(PI-002) Strategies to improve equity in wound bacterial-infection assessments on skin of color

Alton Johnson, DPM, FACPM, FASPS, CWSP; Jonathan Johnson, MD,MBA,CWSP,FAPWCA

Introduction: There is growing literature showing that standard clinical assessment, particularly when based on visual cues, underserves patients of color. This contributes significantly to the profound disparities in wound outcomes among racial/ethnic minority populations. Unique considerations must be made when assessing and treating wounds on highly pigmented skin, as clinical indicators of certain skin conditions or pathologies (e.g. erythema) may be subtle or incorrectly perceived, even when infection, biofilm and/or high bacterial loads are present. This case series explores strategies that enhance and promote equitable wound assessment.

Methods:

This is a 10-patient case series describing complex/chronic wounds findings on patients of color. Case details including wound measurements, clinical assessment findings, and bacterial fluorescence imaging* results are reported, with an emphasis on the unique diagnostic considerations for assessing wounds on darkly pigmented skin. Treatment interventions and subsequent patient outcomes are also described, including the use of antibiotics and antimicrobial dressings, targeted debridement of bacterial loads (including Pseudomonas), and advanced therapies (e.g., skin grafting).

Results: Effective wound assessment on highly pigmented skin was achievable when clinicians: (1) considered patient skin tone and exercised a high index of suspicion, (2) were well educated on the variations in presentation of infection and inflammation on dark skin, (3) supplemented standard assessment with objective diagnostic aids suited for all skin tones (fluorescence and thermal imaging*), and (4) used a holistic assessment approach (i.e., considering health, environment, physical, psychological, and psychosocial factors). Together, these equitable assessment strategies supported appropriate treatment planning, helping our patients to achieve the best possible wound outcome.

Discussion:

The cases presented in this series illustrate how a uniquely tailored, intentional, and equitable wound assessment plan can support patients with high skin pigmentation in achieving the most appropriate and effective treatments(1). Thorough and inclusive education, the acknowledgement and consideration of implicit bias, along with objective assessment technologies and techniques are key pillars of wound care equity to help fight the mounting healthcare disparities facing patients of color. Imaging modalities with proven effectiveness across skin pigmentations can be pivotal tools to overcome diagnostic disparity on dark skin(2).

Trademarked Items: *MolecuLight i:X, D:X

References: 1. Andersen CA, McLeod K, Steffan R. Diagnosis and treatment of the invasive extension of bacteria (cellulitis) from chronic wounds utilising point-of-care fluorescence imaging. Int Wound J [Internet]. 2022 Aug 1 [cited 2023 Apr 13];19(5):996–1008. Available from: https://pubmed.ncbi.nlm.nih.gov/34609047/
2. Johnson J, Johnson AR, Andersen CA, Kelso MR, Oropallo AR, Serena TE. Skin Pigmentation Impacts the Clinical Diagnosis of Wound Infection: Imaging of Bacterial Burden to Overcome Diagnostic Limitations. J Racial Ethn Health Disparities [Internet]. 2023 [cited 2023 Jun 11]; Available from: https://pubmed.ncbi.nlm.nih.gov/37039975/