In-Context Learning for Wound Classification with Small Multimodal Language Models

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.

Assessing chronic wound infection from photographs is challenging because visual appearance varies across wound etiologies, anatomical locations, and imaging conditions. Prior image-based deep learning methods have mainly focused on classification with limited interpretability, despite the need for evidence-grounded explanations to support point-of-care decision making. We present Infection-Reasoner, a compact 4B-parameter reasoning vision-language model for chronic wound infection classification and rationale generation. To address the scarcity of expert-labeled wound images with reasoning annotations, Infection-Reasoner is trained using a two-stage pipeline: (1) reasoning distillation, in which GPT-5.1 generates chain-of-thought rationales for unlabeled wound images to initialize wound-specific reasoning in a smaller student model (Qwen3-VL-4B-Thinking), and (2) reinforcement learning post-training with Group Relative Policy Optimization on a small labeled infection dataset to refine classification reasoning. On a held-out heterogeneous wound dataset, Infection-Reasoner achieved 86.8% accuracy, 86.4% sensitivity, and 87.1% specificity, outperforming several strong baselines, including GPT-5.1. Rationale quality was further evaluated using both multimodal large language model (MLLM) judges and wound expert review. Across four MLLM judges, visual-support agreement scores ranged from 0.722 to 0.903, while expert review rated 61.8% of rationales as Correct and 32.4% as Partially Correct.

Multimodal Large Language Models (MLLMs) have demonstrated remarkable abilities when analyzing images, yet translating these capabilities to few-shot image classification remains challenging. To bridge this gap, we present DeCoDe, a simple yet effective technique that enables off-the-shelf MLLMs to act as strong few-shot classifiers without any additional training. Our approach builds on the idea of few-shot classification as a set of pairwise image comparisons, decomposing the task into a set of binary decisions. Given a query image and a support image from a candidate class, the MLLM is prompted to decide whether the two images depict the same class. The logit corresponding to an affirmative response is then used as a similarity score to assign the query image to the most likely class. While this already yields good results, we show that providing additional high-level information, such as the data domain, to the model further improves performance. Our evaluation provides an extensive analysis of various inference variants on a suite of twelve datasets, six established and six newly curated few-shot benchmarks spanning across diverse domains. The results show that the proposed simple decomposition technique can turn off-the-shelf MLLMs into powerful few-shot learners, significantly outperforming current state-of-the-art few-shot methods on both standard and novel domains. Code is available at https://github.com/yunhanwang1105/DeCoDe.