Write a short note on Marjolin's Ulcer.

The Concept

A Marjolin's ulcer is a squamous cell carcinoma that arises in a chronic wound, scar or long-standing ulcer — for example an old burn scar, a chronic venous ulcer, a chronic sinus, or an area of chronic osteomyelitis. It is an important concept because it means a chronic, apparently benign wound can undergo malignant change, and the key clinical skill is to recognise this transformation.

Characteristic Features

A Marjolin's ulcer has several distinctive features that follow from arising in scar tissue: it tends to be slow-growing (the scar has few lymphatics, so lymphatic spread is slow) and is painless (scar tissue is relatively insensate). Signs of malignant change in a chronic ulcer include a raised, everted edge, increased or heaped-up growth, bleeding, and a change in the appearance of a previously stable wound.

Diagnosis & Management

The diagnosis is confirmed by biopsy of the ulcer edge — reinforcing the general rule that any chronic, non-healing or changing ulcer should be biopsied to exclude malignancy. Treatment is wide surgical excision (with management of lymph nodes if involved). Once it does spread to nodes, the prognosis worsens.

A Note on the Mechanism

The mechanism of malignant change is thought to involve chronic inflammation, repeated cycles of ulceration and healing, and long-standing epithelial instability in the scar or wound, eventually giving rise to squamous carcinoma — often after many years or decades. This long latency is why a burn scar that ulcerates years later, or a venous ulcer of very long standing that changes character, must always raise the suspicion of a Marjolin's ulcer and prompt a biopsy.

The Bottom Line

A Marjolin's ulcer is a squamous cell carcinoma arising in a chronic scar or ulcer — slow-growing and painless — so any chronic or changing wound must be biopsied to exclude it and treated by wide excision.

A Note on Prognosis & Nodal Spread

Although a Marjolin's ulcer is often described as slow-growing while confined to the scar (which has few lymphatics), this apparent indolence is deceptive: once the tumour grows beyond the scar into normal tissue with intact lymphatics, it can spread to regional lymph nodes, and at that point the prognosis becomes significantly worse. This is a further argument for early biopsy and wide excision before nodal spread occurs, and for examining and, if necessary, treating the draining lymph nodes.

Slow-growing and painless because scar tissue lacks nerves and lymphatics.

• Marjolin's ulcer = squamous cell carcinoma arising in a chronic wound/scar/ulcer (old burn scar, chronic venous ulcer, sinus, osteomyelitis).
• Slow-growing (few lymphatics in scar) and painless (insensate scar); malignant change shown by a raised/everted edge, heaped growth, bleeding.
• Biopsy the ulcer edge — any chronic/changing ulcer must be biopsied to exclude malignancy.
• Treat by wide surgical excision (± node management).