What are the different types of ulcers, their typical causes, locations, and recommended management strategies?

Types of Ulcers: Classification, Causes, and Management

Ulcers are broadly classified into four major categories based on anatomic location and underlying pathophysiology: peptic ulcers (gastric/duodenal), diabetic foot ulcers (neuropathic, ischemic, neuro-ischemic), lower extremity vascular ulcers (venous, arterial, pressure), and oral ulcers (traumatic, infectious, autoimmune, malignant)—each requiring distinct diagnostic and therapeutic approaches that directly impact morbidity, mortality, and quality of life.

Peptic Ulcers (Gastric and Duodenal)

Location and Characteristics

• Duodenal ulcers are typically large, posterior lesions with bleeding often originating from the gastroduodenal artery, carrying significantly higher 90-day mortality and re-operation rates compared to gastric ulcers 1
• Gastric ulcers require resection or biopsy due to malignancy risk 1

Management of Bleeding Peptic Ulcers

• Open surgical intervention is recommended when endoscopic treatments and angioembolization fail, particularly with ongoing bleeding and hemodynamic instability 1
• Intraoperative endoscopy facilitates localization of the bleeding site 1
• For duodenal ulcers, triple-loop suturing of the gastroduodenal artery via duodenotomy is critical due to collateral blood supply to transverse pancreatic arteries 1
• Vagotomy/drainage procedures demonstrate lower mortality than simple ulcer oversew for intractable bleeding 1
• Damage control surgery should be considered for patients with hemorrhagic shock and severe physiological derangement to rapidly control bleeding and allow ICU admission 1

H. pylori Testing

• All patients with bleeding peptic ulcer must undergo H. pylori testing, as eradication significantly reduces ulcer recurrence and rebleeding rates (baseline prevalence 20-50%) 1
• Empirical antimicrobial therapy is not recommended for bleeding peptic ulcers 1

---

Diabetic Foot Ulcers

Classification by Type

Most diabetic foot ulcers fall into three categories that determine treatment strategy 1:

1. Neuropathic Ulcers

• Location: Plantar surface of the foot or over bony deformities 1
• Cause: Loss of protective sensation combined with repetitive trauma, most commonly from ill-fitting shoes 1
• Management: Immediate debridement of callus and necrosis (can be performed without general anesthesia) 1
• Offloading: Total contact casting is the preferred method for plantar ulcers 1

2. Ischemic Ulcers

• Location: Tips of toes or lateral border of the foot 1
• Critical finding: Absent pedal pulses or ankle-brachial pressure index <0.9 indicates peripheral arterial disease 1
• Management: Do NOT debride ischemic ulcers without signs of infection 1
• Revascularization indications: Ankle-brachial index <0.6, toe pressures <50 mmHg, or TcPO₂ <30 mmHg 1

3. Neuro-ischemic Ulcers

• Location: Tips of toes or lateral border of the foot 1
• Management: Combined approach addressing both neuropathy and vascular insufficiency 1

Critical Management Principles

• Vascular assessment is mandatory for all diabetic foot ulcers; if pedal pulses are absent or ulcer fails to improve despite optimal treatment, perform ankle-brachial pressure index, toe pressure, or TcPO₂ measurements 1
• Healing is severely impaired with ankle-brachial index <0.6, toe pressures <50 mmHg, or TcPO₂ <30 mmHg—revascularization should always be considered in these cases 1
• Ulcers deeper than subcutaneous tissues require intensive treatment and hospitalization consideration 1
• Ill-fitting shoes are the most frequent cause of ulceration, even in "pure" ischemic ulcers—meticulous shoe examination is mandatory 1

---

Lower Extremity Vascular Ulcers

Venous Leg Ulcers

• Most common type of chronic lower extremity ulcers, affecting 1-3% of the U.S. population 2
• Pathophysiology: Venous hypertension from venous reflux (incompetence) or obstruction 2
• Clinical features: Irregular, shallow ulcers with well-defined borders, typically over bony prominences 2
• Associated findings: Varicose veins, edema, venous dermatitis, telangiectasias, lipodermatosclerosis, inverted champagne-bottle deformity 2
• Primary treatment: Compression therapy is a recommended component unless contraindicated 3, 4
• Poor prognostic factors: Duration >3 months, initial length ≥10 cm, lower limb arterial disease, advanced age, elevated BMI 2
• Surgical intervention: Early venous ablation to correct superficial venous reflux improves healing and decreases recurrence 2

Arterial Ulcers

• Pathophysiology: Skin and soft tissue ischemia from arterio-occlusive disease 4
• Risk factors: Hypertension, diabetes, chronic kidney disease, smoking 4
• Critical diagnostic step: Ankle-brachial index measurement to identify decreased perfusion and determine need for vascular surgery referral 4

Pressure Ulcers

• Pathophysiology: Localized injury from unrelieved pressure, usually over bony prominences 5
• Intrinsic risk factors: Limited mobility, poor nutrition, comorbidities, aging skin 5
• Extrinsic risk factors: Pressure, friction, shear, moisture 5
• Prevention: Patient repositioning schedule, keeping head of bed at lowest safe elevation to prevent shear, pressure-reducing surfaces, nutritional assessment and supplementation 5
• Primary therapy: Pressure offloading 3
• Debridement indications: Urgent sharp debridement for advancing cellulitis or sepsis; nonurgent mechanical, enzymatic, or autolytic methods for stable necrotic tissue 5
• Infection management: Topical antibiotics if no healing improvement after 14 days; systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 5

---

Oral Ulcers

Classification by Duration

• Acute: <2 weeks 6
• Recurrent: ≥4 episodes/year 6
• Chronic: >2 weeks 6

Major Etiologic Categories

Traumatic Causes

• Mechanical injury from sharp food, dental appliances, or accidental biting 7, 6, 8
• Thermal burns from hot foods/beverages 7
• Chemical injury from acids, alkalis, or caustic substances 7
• Diagnosis: Ulcer location and shape correspond to inciting factor 7, 8

Infectious Causes

• Tuberculosis: Stellate ulcers with undermined edges and clear boundaries 7, 6, 8
• Syphilis: Requires serology testing 7, 6, 8
• Deep fungal infections: Particularly in patients with hyperglycemia or immunosuppression 7, 8
• HIV infection: Requires antibody testing in persistent cases 7, 6

Autoimmune/Inflammatory Causes

• Recurrent aphthous ulcers (RAU): Well-demarcated, oval/round ulcers with white/yellow pseudomembrane and erythematous halo 7, 6, 8
• Pemphigus vulgaris and mucous membrane pemphigoid: Require serum antibodies (Dsg1, Dsg3, BP180, BP230) 7, 6
• Behçet's syndrome: Recurrent bipolar aphthosis 7
• Inflammatory bowel disease (Crohn's, ulcerative colitis) 7

Hematologic/Systemic Causes

• Anemia (iron, folate, B12 deficiency) 7, 6
• Leukemia: Widespread necrotic ulcers with yellowish-white pseudomembrane, especially with neutropenia <2.0% 7, 6
• Neutropenia 7

Diagnostic Algorithm for Persistent Oral Ulcers

Mandatory laboratory workup before biopsy 7, 6, 8:

• Full blood count (detect anemia, leukemia, neutropenia)
• Coagulation studies (identify biopsy contraindications)
• Fasting blood glucose (exclude diabetes predisposing to fungal infection)
• HIV antibody test
• Syphilis serology
• Serum antibodies (Dsg1, Dsg3, BP180, BP230) if bullous disease suspected

Biopsy indications 7, 6, 8:

• Any ulcer persisting >2 weeks
• Ulcers not responding to 1-2 weeks of treatment
• Solitary chronic ulcers (to exclude squamous cell carcinoma or lymphoma)
• Atypical clinical features (unusual size, shape, induration)
• Multiple biopsies if lesions vary in appearance across sites

Biopsy technique 7, 6, 8:

• Obtain adequate depth and size to avoid missing diagnostic features
• Consider direct immunofluorescence, immunohistochemistry, T-cell receptor profiling based on initial histology

Critical Pitfalls to Avoid

• Never rely solely on topical treatments for persistent ulcers without establishing definitive diagnosis—this delays identification of malignancy or systemic disease that directly impacts mortality 7, 6, 8
• Inadequate biopsy (too small or superficial) misses diagnostic features 7, 6
• Overlooking systemic causes leads to delayed diagnosis and inappropriate management 7, 6
• Pathology reports stating "inflammatory ulcer with lymphocytic infiltration" are nonspecific and may require consultation or repeat biopsy 6

Specialist Referral Criteria

Refer to oral medicine specialist for 7, 6, 8:

• Ulcers lasting >2 weeks
• Ulcers not responding to 1-2 weeks of treatment
• Recurrent, severe, or atypical presentations
• Cases requiring biopsy or advanced diagnostic testing
• Systemic symptoms suggesting underlying disease

---

Common Pitfalls Across All Ulcer Types

• Failing to assess vascular status in lower extremity ulcers delays appropriate revascularization and worsens outcomes 1, 2, 4
• Debriding ischemic ulcers without infection increases tissue loss 1
• Inadequate pressure offloading perpetuates pressure ulcers despite optimal wound care 3, 5
• Treating oral ulcers empirically beyond 2 weeks without biopsy risks missing malignancy 7, 6, 8
• Overlooking H. pylori testing in peptic ulcer disease increases recurrence rates 1