When should a patient with a wound be treated by wound nursing versus dermatology?

When to Refer Wounds to Dermatology vs. Wound Nursing

Dermatology consultation is mandatory when wounds exhibit red flags for malignancy (non-healing >4 weeks, rapidly growing heaped-up appearance, deep punched-out ulcers with rolled edges, hyperkeratosis with raised borders, or altered sensation), while wound nursing should manage standard acute and chronic wounds following evidence-based protocols under nurse-led multidisciplinary coordination. 1, 2, 3

Immediate Dermatology Referral Criteria

Refer to dermatology immediately when:

• Non-healing wounds persisting >4 weeks despite appropriate standard care, as this raises suspicion for cutaneous squamous cell carcinoma or other malignancies 1, 3
• Rapidly growing wounds with heaped-up appearance resembling exuberant granulation tissue, which may represent malignant transformation 1, 3
• Deep punched-out ulcers with raised or rolled edges, a classic presentation of cutaneous malignancy 1, 3
• Areas of hyperkeratosis surrounded by raised skin, particularly in patients with chronic wounds or previous radiation exposure 1, 3
• Wounds with altered sensation (tingling, increased pain) relative to expected presentation 1
• Dermal fibrosis with telangiectasia, which can masquerade as benign chronic wounds but may represent dermatofibrosarcoma protuberans or other malignant processes 3

Critical pitfall: Standard wound care teams often miss early malignant transformation in chronic wounds. Dermatologists possess specialized training in recognizing atypical wound presentations and performing appropriate diagnostic biopsies (deep punch or incisional) to rule out malignancy. 1, 3

Wound Nursing Management Scope

Wound nursing should manage:

• Standard acute surgical wounds requiring dressing changes, infection monitoring, and healing assessment 1, 2, 4
• Chronic wounds with identified etiology (venous stasis, diabetic neuropathy, arterial insufficiency, pressure injuries) following evidence-based protocols 2, 4, 5
• Wounds requiring daily to weekly monitoring for signs of infection (increased exudate, odor, pain, erythema, warmth, purulent drainage) 2, 4
• Implementation of core wound care principles: pressure offloading, conservative debridement, moisture-retentive dressings, edema control, and infection management 2, 4

Nurse-led multidisciplinary coordination is essential because wound management requires interprofessional collaboration while nurses serve as primary advocates for holistic patient-centered skin care. 1, 2

Specialized Dermatology Scenarios

Dermatology expertise is required for:

• High-risk patient populations: Patients with epidermolysis bullosa require dermatologist-led skin examinations every 3-6 months starting at age 10 years (for severe subtypes) due to extremely high squamous cell carcinoma risk 1
• Stevens-Johnson syndrome/toxic epidermal necrolysis: Requires dermatology-coordinated multidisciplinary team with specialist nurses familiar with skin fragility disorders, as careful handling to minimize shearing forces is critical 1
• Wounds requiring biopsy: When deep punch or incisional biopsy is needed to differentiate benign from malignant processes using immunostaining (CD34, factor XIIIa) 3
• Complex diagnostic uncertainty: Wounds with atypical presentations, unusual locations, or failure to respond to standard therapy warrant dermatologic evaluation 1, 3

Nurse-Led Wound Care Protocol

Wound nurses should execute:

1. Comprehensive baseline assessment: Measure wound dimensions, assess depth for bone involvement, document surrounding cellulitis extent, drainage characteristics, and necrotic tissue presence 2

2. Vascular perfusion evaluation: Obtain ankle-brachial index (ABI), toe pressures, and transcutaneous oxygen pressure (TcPO₂) measurements, as inadequate blood supply must be identified before definitive treatment 2

3. Conservative debridement: Remove hyperkeratosis, necrotic tissue, and slough using tissue-preserving techniques—never perform aggressive debridement as this exposes bone/tendon and leads to chronic osteomyelitis or amputation 1, 2

4. Infection management: Obtain culture specimens from debrided wound base via curettage or tissue biopsy (not swabs), and initiate prompt antibiotic therapy only when clinical infection signs are present 2, 3, 4

5. Evidence-based dressing selection: Cleanse with sterile normal saline only (avoid iodine/antibiotic solutions), apply moisture-retentive dressings that absorb exudate while maintaining moist environment 2, 4

6. Systematic follow-up: Monitor hospitalized patients daily and outpatients every 2-5 days initially, re-evaluating at 2 weeks to assess for ≥50% wound area reduction 2, 4

Multidisciplinary Coordination Algorithm

When wound nursing identifies concerning features:

• At 2-week reassessment: If wound shows <50% area reduction despite optimal standard care, escalate to multidisciplinary team discussion for consideration of advanced therapies or specialist consultation 2
• Severe infection indicators: Hospitalize patients with systemic toxicity, metabolic instability, rapidly progressive infection, substantial necrosis, or critical ischemia—arrange urgent vascular surgery consultation if ABI <0.5 or ankle pressure <50 mmHg 2
• Suspected malignancy: Immediate dermatology referral for biopsy and multidisciplinary tumor board discussion with dermatologist, plastic surgeon, histopathologist, and oncologist 1, 3

The fundamental distinction: Wound nurses provide evidence-based care for wounds with clear etiology and expected healing trajectories, while dermatologists diagnose and manage wounds with atypical features, malignancy risk, or specialized dermatologic conditions requiring expert recognition and biopsy interpretation. 1, 2, 3