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Copyright (c) 2025 Salha Jaber Mahdi Ghashem, Abdul Latif Obaidullah Hammad Al-Balawi, Areej Ahmed Alhamzi, Daad Saeed Alamoudi, Ali Hamad Mohammed Tomihy, Nahari Jaber Yahya Harashy, Ahmed Ali Mohammed Qadimi, Almuhannad Hamad Ahmed Bajawi, Amina Ali Mohammad Albatti, Dalia Abdullah Almutairi, Fatimah Fuhayman Eid Albalawi, Khadijah Ali Ali Awaji, Khalid Hamad Ali Sahli
This work is licensed under a Creative Commons Attribution 4.0 International License.
Marjolin Ulcer: Pathogenesis, Clinical Features, and Management in Chronic Wounds-An Updated Review
Corresponding Author(s) : Salha Jaber Mahdi Ghashem
Saudi Journal of Medicine and Public Health,
Vol. 2 No. 2 (2025)
Abstract
Background: Marjolin ulcer is an aggressive cutaneous malignancy that develops within chronically injured, inflamed, or scarred tissue, most commonly arising from burn scars but also associated with chronic wounds, venous ulcers, osteomyelitis, pressure sores, and radiation induced injury. These malignancies—predominantly squamous cell carcinoma—demonstrate high metastatic potential, recurrence rates, and poor overall prognosis.
Aim: This review aims to synthesize updated evidence on the etiology, epidemiology, pathophysiology, clinical features, diagnostic evaluation, management strategies, and prognosis of Marjolin ulcers to support improved recognition and management.
Methods: A comprehensive narrative review was conducted using current literature describing malignancies arising in chronic scars and wounds. Key themes include biological mechanisms, histopathology, diagnostic standards, and therapeutic approaches, including surgery, radiotherapy, and adjuvant therapies.
Results: Marjolin ulcers are most frequently squamous cell carcinomas (80–90%), followed by basal cell carcinoma and melanoma. They typically appear decades after the initial injury, exhibit rapid local invasion, and metastasize in up to 40% of cases. Prognosis is significantly worse than de novo cutaneous malignancies. Wide local excision with 2–3 cm margins remains the gold standard, while amputation is reserved for extensive or unresectable disease. Adjuvant radiotherapy and chemotherapy are indicated in high risk or inoperable cases. Emerging immunotherapies show promise but require further evaluation.
Conclusion: Early detection, timely biopsy, and complete excision are critical to reducing morbidity, recurrence, and mortality. Management requires a multidisciplinary team and rigorous long term follow up due to high recurrence and metastatic potential.
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- Sarisarraf N, Araghi F, Asadikani Z, Moravvej Farshi H. Invasive squamous cell carcinoma on sternotomy scar. Clin Case Rep. 2024 Apr;12(4):e8655.
- Bazaliński D, Przybek-Mita J, Barańska B, Więch P. Marjolin's ulcer in chronic wounds - review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202.
- Khan K, Schafer C, Wood J. Marjolin Ulcer: A Comprehensive Review. Adv Skin Wound Care. 2020 Dec;33(12):629-634.
- Latta S, Helbig SJ, Kasti K, Paulus E. Giant Basal Cell Carcinoma Within a Marjolin's Ulcer: A Case Discussion. Cureus. 2024 Aug;16(8):e67629.
- Elkins-Williams ST, Marston WA, Hultman CS. Management of the Chronic Burn Wound. Clin Plast Surg. 2017 Jul;44(3):679-687.
- Copcu E. Marjolin's ulcer: a preventable complication of burns? Plast Reconstr Surg. 2009 Jul;124(1):156e-164e.
- Saaiq M, Ashraf B. Marjolin's ulcers in the post-burned lesions and scars. World J Clin Cases. 2014 Oct 16;2(10):507-14.
- Giesey R, Delost GR, Honaker J, Korman NJ. Metastatic squamous cell carcinoma in a patient treated with adalimumab for hidradenitis suppurativa. JAAD Case Rep. 2017 Nov;3(6):489-491.
- Maranga A, Ravipati A, Martinez-Escala ME, Shea CR, Xu AZ. Marjolin cutaneous squamous cell carcinoma arising in dissecting cellulitis of the scalp. JAAD Case Rep. 2024 Oct;52:85-87.
- Guedes NL, Lourenço SV, Nico MMS. Mucosal Cancers Arising in Potentially Malignant Lesions of the Oral Mucosa Are Marjolin Ulcers: New Insights Into Old Concepts. Dermatol Pract Concept. 2024 Jul 01;14(3)
- Rusia K, Madke B, Kumar P, Kashikar Y. Petticoat cancer: Marjolin ulcer of the waist in South Asian women (a site-specific malignancy). BMJ Case Rep. 2024 Nov 05;17(11)
- Bradford PT. Skin cancer in skin of color. Dermatol Nurs. 2009 Jul-Aug;21(4):170-7, 206; quiz 178.
- Cheng KY, Yu J, Liu EW, Hu KC, Lee JJ. Prognostic Factors of Marjolin Ulcers: A Meta-Analysis and Systematic Review Assisted by Machine Learning Techniques. Plast Reconstr Surg. 2023 Apr 01;151(4):875-884.
- Fleming MD, Hunt JL, Purdue GF, Sandstad J. Marjolin's ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil. 1990 Sep-Oct;11(5):460-9.
- Pekarek B, Buck S, Osher L. A Comprehensive Review on Marjolin's Ulcers: Diagnosis and Treatment. J Am Col Certif Wound Spec. 2011 Sep;3(3):60-4.
- Mousa AK, Elshenawy AA, Maklad SM, Bebars SMM, Burezq HA, Sayed SE. Post-burn scar malignancy: 5-year management review and experience. Int Wound J. 2022 May;19(4):895-909.
- Mitra S, Panda S, Sikka K, Mallick S, Thakar A. Multimodality management of locoregionally extensive Marjolin ulcer: a case report and review of the literature. Wounds. 2024 May;36(5):166-169.
- Siar J, Patel D, Rohr-Kirchgraber T. Melanoma Marjolin ulcer in residual limb of patient of color with below-knee amputation. JAAD Case Rep. 2024 Oct;52:109-111.
- Sinha S, Arora R, Kutluberk E, Verly M, Small C, Herik A, Burnett L, Cao L, Manoharan VT, Chockalingam K, van der Vyver M, Ponjevic D, Sparks HD, Morrissy S, Harrop AR, Brenn T, Nikolic A, Temple-Oberle C, Rosin N, Gabriel V, Biernaskie J. Spatial and Single-Cell Transcriptomics Reveal that Oncofetal Reprogramming of Fibroblasts Is Associated with Malignant Degeneration of Burn Scar. J Invest Dermatol. 2025 Feb;145(2):444-451.e11.
- Dos Santos AGE, Moreira AA. Malignant transformation of a long-term ulcer in a patient with leprosy sequelae: a case report. J Vasc Bras. 2024;23:e20240044.
- CASTANARES S. Malignant degeneration in burn scars. Calif Med. 1961 Mar;94(3):175-7.
- Sadegh Fazeli M, Lebaschi AH, Hajirostam M, Keramati MR. Marjolin's ulcer: clinical and pathologic features of 83 cases and review of literature. Med J Islam Repub Iran. 2013 Nov;27(4):215-24.
- Miodovnik M, Dolev Y, Buchen R, Brezis MR, Nikolaevski-Berlin A, Finkel I, Wolf I, Ospovat I, Gutfeld O, Leshem Y. Squamous cell carcinoma arising in chronically damaged skin (Marjolin's Ulcer): still an unmet need in the era of immunotherapy. Oncologist. 2024 Dec 04;
- Naeem A, Tabassum S, Bibi A, Gill S, Afzal F, Anand A. Management of Marjolin's ulcer with popliteal lymphadenopathy with surgical resection and lymphadenectomy in a young patient, an uncommon lesion and overlooked entity: A case report. Clin Case Rep. 2023 Sep;11(9):e7876.
- Metwally IH, Roshdy A, Saleh SS, Ezzat M. Epidemiology and predictors of recurrence of Marjolin's ulcer: experience from Mansoura Universityxs. Ann R Coll Surg Engl. 2017 Mar;99(3):245-249.
- Dulet M, Taywade S, Verma V, Kumar R. FDG PET/CT in a Case of Marjolin Ulcer of the Scalp Over a Long-standing Burn Scar. Clin Nucl Med. 2025 Jun 01;50(6):e374-e375.
- Challa VR, Deshmane V, Ashwatha Reddy MB. A Retrospective Study of Marjolin's Ulcer Over an Eleven Year Period. J Cutan Aesthet Surg. 2014 Jul;7(3):155-9.
- Oruç M, Kankaya Y, Sungur N, Özer K, Işık VM, Ulusoy MG, Uysal A, Koçer U. Clinicopathological evaluation of Marjolin ulcers over two decades. Kaohsiung J Med Sci. 2017 Jul;33(7):327-333.
- Iqbal FM, Sinha Y, Jaffe W. Marjolin's ulcer: a rare entity with a call for early diagnosis. BMJ Case Rep. 2015 Jul 15;2015
- Ad Hoc Task Force. Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W, Ratings Panel. Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 Oct;67(4):531-50.
- Simman R, Caudil J. Marjolin Ulcers of the Scalp Post Trauma and of the Neck Post Radiation, Diagnosis, and Reconstruction. Eplasty. 2022;22:ic10.
- Alvarez Rio A, Roca Mas JO, Navarro Sanchez D, Monge Castresana I, Soroa Moreno GJ, Estrada Cuxart J. Aggressive Acute Marjolin's Ulcer Arising in a Burn Scar. Case Rep Dermatol Med. 2022;2022:8329050.
References
Sarisarraf N, Araghi F, Asadikani Z, Moravvej Farshi H. Invasive squamous cell carcinoma on sternotomy scar. Clin Case Rep. 2024 Apr;12(4):e8655.
Bazaliński D, Przybek-Mita J, Barańska B, Więch P. Marjolin's ulcer in chronic wounds - review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202.
Khan K, Schafer C, Wood J. Marjolin Ulcer: A Comprehensive Review. Adv Skin Wound Care. 2020 Dec;33(12):629-634.
Latta S, Helbig SJ, Kasti K, Paulus E. Giant Basal Cell Carcinoma Within a Marjolin's Ulcer: A Case Discussion. Cureus. 2024 Aug;16(8):e67629.
Elkins-Williams ST, Marston WA, Hultman CS. Management of the Chronic Burn Wound. Clin Plast Surg. 2017 Jul;44(3):679-687.
Copcu E. Marjolin's ulcer: a preventable complication of burns? Plast Reconstr Surg. 2009 Jul;124(1):156e-164e.
Saaiq M, Ashraf B. Marjolin's ulcers in the post-burned lesions and scars. World J Clin Cases. 2014 Oct 16;2(10):507-14.
Giesey R, Delost GR, Honaker J, Korman NJ. Metastatic squamous cell carcinoma in a patient treated with adalimumab for hidradenitis suppurativa. JAAD Case Rep. 2017 Nov;3(6):489-491.
Maranga A, Ravipati A, Martinez-Escala ME, Shea CR, Xu AZ. Marjolin cutaneous squamous cell carcinoma arising in dissecting cellulitis of the scalp. JAAD Case Rep. 2024 Oct;52:85-87.
Guedes NL, Lourenço SV, Nico MMS. Mucosal Cancers Arising in Potentially Malignant Lesions of the Oral Mucosa Are Marjolin Ulcers: New Insights Into Old Concepts. Dermatol Pract Concept. 2024 Jul 01;14(3)
Rusia K, Madke B, Kumar P, Kashikar Y. Petticoat cancer: Marjolin ulcer of the waist in South Asian women (a site-specific malignancy). BMJ Case Rep. 2024 Nov 05;17(11)
Bradford PT. Skin cancer in skin of color. Dermatol Nurs. 2009 Jul-Aug;21(4):170-7, 206; quiz 178.
Cheng KY, Yu J, Liu EW, Hu KC, Lee JJ. Prognostic Factors of Marjolin Ulcers: A Meta-Analysis and Systematic Review Assisted by Machine Learning Techniques. Plast Reconstr Surg. 2023 Apr 01;151(4):875-884.
Fleming MD, Hunt JL, Purdue GF, Sandstad J. Marjolin's ulcer: a review and reevaluation of a difficult problem. J Burn Care Rehabil. 1990 Sep-Oct;11(5):460-9.
Pekarek B, Buck S, Osher L. A Comprehensive Review on Marjolin's Ulcers: Diagnosis and Treatment. J Am Col Certif Wound Spec. 2011 Sep;3(3):60-4.
Mousa AK, Elshenawy AA, Maklad SM, Bebars SMM, Burezq HA, Sayed SE. Post-burn scar malignancy: 5-year management review and experience. Int Wound J. 2022 May;19(4):895-909.
Mitra S, Panda S, Sikka K, Mallick S, Thakar A. Multimodality management of locoregionally extensive Marjolin ulcer: a case report and review of the literature. Wounds. 2024 May;36(5):166-169.
Siar J, Patel D, Rohr-Kirchgraber T. Melanoma Marjolin ulcer in residual limb of patient of color with below-knee amputation. JAAD Case Rep. 2024 Oct;52:109-111.
Sinha S, Arora R, Kutluberk E, Verly M, Small C, Herik A, Burnett L, Cao L, Manoharan VT, Chockalingam K, van der Vyver M, Ponjevic D, Sparks HD, Morrissy S, Harrop AR, Brenn T, Nikolic A, Temple-Oberle C, Rosin N, Gabriel V, Biernaskie J. Spatial and Single-Cell Transcriptomics Reveal that Oncofetal Reprogramming of Fibroblasts Is Associated with Malignant Degeneration of Burn Scar. J Invest Dermatol. 2025 Feb;145(2):444-451.e11.
Dos Santos AGE, Moreira AA. Malignant transformation of a long-term ulcer in a patient with leprosy sequelae: a case report. J Vasc Bras. 2024;23:e20240044.
CASTANARES S. Malignant degeneration in burn scars. Calif Med. 1961 Mar;94(3):175-7.
Sadegh Fazeli M, Lebaschi AH, Hajirostam M, Keramati MR. Marjolin's ulcer: clinical and pathologic features of 83 cases and review of literature. Med J Islam Repub Iran. 2013 Nov;27(4):215-24.
Miodovnik M, Dolev Y, Buchen R, Brezis MR, Nikolaevski-Berlin A, Finkel I, Wolf I, Ospovat I, Gutfeld O, Leshem Y. Squamous cell carcinoma arising in chronically damaged skin (Marjolin's Ulcer): still an unmet need in the era of immunotherapy. Oncologist. 2024 Dec 04;
Naeem A, Tabassum S, Bibi A, Gill S, Afzal F, Anand A. Management of Marjolin's ulcer with popliteal lymphadenopathy with surgical resection and lymphadenectomy in a young patient, an uncommon lesion and overlooked entity: A case report. Clin Case Rep. 2023 Sep;11(9):e7876.
Metwally IH, Roshdy A, Saleh SS, Ezzat M. Epidemiology and predictors of recurrence of Marjolin's ulcer: experience from Mansoura Universityxs. Ann R Coll Surg Engl. 2017 Mar;99(3):245-249.
Dulet M, Taywade S, Verma V, Kumar R. FDG PET/CT in a Case of Marjolin Ulcer of the Scalp Over a Long-standing Burn Scar. Clin Nucl Med. 2025 Jun 01;50(6):e374-e375.
Challa VR, Deshmane V, Ashwatha Reddy MB. A Retrospective Study of Marjolin's Ulcer Over an Eleven Year Period. J Cutan Aesthet Surg. 2014 Jul;7(3):155-9.
Oruç M, Kankaya Y, Sungur N, Özer K, Işık VM, Ulusoy MG, Uysal A, Koçer U. Clinicopathological evaluation of Marjolin ulcers over two decades. Kaohsiung J Med Sci. 2017 Jul;33(7):327-333.
Iqbal FM, Sinha Y, Jaffe W. Marjolin's ulcer: a rare entity with a call for early diagnosis. BMJ Case Rep. 2015 Jul 15;2015
Ad Hoc Task Force. Connolly SM, Baker DR, Coldiron BM, Fazio MJ, Storrs PA, Vidimos AT, Zalla MJ, Brewer JD, Smith Begolka W, Ratings Panel. Berger TG, Bigby M, Bolognia JL, Brodland DG, Collins S, Cronin TA, Dahl MV, Grant-Kels JM, Hanke CW, Hruza GJ, James WD, Lober CW, McBurney EI, Norton SA, Roenigk RK, Wheeland RG, Wisco OJ. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012 Oct;67(4):531-50.
Simman R, Caudil J. Marjolin Ulcers of the Scalp Post Trauma and of the Neck Post Radiation, Diagnosis, and Reconstruction. Eplasty. 2022;22:ic10.
Alvarez Rio A, Roca Mas JO, Navarro Sanchez D, Monge Castresana I, Soroa Moreno GJ, Estrada Cuxart J. Aggressive Acute Marjolin's Ulcer Arising in a Burn Scar. Case Rep Dermatol Med. 2022;2022:8329050.