Introduction

Fellow wound care specialists may agree that interdisciplinary clinical teams often seek their expertise when a patient presents with a “chronic-appearing wound with an unknown or indeterminate etiology.” As in any other discipline, a comprehensive wound assessment begins with a thorough exploration of possible underlying etiologies—the main causative factors for wound development.¹ Moreover, chronic, nonhealing wounds may warn clinicians to explore possible unaddressed underlying complex etiologies.¹

As one of the most common classifications of chronic wounds, pressure injuries are often the primary wound type that comes to mind for most clinicians. However, it is vital to note that various causative factors may influence chronic wound development. The currently accepted definition for pressure injury involves localized tissue damage resulting from prolonged pressure or pressure in combination with shear that usually emanates from bony prominences or medical devices.²

Etiologic Categories

Several wound etiologies can be grouped into the following causative factors and resulting wound classification that will, in turn, influence clinical selection for more appropriate care and management:

Moisture. The influence of moisture, such as moisture emanating from excessive perspiration and urinary or fecal incontinence, cannot be underestimated. My previous blog post looked more closely at the effect of moisture and maceration on wound development. The broad spectrum of moisture-associated skin damage skin (MASD) can further be broken down into the following subcategories: incontinence-associated skin damage (IAD), which is usually caused by urinary or fecal incontinence; intertriginous dermatitis (ITD), which occurs from excessive moisture and friction, particularly on skin folds; and MASD on periwound and peristomal skin.³ Clinical management should be geared at eliminating moisture, friction, and incontinence, along with the use of moisture barrier creams and skin sealants.³

Chronic Vascular Insufficiency. Diseases that affect the patency and flow of the vascular and neuropathic system can lead to chronic wound conditions.^1,4 Lower extremity venous disease (LEVD) is associated with venous stasis and venous insufficiency. Lower extremity arterial disease (LEAD) is associated with atherosclerosis of the arterial vessels. Lower extremity neuropathic disease (LEND) is associated with neuropathy that is usually a complication of diabetes. These are several types of vascular insufficiency–related wounds.^1,4 Clinical management should be geared at addressing the underlying cause, which is vascular insufficiency, and it may involve revascularization procedures, compression, and offloading therapy, as well as treatment of systemic disease processes.¹

Autoimmune and Infectious Diseases. The pathology of inflammatory, autoimmune responses, and infective processes can influence chronic wound conditions. Moreover, several autoimmune and infectious diseases have specific wound care characteristics that delineate them from other wound types. Clinical management aims to combat the underlying autoimmune response or underlying infectious disease.¹

Conclusion

Wound care specialists are often tasked with exploring etiologies related to chronic wound conditions. It is therefore essential to have a thorough understanding of patient history and presenting wound characteristics, along with taking a deep dive into the investigation of different causative factors that may influence wound development.¹

References

1. Krapfl LA, Peirce BF. General principles of wound management: goal setting and systemic support. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:93-103.
2. Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. doi:10.1097/WON.0000000000000281
3. Thayer D, Rozenboom BJ, LeBlanc K. Prevention and management of moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), and skin tears. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:323-353.
4. Kelechi TJ, Brunette G, Bonham PA, et al. 2019 guideline for management of wounds in patients with lower-extremity venous disease (LEVD). J Wound Ostomy Continence Nurs. 2020;47(2):97-110. doi:10.1097/WON.0000000000000622

About the Author

Alex M. Aningalan, MSN, RN, CWON, WCC, is a board-certified wound and ostomy nurse clinician and specialist. He has varied experiences in both acute and long-term care. In addition to wound healing, he is passionate about nursing education, nursing mentorship, and nursing scholarship. He loves to share the value of the wound and ostomy care specialty, especially among new-to-practice nurses, while encouraging and promoting it to fellow and emerging clinicians who share his passion for wound and ostomy care. In addition, he values the importance of leadership, evidence-based practice, and interprofessional collaboration among clinicians and patient populations.