Wound healing — SAQ

Stem

A 72-year-old woman has a shallow irregular ulcer over the medial gaiter area for 4 months, with haemosiderin staining and lipodermatosclerosis. Pulses are palpable. A second clinic patient with diabetes has a plantar first-metatarsal ulcer and loss of protective sensation on monofilament testing.^[10][14]

Questions

a) Outline the phases of cutaneous wound healing (Wang) and the TIME local factors of wound-bed preparation. (2 marks)

• Wang: three successive but overlapping phases — hemostasis/inflammatory, proliferative, and remodeling. Aberration yields excessive healing (hypertrophic scar/keloid) or chronic wound (ulcer).^[2]
• Sibbald TIME local factors: tissue debridement, infection or inflammation, moisture balance, and edge effect.^[8]

b) Give sourced epidemiology for diabetic foot ulcers and for venous/leg ulcers. (3 marks)

• Singh: among people with diabetes, DFU prevalence 4% to 10%, annual incidence 1.0% to 4.1%, lifetime incidence as high as 25%; usual first step to lower-extremity amputation. Primary-care screening: brief history + Semmes-Weinstein monofilament.^[10]
• Kantor: venous ulcers 40-70% of lower-extremity chronic wounds. Bonkemeyer Millan: most common chronic lower-extremity ulcer; 1% to 3% of the US population.^[13][14]
• Nelson: 20% of people with leg ulcers have arterial disease ± venous disorders; active ulcers 1.5–3.0/1000, about 20/1000 aged over 80.^[11]

c) First-line venous-ulcer treatment and the 4-week healing predictor. (3 marks)

• Bonkemeyer Millan: compression therapy, exercise, dressings, pentoxifylline, and tissue products; early ablation of superficial reflux can improve healing and decrease recurrence. Assess arterial disease (poor prognostic sign) before compression.^[14]
• Kantor: percentage change in area from baseline to week 4 — PPV 68.2%, NPV 74.7%, ROC 0.75 — predicts complete healing by 24 weeks (not an unsourced 12-week rule).^[13]

d) Name first-line systemic options for pyoderma gangrenosum and why debridement is avoided. (2 marks)

• Tan: first-line with greatest evidence — systemic corticosteroids, cyclosporine, and TNF-α inhibitors; wound care and treatment of associated disease.^[17]
• Pathergy: surgical debridement can worsen PG — medical therapy first.^[17]

References7ShowHide

1. [2]Wang PH, Huang BS, Horng HC, Yeh CC, Chen YJ. Wound healing. J Chin Med Assoc, 2018.PMID 29169897
2. [8]Sibbald RG, Orsted H, Schultz GS, Coutts P, Keast D. Preparing the wound bed 2003: focus on infection and inflammation. Ostomy Wound Manage, 2003.PMID 14652411
3. [10]Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA, 2005.PMID 15644549
4. [11]Nelson EA Venous leg ulcers. BMJ Clin Evid, 2011.PMID 22189344
5. [13]Kantor J, Margolis DJ A multicentre study of percentage change in venous leg ulcer area as a prognostic index of healing at 24 weeks. Br J Dermatol, 2000.PMID 10809855
6. [14]Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician, 2019.PMID 31478635
7. [17]Tan MG, Tolkachjov SN. Treatment of Pyoderma Gangrenosum. Dermatol Clin, 2024.PMID 38423680