The study was led by Hyung-Ju Na, a wound, ostomy, and continence nurse at Seoul Metropolitan Dongbu Hospital, together with Sung-Hee Yoo of the College of Nursing at Chonnam National University. Rather than simply cataloging gaps in practice, the researchers anchored their investigation in the Information–Motivation–Behavioral Skills model, or IMB model, a framework originally developed to explain health behavior change and later adapted to clinical performance. The model proposes that behavior is driven by three interacting ingredients: accurate information, motivation to act, and the behavioral skills needed to translate intention into action. In this study, those ingredients were mapped onto pressure injury care knowledge, attitudes and institutional support, and self-efficacy, respectively.

Pressure injuries develop when sustained pressure, often combined with shear and moisture, compromises blood flow to the skin and underlying tissue, particularly over bony prominences such as the sacrum, heels, and hips. In frail, elderly residents who may be immobile, incontinent, or malnourished, the risk escalates dramatically. Once a deep injury forms, it can take months to heal, exposes the patient to infection and pain, and signals a breakdown in preventive care. That is why pressure injury management is widely treated as a critical indicator of nursing quality in long-term care facilities, and why understanding its determinants carries weight well beyond the ward.

To probe those determinants, the team conducted a descriptive, cross-sectional survey of 200 nurses working at five long-term care facilities in Seoul. Data were collected between June 1 and December 1, 2020, using a self-administered questionnaire that measured four domains: knowledge of pressure injury care, attitudes and perceived institutional support, self-efficacy, and actual performance of evidence-based pressure injury care. The researchers then used hierarchical stepwise regression, a statistical technique that adds predictor variables in stages to see how much additional explanatory power each contributes, while first accounting for the nurses’ general characteristics such as age, experience, and education level.

The headline finding was sobering but instructive. The mean item score for evidence-based pressure injury care performance was 3.89 out of 5, with a standard deviation of 0.61. In other words, nurses in these facilities were performing reasonably well but not at the near-perfect level that evidence-based prevention ideally demands. The regression analysis then identified four significant factors, ranked by the strength of their influence. Knowledge of pressure injury care came first, with a standardized beta coefficient of 0.38 and a p-value below 0.001. Self-efficacy followed at 0.23 (p = 0.001), then the provision of annual pressure injury care education at 0.22 (p = 0.003), and finally education level at 0.17 (p = 0.003). Together, these variables explained 38.3 percent of the total variance in performance, a substantial share for a complex clinical behavior measured in a real-world setting.

The prominence of knowledge is perhaps the most striking result. In the IMB framework, information is the foundation upon which motivation and skills build, and the data here bear that out: nurses who scored higher on pressure injury knowledge were markedly more likely to perform evidence-based care. This matters because clinical knowledge is not static. Pressure injury prevention guidelines evolve, covering topics such as risk assessment tools, repositioning schedules, support surfaces, skin moisture management, and nutrition. Nurses whose training predates current recommendations may be applying outdated techniques without realizing it, which makes periodic knowledge updating a genuine safety issue rather than an administrative box-tick.

Yet knowledge alone did not carry the story. Self-efficacy, the confidence a nurse has in her own ability to execute the required behaviors, emerged as the second strongest predictor. This aligns with a large body of behavioral science showing that people who believe they can perform an action are more likely to persist at it, especially when the action is effortful or the environment is challenging. Preventing pressure injuries in a busy long-term care ward is exactly that kind of effortful behavior: it requires vigilance, coordination with aides, advocacy for equipment, and repeated reassessment. A nurse who knows what to do but doubts her capacity to do it amid competing demands may quietly let best practice slip.

The third significant factor, the provision of annual pressure injury care education, shifts the lens from the individual to the organization. This is a notable finding because it demonstrates that institutional support contributes to performance independently of nurses’ personal educational backgrounds. A facility that commits to yearly training is, in effect, doing two things at once: refreshing the knowledge base of its staff and signaling that pressure injury prevention is a priority worth the organization’s time and resources. The authors conclude that enhancing care quality requires systematic, multi-level interventions that focus on updating clinical knowledge and bolstering nurses’ self-efficacy through sustained organizational commitment, not one-off lectures or posters in the break room.

Even the weakest predictor in the model, education level, carries practical implications. Its significance suggests that nurses with higher formal qualifications tend to perform better evidence-based care, but the fact that it ranked last—behind knowledge, self-efficacy, and annual training—implies that targeted continuing education can compensate for differences in academic credentials. For long-term care facilities, which often struggle to recruit highly credentialed nurses, this is an encouraging message: investment in structured, recurring in-service education may narrow the gap that degrees alone cannot.

The study does have boundaries worth noting. It was cross-sectional, capturing a single moment in time, so it can identify associations but cannot prove that boosting knowledge or self-efficacy causes better performance. The sample comprised 200 nurses from five facilities in a single city, and data were self-reported, which introduces the possibility of response bias. The researchers also note that the work received no specific grant from any funding agency, and the study was approved by the Institutional Review Board of Chonnam National University with written informed consent from all participants, conducted in accordance with the Declaration of Helsinki. Still, by grounding the analysis in a tested behavioral model and quantifying the relative weight of each factor, the study offers long-term care administrators a concrete roadmap: audit and refresh staff knowledge, build confidence through skills-based training and supportive supervision, and institutionalize annual pressure injury education. In a field where a single deep wound can mean months of suffering for a vulnerable resident, those levers may prove among the most cost-effective tools available.

Subject of Research: Determinants of evidence-based pressure injury care performance among nurses in long-term care facilities using the Information–Motivation–Behavioral Skills model

Article Title: Factors associated with evidence-based pressure injury care among nurses in long-term care facilities: an information–motivation–behavioral skills model-based study

Article References: Na, H.-J., & Yoo, S.-H. (2026). Factors associated with evidence-based pressure injury care among nurses in long-term care facilities: an information–motivation–behavioral skills model-based study. BMC Nursing. https://doi.org/10.1186/s12912-026-05472-4

Image Credits: AI Generated

DOI: 10.1186/s12912-026-05472-4

Keywords: pressure injury, bedsores, long-term care facilities, nursing, evidence-based practice, IMB model, self-efficacy, nurse education, cross-sectional study, South Korea, wound care, nursing quality

The so-called beta blocker era began in 2008, when the cardiac drug propranolol was serendipitously found to shrink problematic hemangiomas, a discovery that transformed pediatric dermatology and vascular anomaly care almost overnight. Before propranolol became standard therapy, ulceration was reported in approximately fifteen to thirty percent of infants with hemangiomas. Widespread beta blocker use has driven that figure down to around eleven percent, and a recent retrospective cohort study found that only about five percent of propranolol-treated patients developed a new ulcer after starting treatment. These are genuine gains, but the review’s authors are emphatic that the complication has not been eliminated. Ulcers still develop before therapy begins, and, perhaps counterintuitively, some emerge or even worsen after propranolol has been started, a paradox that the researchers trace back to the underlying biology of the tumors themselves.

Understanding who is at risk has become considerably more precise. Ulceration shows a strong predilection for specific lesion types and anatomical locations. Rapidly proliferating, large, superficial, mixed, and segmental lesions are the most vulnerable, particularly when they involve the lips, neck, diaper area, perineum, anogenital region, or skin folds, where friction, moisture, and mechanical stress relentlessly assault a fragile epidermal barrier. The numbers from referral cohorts are striking. In a multicenter study of 435 anogenital hemangiomas, more than half, 53.3 percent, developed ulceration, rising to 71.7 percent among segmental or partially segmental lesions. Among 69 lip hemangiomas, 53.6 percent ulcerated. Multivariate analyses have quantified these risks further: segmental morphology roughly doubled the odds of ulceration in anogenital lesions, mixed type more than tripled them, and a lower-lip location increased the odds more than eightfold compared with upper-lip disease.

Crucially, the review highlights that risk factors for ulceration after propranolol initiation may not mirror those before treatment. In a cohort of propranolol-treated infants, mixed, indeterminate, and segmental hemangiomas were independent risk factors for new ulcers, with segmental lesions carrying an odds ratio exceeding twenty-two, while trunk and extremity locations appeared protective. This distinction matters clinically, because it means that even after systemic beta blocker therapy has begun, physicians cannot assume that a lesion’s morphology has stopped mattering. Girls account for roughly three quarters of ulcerated cases, consistent with the overall female predominance of hemangiomas, though the evidence does not support sex as an independent risk factor once other variables are accounted for. Prematurity, black ethnicity, and lower socioeconomic status have also been linked to ulceration, though the latter associations may partly reflect delayed diagnosis and unequal access to specialist care rather than biology alone.

The pathogenesis of ulceration, the review argues, is best understood not as a simple surface wound but as a dynamic, multifactorial process rooted in tumor biology. During the rapid proliferative phase, the metabolic demands of tumor cells, endothelial cells, and stromal cells surge, yet the newly formed vessels feeding the lesion are structurally immature and often fail to deliver adequate oxygen. This supply-demand mismatch leaves the superficial tissues relatively hypoxic, priming them for necrosis and epidermal breakdown. One of the most clinically valuable insights concerns early white discoloration of the lesion, which histological studies have linked to upper dermal fibrosis and matrix remodeling. This pallor is now recognized as an important warning sign of impending ulceration, giving clinicians a window to intervene before the skin actually breaks down.

The review also delivers a sobering technical caveat about imaging. Conventional Doppler ultrasound, the workhorse for characterizing hemangiomas and monitoring treatment response, measures macroscopic blood flow rather than capillary perfusion or oxygen diffusion at the epidermal-dermal interface. Preserved intralesional flow on Doppler therefore does not exclude focal superficial ischemia, meaning that no Doppler parameter has been validated to predict ulceration. Ultrasound should complement, not replace, clinical risk assessment based on lesion morphology, location, growth pattern, and early whitening. In the diaper area, the authors describe a double-hit mechanism: intrinsic proliferative hypoxia weakens the barrier, while moisture, maceration, pH changes, enzymatic irritation, and microbial colonization continuously erode the stratum corneum, pushing the lesion from early ischemic whitening toward overt ulceration.

Once an ulcer has formed, molecular mechanisms may conspire to keep it open. Relative tissue hypoxia stabilizes hypoxia-inducible factor-1 alpha, drives vascular endothelial growth factor signaling that produces functionally immature vessels, and increases matrix metalloproteinase activity. The resulting degradation of the extracellular matrix and basement membrane amplifies barrier failure, promoting ulcer persistence, delayed healing, and scarring. The authors caution that direct evidence for this protease-inhibitor imbalance in hemangioma ulcers specifically remains limited, borrowing plausibility from the chronic wound literature, but the framework offers a coherent explanation for why some ulcers heal slowly, become infected, and leave prominent scars. Timing is also characteristic: approximately eighty to ninety-five percent of ulcers develop during the proliferative phase, most often between two and four months of age, with more than half occurring within the first four months of life.

On the treatment side, the review’s central message is that no single modality suffices. Oral propranolol remains the mainstay of systemic therapy, controlling tumor proliferation, relieving pain, and promoting wound healing, with reported median healing times of roughly six to seven weeks in multicenter cohorts. Yet the optimal dose remains unresolved. One analysis found that doses of one milligram per kilogram per day or less were associated with shorter healing times, while a prospective study using two milligrams per kilogram per day reported complete healing in a mean of 5.5 weeks. Because dose selection is confounded by age, ulcer severity, and clinician preference, the authors suggest that a cautious initial dose with individualized titration may be reasonable, while stressing that the question demands proper randomized trials. A small number of children experience worsening ulcers after propranolol initiation or escalation, particularly when tissue ischemia or barrier damage predates treatment, so dynamic reassessment during therapy is essential.

Around this systemic backbone, the review maps the supporting cast. Wound care, gentle cleansing, nonadherent dressings, barrier creams, hydrocolloids, and antimicrobial dressings, forms the cornerstone of management, though no single method has proven superior, and caregivers need clear written instructions and warning signs that warrant medical review. Pain should be assessed at every visit with age-appropriate behavioral scales, with acetaminophen preferred for systemic analgesia and topical lidocaine used sparingly under supervision. Topical timolol offers a local option for small, superficial, focal ulcers, with reported healing times ranging from about nineteen days in randomized study conditions to five weeks in broader cohorts. Pulsed dye laser therapy, which targets superficial vascular components, can accelerate healing of painful or bleeding superficial ulcers, with one randomized trial reporting a mean healing time of 19.22 days, but it is not effective for all lesions and should not be considered routine first-line therapy. For moderate to severe or complex ulcers, multimodal combinations are often necessary, though claims of synergy between propranolol and laser therapy rest on small, uncontrolled series.

Perhaps the review’s most important contribution is conceptual: ulcerated infantile hemangioma should be judged not by the size of the wound alone but across multiple dimensions, including pain, infection, anatomical function, healing trajectory, caregiver burden, and long-term cosmetic outcome. Even small ulcers under five square centimeters can devastate feeding, sleep, and diaper care when they sit on the lip, perineum, or periocular region. No validated ulceration-specific scoring system yet exists, and the authors call for prospective multicenter studies to standardize severity definitions, refine risk-stratified treatment algorithms, and test emerging therapies such as atenolol, nadolol, dual-wavelength lasers, and topical brimonidine-timolol combinations. Their proposed framework, connecting quantitative risk recognition, dynamic pathogenesis, lesion-directed therapy, wound care, and family-centered outcomes, aims to shift practice from reactive wound management toward earlier, individualized, multidisciplinary care. For the infants and families who bear the burden of this painful complication, that shift cannot come soon enough.

Subject of Research: Ulcerated infantile hemangioma: risk factors, pathogenesis, and management in the beta-blocker era

Article Title: Ulcerated infantile hemangioma in the β-blocker era: recent advances

Article References: Zhang, K.-Z., Guo, R.-M., Qiu, T., Yang, M., & Ji, Y. (2026). Ulcerated infantile hemangioma in the β-blocker era: recent advances. World Journal of Pediatrics. https://doi.org/10.1007/s12519-026-01101-x

Image Credits: AI Generated

DOI: 10.1007/s12519-026-01101-x

Keywords: infantile hemangioma, ulceration, propranolol, beta blockers, pediatric dermatology, wound care, topical timolol, pulsed dye laser, PHACE syndrome, LUMBAR syndrome, risk stratification, tissue hypoxia

The research, led by Doreen Mukona of the University of Massachusetts Dartmouth together with colleagues at Ajman University, the University of Zimbabwe, and the University of Global Health Equity in Kigali, took place at a tertiary health sciences college in the United Arab Emirates. The team designed a concurrent, equal-status mixed-methods study, meaning that quantitative survey data and qualitative free-text responses were collected at the same time and given equal analytical weight. A total of 133 nursing students in academic years two through four participated. The quantitative arm used an adapted 31-item Pressure Injury Prevention Knowledge questionnaire, derived from the internationally recognized Pressure Ulcer Knowledge Assessment Tool, while two open-ended questions invited students to describe the barriers they perceived and the improvements they would suggest.

The headline finding is sobering. On average, students scored 19.9 out of 31 points, equivalent to 64.1 percent, with a standard deviation of 16.6 percent. Only 20.3 percent of participants reached the pre-specified threshold for good knowledge of 80 percent or higher. A further 42.1 percent fell into the moderate band of 60 to 79 percent, while 37.6 percent scored below 60 percent, classed as poor. In other words, nearly four in ten future nurses at this institution had knowledge levels that fell short of what most educators would consider safe for independent clinical practice. The participants, who had a mean age of 21.9 years and were almost entirely Emirati nationals at 99.2 percent, represent the demographic that will staff the country’s expanding hospital network in the coming years.

One of the most technically revealing results concerns how students performed on different types of test items. The questionnaire included both true-keyed items, where the correct answer affirms a correct practice, and false-keyed items, where the correct answer requires students to reject a plausible but wrong statement. Students scored a striking 79.7 percent correct on true-keyed items but only 40.5 percent on false-keyed ones, a difference that was highly statistically significant with a paired t-value of 18.96 and p less than 0.001, corresponding to a very large effect size with Cohen’s d of 1.65. This pattern suggests that students can recognize correct prevention practices when they see them but struggle to identify incorrect ones, a cognitive profile consistent with surface learning rather than the deep conceptual understanding needed to make sound clinical judgments in ambiguous real-world situations.

The researchers also explored whether knowledge grew with experience. Knowledge was weakly but significantly associated with year of study, with Spearman correlation coefficients between 0.23 and 0.25 and p values below 0.01, and with the number of clinical placements completed, at rho equal to 0.22 and p equal to 0.01. However, when the team built an adjusted multivariable linear regression model, no individual predictor remained statistically significant, and the model explained only seven percent of the variance in knowledge scores, with p equal to 0.09. This weak explanatory power is itself informative: it implies that academic seniority alone does not reliably produce pressure injury expertise, and that other factors, such as teaching quality, curriculum emphasis, and individual study habits, likely play larger roles than the researchers could capture with the variables available.

The qualitative arm of the study painted a vivid picture of why knowledge fails to translate into action. Using qualitative content analysis, the researchers identified six categories of barriers. The most frequently cited was a poor training-practice linkage, reported by 54 percent of students, meaning that what they learned in lectures did not match what they encountered or were allowed to do during clinical placements. Lack of time followed closely at 51 percent, reflecting the relentless pace of hospital wards where prevention tasks such as repositioning patients every two hours compete with medications, documentation, and emergencies. Workforce-capacity constraints were cited by 43 percent of respondents, pointing to understaffing that leaves too few hands to turn and reposition immobile patients as often as guidelines demand.

The remaining barriers, though less frequently mentioned, are no less important. Lack of equipment was reported by 26 percent of students, a reminder that even well-trained nurses cannot deliver prevention without pressure-redistributing mattresses, cushions, and adequate dressing supplies. Communication or documentation breakdowns accounted for 13 percent of responses, highlighting how prevention depends on seamless handovers and accurate skin assessments recorded across shifts. Finally, patient-related complexity, cited by 12 percent, acknowledged that some patients present challenges, such as restlessness, obesity, or medical instability, that make standard prevention protocols difficult to follow. Together, these six categories describe a system problem rather than an individual failing: students may know exactly what to do, yet find themselves embedded in clinical environments that do not support doing it.

When asked how nursing education could be improved, the students were remarkably consistent. Regular training was the most popular suggestion at 58.9 percent, followed by simulation-based learning at 35.7 percent and updated guidelines at 22.3 percent. Simulation deserves particular attention from educators and policymakers alike. High-fidelity manikins and scenario-based exercises allow students to practice skin assessments, risk scoring with tools such as the Braden Scale, and repositioning techniques in a safe environment where mistakes carry no human cost. The strong student demand for simulation echoes a broader international movement in nursing education toward experiential learning, and the findings suggest that in the UAE context this shift has not yet gone far enough to close the theory-practice gap that students themselves identified as the leading barrier.

The study’s methodology merits confidence as well as scrutiny. The authors followed the STROBE reporting guidelines for observational studies and the SRQR standards for qualitative research, and they used Kuder-Richardson Formula 20 to assess the internal consistency of the adapted questionnaire. Ethical approval was granted by the Fatima College of Health Sciences Research Ethics Committee, and the study was conducted in accordance with the Declaration of Helsinki, with electronic informed consent and voluntary participation. The authors transparently disclose that the first author held a teaching role at the participating institution, a potential influence on both student disclosures and data interpretation, and they describe coding safeguards used to mitigate this. The study was not prospectively registered and received no external funding, details that readers should weigh when interpreting the results.

What, then, should change? The findings point to a coordinated agenda. Nursing curricula in the UAE and similar settings should place greater emphasis on false-keyed reasoning, teaching students not just what correct prevention looks like but how to spot and correct unsafe practice. Clinical placements need structured, supervised opportunities to perform actual prevention tasks rather than merely observe them. Hospitals and colleges should jointly invest in simulation laboratories, ensure equipment availability, and address the workforce and time constraints that students identified so clearly. Pressure injuries cost health systems enormously in prolonged stays, infections, and litigation, and they inflict real suffering on vulnerable patients. If nearly 80 percent of graduating nurses fall short of good knowledge, and if even knowledgeable students are blocked by systemic barriers, then the solution must span the classroom, the simulation suite, and the ward floor simultaneously. This study provides the regional evidence base to start that conversation.

Subject of Research: Nursing students' knowledge of pressure injury prevention and barriers to applying it in the United Arab Emirates

Article Title: Knowledge of pressure injury prevention and perceived barriers to applying it among nursing students at a tertiary institution in the United Arab Emirates: a mixed-methods study

Article References: Mukona, D., Mukona, R. F., Zvinavashe, M., & Ndaimani, A. (2026). Knowledge of pressure injury prevention and perceived barriers to applying it among nursing students at a tertiary institution in the United Arab Emirates: a mixed-methods study. BMC Medical Education. https://doi.org/10.1186/s12909-026-10537-8

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10537-8

Keywords: pressure injuries, pressure ulcers, nursing education, nursing students, knowledge assessment, mixed methods, theory-practice gap, simulation training, clinical placements, United Arab Emirates, wound care, patient safety

HS is a chronic, immune-mediated inflammatory condition that targets hair follicles in intertriginous areas, most commonly the axillae, groin, perineum, and inframammary regions. Its pathogenesis involves follicular occlusion, rupture, and a cascade of innate immune activation driven in large part by interleukin-17 and interleukin-23 signaling, producing the painful nodules, abscesses, and draining tunnels known as sinus tracts that define moderate-to-severe disease. Because these lesions recurrently open, drain, and heal only to flare again, many patients live with wounds that never fully resolve. The result is a skin disease that behaves, in functional terms, like a chronic wound disorder, demanding dressings, drainage management, infection surveillance, and frequent clinical attention, often for decades of a patient’s life.

That wound-care burden is precisely where the new survey focuses. The authors distributed their questionnaire with assistance from the HS Foundation, capturing the experiences of patients already connected to a specialty clinic, a population that, despite being relatively well served compared with many people living with HS, still reported meaningful friction in obtaining wound care. The study received ethical approval from the University of Connecticut Health Center Institutional Review Board and was conducted in accordance with the Declaration of Helsinki, with informed consent obtained from all participants. The datasets themselves are not publicly available due to patient privacy and institutional review board restrictions, but the published letter frames a set of concerns that align closely with what prior literature has documented about the structural barriers surrounding HS care.

Those barriers are not abstract. A 2023 qualitative study published in JAMA Dermatology by Barnes and colleagues documented patient perspectives of health system obstacles to accessing HS care, describing delays in diagnosis, fragmented referral pathways, and the exhausting effort required to navigate appointments across multiple specialties. A separate 2023 study by Poondru, Scott, and Riley in the International Journal of Women’s Dermatology examined wound care counseling from the dermatologists’ side, revealing that clinicians themselves often feel underprepared to guide patients through the practical realities of managing draining lesions at home. The new survey complements these works by centering the patient’s own perception of whether wound care is actually reachable, affordable, and coordinated, a question that has rarely been asked directly in this population.

The economic backdrop makes the findings more urgent. A 2019 retrospective analysis of US administrative claims data by Marvel and colleagues, published in BMJ Open, quantified the substantial disease burden and cost of HS, showing that patients accumulate high healthcare utilization across dermatology, surgery, and emergency settings. More pointedly, a 2023 single-center study by Towfighi and colleagues at an urban wound-care clinic documented the financial toxicity of HS, describing how the cumulative costs of dressings, clinic visits, and lost productivity weigh on patients who often already face socioeconomic disadvantage. HS disproportionately affects women, people of color, and lower-income populations, meaning that access gaps in wound care compound existing inequities rather than occurring at random.

Against this backdrop, the specialty clinic survey by Klufas, Ajmani, Strelzer, Zhou, and Sarfo serves as a targeted probe of a specific failure point. Wound care for HS is technically demanding: lesions may require absorbent dressings capable of handling continuous drainage, antimicrobial agents when secondary infection is suspected, and careful technique to avoid tissue trauma during dressing changes. Patients frequently perform these tasks themselves, without formal training, and the recent best-practice consensus published in the Journal of Wound Care by Swoboda and colleagues in 2025 represents the first comprehensive attempt to codify how HS lesions should be managed. Yet a guideline is only as effective as the access structures that deliver it, and the survey’s premise is that patients’ perceptions of access, whether they can get appointments, afford supplies, and find clinicians who understand HS-specific wound needs, are a measurable indicator of whether best practice ever reaches the bedside.

The study’s design reflects both the promise and the limits of survey-based research in rare and stigmatized diseases. By recruiting through a specialty clinic and partnering with a patient-focused foundation, the investigators reached individuals with confirmed diagnoses and lived experience of the care pathway, but the same recruitment strategy means the sample may underrepresent patients who have given up on the health system entirely, those without any dermatology connection, and those facing the most severe access barriers. The authors are transparent about these constraints, and the research letter format signals that the work is intended as an exploratory signal rather than a definitive prevalence estimate. Even so, perception data of this kind is valuable precisely because patient-reported access is a strong predictor of adherence, follow-up, and ultimately clinical outcomes in chronic disease management.

What emerges from the collective evidence is a picture of a disease whose wound-care needs fall into a gap between medical specialties. Dermatology clinics are expert in the systemic and biologic management of HS inflammation, with tumor necrosis factor, interleukin-17, and interleukin-23 inhibitors now standard options for moderate-to-severe disease, but they are often not structured to provide recurring wound care visits. Wound care clinics, meanwhile, are equipped for dressing management and debridement but may lack familiarity with HS’s distinctive disease course, in which wounds are not healing failures to be closed but active inflammatory lesions to be managed over time. Patients report shuttling between these systems, duplicating paperwork, repeating their histories, and sometimes paying out of pocket for supplies that no single provider has taken responsibility for. The survey’s contribution is to document, from the patient’s vantage point, how that fragmentation is experienced on the ground.

The implications for clinical practice are concrete. If patients perceive wound care as inaccessible, interventions should target the specific friction points: integrating wound care services into HS specialty clinics, training dermatology teams in HS-specific dressing selection and drainage management, standardizing insurance coverage for the supplies that HS wound care requires, and using patient foundations and telehealth to extend education to people who cannot reach specialty centers. The authors’ acknowledgment of the HS Foundation’s role in survey distribution hints at the kind of partnership model that could carry these improvements forward. Corresponding author Akua Sarfo of UConn Dermatology and her coauthors, who collectively designed the study, collected and analyzed the data, and wrote the manuscript without dedicated funding, frame the work as a call to measure and then dismantle the access barriers that patients themselves identify as most consequential.

For a disease that has historically been underdiagnosed, understudied, and shrouded in stigma, the accumulation of patient-centered evidence marks real progress. The 2025 wound care best-practice consensus, the dermatologist counseling survey, the qualitative health-systems study, and now this access-focused patient survey together form a scaffold on which health systems can build coordinated, equitable wound care for HS. The research letter does not offer a single dramatic finding, but it asks the right question in the right place: not whether wound care for HS is technically possible, but whether the people who need it can actually reach it. As biologic therapies continue to reduce inflammatory burden for many patients, the mechanical, financial, and logistical challenge of wound management will remain, and studies like this one ensure that the patients who live with that challenge daily are the ones defining what better access must look like.

Subject of Research: Patient perceptions of wound care access in hidradenitis suppurativa

Article Title: Perceptions of wound care access for hidradenitis suppurativa patients: a specialty clinic survey

Article References: Perceptions of wound care access for hidradenitis suppurativa patients: a specialty clinic survey. (n.d.). https://doi.org/10.1007/s00403-026-04924-w

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04924-w

Keywords: hidradenitis suppurativa, wound care, healthcare access, dermatology, patient survey, health disparities, chronic wounds, financial toxicity, specialty clinics, skin disease, wound management, patient-reported outcomes

Osteomyelitis of the foot is a familiar adversary in medicine, particularly among patients with diabetes and peripheral neuropathy, where loss of protective sensation allows small wounds to deepen unnoticed until bacteria reach bone. The standard playbook combines targeted antibiotics with surgical removal of infected bone, an approach widely accepted as effective for most cases of diabetic foot osteomyelitis. But the operation itself is only the opening act. Wound care after amputation remains one of the most deceptively difficult phases of treatment, because the surgeon is working with tissue that is already infected, poorly perfused, and dependent on a patient’s long-term cooperation. In this case, the toe was amputated at a secondary hospital, yet the story took a turn that clinicians see all too often: after seven days of hospitalization, dissatisfied with the service and the wound dressing care he was receiving, the patient discharged himself against medical advice.

Several days later he arrived at an outpatient clinic with an oozing wound at the amputation stump. Examination revealed loss of the cutaneous layer, with swollen subcutaneous tissue exposed to the air. Encouragingly, his white blood cell count and C-reactive protein levels were within normal limits, no microbial growth was identified in cultures, and no peripheral necrosis or vascular disease was detected. The wound was not systemically infected. But it refused to dry. The volume of exudate did not decrease, and a transparent yellow discharge, suspicious for synovial fluid leaking from the disrupted joint, persisted day after day. That detail mattered enormously. A dehisced stump with no protective skin barrier, sitting over a joint capsule that might be leaking synovial fluid, is an open invitation for bacteria to colonize the wound and seed the deeper structures. The treating team concluded that flap reconstruction was indispensable, not merely to close a hole but to rebuild the biological wall separating the outside world from the joint.

The operation they chose was the Limberg flap, also known as a rhomboid flap, a workhorse of reconstructive surgery first described decades ago and still prized for its elegant geometry. The technique recruits a diamond-shaped segment of adjacent healthy skin and subcutaneous tissue, transposes it across a pivot point, and uses the laxity of surrounding skin to fill the defect while distributing mechanical tension along the closure lines. Here, the surgeons first performed a rhomboid-shaped debridement, excising necrotic and swollen tissue to leave a clean 3.5 by 3.5 centimeter defect, then raised the Limberg flap with its pivot point at the medial side of the proximal phalanx stump. The geometry was constrained by the previous surgery and the scarcity of healthy adjacent tissue, meaning that mechanical tension on the flap was unavoidable, a compromise the team accepted because no better local option existed.

Perioperative care was built to protect the fragile reconstruction. The patient received a prophylactic first-generation cephalosporin to guard against infection, a prostaglandin E1 analogue to promote vasodilation, and antiplatelet therapy to enhance blood supply to the flap, a rational combination given that microvascular perfusion determines whether transferred skin lives or dies. In the immediate aftermath, the strategy appeared to work. Exudate dropped markedly, and the suspicious synovial fluid leakage stopped entirely, confirming that the flap had successfully sealed the joint. One week after surgery, however, mild edematous changes appeared in the flap, and the tissue eventually became necrotic. The reconstruction had partially failed, a consequence of the tension under which it was placed and the compromised local conditions.

What happened next is arguably the most instructive part of the case. Rather than rushing back to the operating room for another flap or a skin graft, the team pivoted to conservative management: daily dressing changes with intermittent debridement of the necrotic material. Although the skin flap did not fully survive, it continued to serve as a physical barrier and provided structural support to the adjacent tissue, promoting recovery and the formation of healthy granulation tissue beneath it. Over the following two months, healthy tissue gradually covered the lesion, and the wound healed by secondary intention. The authors point out that this outcome echoes a concept recognized in the literature, in which even a failed flap can function as a biological dressing, reducing contamination and inflammation and facilitating the development of healthy tissue before any subsequent grafting. In other words, a partially necrotic flap is not always a wasted operation; sometimes it is scaffolding.

The case also shines a light on how often amputation wounds go wrong in broader populations. Stump-related complications are dominated by wound infection and poor healing, which account for roughly 70 percent of problems, followed by poorly fashioned stumps at 20 percent and phantom pain at 10 percent. Research has linked smoking to both immediate and late complications, preoperative infection to immediate and intermediate complications, and amputations performed for peripheral vascular disease or trauma to late complications. One study of 739 patients who underwent lower-limb amputation found that 8.3 percent were readmitted within 30 days because of stump-related complications, and 61 percent of those complications required surgical intervention, with readmission rates of 35.9 percent after above-knee amputation and 68.7 percent after below-knee amputation. In the present patient, the authors suggest that both his smoking history and the underlying osteomyelitis likely contributed to the wound breakdown, and they note that pre-emptive vascular examinations to identify peripheral vascular disorders would have aided wound care planning from the start.

The report also engages with a genuine technical controversy in modern wound care: the use of topical negative pressure therapy, or TNP, in which vacuum sealing drainage systems actively draw fluid from a wound to promote granulation. While TNP has advanced the management of soft-tissue defects and amputation wounds, its application over open joints remains contested, with variable reported outcomes. In this case, the authors argue that applying negative pressure directly to the wound could have caused excessive drainage of synovial fluid and potential joint disruption. Their proposed sequence for similar situations is therefore deliberate: flap reconstruction first, to close the joint and reestablish the skin barrier, followed by TNP dressing only afterward, once the joint is protected. This ordering, they suggest, captures the benefits of vacuum therapy without exposing a leaking joint to its risks.

Perhaps the most sobering threads running through the case are the ones that have nothing to do with surgical technique. The patient’s poor sanitary conditions, his ingrown toenails, his self-discharge against medical advice, and his refusal to return to the hospital where the amputation was performed all shaped the clinical course as powerfully as any incision. The authors emphasize that understanding patient needs and providing clear explanations of wound status at every visit are essential for building trust, and that consistent wound care until complete recovery is non-negotiable, yet the high cost of treatment often limits access to appropriate care. This patient was a type I medical aid recipient in South Korea, with his basic wound care almost fully covered by government support, a fact the authors credit with making the prolonged dressing regimen feasible. They call for greater coordination among healthcare systems, insurance providers, and government assistance programs to reduce the burden of medical poverty, arguing that patient compliance, trust in clinicians, and financial support together determine whether complicated wounds heal. The case, prepared in accordance with the SCARE reporting criteria, ultimately delivers a double lesson: a well-executed Limberg flap can rescue a failing amputation stump even when the flap itself partially dies, but surgery is only one pillar of recovery, and the quieter work of daily dressings, repeated debridement, and sustained patient engagement is what carries the wound across the finish line.

Subject of Research: Management of a complicated post-amputation stump wound using Limberg flap reconstruction and persistent wound care following toe osteomyelitis

Article Title: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report

Article References: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report. (n.d.). https://doi.org/10.1186/s44452-026-00028-6

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00028-6

Keywords: osteomyelitis, amputation, Limberg flap, wound care, flap reconstruction, debridement, stump complications, topical negative pressure, patient compliance, diabetic foot, reconstructive surgery, synovial fluid leakage