The next step is a three-year study funded by the National Institutes of Health. Under way since May, the study will monitor autoimmune-related wounds over time. "We are hoping to get some understanding of what happens on the cellular and molecular level in people who don't heal well," Dr. Shanmugam says.

One theory is that diabetes and autoimmune disorders cause wounds to become stalled in the inflammatory stage of repair, when the body normally develops new blood vessels. Why this occurs and what happens at the level of the wound itself are questions she hopes to answer.

She also will explore whether treating underlying autoimmune diseases such as RA improves wound healing. "There is concern about using potent immune suppressants in people with open wounds," she says, noting that immunosuppressive drugs are known to interfere with wound healing after surgery. "But in a cohort of rheumatoid arthritis patients, we found that aggressive treatment before skin graft surgery resulted in better outcomes."   

Eric Matteson, MD, chairman of rheumatology at Mayo Clinic in Rochester, Minn., agrees with the approach. "People with rheumatoid arthritis develop wounds for many reasons. One is that they may have low-grade vasculitis – inflammation affecting the small blood vessels in the skin. When the wound is related to the underlying systemic inflammation of rheumatoid arthritis, not having that inflammation under control makes it much more difficult to achieve good wound healing."

He says that successful wound care requires cooperation and vigilance. "Perhaps the biggest message here is that treating people with autoimmune-related wounds really calls for a team approach among the rheumatologist, wound-care specialist and surgeon,” says Dr. Matteson. “What you often see, unfortunately, is a primary care doctor who can't properly manage the wound because of the complexity of the underlying disorder."

Dr. Shanmugam believes her findings will affect patient care in the future. “Understanding how people respond to wound care on a molecular level can help guide therapy and may reduce the risk of infections, which can lead to surgery and even amputation," she says.

As important, she hopes her research will alert other physicians to this under-recognized problem. "When a patient has a leg ulcer that hasn't healed after three or four months of normal treatment, I hope doctors will check for autoimmune disease," says Dr. Shanmugam.