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Chapter 8: Atypical Wounds

Rose L. Hamm; Jayesh B. Shah

INTRODUCTION

CHAPTER OBJECTIVES

At the end of this chapter, the learner will be able to:

  1. Recognize signs of an atypical wound.

  2. Categorize an atypical wound according to a basic pathology.

  3. Determine the appropriate medical specialist for a given wound.

  4. Develop an evidence-based care plan for an atypical wound.

  5. Educate the patient and family about the wound diagnosis.

Most wounds are diagnosed as arterial, venous, pressure, neuropathic, surgical, or burn and are treated according to the principles that have been discussed in the previous chapters. If a wound has a different appearance or does not respond to standard care, the clinician is challenged to determine either the factors that are inhibiting healing or to consider a different diagnosis. This chapter reviews the basic morphology of skin disease, red flags of atypical wounds, and characteristics of different diagnostic categories. The pathophysiology, clinical presentation with photographs, differential diagnosis, medical management, and wound management of each wound category are provided to assist the clinician in making sound clinical decisions.

CHARACTERISTICS OF ATYPICAL WOUNDS

The first indication that a wound is atypical is that little signal in the clinician's instinct that says, “This is just not quite what it looks to be.” And usually it behooves the clinician to follow those instincts, to at least rule out an atypical diagnosis, and at most to make a differential diagnosis that completely changes the care plan and results in wound healing. TABLE 8-1 provides a list of characteristics that suggest a wound does not fall into the typical categories.1,2

TABLE 8-1Characteristics of Atypical Wounds
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TABLE 8-1 Characteristics of Atypical Wounds

  • Unusual location

  • Unusual age of patient

  • Asymmetric lesion

  • Granulation extending over the wound edge

  • Exuberant granulation tissue or callus

  • Friable granulation tissue

  • Purple-red color around ulcer (termed violaceous)

  • Ulcer in center of pigmented lesion

  • History of repeated trauma

  • Rolled out edges

  • Fungating growth

  • History of radiation therapy

  • Wound secondary to burns, trauma, and diabetes

  • No obvious diagnosis

MORPHOLOGY OF SKIN DISEASE

Many diseases will cause changes in the skin that are predictable and/or suggestive of a certain diagnosis. TABLE 8-2 provides a list of terms and definitions of integumentary characteristics (based on size, texture, and color) that are used to describe abnormal skin appearance.2 These terms are used in the following descriptions of atypical wound clinical presentations.

TABLE 8-2Skin Disease Morphology
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TABLE 8-2 Skin Disease Morphology

  1. Macule—A circumscribed, flat, nonpalpable lesion that is flush with the level of surrounding normal skin; smaller than 10 mm in diameter

  2. Patch—A flat, nonpalpable lesion that is flush with the level of surrounding normal skin; greater than 10 mm in diameter

  3. Papule—A superficial, circumscribed dome-shaped or-flat topped palpable lesion elevated above the skin ...

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