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CASE
• Name : Vasudevan
• Age :62/M
• Address :Atukkal
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Presenting Complaints
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History of Presenting Complaints
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Past History
Nothing Particular
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Family History
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Personal History
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Personal History
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Physical Generals
• Appt : Good
• Thirst : Good
• Food desires & aversions – Nothing Particular
• Sleep :disturbed due to burning sensation in foot
• Stool : regular
• Urine : Nothing particular
• Sweat : Not charecteristic
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Physical Examination
• Built : Moderate
• Complexion:Dark Pulse :72/mt,
• Temp :afebrile RR :18/ mt
• Anaemia :No pallor BP :138/86 mm of Hg
• Cyanosis :Absent
• Jaundice : not icteric
• Clubbing :absent
• Oedema :nill
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Local Examination of Ulcer
Inspection
Shape : Oval
Number : Single
Position : Above medial malleolus, Lt. ankle
Floor : covered with slough
Edge : Inflammed with oedema
Discharge : Profuse, purulent
Surrounding area : Oedematous, blackish
discolouration, rough dry skin
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Palpation
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Diagnosis of Disease
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Lab Investigations
• Hb: 13g%
• TC: 6700cells/mm3
• ESR: 71mm/Hr
• N55, L44,E11
• FBS; 84mg%
• S.cholestrol: 183mg%
• Urine, Albumin: nill
Sugar: nill
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Diagnosis Of The Patient
• Chilly patient
• Severe burning sensation < night
• Oversensitive to touch with pain
• Blakish discoloration of surrounding skin
• < walking
• > rest
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Remedy Given
12 -11-09
RX
Ars alb 0/3
C & D With Calendula Q
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Follow up
26/ 11/09
Burning pain slight relief
Bloody discharge occasional
Ulcer size remains same
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Follow up
10/ 12/09
Burning pain >
Discharge occasional
Ulcer shows tendency to heel, Signs of granulation
tissue seen, size remains same.
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Follow up
17/ 12/09
Burning pain >
No discharge
Ulcer is heeling, size decreases
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Follow up
24/ 12/09
Burning pain >
Ulcer is heeling
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An ulcer is is the break in the continuety of the
covering epithelium, skin or mucus membrane.
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The life history of an ulcer consists of 3 phases
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.
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The life history of an ulcer consists of 3 phases
1) Extension - During this stage the floor is covered with exudates and sloughs while the base is indurated. The discharge is purulent and even blood
stained
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The life history of an ulcer consists of 3 phases
1) Extension - During this stage the floor is covered with exudates and sloughs while the 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.
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Pathophysiology
Blood Flow in veins – In the direction of heart
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Callous ulcer / Chronic ulcer
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Traumatic ulcer
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Specific ulcers
• Tuberculous ,
• syphillitic ,
• Soft sores,
• Actinomycosis.
• Malignant ulcers
• Epithelioma,
• Marjolins ulcers,
• Rodent ulcers.
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Venous ulcer
• Abnormal venous
hypertension on the lower
third of leg.
• Follow many years after
venous disease,
• So patients are around age
group of 40-60.
• lower part of leg on medial
side, above medial malleolus.
• Never seen above middle and
upper third of leg
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Venous ulcer
• Edge is sloping.
• Margin is thin and blue of growing
epithelium
• Floor is formed by pale
granulation tissue.
• Usually shallow, never penetrates
the deep fascia.
• Surrounding skin shows signs of
chronic venous Hypertension.
• Squamous cell carcinoma from
long standing venous ulcer -
Marjollins ulcer.
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Arterial ulcer ( Ischaemic ulcer)
• Rare when compared to
venous ulcer.
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Trophic ulcer /Neuropathic ulcer
• Develops in an anesthetic
limb.
• Causes Repeated trauma,
Follows Spinal d/s,
leprosy, Transeverse
myelitis, nerve injury,
Diabetic neuropathy
• Punched out edge and
slough in the floor
resembling gummatous
ulcers.
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Trophic ulcer /Neuropathic ulcer
• Common site – on
pressure points - heel and
ball of foot
• old age
• associated with
hypertension,
atherosclerosis
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Martorelles ulcer / Hypertensive ulcer.
• punched out ulcer.
• severe pain.
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Tropical ulcer / Phagedenic ulcer
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Meleney’s ulcer
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Meleney’s ulcer
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Tuberculous ulcer
• A form of cutaneous
tuberculosis.
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Lupus vulgaris
•single or multiple
cutaneous nodules gradually
turns into small superficial
ulcerations on the skin.
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Syphilitic ulcer:
1) Primary stage - Hard Chancre on the external
genitalia,painless with indurated base.
• Caused by H. Ducrey
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Rodent ulcer
• Malignant, Exposure to
sun light or UV rays
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Clinical Features
• Aching pain
• Heaviness
• Leg Tiredness
• Cramps
• Itching, Burning & Swelling
• Discomfort and tenderness of the skin
• Pigmentation, eczema
• < Standing
• > Elevation of Leg
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Location of the Ulcer
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Floor of the ulcer
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Discharge from the Ulcer
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Edge, Margin of Ulcer
Edge - This is between floor of ulcer & margin
Margin - junction between normal epithelium & ulcer
These are the areas of maximum activity
• Sloping edge - Healing ulcer – traumatic & venous ulcer
• Punched out edge - Gummatous ulcer & trophic ulcer
• Undermined edge - Tuberculous ulcer
• Raised edge - Rodent ulcer
• Everted edge - Squamous cell ca.
On Palpation
• Induration (Hardness) – Squamous cell ca, C/c ulcers, Long
standing varicose ulcers
• Tenderness – infected ulcers, arterial ulcers
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Surrounding area
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Base
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Palpation - Mobility
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Reginal Lymph nodes
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Spreading ulcer - Management
Application of a multilayer
compression system
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• Patients with venous insufficiency are advised to elevate their
legs above the heart level while sleeping, and to avoid standing for
long periods.
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Maggot therapy
• Removing necrotic or devitalzed tissue is also the aim of,
Maggot therapy the intentional introduction by a health care
practitioner of live, disinfected maggots into non-healing wounds.
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Surgery
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Skin grafts
• Pinch grafts may be performed as an outpatient procedure
in patients with small ulcers.
• Small punch biopsies are taken from the patient’s thigh and
placed dermal side down on the ulcer bed. Split thickness graft
is used for large ulcers.
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Artificial skin
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Hahnemann classified the ulcers of the skin in local
maladies under one sided disease of the large class of chronic
diseases.
Syphilitic miasm
Syphilitic miasm is predominant in open ulcers.
Ulcers which heal slowly with putrefaction of tissues.
Ulcerated skin with pus and blood represents syphilis.
Putridity, acridity, offencivenes of discharges
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Psora
small,sensitive painful non suppurating
boils,which may shed scurfy scales.
Itching without pus or discharge is characteristic
of psora.
Unhealthy dry skin with itching and burning.
Skin complaints are aggrevated by cold, winter.
Sycosis:
vesicular eruptions are generally sycotic.
Tubercular
Bleeding ulcers, varicose ulcer
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• Burning in interior of ulcer
• base of ulcer of blackish color, or lardaceous; foetid proud
flesh in the ulcer;
• pus copious, bloody, ichorous, or corrosive, putrid, thin and
watery;
• Phagedenic ulceration, ulceration extending in breadth (Sil.,
in depth);
• amel. from warmth (Sec., aggr. from warmth).
• Ulcers with offensive discharge.
• The ulcers burn like fire, pain even during sleep, discharge may
be copious or scanty, the base blue, black or lardaceous.—Nash
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• Ulcers resulting from cutaneous irritation; discharges
thin, offensive, with rapid loss of tissue, corroding every
part over which it passes.
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• Ulcers with intermittent pricking pain, high hard edges,
easily bleeding; shooting pains around ulcer;
• pus profuse, greenish, thin, offensive, even ichorous;
• ulcers turn black.
• Ulcers, particularly when affecting the bones, discharging
ichorous, thin and foetid pus; ulcerations from burns and
scalds, with great sensitiveness to suffering; intolerable
soreness around ulcer.
• Great sensitiveness to contact; in ulcers, especially
periosteal.
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• cadaverous-smelling and corroding, scanty secretion; mottled
appearance of skin around ulcer; flat, spreading ulcer of an
adynamic type, discharging thin, corrosive,ulcer in folds of
skin.
• Lividity is a common indication; indolent gangrene; varicose
veins of arms, legs, vulva, Varicose ulcers—Clarke
• Burning is generally a sensation that runs through the remedy.
burning in various parts of the skin. Often an internal burning
is attended by external coldness. .
• Elderly patients with indolent skin ulcers, with heart diseases,
weak, fainting.- Vitholkus
• General bruised soreness or heavy aching burning; in bones,
ulcers, etc.
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• Slight pain, with severe ulceration or inflammation.
[Conium opposite.]
• Ulcers, with paroxysmal stitches; aggravated at night.
• Syphilitic ulcers, with cheesy, tenacious exudation.
• Punched-out, perforating ulcers, occurring on skin,
mucous membranes, and affecting bones—Clarke
• Ulcers; with dark dots, deep, perforating, round; look
punched out; septal; peptic; with overhanging edges or
thick crusts.-- Boger
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• Ulcers and wounds bleed profusely; even "small wounds bleed
much," wounds easily become gangrenous.
• flat ulcers, hard at circumference and very sensitive, with black
bottom, discharging very little pus, but easily bleeding; ulcers
sensitive to touch, with ichorous, offensive discharge,
• better from warmth; bedsores, with black edges; with
tendency to extend rapidly;
• burning pain only when touching the sore; smooth ulcers, with
jagged edges, surrounded by papillae or small ulcers, and of a
livid appearance.
• Boils, carbuncles, ulcers, with bluish, purple surroundings.
• Blood decomposes, breaks down, haemorrhages; blood
uncoagulable;
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• Readily bleeding ulcers, with a lardaceous base,
• worse from heat of bed and hot and cold applications;
• spreading ulcers, exceedingly painful, and sensitive to
slightest touch; ulcers of a bluish or livid appearance, pus
scanty or copious, but never laudable.
• Ulcers, irregular in shape, edges undefined.
• Ulcers, irregular, spreading, shallow, bleeding; with
cutting and proud flesh.--Boger
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• zigzag, irregular edges; base looks like raw flesh.
• which pains as if splinters were sticking in affected parts,
or burning, aggr. from cold water;
• syphilo-mercurial or scrofulous ulcers.
• fistulous ulcers difficult to heal; pus copious, bloody,
corroding, ichorous;
• rapid destruction of parts.
• This remedy is very often of curative value in angry, deep-
seated ulcers of a perforating character (Fluor-Ac., Kali-B.,
Sil.).--Lippe
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• Ulcers phagedenic, extending in depth;
• becoming black at base or edges, and bleeding; boring or
burning in edges and sensation of coldness in ulcer; deep or flat,
crusty ulcers; hard, fistulous or gangrenous ulcers; proud flesh in
ulcer, which is difficult to heal;
• Pus scanty, putrid, thin, watery, yellow; worse in open air, from
weather change, lying on painful side, or pressure;
• Unhealthy skin; every injury tends to ulceration.
• It seems to make no particular difference whether the
suppuration takes place in the soft or hard parts, for it is equally
efficacious in glandular or bony ulcerations.-- Nash
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• Burning ulceration
• The greatest general psoric remedy for almost every kind of itch,
sore, ulcer,
• Cancer-like ulcers.
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• Painful ulcers, < warmth, >cold, with copious discharge;
• varicose veins and ulcers on legs;
• burning pains on small spots on skin.
• Senile gangrene
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• Putrid flat ulcers with a pungent sensation,
• pain relieved by keeping limb elevated and from
outward pressure;
• pus white and putrid.
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• This nosode has proven a great remedy in epidemic
spleen diseases of domestic animals, and in septic
inflammation, carbuncles and malignant ulcers.
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• Ulcers, with sensitive areolae and easily bleeding, painful at
night, burning vesicles around ulcers; worse from rubbing or
scratching; linen sticks to ulcer, and when torn away it bleeds.
• Eruptions ulcerate and form thick scabs under purulent matter
exudes.
• Eruptions upon the legs and arms, on parts with poor circulation
as the ears, wrists, backs of the hands, skin eruptions followed by
ulcers; discharging a thick, white, offensive matter. - Kent
• Ulcer on leg with intense itching in surroundig skin and in scalp,
much agg. in warmth; with slight diarrhoea.- Clarke
• Deep, hard, painful ulcers; acrid pus, drying into crusts; agg.
touch and warmth.-- Boger
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• Stinging, itching and painful ulcers, with foetid odor,
though covered with a crust;
• Carbuncles;
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• ulcers on toes, originating in blisters;
• feet tender and bathed in a foul moisture; ulcers with
stinging pain and proud flesh, often deep ulcers, with raised
edges;
• pus scanty, acrid, corroding; sanious and watery; worse from
cold in winter.
• Skin unhealthy; every injury tends to ulceration.
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• Ulcers of a bluish color, bleeding easily, attended by
a bruised sensation in contiguous parts;
• results of contusions
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• Sycosis, flabby, lymphatic constitution;
skin destitute of pliability and elasticity; tetters.
Ulceration with sharp pains, piercing to scapulae.
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• Deep ulcers affecting the bones;
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• Useful in cases of burns, when the affected parts
ulcerate - Lippe
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• Congenital syphilis manifesting itself in ulcerating of
mouth and throat, caries and necrosis with boring
pains and heat in parts.
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• Ulceration of the skin and ulcers bluish, burning,
cancerous, crusty,deep, corrosive, offensive with
yellow pus, fistulous, foul, indolent indurated,
stinging, and unhealthy.—Kent
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• Inflamed ulcers, painful as if beaten;
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• Ulceration and decomposition.
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• Bleeding ulcers with blisters on the surrounding skin;
boring and burning in ulcers; burning on edges; pain
as if burnt;
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• Old ulcers with foetid pus,
• skin not inclined to heal, cracks and fissures, easily
ulcerating;
• sensitive, sore, spongy ulcers, with a salty discharge;
crusty and scabby ulcers;
• pus bloody, watery, acrid and corroding, smelling like
herring-brine.
• It is of service in eczema, rhagades, excoriations and
ulcers of the skin that are characterized by a sticky,
glutinous discharge that is oozing out all the time.--
Blackwood
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• Cancer and cancerous state, before ulceration, when
pain is principal symptom.
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• Haemorrhages, ulcerations, cancerous affections.
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• Syphilitic ulcers when perforation threatens.
• Covered with ulcerations.
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• Ulcers, with very offensive pus.
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• Swelled and easily bleeding gums, ulcerated.
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• Veins in the forearm , hands are swollen. Shifting
pains ,
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• oozing blisters on legs, from small pustules,
increasing in size, with tearing pains;
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• fistulous, gaping, angry ulcers in the mammae;
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• Next to the Night agg., is Ulceration : and the ulcers
have greyish bases; - Clarke
• Non-healing ulcerations,
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• The root contains a crystalline solid, that stimulates
the growth of epithelium on ulcerated surfaces.
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• Fistulous, deep and flat ulcers; spongy ulcers, with
itching or pricking;
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• Deeply penetrating, malignant ulcers;
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• The greatest use of this medicine will be found in
nervous conditions, throbbings, jerking and
spasmodic condition of muscles, ulceration of the
skin and mucous membranes, and all this in such
patients as are tending towards a state of imbecility, a
state of confusion or weakness of mind.-- Kent
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• Phagedaenia ulcers.
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• Hemorrhagic diathesis,
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• Locally, for ulcers and rheumatic pains.
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• Hardening of tissues of tongue, rectum, uterus, etc.;
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• Flat ulcers, eating into the bones; abscess of ankle-
joint; spinal caries, aggr. after rubbing and in bed.
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• Profuse discharge from granulating ulcers.
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• Eczema, with ulceration.
• As a stimulant to raw surfaces in indolent
ulcers, scabies, cracked nipples, rhagades, itch.
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• The clinical experience of Hering and his fellow-
provers has shown this to be highly useful remedy in
cracked and ulcerated nipples.
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• Old, putrid, spreading ulcers, with a history of liver
disease, or of a tubercular diathesis
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• Poisoned wounds, bites, phagedenic ulcers.
• Mercurio-syphilitic ulcers.
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• The ulcers are deep with hard edges, the
surrounding skins being covered with small
shining scales.
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• Very fiery red looking ulcer, Associated with ciliary
neuralgia and ulceration
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• Indolent ulcers, with hard, callous edges and foul,
ichorous discharge; old ulcers, appearing cancerous.
• Varicose ulcers.
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• Ulcers; gangrene.
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• Erysipelas and foul ulcers.
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• Typhoid when ulcers have eaten into tissues, and
black blood is discharged.
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• Foul, indolent ulcer, Pricking sensation followed by
painful aching
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• Very sensitive and oedematous mucous membranes
with ulceration.
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• Has clinical confirmation of its use in cancerous
ulcers and nodulated tumors of the tongue.
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• Obstinate ulcers.
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• tertiary syphilis and Paralysis,
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• Locally, applied to ulcers and unhealthy wounds.
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• phlegmonous inflammations, hastens suppuration;
• powerful antiseptic.
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• Chronic ulcers on lower parts of body, leg, foot, toe,
also breast, rectum.
• Painful ulcer, oozing offensive moisture on perineum.
• Haemorrhoids, fissures, ulceration of anus and
perineum, purple, covered with crusts.
• Ulcers below coccyx, around sacrum; varicose veins.
• Ulcers in general, from pressure, bedsores, etc.
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• The skin is covered with scales, which when they
drop off, leave white spots that may ulcerate.
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• Superficial ulcers and sores on lower extremities,
especially in females at climacteric.
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• Ulcers due to Radium burns, take a long time to heal.
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• It has been employed extensively locally in powder
form or as an ointment, in old indolent ulcers,
pruritus and in tubercular and epithelimatous
conditions of the skin. - Blackwood
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• Thickened ulnar nerves. Neurofibromatosis-like
nodules.
• Loss of toes and fingers.
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• It is useful in epithelioma of the skin and of cancer
especially of scrotum and uterus.
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• "Malignant erysipelas, particularly if attended by
large formation of pus, and destruction of parts. Non-
healing ulcers, livid appearance“ Clarke.
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• Venous congestion & passive haemorrhages,
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• Strengthens the heart;
• blood purifier;
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• In ulcer It is an infallible remedy for any kind of
chronic ulcer particularly of the throat; cancer of the
throat; tongue with bad smelling saliva and
inflammation.
• Application of the pulp of cheroot substance as
mentioned above is useful in ulcer or gonorrhoea,
syphilis and wound of scabies.
• Gargling with the decoction (diluted with water) of
this drug relieves ulcer of the throat and tonsil.
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• Oozing of a fetid juice from the ulcer or wound;
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• It is also very effective for the dressing of the wounds
and ulcers.
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• Healing of whitlows and perforating ulcers and
gradual improvement of anaesthesia and muscular
atrophy are also said to occur.
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• Dry skin with scabies, aggravation at night;
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• Dry skin with scabies, aggravation at night;
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.
• Erysipelatous inflammation of skin. Lupus. Indolent
ulcers.
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• an extremely effective herb used to restore the
functioning of the circulatory system and improve
peripheral blood flow to the extremities.
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• known as a strong anti-inflammatory and pain
reliever,
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• Skin troubles worse from heat and better from cold.
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• Old ulcers of skin.
• Diabetic ulceration.
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• can help to dilate and strengthen blood vessels.
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• For skin health, Natrium mur, Kali mur and Kali sulph
are three homeopathic ingredients hailed for their
ability to cleanse blood and lymph, help eliminate
waste in the blood and act as a natural anti-
inflammatory.
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• Furthermore, by providing essential oxygen to
inflamed or infected cells, Kali. sulph. effectively
assists healing, reduces inflammation and removes
infected or dead cells.
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1) Activate your calf muscles regularly by walking and
exercising.
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4) Avoid sitting with your legs crossed. This impairs
blood circulation.
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