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Becker SL, Kody S, Fett NM, Hines A, Alavi A, Ortega-Loayza AG. Approach to the Atypical Wound. Am J Clin Dermatol 2024; 25:559-584. [PMID: 38744780 DOI: 10.1007/s40257-024-00865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The heterogeneity of atypical wounds can present diagnostic and therapeutic challenges; however, as the prevalence of atypical wounds grows worldwide, prompt and accurate management is increasingly an essential skill for dermatologists. Addressing the underlying cause of an atypical wound is critical for successful outcomes. An integrated approach with a focus on pain management and patient engagement is recommended to facilitate enduring wound closure. Advances in treatment, in addition to further research and clinical training, are necessary to address the expanding burden of atypical wounds.
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Affiliation(s)
- Sarah L Becker
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Shannon Kody
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | - Nicole M Fett
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA
| | | | - Afsaneh Alavi
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Alex G Ortega-Loayza
- Department of Dermatology, Oregon Health & Science University, 3303 S Bond Ave Building 1, 16th Floor, Portland, OR, 97239, USA.
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2
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Ring NAR, Dworak H, Bachmann B, Schädl B, Valdivieso K, Rozmaric T, Heimel P, Fischer I, Klinaki E, Gutasi A, Schuetzenberger K, Leinfellner G, Ferguson J, Drechsler S, Mildner M, Schosserer M, Slezak P, Meyuhas O, Gruber F, Grillari J, Redl H, Ogrodnik M. The p-rpS6-zone delineates wounding responses and the healing process. Dev Cell 2023; 58:981-992.e6. [PMID: 37098351 DOI: 10.1016/j.devcel.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/31/2023] [Accepted: 04/01/2023] [Indexed: 04/27/2023]
Abstract
The spatial boundaries of tissue response to wounding are unknown. Here, we show that in mammals, the ribosomal protein S6 (rpS6) is phosphorylated in response to skin injury, forming a zone of activation surrounding the region of the initial insult. This p-rpS6-zone forms within minutes after wounding and is present until healing is complete. The zone is a robust marker of healing as it encapsulates features of the healing process, including proliferation, growth, cellular senescence, and angiogenesis. A mouse model that is unable to phosphorylate rpS6 shows an initial acceleration of wound closure, but results in impaired healing, identifying p-rpS6 as a modulator but not a driver of healing. Finally, the p-rpS6-zone accurately reports on the status of dermal vasculature and the effectiveness of healing, visually dividing an otherwise homogeneous tissue into regions with distinct properties.
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Affiliation(s)
- Nadja Anneliese Ruth Ring
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Helene Dworak
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Barbara Bachmann
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Barbara Schädl
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria; University Clinic of Dentistry, Medical University of Vienna, 1090 Vienna, Austria
| | - Karla Valdivieso
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria; Institute of Molecular Biotechnology, Department of Biotechnology, University of Natural Resources and Life Sciences, 1180 Vienna, Austria
| | - Tomaz Rozmaric
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Patrick Heimel
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria; Core Facility Hard Tissue and Biomaterial Research, Karl Donath Laboratory, University Clinic of Dentistry, Medical University of Vienna, 1090 Vienna, Austria
| | - Ines Fischer
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Eirini Klinaki
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Aniko Gutasi
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Kornelia Schuetzenberger
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Gabriele Leinfellner
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - James Ferguson
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Susanne Drechsler
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Michael Mildner
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Schosserer
- Austrian Cluster for Tissue Regeneration, Vienna, Austria; Institute of Molecular Biotechnology, Department of Biotechnology, University of Natural Resources and Life Sciences, 1180 Vienna, Austria; Institute of Medical Genetics, Center for Pathobiochemistry and Genetics, Medical University of Vienna, 1090 Vienna, Austria
| | - Paul Slezak
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Oded Meyuhas
- Department of Biochemistry and Molecular Biology, Institute for Medical Research Israel-Canada, Hebrew University-Hadassah Medical School, 91120 Jerusalem, Israel
| | - Florian Gruber
- Austrian Cluster for Tissue Regeneration, Vienna, Austria; Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria
| | - Johannes Grillari
- Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria; Institute of Molecular Biotechnology, Department of Biotechnology, University of Natural Resources and Life Sciences, 1180 Vienna, Austria
| | - Heinz Redl
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Mikolaj Ogrodnik
- Ludwig Boltzmann Research Group Senescence and Healing of Wounds, 1200 Vienna, Austria; Ludwig Boltzmann Institute for Traumatology, The Research Centre in Cooperation with AUVA, 1200 Vienna, Austria; Austrian Cluster for Tissue Regeneration, Vienna, Austria.
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3
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Samy AM, El-Halim MA, El-Sabbagh AH. Micropunch grafting for healing of refractory chronic venous leg ulcers. CHINESE JOURNAL OF PLASTIC AND RECONSTRUCTIVE SURGERY 2022; 4:166-170. [DOI: 10.1016/j.cjprs.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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4
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Min MS, Kus K, Wei N, Kassamali B, Faletsky A, Mostaghimi A, Lebwohl MG. Evaluating the role of histopathology in diagnosing pyoderma gangrenosum using Delphi and PARACELSUS criteria: a multicenter, retrospective cohort study. Br J Dermatol 2022; 186:1035-1037. [PMID: 34981834 DOI: 10.1111/bjd.20967] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 12/01/2021] [Accepted: 12/24/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Michelle S Min
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,University of California Irvine School of Medicine, Irvine, CA, USA
| | - Kylee Kus
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Nancy Wei
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
| | - Bina Kassamali
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam Faletsky
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Tufts University School of Medicine, Boston, MA, USA
| | - Arash Mostaghimi
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Geisler AN, Taylor N. Venous Stasis Ulcers: an Update on Diagnosis and Management. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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6
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Shalin SC, Ferringer T, Cassarino DS. PAS and GMS utility in dermatopathology: Review of the current medical literature. J Cutan Pathol 2020; 47:1096-1102. [PMID: 32515092 DOI: 10.1111/cup.13769] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/06/2020] [Accepted: 05/25/2020] [Indexed: 12/19/2022]
Abstract
The American Society of Dermatopathology has established an Appropriate Use Criteria (AUC) Committee with the intention of establishing evidence-based recommendations regarding the appropriateness of various ancillary tests commonly utilized by dermatopathologists. Periodic acid Schiff (PAS) and Grocott (or Gomori) methenamine silver (GMS) stains represent some of the most commonly employed ancillary tests in dermatopathology. The utility of these tests was targeted for evaluation by the AUC. This literature review represents a comprehensive evaluation of available evidence for the utility of PAS and/or GMS staining of skin and nail biopsies. In concert with expert opinion, these data will be incorporated into future recommendations by the AUC for PAS and GMS staining in routine dermatopathology practice.
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Affiliation(s)
- Sara C Shalin
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Tammie Ferringer
- Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania, USA.,Department of Laboratory Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - David S Cassarino
- Department of Pathology and Laboratory Medicine, Southern California Permanente Medical Group, Los Angeles, California, USA
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Alonso-León T, Hernández-Ramírez HH, Fonte-Avalos V, Toussaint-Caire S, E Vega-Memije M, Lozano-Platonoff A. The great imitator with no diagnostic test: pyoderma gangrenosum. Int Wound J 2020; 17:1774-1782. [PMID: 32779354 DOI: 10.1111/iwj.13466] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022] Open
Abstract
Pyoderma gangrenosum is a rare, neutrophil-mediated, auto-inflammatory dermatosis that wound care specialists must be prepared to recognise. This condition has clinical features analogous to infectious processes. There is no specific diagnostic test and the diagnosis is usually obtained from exclusion. Its early recognition and proper management with prompt initiation of immunosuppressive therapy are essential to improve the quality of life and the prognosis of patients.
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Affiliation(s)
- Teresa Alonso-León
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | | | - Veronica Fonte-Avalos
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - Sonia Toussaint-Caire
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
| | - María E Vega-Memije
- Division of Dermatology, "Dr. Manuel Gea González" General Hospital, Mexico City, Mexico
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8
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Shaigany S, Steuer A, Seminara N, Brinster N, Femia A. Comparison between organismal staining on histology and tissue culture in the diagnosis of cutaneous infection: A retrospective study. J Am Acad Dermatol 2020; 82:1400-1408. [PMID: 32004643 DOI: 10.1016/j.jaad.2020.01.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/10/2019] [Accepted: 01/22/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND In instances of suspected cutaneous infection, the standard of care includes obtaining skin biopsy specimens for histology and tissue culture. Few studies have compared the clinical utility of each test. OBJECTIVE To assess the concordance of results between tissue culture and histology, as well as the clinicopathologic features that may influence the diagnostic yield of each test. METHODS A retrospective review of all patients who underwent skin biopsy for histology and tissue culture at New York University from 2013 through 2018. RESULTS Of 179 patients, 10% had positive concordance, 21% had positive tissue culture only, and 7% had positive histology only. We calculated a kappa correlation coefficient of 0.25 between histology and tissue culture (reference, 0.21-0.39 indicates minimal agreement). Histology exhibited higher sensitivity in detecting fungi, whereas tissue culture was more sensitive in identifying Gram-negative bacteria. Antimicrobial use before biopsy led to significantly fewer positive cultures (37.5% vs 71%; P = .023) in patients ultimately diagnosed with infection. LIMITATIONS This study was conducted at a single institution, thereby restricting its broad applicability. The lack of a validated criterion standard to diagnose infection also limits interpretation of the results. CONCLUSION Tissue culture and histopathology often yield discordant results. Dermatologists should recognize specific limitations, yet high clinical utility in special circumstances, of tests when approaching cases of suspected infection.
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Affiliation(s)
- Sheila Shaigany
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Alexa Steuer
- New York University School of Medicine, New York, New York
| | - Nicole Seminara
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Nooshin Brinster
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York.
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9
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Hammer P, Latour E, Bohnett MC, McKenzie F, Korcheva VB, Mengden S, White KP, Ortega-Loayza AG. The utility and challenges of histopathologic evaluation in the diagnosis of nonmalignant skin ulcers. Wound Repair Regen 2019; 28:219-223. [PMID: 31705777 DOI: 10.1111/wrr.12780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/17/2019] [Accepted: 11/06/2019] [Indexed: 12/12/2022]
Abstract
Histopathologic evaluation of cutaneous ulcers is indicated when the clinical diagnosis is unclear or when ulcers have not responded to standard of care. Many nonmalignant skin ulcers lack specific histologic findings on biopsy and pose a diagnostic challenge. While the usefulness of skin biopsies to diagnose underlying malignancy in ulcerated lesions has been demonstrated in previous studies, their utility in the diagnosis of ulcers of other etiologies has not been reported. We conducted a retrospective study of 45 nonmalignant ulcer biopsies in a 3-year period to compare the histologic diagnosis with the final diagnosis. Additionally, we assessed the diagnostic concordance among three blinded dermatopathologists when reviewing these cases. The leading histologic diagnosis from each of the three observers agreed with the final clinical diagnosis, on average, for 29.6% of the cases (average pairwise kappa = 0.15). Inflammatory ulcers had the lowest concordance between the observers and final diagnosis with an average of 26.0% of cases (average pairwise kappa = 0.06). The observers agreed with each other for 35.6% of the cases (Fleiss' kappa = 0.32). The highest agreement among observers was in the vascular/vasculopathic category (50%, Fleiss' kappa = 0.44). Our results indicate that skin biopsies alone are useful in the evaluation of nonmalignant ulcers to rule out other conditions (e.g. neoplasm) but frequently not sufficient to establish a definitive diagnosis. Additional clinicopathologic correlation is necessary in the final assessment of nonmalignant ulcers to determine the diagnosis. Future research endeavors should explore alternative approaches to more efficiently diagnose nonmalignant skin ulcers.
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Affiliation(s)
- Phoebe Hammer
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Emile Latour
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Mary C Bohnett
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Fatima McKenzie
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Veselina B Korcheva
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Stephanie Mengden
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Kevin P White
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
| | - Alex G Ortega-Loayza
- Oregon Health & Science University, Department of Dermatology, Portland, Oregon, USA
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