Knife or Not? Pathergy and the Need for Caution in Debriding Wounds

Pathergy phenomenon has classically been associated with Bechet's disease and pyoderma gangrenosum (PG) 1. However, clinical experience shows that this inflammatory, exacerbating reaction may unintentionally be iatrogenically provoked in also other wounds treated in the acute inflammatory phase. Inflammation is an essential step in wound healing involving the release of vasoactive and pro-inflammatory mediators that increase vascular permeability and recruit immune cells 2. Yet, in wounds with impaired regulation of this inflammatory phase such as PG, vasculitis or arteriolosclerotic ulcers, any additional trauma associated with wound care, including sharp debridement—may exacerbate tissue damage and delay healing (Figure 1). To wit, one must be cautious with sharp debridement, because not all necrotic tissue requires it. The aetiology behind necrosis must be identified meticulously and addressed accordingly whether it is due to infection, ischemia, inflammation, or mechanical pressure. Wet necrosis with signs of infection and other acute necrotic infections like necrotizing fasciitis demand urgent surgical action that should not be delayed 3. Dry necrosis on the contrary—particularly when stable and adherent—may have a protective role in wounds 4. We call this the ‘crust effect’, where the necrotic plaque acts as a physiological scab 5. When maintained dry and protected—especially with the help of zinc oxide and alginate dressings—these plaques may prevent bacterial colonisation and reduce the need for painful and traumatic debridement. This protective and dry ‘natural wound dressing’ helps to preserve viable tissue, allows underlying healing, and enables wound epithelialization until detaching atraumatically without exacerbating inflammation 6. Additionally, anti-edema strategies like compression therapy should be considered a first-line component of leg ulcer management. Its anti-inflammatory, anti-oedema, and vascular-stabilising effects support wound healing and may help avoid unnecessary invasive procedures 7. In our practice, we prioritise early initiation of compression therapy and minimise dressing changing frequency to preserve the wound environment. Moreover, before proceeding with traumatic wound debridement, exact wound diagnosis should be reached and a wholesome aetiology-driven care implemented. Pressure ulcers demand offloading; arterial ulcers require improved perfusion; inflammatory ulcers call for immunosuppressive treatments; vasculopathies benefit from anticoagulants or other vascular-targeted therapies; and infected wounds need targeted anti-infective management. In arteriolosclerotic ulcers, warfarin should be discontinued and metabolic disturbances addressed, blood pressure levels optimised, and appropriate compression therapy initiated. Early skin grafting should be encouraged and in severely livedoid cases, agents like sodium thiosulfate may be used to halt the calcific process 8. The term ‘vascular ischemic wounds’ encompasses a broad spectrum of wounds including arterial ulcers and atypical presentations such as vasculitis, calciphylaxis and other vasculopathic and arteriolosclerotic ulcers. These share common features of compromised blood supply and fragile vessel reactivity. In all such cases, the use of a scalpel should be cautiously considered only after systemic and local conditions are optimised. The trauma of debridement may provoke impaired arteriolar reactivity leading to a cascade of vasoconstriction, ischemia, and further necrosis. This may further perpetuate a pathological inflammatory state and result in pathergy and wound deterioration 9. In fact, some current recommendations emphasise a conservative approach as the initial strategy in wound care. The initial focus is on inflammation control, optimization of perfusion, and preservation of necrotic tissue as a transient biologic cover until the lesion stabilises 10. In conclusion, sharp debridement remains a valuable tool in wound care, but it must be applied with caution in complex wounds with inflammatory and ischemic components. Not all necrosis is equal and should thus not be treated equally. Pathergy phenomenon occurs in wounds beyond PG, and it is essential to remember that sometimes, less scalpel may make the most sense. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The patients in this manuscript have given written informed consent to the publication of their case details. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.