Understanding the Zebras of Wound Care: An Overview of Atypical Wounds

Elizabeth Ansert, DPM, MBA, MA; Anthony Tickner, DPM, FACCWS, FAPWCA, FAPWH; Donald Cohen, DPM; Weldon Murry, DPM; Samuel Gorelik, DPM


Wounds. 2022;34(5):124-134. 

In This Article


Calciphylaxis occurs in people with chronic kidney disease. Laboratory values used to evaluate the risk level for development of calciphylaxis include bone morphogenetic protein, complete blood count, liver function, inflammatory markers, hypercoagulation, parathyroid levels, and autoimmune indicators. Morbidity associated with calciphylaxis is related to nonhealing wounds, and the 1-year mortality rate in patients with calciphylaxis ranges from 45% to 80%.[26] Sepsis is the leading cause of death in patients with calciphylaxis.

Painful skin lesions, livedo reticularis, violaceous plaques, and indurated lesions are markers of calciphylaxis (Figure 2). These lesions typically have a presentation that coincides with the bursting of small blood vessels near the skin, creating a purplish appearance and a lace-like pattern. After these areas blister and ulcerate, patients are at increased risk for infection. These ulcerations may resemble eschar in appearance. These patients are also at risk for vascular calcifications, which increases the likely associated comorbidities. Definitive diagnosis requires biopsy and histological evaluation. Calcification with microthrombi and hyperplasia of small dermal and subcutaneous arteries are histologic features of calciphylaxis.

Figure 2.

A diagnosis of calciphylaxis was made based on the clinical presentation of eschar in portions of the wound, the purple-colored wound edges (particularly in the superior middle right portion of the wound edges, see green arrow), and indurated borders along an abdominal wound. This presentation may be more common in the later phases of the wound pathology.

After management of renal disease, the most common first-line treatment for calciphylaxis is intravenous sodium thiosulfate. Other treatments include wound care management, hyperbaric oxygen therapy, pain management, and close monitoring of calcium and phosphorus levels.[27] Sepsis is a reason for the high level of morbidity associated with calciphylaxis. Infected wounds associated with calciphylaxis must be treated promptly. Surgical debridement and/or maggot therapy have both been shown to be viable options. Debridement has been shown to be most effective when combined with a healthy wound bed and skin grafting. One study reported a 62% survival rate after surgical debridement compared with a 27% survival rate when surgical debridement was not performed.[28,29]