What is the best course of action for a patient with a non-healing incision (post-operative wound) on the upper left chest, 4 months status post (s/p) surgery, who may have underlying conditions such as diabetes?

Management of Non-Healing Upper Chest Incision 4 Months Post-Surgery

Immediate Dermatology Referral is Mandatory

Yes, refer to dermatology immediately—this 4-month non-healing surgical incision on the upper left chest requires urgent evaluation for postoperative pyoderma gangrenosum (PSPG), which is frequently misdiagnosed as wound infection and can be catastrophically worsened by debridement. 1, 2

Critical First Step: Rule Out Pyoderma Gangrenosum Before Any Intervention

Why Dermatology Must See This First

• PSPG occurs in 16.8% of patients with prior pyoderma gangrenosum history, and cardiothoracic/chest surgeries account for 14% of all PSPG cases 2
• Signs of wound complication from PSPG typically appear around 7 days post-surgery, but can present later 2
• 73% of PSPG cases undergo debridement before correct diagnosis, causing additional pathergic wound breakdown and potentially devastating consequences 1, 2
• 90% of PSPG patients are incorrectly started on antibiotics, delaying proper immunosuppressive treatment 1

Red Flags Suggesting PSPG Over Infection

• Rapidly expanding ulceration with violaceous, undermined borders 1, 2
• Wound deterioration despite antibiotic therapy 1
• History of inflammatory bowel disease, rheumatoid arthritis, or hematologic disorders (though 66% have no systemic disease) 1, 2
• Chest/upper torso location in male patients 1

What Dermatology Will Assess

Diagnostic Evaluation

• Clinical diagnosis based on characteristic appearance: rapidly expanding ulcer with violaceous borders and pathergy 1, 2
• Skin biopsy to exclude infection, malignancy, and vasculitis—not to confirm PSPG (which is a diagnosis of exclusion) 1
• Wound culture from debrided base if infection suspected, never surface swab 3

If PSPG is Confirmed

• Immediate initiation of systemic corticosteroids (typically prednisone 0.5-1 mg/kg/day) 2
• Absolute avoidance of debridement—this causes pathergic worsening 1, 2
• Gentle wound care with non-adherent dressings only 1

If PSPG is Excluded: Standard Non-Healing Wound Management

Immediate Actions at Dermatology Visit

Vascular Assessment is Non-Negotiable

• Check for arterial insufficiency—wounds cannot heal without adequate perfusion regardless of local care 3, 4
• Obtain ankle-brachial index if lower extremity involved, or assess chest wall perfusion clinically 3

Infection Evaluation

• Assess for clinical signs: increasing pain, erythema, warmth, purulent discharge, systemic signs 3
• If infected: obtain tissue specimens from wound base after debridement, initiate empiric broad-spectrum antibiotics covering Staphylococcus aureus (including MRSA if risk factors present) 3
• Surgical debridement required for abscess, gas, or necrotizing infection 3

Sharp Debridement (Only if PSPG Excluded)

• Remove all necrotic tissue, slough, and surrounding callus using scalpel or scissors 3, 4
• Debride before obtaining cultures if infection suspected 4

Wound Care Protocol

Basic Dressing Management

• Use simple moisture-retentive dressings (basic gauze or non-adherent) to absorb exudate while maintaining moist wound environment 5, 4
• Do NOT use collagen, alginate, or antimicrobial dressings—these do not improve healing and waste resources 5, 4
• Basic wound contact dressings perform equally well as expensive specialized dressings 5

Consider Negative Pressure Wound Therapy (NPWT) at This 4-Month Mark

• NPWT should be strongly considered for post-surgical wounds at 2-4 months, especially after debridement, to accelerate healing 3, 6
• Apply only to clean, debrided wound beds 3, 6
• NPWT reduces wound size and promotes granulation tissue formation in post-operative wounds 3

Medical Optimization (Critical for Healing)

If Diabetic

• Optimize glycemic control immediately—target HbA1c <7% 3, 6, 4
• Hyperglycemia profoundly impairs wound healing and immune function 4, 7
• Maintain perioperative glucose 7.7-10 mmol/L (140-180 mg/dL) if still in acute phase 3

Smoking Cessation

• Mandatory—smoking causes vasoconstriction and tissue hypoxia that prevents healing 3, 6

Nutritional Support

• Ensure adequate protein intake to support tissue repair 6

Pain Control

• Adequate analgesia improves compliance and quality of life 6

Follow-Up Protocol

Weekly Reassessment

• Document wound measurements and photograph for serial comparison 6, 4
• Monitor for signs of biofilm, persistent infection, or deterioration 3, 6
• Evaluate healing progress—if <50% reduction in area after 2 weeks of optimal care, consider adjunctive therapies 4

Multidisciplinary Coordination

• Dermatology for diagnosis and ongoing management 1, 2
• Wound care specialists for complex wounds 6
• Infectious disease if persistent infection 6
• Plastic surgery consultation if surgical reconstruction needed 6

Common Pitfalls to Avoid

• Never debride before dermatology evaluation—you risk catastrophic pathergic worsening if this is PSPG 1, 2
• Do not continue antibiotics indefinitely for uninfected wounds—they do not promote healing 3, 4
• Do not use expensive specialized dressings routinely—basic dressings work equally well 5
• Do not ignore underlying medical conditions (diabetes, vascular disease)—these must be optimized 3, 4