Summary: Published March 10, 2026 in Healio Dermatology‘s video interview series Beneath the Surface, Part 1 of a two-part edition on chronic wound management features Joel M. Gelfand, MD, MSCE, FAAD (James J. Leyden Professor of Clinical Investigation at the University of Pennsylvania’s Perelman School of Medicine and Healio Dermatology Chief Medical Editor) in conversation with Robert S. Kirsner, MD, PhD (Chairman and Professor, Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine; Director, University of Miami Hospital and Clinics Wound Center; past Vice President of the American Academy of Dermatology). Kirsner frames the interview around a central principle for approaching chronic wound diagnosis: think like a real estate agent — where a wound is located and what surrounds it tells the clinician what to look for first. For lower extremity wounds, he identifies arterial evaluation as by far the most critical diagnostic step, recommending ankle-brachial index (ABI) testing: triphasic, high-amplitude pulse volume recordings indicate normal perfusion; biphasic or monophasic results indicate worsening arterial disease; an ABI below 0.9 is an independent risk factor for myocardial infarction and should prompt referral to vascular medicine or medication adjustment. For wounds overlying bony prominences, osteomyelitis assessment is essential — starting with probe-to-bone testing and imaging (X-ray or MRI), with bone biopsy as the definitive gold standard. For atypical wounds — those in unusual locations, with strange morphology, or failing to respond to standard care — biopsy for both histology and tissue culture is the recommended first diagnostic step to rule out malignancy, unusual infection, or inflammatory etiology. Kirsner notes that once common chronic wound types are diagnosed, initial treatment is relatively straightforward: compression therapy is central for venous leg ulcers with adequate arterial supply; offloading via boot or cast is primary for diabetic foot ulcers and pressure injuries; nutritional assessment and optimisation is essential for all wound types. He highlights fat cell injection as a particularly exciting emerging modality — adipose tissue placed around or below chronic wounds has shown faster healing in recent studies, believed to be due to the regenerative, angiogenic, and immunomodulatory potential of adipose-derived stromal cells. Part 2 of the series covers complex inflammatory wound conditions including pyoderma gangrenosum.
Key Highlights:
- Core diagnostic principle: approach wound assessment “like real estate” — location of the wound determines the diagnostic priority and guides initial workup for underlying vascular, bone, or tissue pathology
- ABI testing for lower extremity wounds: triphasic = normal; biphasic/monophasic = worsening arterial disease; ABI <0.9 = independent MI risk factor — warrants vascular medicine referral or pharmacologic intervention
- Osteomyelitis evaluation: probe-to-bone test + X-ray or MRI for wounds overlying bony prominences; bone biopsy is the gold standard for definitive diagnosis in suspected cases
- Atypical wounds: biopsy for histology AND tissue culture recommended when location is unusual, morphology is atypical, or wound fails standard treatment — to rule out malignancy, atypical infection, or inflammatory conditions before escalating therapy
- Initial treatment standards: compression primary for VLUs with adequate arterial supply; offloading (boot or cast) primary for DFUs and pressure injuries; nutritional optimisation essential for all chronic wound types
- Emerging modality: fat (adipose) cell injection around or below chronic wounds — recent studies show accelerated healing, attributed to regenerative and immunomodulatory properties of adipose-derived stromal cells; Kirsner calls fat “a real source of potential to heal wounds”
Keywords: chronic wound diagnosis dermatology, ankle brachial index wound care, venous leg ulcer compression, diabetic foot ulcer offloading, osteomyelitis diabetic foot biopsy, fat injection wound healing
Robert S. Kirsner Joel M. Gelfand