Pressure Ulcers. Ulcers which are primarily caused by prolonged pressure against the skin, ultimately denying blood flow to that area. This includes Deep Tissue Injuries, Stage 1 Pressure Ulcers, Stage 2 Pressure Ulcers, Stage 3 Pressure Ulcers, Stage 4 Pressure Ulcers, and Pressure Ulcers with Necrosis (Unstageable Necrosis). First and foremost, in the treatment of pressure ulcers, the source of pressure must be removed. Many ulcers may require some offloading, but Pressure Ulcers (sometimes called Decubitus Ulcers or Bed Sores) will have no healing whatsoever without stopping the source of the pressure. This offloading may include a specialty bed, a specialty mattress, a schedule of turning (with the patient turning if possible, or being turned by someone else, usually a nurse or nurse's aide), offloading pillows, offloading wedges, or pressure-relieving boots.
Infected Ulcers. Any ulcer, no matter how it begins, can become an infected ulcer. Chronic Ulcers are considered to be Infected Ulcers when either: there is no obvious source for the ulcer; or the ulcer that began some other way has now become so infected that treatment of the infection must override all other treatment modalities. A Primary Infected Ulcer is typically one where the patient says things like: "This just appeared out of nowhere." Infected hair follicles, boils, and carbuncles are examples of Primary Infected Ulcers. Secondarily Infected Ulcers are those ulcers that began by some other means (Diabetic Foot Ulcer, Pressure Ulcer, Post-Surgical Ulcer, etc.), and then an unchecked infection causes further skin death and worsening infection. This typically occurs when ulcers or wounds that occur by other means are not treated properly. Human skin and our everyday environments are covered with bacteria, and our skin is our best defense against hostile bacteria. When the protective barrier of skin is lost, then bacteria, viruses and fungi are able to get access to the deeper layer of tissues. This leads to wide-spread destruction, eventually leading to Systemic (whole-body) illness or even death. This process is known as Wound Sepsis.
Neuropathic Ulcers. These ulcers are those that are primarily caused by a loss of innervation (sensation). The most common of these is the Diabetic Foot Ulcer (DFU). Patients with diabetes have many healthcare challenges, including ambulation. Due to altered or lost sensation in the foot, skin loss and eventual ulceration is common. In some cases, the damage becomes so severe that the bones of the foot collapse. In addition to diabetes, many other diseases can lead to Neuropathy (loss of sensation), ultimately leading to an ulcer. These diseases include Lupus, Rheumatoid Arthritis, Sjogren's Syndrome, Guillain-Barre, and Polyneuropathy. These ulcers often present at late stages, often with infection, because the patient can't feel the area. Diabetic Ulcers, in addition to offloading, often require advanced wound treatment modalities such as Skin Substitutes and Hyperbaric Oxygen Therapy.
Post-Surgical Wounds. This type of skin damage typically occurs faster that other types, because of the nature of process. When an individual undergoes surgery, the skin is deliberately cut, to allow access to deeper tissues. This leads to an immediate loss of blood supply to the local area. While surgery is done using Sterile Technique (where the skin and surrounding tissues are sterilized, the instruments and products used are sterile, and the surgeon's hand and body is covered with a sterile coverings), some bacteria inevitably enter the wounded skin, either during or shortly after the surgery. Topical, oral, and IV antibiotics can stop some of these bacteria, but because of the damaged local blood supply, bacteria can overwhelm our defenses. When the pathogen's ability to multiply and damage tissue exceeds our body's ability to fight the pathogens off, post-surgical wounds will not heal.
Vascular Ulcers: The primary problems with vascular ulcers is limited oxygen delivery to the damaged tissues, due to impaired vascular channels. These include:
Arterial Ulcers, where oxygen-rich blood can't reach the area because the arteries are partially or completely blocked
Venous Ulcers, where oxygenated blood can get to the ulcer, but there is impaired drainage, leading to swelling, edema, and pooling around the damaged area
Lymphedematous Ulcers, where the Lymphedema Channels are blocked, leading to swelling, often severe, in the affected area
Mixed Ulcers, where a combination of Arterial, Venous and Lymph derangements make for a complex ulcer. These ulcers are generally treated with Revascularization and Edema/Lymphedema Management (usually with some form of compression)
Traumatic Wounds: These wounds occur due to immediate tissue damage. The most devastating of the Traumatic Wounds are Burn Wounds. These acute thermal wounds lead to immediate damage to the skin from a temperature differential, usually heat, but sometimes cold. These include Flame and Heat Burns, Scalding Burns (Water Immersion, Splash or Steam Burns), Electrical Burns, Radiation Burns, Radiation Necrosis, Sunburn, Scalding, Industrial Burns (Thermites, Metal Scalding), Wounds from Industrial Freezing (Liquid CO2, Liquid Nitrogen), and Frostbite (cold weather tissue damage). Traumatic Wounds also include Skin Tears, which are more common in Geriatric Patients and patients with Collagen Vascular Diseases (such as Ehlers-Dahnlos Syndrome), Penetrating Traumatic Wounds (including Stabbing, Shooting, and Slashing Wounds), Blunt Traumatic Wounds (trauma from sudden impact such as car crashes), Degloving Injuries (Skin Tears that also damage underlying tissues) and Crush Injuries (where large areas of skin and deeper tissues are destroyed).
Autoimmune Wounds. These are wounds related to skin damage in patients with autoimmune diseases, such as Rheumatoid Arthritis, Lupus, Multiple Sclerosis, Myasthenia Gravis, Vasculitis, Psoriasis, Guillain-Barre, Scleroderma, Bullous Pemphigoid, Dermatomyositis, and Sacrcoidosis. Skin damage in autoimmune diseases can be caused primarily (by the disease itself) or secondarily (from medicines taken to combat the disease but have a side effect of damaging skin. Both Autoimmune Disease and Immunosuppresants (medication taken to treat Autoimmune Disease) can also make the skin more vulnerable to skin damage and skin infection that otherwise healthy skin would not have been damaged by.
Wounds and Ulcers in High Risk Populations. Certain groups are at overall higher risk of developing wounds and ulcers. These include: Geriatrics (elderly individuals); Diabetics; those with Peripheral Arterial Disease; those who live in Skilled Nursing, Long Term Care, or Assisted Living Facilities; and people with multiple co-morbidities (being treated for many diseases at once). In patients with Diabetes, for example, one of the elements of the disease is abnormal arterial blood supply in the small blood vessels. This makes it hard for oxygen to get to the skin cells, leading to higher risk of wound formation, and very poor wound healing.