Marjolin Ulcer: When Chronic Wounds Turn Malignant
Recognize Marjolin ulcer warning signs in chronic wounds, understand malignant transformation risk factors, and know when biopsy and referral are urgent.
Damon Ebanks
Medipyxis
Marjolin Ulcer: Recognizing Malignant Transformation in Chronic Wounds
Every wound care clinician manages chronic wounds that resist healing. Most are explained by underlying vascular disease, uncontrolled diabetes, inadequate offloading, or poor nutritional status. But a small percentage of chronic wounds that fail to heal — particularly those present for years or decades — undergo malignant transformation. The result is a Marjolin ulcer, an aggressive squamous cell carcinoma that develops within chronically inflamed or scarred tissue.
First described by Jean-Nicolas Marjolin in 1828, these malignancies are rare but carry significant morbidity because they are frequently diagnosed late. The wound care clinician is often the first provider to notice the changes, and early recognition is the difference between limb-sparing excision and amputation.
Risk Factors for Malignant Transformation
Not every chronic wound is at equal risk. The factors that increase the probability of Marjolin ulcer development are well established.
Duration of the Wound
The single strongest risk factor is wound chronicity. The average latency period between the original injury and malignant transformation is 30 to 35 years, though cases have been reported with latency periods as short as 1 to 2 years, particularly in immunocompromised patients. Any wound that has been present for more than 3 to 5 years without healing warrants heightened surveillance.
Wound Etiology and Location
Marjolin ulcers arise most commonly from burn scars, but they also develop in chronic venous ulcers, pressure injuries, osteomyelitis sinus tracts, hidradenitis suppurativa, and sites of chronic fistulae. Lower extremity wounds carry the highest risk, followed by the head and neck.
Tissue Environment
Chronically inflamed tissue, unstable scar tissue, and areas of repeated breakdown and re-epithelialization create the cellular environment for malignant transformation. Immunosuppression — whether from medication, diabetes, or advanced age — further elevates risk.
Clinical Warning Signs of Marjolin Ulcer
The challenge of Marjolin ulcer recognition is that early changes can be subtle and easy to attribute to the underlying chronic wound. Clinicians should maintain a high index of suspicion when any of the following features appear.
Changes in Wound Character
A wound that has been stable or slowly progressing suddenly changes behavior. The wound bed develops raised, nodular, or exophytic tissue that is firm to palpation. Granulation tissue appears exuberant — heaped up above the wound margins in a way that does not match the wound's healing trajectory. The wound edges become rolled, everted, or indurated rather than the flat, migrating epithelial edges seen in normal healing.
Bleeding and Drainage Changes
The wound begins bleeding spontaneously or with minimal contact. Drainage increases without an identifiable infectious source, or the drainage character changes — becoming serosanguinous or hemorrhagic when it was previously serous.
Pain Pattern Changes
A previously painless chronic wound develops new or escalating pain that is disproportionate to the wound appearance. Conversely, a wound that was painful becomes numb, suggesting deeper tissue invasion.
Odor
A foul odor that does not resolve with appropriate wound care and infection management can indicate necrotic tumor tissue rather than bacterial colonization.
When to Biopsy: Indications and Technique
The threshold for biopsy in a chronic wound with suspicious features should be low. The cost of a negative biopsy is trivial compared to the cost of a delayed malignancy diagnosis.
Biopsy Indications
Biopsy is indicated when a chronic wound of any duration develops raised or exophytic tissue in the wound bed, when wound edges become rolled or indurated, when a wound that was previously progressing toward closure reverses course without identifiable cause, when a wound present for more than 3 years fails to respond to appropriate treatment, or when any chronic wound develops new bleeding, pain, or rapid size increase without infectious etiology.
Biopsy Considerations
Multiple biopsies from different wound regions improve diagnostic yield. A single punch biopsy from the wound center may miss the malignancy if the sample captures necrotic tissue rather than the advancing tumor margin. Samples from the wound edge, any raised areas, and the wound base provide the broadest diagnostic coverage.
The biopsy should be incisional, not excisional, and should include tissue deep enough to capture the dermis and subcutaneous junction. Superficial shave biopsies may miss invasion depth and lead to understaging.
Referral Urgency and Specialist Coordination
Marjolin ulcers are more aggressive than de novo squamous cell carcinomas arising in sun-damaged skin. The metastasis rate for Marjolin ulcers ranges from 20 to 40%, compared to approximately 5% for typical cutaneous squamous cell carcinoma. This difference demands urgent specialist referral once biopsy confirms malignancy — or when clinical suspicion is high enough to warrant evaluation before biopsy results return.
Referral Pathway
Surgical oncology or a dermatologic surgeon with oncologic experience should evaluate the patient for wide local excision with margin assessment. Sentinel lymph node evaluation may be indicated depending on tumor depth and location. For lower-extremity Marjolin ulcers, vascular surgery consultation may be needed to assess perfusion and plan reconstruction.
The wound care clinician's role shifts to supporting the oncologic treatment plan — managing the surgical wound post-excision, monitoring for recurrence at the excision site, and continuing surveillance of other chronic wound sites in the same patient.
For guidance on when other wound findings warrant specialist involvement, see the guide on when to refer to a wound care specialist. For clinicians managing the biopsy referral process, the tissue biopsy referral guide covers the coordination workflow. Wound edge changes that can mimic malignancy are covered in the wound edge assessment guide.
Key Takeaways
- Marjolin ulcer is an aggressive squamous cell carcinoma that develops in chronic wounds, burn scars, and unstable scar tissue, with an average latency of 30 to 35 years from original injury.
- Clinical warning signs include exophytic or nodular wound bed tissue, rolled or everted wound edges, spontaneous bleeding, new pain in a previously painless wound, and persistent foul odor.
- The biopsy threshold should be low — any chronic wound with suspicious features warrants multiple incisional biopsies from wound edges, raised areas, and the wound base.
- Marjolin ulcers metastasize at 3 to 8 times the rate of typical cutaneous squamous cell carcinoma, making early detection and urgent surgical oncology referral critical.
- Every wound care clinician managing chronic wounds of more than 3 years duration should include malignant transformation in the differential assessment at each visit.