Editor’s Note: Please see the update for this case by Hall, Goldberg, and Phillips in the March 2004 issue (posted on the website under March 2004 content).

Dear Editor:

I agree that many ulcerated skin cancers are treated as benign wounds at least initially and a high index of suspicion is necessary [Hall G, Goldberg LJ, Phillips TJ. Chronic ulceration in a radiotherapy site (Diagnostic Dilemmas). WOUNDS 2003;15(10):346–50.]. A biopsy should be taken of any chronic wound that occurs in a previously irradiated field. I do not agree with much of the rest of the management in this case report.

I doubt the need for systemic antibiotics for a wound without any description of cellulitis in the details of the exam. I personally would provide perioperative antibiotics if I was going to attempt closure at the time of excision but would not give systemic antibiotics prior to surgery. This allows only for selection of resistant organisms.
I find the use of daily packing with iodoform gauze prior to surgical intervention unnecessary although of no real harm. Daily cleansing of the wound and coverage with gauze to avoid soiling of clothing is all that is required preoperatively.

An imaging study to delineate the extent of the tumor and its relationship to the underlying neurovascular structures is an imperative preoperative evaluation. In our experience, these lesions tend to be deeper than basal cell cancers that are not induced by radiation thus requiring more radical operations for true cure.

The most important disagreement I have with this article, however, is the referral. The vasculitis caused by radiation is progressive and unrelenting. These areas often require reconstructive techniques to accomplish closure with adequate functional results. I feel the referral in a case such as this should be to a surgeon capable of reconstructive surgery.

David W. Voigt, MD
Director of Burn Research
Saint Elizabeth’s Regional Burn and
Wound Care Center
Vice President of Lincoln Surgical Group, PC
Lincoln, Nebraska