A 62-year-old male presents to the emergency room with lethargy and fever. He is noted to have a leukocytosis of 21,000/mm3, lactic acid elevation, low-grade tachycardia, and fever but otherwise normal vital signs. He is determined to have clinical evidence of sepsis. The workup of the source of sepsis is negative aside from an open skin ulcer on the medial side of his left lower leg. He reports that the area has been open for two months now and started as an abrasion from a new cowboy boot, which he had worn to a hoe-down without high socks. Upon further questioning, the patient’s wife admits the wound has been weeping more fluid lately.

On examination, the wound is foul-smelling, surrounded by erythema, and is hot to the touch. It has a thick, foul-smelling, purulent discharge, and the wound is without fluctuance. Also, notice that the hair is missing from most of his lower legs bilaterally. The patient’s wife reports his hair has been scant on his legs for a few years.

Wound care support: Even though you can provide exceptional wound care yourself, consult the wound care team if available is warranted as they can help with many aspects of management. However, it’s dangerous and can cause a delay in care to rely on the wound care team to manage 100%. If they’re not available immediately, the patient can go without proper management until seen.

Sepsis treatment: This patient warrants the full sepsis treatment protocol, including IV fluids and antibiotics to treat his sepsis that will target specifically skin infections.

Monitor treatment progress: The edges of the erythema should be demarcated with a marker to gauge progress with the treatment. His lactic acid should also be monitored.

Assess vascular status: Given his chronic non-healing wound, especially with hair patterns indicating peripheral vascular disease, vascular studies are warranted to assess blood flow. On exam, you astutely assess pulses but are unable to palpate dorsalis pedis or posterior tibial pulses. However, you note palpable pulses in the popliteal arteries bilaterally. Ankle-brachial indices are a reasonable next step. Depending on the results and resources available, he may require further imaging and/or referral to vascular surgery for evaluation of stent placement or other treatment, which will in turn promote wound healing.

Consider deep extension of wound: Consider if there is further extension of the wound beyond the soft tissue. Is there any concern of osteomyelitis or abscess? If so, further imaging is warranted.

Debridement: The wound warrants debridement of the nonviable tissue to promote proper new tissue growth. If a wound care team is available, they can provide this service. Otherwise, general surgery often can help.

Wound dressings: Finally, be aware of what type of dressing is available and, most importantly, what your patient needs. As a general rule of thumb, if the patient’s wound is clearly very wet, the dressings you choose should be very absorbent and frequently changed to keep the wound clean. It may need to be changed to BID or daily until the drainage starts improving. You can gauge if your dressings and frequency of changes are adequate by ensuring the wound drainage isn’t soaking through the dressings before the next change.

Wound culture: Wound culture should be used with caution as it is often very difficult to obtain an accurate culture. Culturing the fluid from superficial wounds like this will often yield skin flora or contaminants. If obtaining a wound culture, the wound needs to be cleaned first, with only freshly expressed fluid obtained in a sterile fashion sent for culture.

Edema: Control edema around the site of wounds, as this will improve wound healing, including with diuretics and elevation of the leg. Compression stockings should be used once an infection and acute sepsis have improved.

Pressure: Always see how you can help offload pressure from the site, including removing any materials that may cause further irritation of the skin. If the wound is in an area where pressure is difficult to manage such as the sacrum or heel, there are creative ways to position the patient so that this area is not given additional pressure such as turning the patient, propping the patient at an angle with pillows and foam wedges, and elevating the legs.

Diet and other considerations: Optimize nutrition and metabolic factors; glycemic control is paramount for wound healing. Check for and treat protein-calorie malnutrition, as increasing protein intake will improve wound healing.