Hi Karla

Thank you for sharing this case. Other colleagues might have additional thoughts - Samantha Kuplicki MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, CRNFA, Kathy Whiston-Lemm ACNP, CWON-AP, and I exchanged notes and here are some initial thoughts:

To treat the cause and cofactors impeding healing, it's important to identify the etiology(es), by assessing for adequate blood supply to heal the ulcer, assessing for venous and lymphatic status, presence of Infection, pressure, neuropathy, presence of autoimmune conditions, and malignancy. In order to diagnose an atypical ulcer, exclusion of typical etiologies (i.e. venous insufficiency, arterial insufficiency, neuropathy and pressure) would be the first step. Of note, patients may also present with concurrent mixed etiologies. If the wound does not fit within typical presentations, an atypical cause of wound should be suspected. Some thoughts, in a checklist format:

- Regarding blood supply: patients with hypertension and dyslipidemia have higher risk for development of PVD (PAD). How was her medical history of PVD diagnosed? As for the arterial doppler, was it performed on both legs, assessing DP and PT arteries? In the presence of suspected PAD, clinical signs of PAD (or non-triphasic doppler waveforms), clinical guidelines recommend further investigation with noninvasive arterial testing (e.g. ABI, TBI/TP) to confirm diagnosis of PAD.
- Regarding assessment of venous status: the diagnosis of VLU is predominantly clinical (e.g. "edema, copious drainage", presence of that looks like hemosiderin staining on the pictures). However, as per clinical guidelines, peripheral arterial disease (PAD) needs to be ruled out and venous disease should be documented with duplex ultrasound.
- Assessment of infection: Is the Pseudomonas infection under control? Any other type of infection? Source? Have wound cultures been obtained?
- Assessment of other atypical etiologies: Improvement with prednisone might indicate an underlying autoimmune condition. For all wounds that have been initially diagnosed as a "typical ulcer" but have not shown signs of healing within 4 to 12 weeks of adequate treatment, at least one biopsy should be obtained. For specific guidance on biopsy for suspected cancerous, autoimmune, vasculitic, inflammatory or infectious lesions see section 'Selection of the Biopsy Site, Technique and Transport Medium' and algorithm 'How to select skin biopsy technique, site and transport media' in topic "How to Perform a Wound Biopsy".

As for pain, Kathy mentioned that in her experience, patients reported less pain during dressing changes with gel with surfactant micelles (e.g. PluroGel). It acts to hydrate the wound, control exudate and provide gentle debridement.

Hope this helps!

https://woundreference.com/files/13445.pdf
https://woundreference.com/app/topic?id=venous-ulcers-treatment%20and%20prevention#treat-the-cause-and-co-factors-impeding-healing-
https://woundreference.com/app/topic?id=arterial_ulcers_intro_assessment#diagnosis
https://woundreference.com/app/topic?id=atypical-ulcers#-assessment
https://woundreference.com/app/topic?id=how-to-collect-a-wound-biopsy#-selection-of-the-biopsy-site,-technique-and-transport-medium

Thank you for the response. The BLE duplex was negative, but just baffles me. The multiple cultures in the past have indicated pseudo, last was staph/strep, however, did not respond to topical gentamicin or doxy. We are retesting as there has not been much improvement. I am asking she f/u with ID as she has high resistances.
The PVD dx was from PCP. It does seem to have a mixed etiology. The other option I wanted to try was actually the pluroGel, but I have waited since EVERYTHING causes her pain and burning. Currently, I really don't have anything to put on her that would decrease the bacterial burden. I have been extending the use of the gentamicin as I really don't have other options. I am going to try the pluroGel. She is also refusing to go to a cardiac interventionalist. She was getting lymphedema therapy but P/T have signed off, without even getting pumps, so that is another battle I am working on. She has also refused a biopsy... Thanks for the feedback!!