Wound management commonly falls within the dermatology scope of practice, particularly for wounds that are chronic in nature. A broad range of differentials need to be considered, tailored to individual patient factors. An important differential is malignancy, which can present as a wound, or may develop within a longstanding wound. However, there are less common conditions that need to be considered when a patient presents with a persistent wound.
A 48-year-old female was referred to dermatology for a slow healing surgical wound. She had been diagnosed with non-small cell lung cancer with brain metastases to the left frontal lobe. She underwent a craniotomy, which was complicated by infection, and subsequently underwent debridement and replacement of the wound plate after the initial surgery.
Six months after debridement, the patient presented to her GP with persistent wounds over the craniotomy scar, with occasional purulent discharge. Bacterial cultures were negative, and she was nonresponsive to topical mupirocin. Eight months after surgery, she was referred to dermatology, who noted two crusted and indented lesions on her left forehead. Culture continued to be negative, and so she was instructed to wash with soap and water, gently remove crust in the shower, and apply petroleum jelly three times daily.
She was reviewed by dermatology again two months later, with ongoing cystic lesions with purulent discharge positive for staphylococcus aureus above the metal plate, connected under a bridge of normal skin. Dermatology was suspicious of intracranial extension, and urgent neurosurgery review was requested. X-ray and MRIs were consistent with a diagnosis of osteomyelitis. Fourteen months after initial craniotomy, the patient underwent debridement, and the chronically infected bone plate was removed. This interesting case will highlight the importance of considering broad differentials, particularly in high-risk patient populations, and the approach to diagnosis and management of chronic wounds.