Considerations in Evaluating Atypical Wounds in Clinical Practice

An atypical wound is a wound of unknown etiology that does not fit within a primary nonhealing wound type, such as diabetic foot, venous, arterial, or pressure-related wounds. With atypical etiologies accounting for 5% to 20% of chronic ulcers, research interest is lower in these wounds than in some of the above categories.

In a recent conference lecture, Andrea Maderal, MD, and Jennifer L. Adams, MD, provided clinical insights into the evaluation and management of atypical wounds. This session was held on Sunday, October 16, at the Symposium on Advanced Wound Care Fall.

Read a recent Review for more information on atypical wounds: Understanding the Zebras of Wound Care: An Overview of Atypical Wounds

In their session, Dr. Maderal approaches the topic with case examples demonstrating ulcers in rheumatoid arthritis and management strategies. With rheumatoid arthritis, patients may present with symmetric, inflammatory, or peripheral polyarthritis. Ulcer prevalence is about 10% in persons with rheumatoid arthritis,¹ with known risk factors including age, positive rheumatoid factor, rheumatoid nodules, and venous thromboembolism.² Ulcers related to rheumatoid arthritis also include venous leg ulceration, atherosclerotic disease, vasculitis, and pyoderma gangrenosum.

Read a recent Case Report for additional atypical presentations: Atypical Ulcer Arising on Stasis Dermatitis: Achromic Melanoma

To address atypical presentations, Dr. Adams provided patient case examples of monkeypox, cocaine-induced midline destructive lesion (CIMDLs), cutaneous herpes in an HIV-positive patient, and actinomycetoma. The patient with CIMDLs presented with nonpainful, chronic nasal ulcerations with a 2-year duration and also reported long-term daily use of cocaine. As a complication of routine nasal cocaine inhalation, CIMDL appears in 4.8% of cocaine users³; however, Dr. Adams cautions against ruling out other diagnoses too early. For instance, granulomatosis with polyangiitis (Wegener's granulomatosis) shares a similar path to CIMDL, but lack of distinct histologic characteristics of vasculitis or unresponsiveness to standard care may favor the diagnosis of CIMDL.³

Additional information presented in the lecture included further cases demonstrating atypical wounds and their presentation, strategic management options, and differential diagnoses.

—Jaclyn Gaydos, Sr. Managing Editor

Information was adapted from a conference lecture presented by Andrea Maderal, MD, and Jennifer L. Adams, MD, at the 2022 Symposium on Advanced Wound Care Fall. Dr. Maderal is Assistant Professor with the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine. Dr. Adams is Assistant Professor with the Department of Dermatology at the University of Nebraska Medical Center.

References

1.     Thurtle OA, Cawley MI. The frequency of leg ulceration in rheumatoid arthritis: a survey. J Rheumatol. 1983;10(3):507-509.

2.     Jebakumar AJ, Udayakumar PD, Crowson CS, Gabriel SE, Matteson EL. Occurrence and effect of lower extremity ulcer in rheumatoid arthritis -- a population-based study. J Rheumatol. 2014;41(3):437-443. doi:10.3899/jrheum.130392

3.     Trimarchi M, Bertazzoni G, Bussi M. Cocaine induced midline destructive lesions. Rhinology. 2014;52(2):104-111. doi:10.4193/Rhino13.112