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

Infectious Ulcer

Infectious ulcerations are not typically seen in the United States; however, with travel and immigration, the number of such ulcerations in the United States may increase. Additionally, infectious ulcerations can be among the first indications of a compromised immune system. The 2 bacteria discussed herein are Mycobacterium and Leishmania.

Mycobacterium ulcerans causes Buruli ulcer.[38] Buruli ulcer typically presents as a painless ulceration, but it has a characteristic plaque that develops approximately 1 month into treatment[39] (Figure 5). The bacteria produce mycolactone, a toxin that causes immunosuppression and allows the bacteria to spread.[39] The ulceration typically has a white and yellow base and occurs in tropical regions. Granulomas are among the most important clinical features. In the absence of granulomas, these ulcers have the highest number of bacilli and low interferon gamma, indicating low cellular protection abilities.[39] Current antibiotic treatments are rifampicin 10 mg/kg per body weight daily and clarithromycin 7.5 mg/kg per body weight twice daily.[38] Local wound care, surgical debridement, and lymphedema protocols may also be necessary, depending on the progression of the ulceration. One study noted that surgical debridement plus antibiotic therapy allowed for a high healing rate and low recurrence rate, especially in rural areas.[39]

Figure 5.

Buruli ulcer of leg. Used with permission; Terry Treadwell, MD.

Cutaneous leishmaniasis is the most common manifestation of leishmaniasis, which is caused by a Leishmania parasitic infection and is transmitted by sandflies.[40,41] The ulcer typically begins as painless nodules or papules on the skin and erupts into ulcerations after weeks or months (Figure 6).[40] Ulcerations have a varied clinical appearance and depend on a variety of parasite and host factors that are poorly understood.[42] Typically, a tissue sample obtained from the ulceration is examined for parasitic infestation, or a DNA test for the parasite is performed. In an immunocompromised patient, the ulcerations resolve on their own in 2 to 6 months.[42] If the ulceration sites become infected, antibiotic treatment is recommended. Scar revision may be necessary. If ulcerations are large or persistent, pentavalent antimonial drugs (ie, sodium stibogluconate or meglumine antimonate) 20 mg/kg per day are used for 20 to 28 consecutive days.[1] Amphotericin B, pentamidine isethionate, miltefosine, and thermotherapy can be used as alternative therapies if necessary.[1]

Figure 6.

Ulcerated nodular lesion on the patient's right thigh (A) before topical wound treatment, (B) after 10 days of treatment, (C) after 15 days of treatment, and (D) after 1 month of treatment. Used with permission; Iannone M, Oranges T, Dini V, Romanelli M, Janowska A. Wound management strategy for treatment of localized cutaneous leishmaniasis using the TIME framework. Wounds. 2021;33(1):e6-e9.