Complex Wounds: Common and Uncommon Protection Status
Wound Infection

By the WoundSource Editors

Although complex wounds typically present with clinical challenges in treatment, there are certain types of wounds that clinicians are used to facing: pressure wounds, arterial wounds, venous wounds, diabetic wounds, moisture-related wounds, end-of-life wounds, dehisced or complicated surgical wounds, and wounds of mixed etiology. However, the uncommon complex wounds are the ones often misdiagnosed or misidentified because of a lack of understanding or even ability to have them diagnosed properly. Often the rare or unusual skin lesions or ulcers require advanced diagnostic capabilities, such as the ability to perform a biopsy, tissue culture, radiological study, or other examination. So how do you know that what you're treating is what you think you're treating?

Identifying the Etiology of a Complex Wound

One of the simplest ways to know whether you are treating the wound correctly based on diagnosis is how the wound responds. For example, if you think it is incontinence-associated dermatitis (IAD) and you treat it like IAD and it responds positively to your treatment, it is most likely IAD. If it isn't responding to treatment for IAD and you've tried several treatments recommended for IAD, then it may be more complex, or it may be the wrong diagnosis to begin with.

Another clue that you may not be managing the type of wound that you think you are treating is if the tissue type doesn't fit into the four major categories: slough, eschar, granulation tissue, and epithelial tissue. If it is outside these four major tissue types and you don't recognize the type of tissue, you may very well be looking at a tumor of some kind. It, of course, could be a structure (e.g., ligament, tendon, vein), but most likely if it isn't a structure it IS abnormal tissue and therefore should be treated like a mass or tumor until proven otherwise.

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A third scenario in managing complex wounds is you ARE treating what you think you are treating but it isn't acting as it should. This may be the result of complicating factors. For example, a clinician was treating a female patient who had chronic non-healing wounds. Knowing that approximately 20%–23% of non-healing wounds are refractory to vascular intervention or other treatments, the clinician performed a biopsy of the wound. The biopsy confirmed vasculitis, so the clinician treated the patient for vasculitis for a few months; however, the wounds weren't responding like vasculitis. There was a biopsy proving what the lesions were, but they weren't acting like that type of lesion. The clinician reviewed the patient's chart again. The patient had known systemic lupus erythematosus and hepatitis C, so there were significant autoimmune issues present. Despite these factors, the lesions should have been responding to treatment. After staff interviews at the skilled nursing facility, it was discovered that they have witnessed the patient smoking methamphetamines. This was the complicating factor that was preventing the lesions from responding to therapy.

Diagnostic Testing Options

In this era of modern medicine, more treatments are being developed faster than ever before, adding to the wound care clinician's arsenal to heal wounds and skin lesions as never before. Negative pressure wound therapy, cellular and/or tissue-based products, advanced wound dressings with agents to manage wound bioburden and infection, a myriad of options for wound cleansing and debridement; these are all part of conventional wound care. Additionally, more differential diagnostic studies are being developed than ever before. The era of guesswork is quickly being left behind as more and more tests and tools are developed to provide definitive diagnoses. Studies and diagnostics help clinicians define what precisely the wound is, and how to treat it, along with compounding factors.

There are numerous types of specimen transport media, for example. Each transport medium has a specific use based on what you think you might be treating. Stuart medium, for example, is used to transport specimens that may have gonococci but is generally used to transport throat, vaginal, wound, and skin specimens that may have fastidious organisms growing.1 Amies solution is another transport medium often utilized in wound care diagnostics.1 What's the difference, and how do you know what you need? Simple answer: ask.

Based on what you suspect you are treating, call the laboratory or pathology department that serves the patient you are treating. If it is in a skilled nursing facility, call the pathology department and explain what you think you might be treating (i.e., pemphigoid), and the pathologist should let you know how they want the specimen prepared (i.e., punch biopsy, wedge biopsy, swab) AND what medium it needs transported in, along with whether it needs to be at room temperature or refrigerated.2 Additionally, by speaking to the pathologist, you are essentially adding another expert to the chart; you can document that you spoke to them, what they relayed, the guidance they gave, etc. It shows you are doing what you need to be doing to diagnosis the issue at hand accurately along with determining proper treatment, interventions, and, if possible, a timely cure.


Care of patients with complex wounds begins with accurate identification of the cause of the wound. This requires assessment for possible complicating factors and advanced diagnostic testing in consultation with the pathologist and the laboratory.

1. Rijal N. Transport medium used in microbiology laboratory. Microbeonline. 2015; updated 2019. Accessed July 2, 2019.
2. Stuart RD. Transport medium for specimens in public health bacteriology. Public Health Rep. 1959;74(5):431-438.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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