# Thermal–Inflammatory Index (TI): An Integrated Biomarker of Severity and Prognosis in Chronic Lower-Limb Ulcers

## TL;DR

This study introduces a new Thermal–Inflammatory Index (TI) that combines wound temperature and blood markers to predict outcomes in patients with chronic leg ulcers.

## Contribution

The TI is a novel composite biomarker integrating thermography and systemic inflammation for severity and prognosis in chronic lower-limb ulcers.

## Key findings

- Higher TI values correlate with colder wound beds and worse outcomes like amputation or lack of healing.
- TI showed moderate discrimination for adverse outcomes and prolonged hospitalization, comparable to individual components.
- The simplified TI score demonstrated clear stepwise associations with adverse outcomes and hospital stay duration.

## Abstract

Background/Objectives: Chronic lower-limb ulcers of mixed etiology are characterized by impaired microcirculation and persistent inflammation, leading to delayed healing, frequent hospitalizations, and a high risk of limb loss. While infrared thermography reflects local perfusion status and systemic inflammatory markers capture whole-body immune activation, these dimensions are usually assessed separately. The objective of this study was to develop and internally evaluate a composite Thermal–Inflammatory Index (TI) integrating wound-bed thermography with systemic inflammatory markers to stratify disease severity and prognosis in patients with chronic lower-limb ulcers. Methods: In this prospective observational study, 82 adults with chronic lower-limb ulcers underwent baseline infrared thermographic assessment of wound-bed temperature using a standardized protocol. Concurrently, neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) were measured. The Thermal–Inflammatory Index was constructed as a standardized composite of inverted wound-bed temperature, NLR, and CRP. A simplified TI score (0–3) was derived using predefined clinical thresholds. The primary endpoint was a composite adverse outcome defined as amputation or failure to achieve complete wound healing within 12 weeks. Secondary outcomes included a prolonged hospital stay (>7 days). Discriminative performance was assessed using receiver operating characteristic analysis, and associations were examined using correlation and logistic regression models. Results: Higher TI values were associated with colder wound beds, elevated systemic inflammatory markers, and increased disease burden. The TI demonstrated moderate discrimination for the composite adverse outcome (AUC 0.75) and prolonged hospitalization (AUC 0.71), performing comparably to the strongest single component (−T_bed, AUC 0.77) while integrating local and systemic information. Each one-standard-deviation increase in TI was independently associated with higher odds of the composite adverse outcome and a prolonged hospital stay. The simplified TI score showed clear stepwise gradients in adverse outcomes and length of hospitalization. Conclusions: The Thermal–Inflammatory Index integrates thermographic and inflammatory signals into a single, clinically interpretable biomarker of severity and prognosis in chronic lower-limb ulcers. TI and the simplified TI score may support early risk stratification using low-cost, bedside-accessible data.