Chapter 10: Identification and Management of Atypical Wounds

Introduction

A variety of etiologies cause chronic wounds, which are frequently seen in medical practices around the world. These chronic wounds can be caused by long-standing diabetes mellitus (diabetic foot ulcers), poor arterial supply (arterial ulcers), venous insufficiency (venous leg ulcers), neurological deficit (neuropathic ulcers), and prolonged pressure (pressure ulcers or bed sores).¹ Wounds secondary to more unusual sources are called atypical wounds, and as a result, some are rare and intricate in nature. Atypical wounds have a spectrum of etiologies, including inflammatory processes, vasculopathies, infectious disease, metabolic disorder, genetic disease, neoplastic origination, and external trauma or injury.² It is estimated that out of 500,000 leg ulcers in the United States alone, an expected 10% are caused by atypical or unusual etiologies.¹ Therefore, it is essential for all health-care specialists to be familiar with this medical issue, including identification and treatment of unusual wound etiologies.

An atypical etiology for a wound must be considered within a differential diagnosis when (1) the location of the wound varies from that of a common or chronic wound, (2) the clinical presentation is unique and different from that of a common or chronic wound, or (3) the suspicious wound fails to respond to standard treatment regimens.^2,3 Since many atypical wounds tend to present similar to each other, a definitive diagnosis based on visualization alone is often difficult, and lesional biopsies are warranted and often crucial for diagnosis. Histopathological evaluation with adjunct studies such as special staining, tissue cultures, or immunofluorescence is essential to properly evaluate a wound once it is suspected to be of an atypical nature. It is also important that a comprehensive history and physical examination be undertaken to accurately diagnose the cause of the wound. Aspects of the patient's history to be taken into account during the workup are the following: epidemiological exposure, family history, personal or unusual habits, recreational and hobby activities, employment history, recent travel, sexual history, substance abuse history, known history of systemic illnesses, immunosuppression status, and laboratory blood testing.^3,4,5

Inflammatory Etiologies

An inflammatory etiology of a wound is identified when the process resulting in ulcer formation primarily involves inflammation as the causative factor. Fundamentally, all skin ulcerations must have an inflammatory component; however, an inflammatory ulcer is defined as directly leading to cutaneous ...