The Importance of Making a Specific Diagnosis for Every Wound
Much of the wound care literature is devoted to specific types of dressing, topical applications, and proprietary treatments. This focus on products is less economically driven as there is a huge amount of money to be made selling dressing supplies and topical treatments for chronic wounds.
Many of these modalities will someday be of proven value, but the focus of this literature is incorrect as all wounds are not the same.
Time and time again, patients who have been treated over many months with a variety of dressings and medications have gotten worse under treatment because the diagnosis is wrong.
The characteristic that identifies a medical practitioner as a wound care expert, no matter what his field of specialization, is his/her ability to make a specific diagnosis.
- Arterial Ulcers: need to be diagnosed not only by their appearance but also by their noninvasive vascular laboratory findings, and possibly the findings on arteriography.
- Venous Stasis Ulcers: need to be diagnosed not just their appearance but by physiologic changes observed in the vascular laboratory. Venous Stasis Disease is not a diagnosis of exclusion.
- Infectious Ulcers: need to be diagnosed by quantitative tissue culture. These wounds commonly do not have surrounding cellulitis. Unusual organisms have often been selected out by antibiotic therapy and by topical application of antibiotic ointments.
- Vasculitic Ulcers: vasculitic ulcers and ulcers caused by connective tissue diseases are particularly difficult to evaluate and treat, but they can't be treated effectively without knowing the etiology.
- Diabetic Foot Wounds: These are complicated because the main problem may be osteomyelitis, neuropathy, vascular insufficiency or some combination of the above. Understanding the "pathways to amputation" in the diabetic is important in designing treatment.
The most common error in treating chronic wounds is to use the dressing or ointment of the day and not to make a specific diagnosis. Sir E. Holm in 1901 said, "It must appear obvious that there is no probability that any one medicine can ever be discovered which...shall have powers adapted to cure all ulcers of the legs...the idea that such a medicine may exist has retarded very considerably...the treatment of ulcers." Nothing has changed in the past century.
Written by Charles O. Brantigan, MD, FACS, FCCP, Vascular Surgeon