What are the treatment options for a non-healing, over-granulated wound in an 88-year-old man, and are cautery or excision reasonable options?

From the Guidelines

For an 88-year-old man with a non-healing, raised granulation tissue wound after trauma, I recommend surgical excision as the primary treatment option. This approach would allow for complete removal of the lesion and provide tissue for histopathological examination, which is crucial given the patient's age and the unusual appearance of the wound. Excision with primary closure would be appropriate for this 13mm lesion. Silver nitrate cauterization is an alternative that can be performed in-office but may require multiple applications and doesn't provide tissue for pathology. Other options include shave excision or electrocautery. Conservative management with topical corticosteroids (such as triamcinolone 0.1% cream applied twice daily) can reduce inflammation and promote healing if the patient is not a surgical candidate. Regular wound care with saline cleansing and petroleum jelly or silicone-based dressings should be continued regardless of the chosen treatment. Given the patient's advanced age and the raised, fleshy appearance of a wound that hasn't healed in two weeks, it's essential to rule out malignancy such as squamous cell carcinoma, which can present as non-healing wounds in elderly patients, making tissue diagnosis particularly important in this case.

The most recent and highest quality study, 1, published in 2025, emphasizes the importance of careful evaluation and management of non-healing wounds, including consideration of surgical offloading procedures and advanced wound therapy. However, the study also notes that the initial treatment and evaluation of ulcerations should include basic principles such as offloading, debridement, revascularization, management of infection, and use of physiologic, topical dressings.

In terms of specific treatment options, the study 1 suggests that advanced wound therapy can be classified into nine broad categories, including topical growth factors, acellular matrix tissues, and bioengineered cellular therapies. However, the study also notes that the use of these modalities should be based on robust RCTs or systematic reviews, and that the choice of treatment should be individualized based on the patient's specific needs and circumstances.

Overall, the evidence suggests that surgical excision is a reasonable treatment option for this patient, given the size and appearance of the wound, as well as the patient's age and medical history. However, the decision to proceed with surgery should be made on a case-by-case basis, taking into account the patient's overall health and any potential risks or benefits associated with the procedure.

Some key points to consider in the management of this patient's wound include:

• The importance of careful evaluation and management of non-healing wounds, including consideration of surgical offloading procedures and advanced wound therapy
• The need for individualized treatment based on the patient's specific needs and circumstances
• The importance of ruling out malignancy, such as squamous cell carcinoma, in non-healing wounds in elderly patients
• The potential benefits and risks of surgical excision, including the possibility of complete removal of the lesion and provision of tissue for histopathological examination.

From the Research

Treatment Options for Pyogenic Granuloma

The patient's symptoms are consistent with a pyogenic granuloma, a benign vascular proliferation of the skin. The following treatment options are available:

• Surgical excision: This method offers the lowest overall recurrence rates (2.94%) 2
• Cauterization with silver nitrate: This is a reasonable option, with no statistical difference in recurrence rates compared to surgical excision (p-value 0.426) 2
• Cryotherapy: This method offers a low overall recurrence rate (1.62%) 2
• Topical corticosteroids: The use of topical clobetasol has been shown to be effective in inducing regression of cutaneous pyogenic granulomas 3
• Laser treatment: This is another option, with several studies demonstrating encouraging results 4

Alternatives to Cautery or Excision

If cautery or excision are not suitable options, the following alternatives can be considered:

• Topical therapy with clobetasol: This can be an effective non-invasive approach 3
• Conservative approaches: Including the application of topical and systemic agents 4
• Laser treatment: This can be used as an alternative to surgical excision or cauterization 4

Wound Infection Prevention and Management

It is essential to prevent and manage wound infections to promote healing. The following measures can be taken:

• Identify and manage wound infection early: This can contribute to faster wound healing and reduce the risk of negative outcomes 5, 6
• Use topical and systemic therapies: To treat wound bed infections 6
• Prevent biofilm formation: This can help prevent chronicity and delays in healing 5