What is Marjolin's Ulcer?
Marjolin's ulcer is a rare, aggressive cutaneous malignancy—most commonly squamous cell carcinoma—that develops in chronically traumatized, inflamed skin, particularly in burn scars, chronic wounds, pressure ulcers, and areas of long-standing inflammation. 1, 2
Clinical Definition and Pathogenesis
Marjolin's ulcer represents malignant transformation occurring in previously injured tissue, with the term originally described by Jean-Nicolas Marjolin in 1828. 1, 2 While classically associated with burn scars, this malignancy can arise from multiple chronic wound types including:
- Burn scars (most common etiology) 1, 3
- Traumatic wounds and lacerations 2, 3
- Chronic pressure ulcers 4, 5, 6
- Venous stasis ulcers 2, 5
- Osteomyelitis sinus tracts 1
- Vaccination sites, snake bites, pilonidal abscesses 1
- Fistulas and leprosy ulcers 2
The proposed pathogenic mechanisms include toxins from damaged tissues, immunologic dysfunction, cocarcinogens, chronic irritation, poor lymphatic regeneration, and local mutations. 1
Epidemiology and Latency Period
The incidence of malignant transformation in burn scars ranges from 0.77% to 2%, though one study found 0.7% incidence among patients with existing scars. 1, 3
Two distinct variants exist:
- Chronic form (more common): Develops slowly with an average latency period of 25-35 years from initial injury to malignant transformation 1, 2, 3
- Acute form (rare): Carcinoma occurs within 1 year of injury 1
A critical finding is that younger patients at the time of initial injury tend to have longer latency periods (negative correlation: r = -0.8, P <0.01), with the pre-ulceration and post-ulceration periods also inversely related to age at injury (r = -0.7, P <0.01). 3
Clinical Presentation
Anatomic distribution: All body parts can be affected, but extremities and scalp are most frequently involved, with pelvic and flank regions also commonly affected. 1, 6
Clinical warning signs include:
- Atrophic and unstable scars showing tendency toward malignant degeneration 1
- Skin breakdown on chronic scars 3
- Chronic unhealed ulcers that fail to respond to standard wound care 2, 5
- Repeated ulceration in previously healed scar tissue 3
The mean post-ulceration period (from ulcer development to diagnosis) averages 7 years, emphasizing the insidious nature of this malignancy. 3
Histopathology
Well-differentiated squamous cell carcinoma is the predominant histological type, though various other cell types can occur. 1, 2, 5 Biopsy with histopathologic interpretation remains the gold standard for diagnosis. 2
Aggressive Behavior and Prognosis
Marjolin's ulcers behave significantly more aggressively than typical cutaneous squamous cell carcinomas, with:
- Higher rates of regional lymph node metastases 1, 6
- Greater propensity for local recurrence 6
- Poor prognosis when nodal metastases are present—all four patients with positive lymph nodes in one series died of systemic disease 6
- Deaths from Marjolin's ulcer are not uncommon 1
High-grade tumors carry particularly grave prognosis due to nodal involvement. 6
Management Principles
Radical surgical excision is the treatment of choice, though consensus on prophylactic lymph node dissection remains lacking. 1, 2, 5 Major oncologic surgical procedures are required to eradicate the cancer. 6
Early recognition and proper staging offer the best chance for cure. 6 Supplementary therapy may be needed given the high metastatic risk and potential for vital organ involvement. 5
Prevention and Surveillance
A critical pitfall is that Marjolin's ulcer is frequently overlooked and inadequately treated, leading to poor outcomes. 2, 5
Prevention strategies include:
- Meticulous wound care for all burn injuries and chronic wounds 1
- Close surveillance during the latency period, particularly monitoring for skin breakdown on chronic scars 3
- High index of suspicion when evaluating any chronic, non-healing wound—this applies to all healthcare providers managing patients with long-standing wounds 2, 5
- Increased oncological alertness by nursing and medical personnel caring for patients with chronic wounds, pressure sores, and leg ulcers 5
The latency period represents a critical window for prevention through vigilant monitoring and early intervention when ulceration occurs. 3