A useful approach to all patients with non-healing wounds can be summarised by the following concept: “Wounds do not heal for no reason.” The development of an ulcer is a priori evidence of some pathological process (e.g. unrelieved pressure). For a wound or an ulcer to persist, there must be a disruption in the elegant cascade of natural events which normally effect healing. Despite its complexity, healing is the NORM. The in-ability to heal is evidence of a disease state.  For a patient to have a non-healing wound or ulcer, there must be factors responsible for the failure of one of the most reliable of physiological processes, that of tissue repair.  Although textbooks and clinical research may force us to think of these ulcers as belonging to clearly defined categories (e.g. venous stasis, diabetic, pressure) the approach to treating them must be based on correcting the agent(s) which produce non-healing, many of which overlap and thus defy categorisation. (In other words, patients with venous ulcers need arterial screening and many patients with pressure ulcers need control of their diabetes.)
 
Clinical practice guidelines from major organisations invariably begin with arterial screening of all non-healing lower extremity ulcers, no matter what the presumed etiology might be (Chronic Wound Care Guidelines). They all include moist wound care, debridement of necrotic material, control of bioburden, control of edema, and off-loading of pressure. When appropriate measures such as these fail to result in healing within 6 weeks, all chronic ulcers should undergo biopsy for histological diagnosis. When a consistent protocol is followed, patients are more likely to get appropriately directed therapy. This case is an excellent example of following such a protocol. A rare condition was discovered and successfully treated “simply” by following a logical plan of assessment and treatment.

Caroline E. Fife, MD
Professor of Medicine, Division of Cardiology
University of Texas Health Science Center, Houston
Director of Clinical Research, Memorial Hermann Center for Wound Healing

The importance of challenging your diagnosis even in straightforward cases