Ulcus gangraenosum – Causes, Symptoms and Treatment

What is Ulcus gangraenosum?

Ulcus gangraenosum refers to a severe, often deep-reaching skin ulcer accompanied by significant tissue death (gangrene). The Latin term combines ulcus (ulcer) and gangraenosum (gangrenous destruction). Clinically, it describes a wound in which the affected tissue dies and undergoes necrotic changes. Ulcus gangraenosum must be distinguished from other chronic wounds due to its rapid tissue destruction and high risk of infection.

Causes

Ulcus gangraenosum can be triggered by various underlying conditions and factors:

• Peripheral arterial disease (PAD): Narrowing or blockage of arteries leads to insufficient blood supply to affected limbs, causing tissue death.
• Diabetic foot syndrome: In diabetes mellitus, nerve damage (neuropathy) and vascular damage can result in deep, gangrenous ulcers.
• Severe bacterial infections: Certain bacteria, such as Clostridia, can cause gas gangrene and lead to extensive tissue necrosis.
• Venous insufficiency: Chronically impaired venous return can, in rare cases, contribute to gangrenous ulcers.
• Autoimmune diseases and vasculitis: Inflammation of blood vessels can impair circulation and promote tissue necrosis.
• Trauma: Severe injuries followed by infection or circulatory disruption can trigger an ulcus gangraenosum.

Symptoms

Ulcus gangraenosum presents with characteristic clinical features that allow for early diagnosis:

• Black or dark brown discoloration of the wound bed due to dead tissue (necrosis)
• Deep, poorly healing wound with irregular wound edges
• Foul-smelling discharge due to bacterial colonization and tissue breakdown
• Pain in the affected area, although in cases of significant neuropathy (e.g., in diabetic patients) pain may be absent
• Redness, swelling, and warmth around the wound as signs of accompanying infection
• Fever and general malaise in cases of systemic infection

Diagnosis

The diagnosis of ulcus gangraenosum is primarily clinical, supported by additional examinations:

• Clinical examination: Assessment of wound depth, color, odor, and surrounding tissue by a physician.
• Blood tests: Inflammatory markers (CRP, leukocytes), blood glucose, and other laboratory values to assess general condition.
• Microbiological wound swabs: Identification of causative pathogens to guide targeted antibiotic therapy.
• Imaging procedures: Ultrasound, Doppler sonography, or MRI to assess circulation and the extent of tissue damage.
• Tissue biopsy: For histological examination in cases of uncertain etiology.

Treatment

Treatment of ulcus gangraenosum is multimodal and tailored to the underlying condition and severity of the findings:

Wound Management

Local wound care includes surgical wound debridement, in which dead tissue is removed. Modern wound dressings (e.g., hydro-active dressings) support wound healing and reduce the risk of infection.

Treatment of the Underlying Condition

Addressing the root cause is essential: in PAD, vascular interventions or surgical procedures (e.g., bypass surgery, stenting) are employed. In diabetic foot syndrome, optimal blood glucose control is indispensable.

Antibiotic Therapy

In cases of confirmed or imminent infection, antibiotics are administered systemically or locally, guided by pathogen identification.

Surgical Measures

In severe cases, amputation of the affected tissue or limb may be necessary to prevent the spread of gangrene and life-threatening sepsis.

Additional Therapeutic Options

Hyperbaric oxygen therapy (HBO) can support wound healing in certain forms of gangrene. Regular follow-up appointments and close interdisciplinary collaboration are essential.

Prognosis and Prevention

The prognosis of ulcus gangraenosum depends heavily on the underlying condition, the extent of tissue damage, and the timing of treatment. Early medical intervention significantly improves healing outcomes. Prevention includes effective management of chronic conditions such as diabetes, regular foot care, and routine check-ups for at-risk patients.

References

1. World Health Organization (WHO): Global Report on Diabetes, Geneva, 2016. Available at: https://www.who.int/publications/i/item/9789241565257
2. Harding K. et al. - Wound care in the 21st century: a development in care for patients with chronic wounds. Journal of Wound Care, 2015.
3. Norgren L. et al. - Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Journal of Vascular Surgery, 2007;45(1 Suppl):S5-S67.