DermatologyTier 1Disease (DEADMAN)

Skin ulcers - traumatic

Description

Ulceration following direct mechanical/thermal/chemical skin injury - distinguished from vascular/neuropathic/pressure ulcers by a clear precipitating traumatic event
Includes lacerations with tissue loss, degloving injuries, skin tears (especially in frail/elderly skin), burns, and chemical/thermal injury
Delayed healing after trauma should always prompt a search for an underlying vascular, metabolic, or infective contributor - trauma may be the trigger but not the whole explanation

Skin tears - common in the elderly (thin, fragile, atrophic skin from photoageing and long-term corticosteroid use), often from minor trauma (bumps, tape removal)
Traumatic ulcers overrepresented wherever falls risk, cognitive impairment, or anticoagulation coexist

Direct tissue disruption -> normal healing cascade (haemostasis -> inflammation -> proliferation -> remodelling) - delay or failure at any stage causes chronic ulceration
Factors impairing healing after trauma: poor perfusion (arterial/venous disease), diabetes, malnutrition, corticosteroids, smoking, infection, repeated mechanical trauma to the same site
Elderly/photoaged skin - thin dermis with reduced collagen/elastin - minimal shear force causes skin tears; slower re-epithelialisation

Clinical

History of a clear traumatic event, wound bed and edge assessment (viable vs necrotic tissue), size/depth/tracking documentation
Classify skin tears (e.g. STAR classification) to guide flap/skin viability management

When to investigate further - a traumatic ulcer failing to heal is not just "a wound"

ABPI if any suspicion of coexisting arterial disease
Diabetes screen if not already known
Swab/culture only if clinical signs of infection (increasing pain, spreading erythema, malodour, delayed healing) - not routinely for all wounds
Biopsy the edge if a chronic non-healing ulcer fails to respond to standard care - exclude malignant transformation (Marjolin's ulcer - SCC arising in a chronic wound/burn scar, typically after years)

A. Acute wound care

Irrigation/debridement of devitalised tissue, hemostasis, tetanus prophylaxis review
Skin tears - preserve and re-approximate the skin flap if viable rather than excising it; appropriate non-adherent dressing
Primary closure vs healing by secondary intention depends on wound age, contamination, and tissue loss

B. Ongoing wound management

Moist wound healing principles - dressing selection matched to exudate level (foam, alginate, hydrocolloid)
Offload/protect the area from repeat trauma
Optimise modifiable factors: glycaemic control, nutrition (protein, vitamin C, zinc), smoking cessation, minimise corticosteroid dose where possible

C. Non-healing despite optimisation

Reassess for an unaddressed vascular/metabolic contributor
Refer for specialist wound care/plastics input - consider debridement, negative pressure wound therapy, or skin grafting for large defects
Biopsy any chronic wound with atypical, raised, or non-healing edges to exclude Marjolin's ulcer

Long-term corticosteroid use, anticoagulation - fragile skin/bleeding risk
Diabetes, peripheral arterial disease - impaired healing
Falls risk, cognitive impairment, frailty - recurrent skin tears
Chronic traumatic/burn scars - risk of malignant transformation (Marjolin's ulcer) after years to decades

Most heal uneventfully with basic wound care in patients without impaired healing factors
Delayed healing - risk of secondary infection, cellulitis, chronic wound formation
Marjolin's ulcer - aggressive SCC arising in a chronic traumatic/burn ulcer, typically after a long latency (years); worse prognosis than typical cutaneous SCC due to delayed recognition
Recurrent skin tears in frail elderly patients - cumulative scarring, chronic wound burden, and falls-prevention becomes part of management

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