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Signature ✍️
- … a wound isn’t healing (”recurrent cellulitis/abscess” “antibiotic failure”)
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DDx 🏳️🌈
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- Peripheral artery disease
- Chronic venous insufficiency
- Polyneuropathy (”neurologic perfusion”)
- Excess pressure (e.g. paraplegia)
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- Infectious 🤔
- “Bug” issue
- Atypical bacterial (e.g. mycobacteria)?
- Fungal (e.g. blastomycosis)?
- Parasitic (e.g. leishmaniasis)?
- “Drug” issue
- Unable to penetrate abscess (i.e. I&D)?
- Wrong spectrum (e.g. MRSA, pseudomonal)?
- Non-infectious 🤔
- Dermatologic
- ⊖ Microvascular Perfusion
- In situ thrombosis (e.g. DIC syndromes)
- Embolism (e.g. septic, cholesterol, NBTE)
- Protein (e.g. type 1 cryo., cryofibrinogenemia)
- Inflammation (e.g. AAV, rheumatic vasculitis)
- Angioinvasive infection (e.g. strongyloidiasis)
- Crystalline (e.g. calciphylaxis)
- Malignant
- Marjolin ulcer
⚪ Note: the framework above assumes the patient does not have systemic processes (e.g. malnutrition with nutrient deficiencies, chronic steroid exposure) as well as local processes (e.g. repetitive scratching) that can impair the local wound healing response
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Principles❗️
- The “non-healing wound” framework is essentially interchangeable with the approach to skin ulceration (i.e. full-thickness loss of the epidermis resulting in exposed dermis ⊕/⊖ subcutaneous space, which can be uncomplicated [i.e. sterile] or complicated [i.e. infected])
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