Most wounds, of whatever aetiology, heal without difficulty. Some wounds, however, are subject to factors that impede healing, although these do not prevent healing if the wounds are managed appropriately. A minority of wounds will become chronic and nonhealing. In these cases the ultimate goal is to control the symptoms and prevent complications, rather than healing the wound. Causes of ulceration x Vascular (venous, arterial, lymphatic, vasculitis) x Neuropathic (for example, diabetes, spina bifida, leprosy) x Metabolic (for example, diabetes, gout)
x Connective tissue disease (for example, rheumatoid arthritis, scleroderma, systemic lupus erythematosus) x Pyoderma gangrenosum (often reflection of systemic disorder) x Haematological disease (red blood cell disorders (for example, sickle cell disease); white blood cell disorders (for example, leukaemia); platelet disorders (for example, thrombocytosis)) x Dysproteinaemias (for example, cryoglobulinaemia, amyloidosis) x Immunodeficiency (for example, HIV, immunosuppressive therapy)
x Neoplastic (for example, basal cell carcinoma, squamous cell carcinoma, metastatic disease)
x Infectious (bacterial, fungal, viral) x Panniculitis (for example, necrobiosis lipoidica)
x Traumatic (for example, pressure ulcer, radiation damage) x Iatrogenic (for example, drugs)
x Factitious (self harm, “dermatitis artefacta”) x Others (for example, sarcoidosis) It is important that the normal processes of developing a diagnostic hypothesis are followed before trying to treat the wound. A detailed clinical history should include information on the duration of ulcer, previous ulceration, history of trauma, family history of ulceration, ulcer characteristics (site, pain, odour, and exudate or discharge), limb temperature, underlying medical conditions (for example, diabetes mellitus, peripheral vascular disease, ischaemic heart disease, cerebrovascular accident, neuropathy, connective tissue diseases (such as rheumatoid arthritis), varicose veins, deep venous thrombosis), previous venous or arterial surgery, smoking, medications, and allergies to drugs and dressings. Appropriate investigations should be carried out.