ABSTRACT
Underrepresentation of diverse skin tones in medical education and providers' implicit racial bias drives inequities in wound care, such as disproportionally poor outcomes for Black patients. Diagnostic indicators (e.g., erythema) can present differently depending on skin pigmentation. This post hoc analysis of 350 chronic wounds from a prospective 14-site clinical trial aimed to determine how the perception of clinical signs and symptoms of infection (CSS) differs by patient skin tone and if fluorescence-imaging can offer a more objective diagnostic solution. Participants were grouped by skin tone (low, medium, high) as measured by the Fitzpatrick Skin Phototype Classification (FSPC) scale. CSS and total bacterial load (TBL) were compared across FSPC groups, along with sensitivity to detect TBL >104 CFU/g using CSS alone and combined with fluorescence-imaging. Erythema was reported less often with increasing FSPC score (p = 0.05), from 13.4% (low), to 7.2% (medium), to 2.3% (high), despite comparable bacterial loads (median = 1.8 × 106 CFU/g). CSS sensitivity in the high group (2.9%) was 4.8-fold to 8.4-fold lower than the low (p = 0.003) and medium groups (p = 0.04). Fluorescence-imaging significantly improved the detection of high bacterial load in each group, peaking in the high group at 12-fold over CSS alone. These findings underscore the threat of pervasive racialized health inequities in wound care, where missed diagnosis of pathogenic bacteria and infection could delay treatment, increasing the risk of complications and poor outcomes. Fluorescence-imaging is poised to fill this gap, at least in part, serving as a more objective and equitable indicator of wound bacteria. Clinicaltrials.gov #NCT03540004 registered 16-05-2018.
Subject(s)
Skin Pigmentation , Wound Infection , Humans , Prospective Studies , Wound Infection/diagnosis , Wound Infection/microbiology , Erythema , BacteriaABSTRACT
The purpose of this case study is to describe the surgical treatment of idiopathic ulcerative cutaneous calcinosis or calcinosis cutis of the lower extremity. A 77-year-old Latin American female who reported no significant past medical history presented to our hospital's emergency department from her home complaining of worsening right lower extremity erythema, edema, increased temperature, and pain. It was noted that the patient presented with multiple cutaneous calcified nodules to bilateral lower extremities, which she stated has been present for approximately 40 years. At the time of evaluation, 1 of the nodules on the lateral aspect of the right lower extremity ulcerated and became infected with unknown etiology, which lead to cellulitis of this limb. Radiographic imaging studies of the bilateral lower extremities showed extensive sheetlike soft tissue calcification overlying the middle to distal lower extremities. Serology reports showed the patient was positive for rheumatoid factor, antinuclear antibodies, SS-A/Ro antibody, and SS-B/La antibody. Because of the evidence of frank purulence and cellulitic changes to the infected nodule, the patient was taken to surgery the following day for sharp debridement and biopsy of the site. Postoperatively, there were minimal signs of improved healing to the wound base, although there was evidence of decreased erythema and edema to the extremity after the initial debridement and biopsy. Four days after the initial surgical invention, the patient was taken for a second operative procedure, which included a wide excisional biopsy with application of acellular dermal matrix and negative-pressure therapy. It was during this secondary debridement that further calcified deposits were encountered and specimens were submitted to pathology. Pathologic examination diagnosed the submitted specimen as cutaneous calcinosis. At this time, the patient is currently undergoing local wound care of the soft tissue deficient to her right lower extremity with the assistance of negative-pressure wound therapy with biweekly clinical follow-up.
