By Gianna Melillo
When Jeffrey Levine, MD, asked attendees at his talk at Internal Medicine Meeting 2025 how many had had a lecture on wound care during medical school, only a few raised their hands. He pointed out the illogic of that.
“Imagine a disease that causes disfigurement, amputations, infections, sepsis, death, quality deficits for hospitals and nursing homes, lawsuits, has tens of millions of dollars in costs, and is not taught in medical school, and you'll enter the dysfunctional world of wound care,” he said, after tallying up the small group.
Dr. Levine, a clinical professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York, provided knowledge about some common chronic wounds during his Friday morning session, “Wound Care for the Ambulatory Internal Medicine Physician.”
He also reminded the audience that “the skin is the largest organ of the body. It weighs six to eight pounds, covers 20 square feet, and receives one-third of the body's blood volume.” Like any other organ, it evolves over the lifespan, becoming more thin and frail and losing hydration as it ages.
Chronic wounds, such as pressure injuries, arterial ulcers, diabetic ulcers, and surgical wounds, occur across the health care continuum, he explained, and can cause “pain, impaired function, missed work, quality-of-life issues, limb loss,” along with high health care costs and medicolegal liability.
The first step when encountering a wound is to get the patient’s baseline labs, place the wound on the problem list indicating its etiology, and, if it’s a pressure wound, stage or describe it, Dr. Levine said. That description should include the wound's length, width, and finally depth, in centimeters, along with mention of any slough, necrosis, or drainage.
That sounds simple, but a lot of complications arise in the field. One is “there is no wound care specialty board certification sanctioned by the [Accreditation Council for Graduate Medical Education], and this has resulted in a diversity of wound treatments because we have limited evidence [and] diverging opinions among disciplines, resulting in huge variation in care across settings, across disciplines, and among providers,” he said.
Limited medical education on the topic has led to the wound care industry having an outsize influence both in education and treatment choices, according to Dr. Levine. Most wound treatments are also classified as medical devices by the FDA, meaning manufacturers are not required to produce efficacy data, he explained.
For example, the unavoidability of some wounds and how to express that situation is a source of debate currently. Dr. Levine uses the term “skin failure” for the pressure injuries that are “increasingly recognized as an unavoidable consequence of underlying illness and involutional processes, including aging, sarcopenia, and the dying process.”
Doctors may think of skin pressure ulcers as primarily a nursing concern, but Dr. Levine stressed that internal medicine physicians need to know the ins and outs of them.
For example, skin color can affect the accuracy of wound assessment. “Stage one pressure injuries and deep tissue injuries can be difficult to detect in patients with dark skin,” he cautioned. When examining patients with dark skin, be sure there is adequate lighting and any visual exam is supplemented with palpitation.
Any warmth or induration reflects inflammation and subcutaneous damage, he noted. He added that clinicians should always suspect infection in pressure injuries, including yeast cellulitis and osteomyelitis, and cautioned that ruling out infection can be challenging in chronic wounds, as “there's no common consensus on what constitutes an infection.”
Wounds should be cleaned with saline and gauze, and physicians can use local antimicrobials such as Dakin's solution, betadine, silver products, cadexomer iodine, or silver sulfadiazine. Although negative pressure therapy works well in select wounds to remove excess drainage and improve blood flow, Dr. Levine called it “an often overused modality.”
For wounds that may require surgical procedures like grafting, he recommends getting a surgical opinion on the chart early. Other specialists may need to be involved, too. “Always consider that a chronic nonhealing wound may be a manifestation of malignancy,” he told attendees.
Physicians should also keep nutrition top of mind and document any weight loss. “The caloric requirements for wound healing [is an] additional 35 kilocalories per kilogram,” he said.
For venous insufficiency ulcers, compression is the standard treatment. But before applying, “we need to assess concomitant arterial insufficiency, because you don't want the patient to come back with a blue toe. … Incorrectly applied compression can do severe damage to your patient,” Dr. Levine said.
A general rule of thumb is that any worsening wound needs prompt evaluation, including blood work, and odor management. Keep in mind that in older patients and those who have diabetes or are immunocompromised, classic signs and symptoms of infection may be absent.
Speaking of diabetes, “always have a high level of suspicion for deep infection in a diabetic foot, such as osteomyelitis, abscess, and necrotizing fasciitis,” he advised.
Diabetic ulcers can become palliative wounds. In these cases, Dr. Levine recommends working with a surgical subspecialist and counseling patients carefully regarding aggressive measures.
“Once you decide that the wound is palliative, you want to do symptom-oriented care, treating pain and physical discomfort, minimizing drainage, addressing odor, addressing these psychiatric- psychosocial things, depression, social isolation, immobility,” he said. “There comes a time where you just have to realize that another endovascular procedure, another limb salvage procedure, is not going to be a benefit to anybody.” ■