Chronic undermining burrowing ulcers

Chronic Undermining Burrowing Ulcers (CUBU) are a type of skin ulcer that presents a significant challenge in dermatology and wound care management. Characterized by their extensive subcutaneous tunneling beneath the skin, these ulcers can lead to severe infections and are indicative of underlying systemic conditions such as diabetes mellitus, vascular disease, or immunosuppression. The management of CUBU requires a multidisciplinary approach, involving specialists from dermatology, surgery, and infectious diseases, among others.

Etiology

Chronic undermining burrowing ulcers often result from a combination of factors including poor blood circulation, neuropathy, and immunosuppression. Conditions such as diabetes mellitus and peripheral arterial disease are frequently associated with the development of these ulcers due to their impact on circulation and sensation. Additionally, prolonged pressure, as seen in bedsores or pressure ulcers, can initiate the formation of CUBU by compromising blood flow to the skin.

Pathophysiology

The pathophysiology of CUBU involves a complex interplay of impaired blood flow, reduced sensation, and compromised immune response. The lack of adequate blood supply leads to tissue ischemia and necrosis, while neuropathy results in a reduced ability to perceive pain, allowing injuries to go unnoticed and untreated. The impaired immune response further exacerbates the condition by allowing infections to develop and spread unchecked, potentially leading to the formation of extensive subcutaneous tunnels or tracts.

Clinical Presentation

Patients with chronic undermining burrowing ulcers typically present with non-healing wounds that have extensive subcutaneous tunneling. These ulcers may exhibit signs of infection such as erythema, warmth, and purulent discharge. The surrounding skin may be edematous and tender to touch. Due to the extensive nature of the undermining, the actual size of the ulcer is often underestimated upon initial examination.

Diagnosis

Diagnosis of CUBU involves a thorough clinical examination, including an assessment of the extent of subcutaneous tunneling. Imaging studies, such as MRI or ultrasound, can be helpful in delineating the full extent of the ulceration and any associated abscess formation. Biopsies may be necessary to rule out malignancy or specific infections.

Treatment

The treatment of chronic undermining burrowing ulcers focuses on addressing the underlying cause, managing the infection, and promoting wound healing. This may involve:

• Antibiotics to treat any underlying infection.
• Debridement to remove necrotic tissue and reduce bacterial load.
• Advanced wound care products and technologies to promote healing.
• Surgery, in some cases, to excise the ulcer and close the defect.
• Management of underlying conditions such as diabetes or vascular disease to improve blood flow and reduce the risk of recurrence.

Prevention

Prevention of CUBU involves the management of risk factors such as diabetes and peripheral arterial disease. Regular foot care, pressure relief strategies, and early intervention at the sign of skin breakdown are crucial in preventing the development of these complex ulcers.

Conclusion

Chronic undermining burrowing ulcers represent a significant challenge in wound care, requiring a comprehensive and multidisciplinary approach to management. Early detection, aggressive treatment of infections, and meticulous wound care are essential in preventing the progression of these ulcers and improving patient outcomes.