic ulcers.
Hard/marked induration – Suggests malignancy.
✔Fixity to Underlying Structures
Move ulcer side to side → Reduced mobility suggests fixation.
If over a muscle, ask patient to contract → If ulcer becomes fixed, suggests
attachment to muscle (Mobility Test).
Focal Examination of Ulcer
✔Regional Lymph Nodes
Malignant ulcer → Hard, non-tender, discrete nodes.
Infected ulcer → Enlarged, tender nodes.
Tuberculous ulcer → Matted, non-tender nodes.
If regional nodes palpable, check higher groups as well.
✔Vascular & Neurological Examination
Veins (for varicose ulcer)
o Ask patient to stand & inspect long & short saphenous veins.
o Look for irregular varicosities.
o Test for DVT → Calf tenderness, Hohmann’s sign, Moses sign.
Arteries (for ischemic ulcer)
o Palpate all related arteries on both sides.
o If ulcer on fingers, toes, dorsum of foot → Do detailed vascular exam.
Nerves (for trophic ulcer)
o Test sensations around ulcer with a sharp pin.
o If diminished sensation → Full neurological exam required.
o Leprosy signs: Thickened posterior tibial, ulnar, auricular nerves,
hypopigmented anesthetic patches, leonine facies.
o If spinal cord lesion suspected → Examine accordingly.
✔Joint Examination
Assess active & passive movements of nearby joints.
Restriction of movement suggests muscle/tendon involvement or painful
inflammation.
Systemic Examination
✔Cardiovascular system – Look for CCF (delays ulcer healing).
✔Respiratory system – Check for TB, secondaries.
✔Abdomen – Palpate for splenomegaly (seen in hemolytic anemia leg ulcers).
This concludes the clinical examination of an ulcer.
