Inflammatory wounds, nonhealing

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Hello there team,

We have been seeing an increase in patients with these acute and chronic inflammatory ulcers (via Pathology report) mostly with medial lower leg ulcers that are very fibrotic. Most are female elderly normal BMI, not obese, no typical signs of lipodermatosclerosis, but we see abundance of fibrotic tissue, some pathergy, and no response to several attempted treatments, including but not limited to Santyl, topical high potency steroids, multi-layer compression wraps, NPWT, collagens, alginates, HFBs, and pink polymems. We have ruled out malignancy, arterial disease, and or infection. Our Dermopath makes specific comments on no Pyoderma and or connective tissue disease. Most but not all have some form of venous insufficiency. The wounds are typically progressive and

On our differential Dx, we always suspect some sort of autoimmune disorder. Any assistance with how to next approach these wounds/recommended work up would be greatly appreciated.
Thank you,
Pardee Wound clinic in Hendersonville NC

Jan 24, 2024 by Samantha Walsh, PA

1 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Samantha

Thank you for sharing this intriguing case. Other colleagues might have additional suggestions; here are some thoughts by Dr Mike White, Jeff, Tiff and me.

The Wound Bed Preparation framework recommends determining healability of an ulcer in order to select treatment interventions. This mainly includes assessing whether the underlying cause be treated, assessing blood supply to the ulcer, and identifying/managing co-existing medical conditions/drugs that might be preventing healing. Since malignancy, arterial disease or infection have been ruled out, wondering if other causes/comorbidities/drugs might be interfering. This topic provides a checklist/tool to facilitate reassessment
Healable stale wounds should be reevaluated for alternate diagnoses by considering:

A wound biopsy. Upon reading the sentence "Our Dermopath makes specific comments on no Pyoderma and or connective tissue disease", wondering if the dermatopathologist mentioned that it doesn't seem to be pyoderma or connective tissue disease, or if he/she did not make any comments on whether it could be pyoderma or connective tissue disease. Either way, it would be worthwhile 1) specimen was properly collected and transported (see section 'Selection of the Biopsy Site, Technique and Transport Medium' in topic "How to Perform a Wound Biopsy"; 2) confirming that the specimen was prepared/ assessed by a dermatopathologist vs. a general pathologist. 3) discussing the report with the dermatopathologist, and sharing clinical findings. It'd be great if the dermatopathologist could share his/her thoughts on possible differential diagnosis. Or if not, if they can help exclude some possible differential diagnosis. For instance, to diagnose ulcerative pyoderma, at least the major criterion and four minor criteria are required, of which, the major criterion is "Biopsy of ulcer edge demonstrating a neutrophilic infiltrate" - did the pathologist exclude this possibility because he/she didn't see any neutrophilic infiltrate in the ulcer edge?
Further reassessment and etiological investigation: regarding cases that have some form of venous insufficiency, we have recently expanded the Differential Diagnosis section in the topic "Venous Leg Ulcers - Introduction and Assessment". We have also just published a module within the Competency Tool focused on differential diagnosis assessment for patients with venous disease. To access it, go to Tools > Competency Tool for Managers> check box 'Pre built templates'> click on the drop down and search for "Clinician (Venous Disease Differential Diagnosis)". The topic 'Atypical Ulcers', 'Cutaneous Vasculitis' the Wound Assessment Tool (aka Differential Diagnosis Generator) might be helpful as well.
Noninvasive arterial testing: it seems like arterial disease might have been ruled out. If the patient has advanced age, diabetes mellitus, chronic kidney disease or other comorbidities that might cause ABI to be falsely elevated, further arterial testing with TBI/TP/TCOM/SPP would be appropriate.
Consults/input from specialists: for instance, if autoimmune disorder is in the list, it makes sense to seek input from a rheumatologist for investigation. For instance, if cutaneous vasculitis (e.g. small vessel vasculitis) is suspected, these labs can be ordered ahead and further testing might be helpful.

Hope this helps!

Jan 26, 2024

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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