Automated multi-class wound assessment using dedicated instance segmentation models for boundary detection and classification

Chronic wounds such as diabetic foot ulcers and pressure injuries require accurate tissue-level assessment to guide treatment planning and monitor healing progression. While deep learning methods have advanced automated wound analysis, most existing approaches focus on binary segmentation and inadequately model heterogeneous tissue composition due to high intra-class variability and limited annotated data. Multi-class wound tissue segmentation, therefore, remains a challenging and clinically relevant problem. We propose WoundFormer, a transformer-based framework that enhances hierarchical spatial feature fusion for multi-class wound tissue segmentation. Specifically, we replace the standard SegFormer decoder with a spatially-preserving multi-scale aggregation head that maintains feature topology during cross-scale integration and strengthens contextual interactions through convolutional fusion. This design improves boundary localization and discrimination between visually similar tissue categories while preserving transformer efficiency. We evaluate WoundFormer on the WoundTissueSeg dataset (147 images, six tissue classes) and a second benchmark (DFUTissue dataset). The proposed method achieves an overall Dice score of 81.9%, outperforming strong CNN- and transformer-based baselines by up to 4.3 Dice points on the WoundTissueSeg benchmark, with consistent improvements across minority tissue classes. These results indicate that explicit modeling of hierarchical spatial interactions enhances transformer representations for heterogeneous wound tissue segmentation and supports more reliable quantitative wound assessment.

Chronic wound assessment remains a clinically challenging task that requires accurate interpretation of wound morphology, tissue composition, vascular characteristics, and infection risk. Recent advances in Vision-Language Models (VLMs) have introduced the possibility of automated multimodal wound analysis through image understanding combined with clinical reasoning. This study evaluates the performance of several general-purpose and medically specialized open-source and proprietary VLMs for clinical wound assessment using an expanded, curated dataset of 20 clinically diverse wounds spanning vascular, surgical, ischemic, venous, lymphedema, and amputation-related etiologies. Six VLMs were evaluated using a structured twelve-question clinical framework covering wound classification, infection risk, vascular intervention recommendations, debridement urgency, wound therapy selection, and advanced management planning. Across 20 wound cases and 240 clinician-graded wound-analysis decisions, ChatGPT achieved the highest overall performance with 174/240 correct responses (72.50%), followed by Claude with 149/240 (62.08%). Among the open-source and medically specialized models, HuluMed achieved the strongest performance with 96/240 correct responses (40.00%), followed by Gemma 3 (81/240, 33.75%), MedGemma 4B (62/240, 25.83%), and MedGemma 27B (42/240, 17.50%). The findings suggest that frontier general-purpose multimodal systems currently demonstrate substantially stronger wound-analysis performance than medically specialized alternatives, highlighting the continued importance of broad multimodal reasoning capabilities alongside domain-specific medical knowledge. Although current VLMs demonstrate promising potential for clinical decision support, substantial limitations remain in advanced wound-management reasoning, procedural planning, and autonomous clinical reliability.

Wound image classification is often treated as a task-specific supervised learning problem, requiring substantial amounts of manually labelled data and retraining when the label space or deployment setting changes. This study evaluated whether small multimodal language models (SMLMs) can provide a training-free alternative for wound classification through retrieval-based in-context learning (ICL). Experiments used two public wound-image datasets: the Kaggle wound dataset (1469 images, 10 classes) and the Medetec dataset (560 images, 9 classes). Eleven SMLMs from the Qwen 3.5, Ministral 3, and Gemma 4 families were evaluated under zero-shot prompting and few-shot prompting with random support examples, embedding-based k-nearest-neighbour (kNN) retrieval, and kNN retrieval followed by maximal marginal relevance reranking (MMR). Retrieval-only weighted-kNN controls, support-set reduction experiments, and support-context size sweeps were used to assess the effects of retrieval, model scale, and prompt length. Query-conditioned ICL consistently outperformed zero-shot and random few-shot prompting. On the Kaggle dataset, the best result was achieved by Qwen 3.5 27B with kNN+MMR, reaching 0.872 accuracy and 0.871 F1 score. On Medetec, Qwen 3.5 27B with kNN+MMR reached 0.678 accuracy and 0.670 F1. Larger models exceeded matched weighted-kNN controls, indicating use of retrieved examples beyond nearest-neighbour voting. Retrieval-based ICL degraded modestly under support-set reduction, and most gains saturated with 8-10 support images. Retrieval-based ICL allows SMLMs to perform adaptable wound image classification without task-specific retraining. Compact retrieved contexts may support practical and privacy-conscious deployment, although performance remains dependent on model scale, retrieval strategy, and dataset difficulty.