What is the management and treatment of chronic wounds?

From the Guidelines

Chronic wounds affect approximately 6.5 million people in the United States, with a significant impact on morbidity, mortality, and quality of life. The management of chronic wounds requires a comprehensive approach focusing on wound assessment, debridement, infection control, moisture balance, and addressing underlying causes.

Key Principles of Chronic Wound Management

• Initial treatment involves thorough wound cleaning and debridement to remove necrotic tissue, which can be done surgically, enzymatically with collagenase, or through autolytic methods 1.
• Infection control is achieved with topical antimicrobials like silver sulfadiazine or systemic antibiotics based on culture results.
• Proper dressing selection is crucial—hydrocolloids for dry wounds, alginates for exudative wounds, and foam dressings for moderate drainage.

Advanced Therapies for Chronic Wounds

• Advanced therapies include negative pressure wound therapy (applied at 125 mmHg continuously or intermittently), growth factors like becaplermin gel (0.01% applied daily), and skin substitutes such as Apligraf or Dermagraft 2.
• Underlying conditions must be addressed, including optimizing blood glucose in diabetic patients (target HbA1c <7%), improving circulation through revascularization procedures if needed, and ensuring adequate nutrition with protein intake of 1.2-1.5 g/kg/day and vitamin supplementation.

Multidisciplinary Approach to Chronic Wound Care

• Pain management should incorporate both pharmacological approaches (acetaminophen, NSAIDs, or opioids as needed) and non-pharmacological methods.
• Regular repositioning every 2 hours for immobile patients and compression therapy (30-40 mmHg) for venous ulcers are essential preventive measures.
• Treatment success depends on consistent wound reassessment, patient education about self-care, and a multidisciplinary approach involving wound care specialists, nutritionists, and vascular surgeons as needed 3.

Recent Guidelines and Recommendations

• The 2023 International Working Group on the Diabetic Foot (IWGDF) guideline on wound healing interventions recommends the use of sucrose octasulfate dressings, negative pressure wound therapies for postoperative wounds, and placental-derived products for promoting healing of foot ulcers in persons with diabetes 1.
• The 2025 standards of care in diabetes recommend considering adjunctive treatment with randomized controlled trial–proven advanced agents for chronic diabetic foot ulcers that have failed to heal with optimal standard care alone 2, 3.

From the Research

Prevalence of Chronic Wounds in the United States

• More than 6 million people in the United States are affected by chronic ulcers, including decubitus, vascular, inflammatory, and rheumatologic subtypes 4.
• The prevalence of chronic wounds is expected to increase due to the growing elderly and diabetic populations 4.

Impact of Chronic Wounds

• Chronic wounds cause significant morbidity and mortality, leading to substantial medical costs 4.
• They negatively impact patients' quality of life due to pain, odor, decreased mobility, and social isolation 5.
• Chronic wounds have 5-year mortality rates comparable to cancer in some cases 5.

Management and Treatment of Chronic Wounds

• Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing 4.
• The TIME principle is the mainstay of treatment: tissue debridement, infection control, moisture balance, and edges of the wound 6.
• Treatment is specific to the ulcer type, such as:
  • Arterial ulcers: immediate referral to a vascular surgeon for appropriate intervention 6.
  • Venous ulcers: compression and elevation of the lower extremities, plus exercise if tolerated 6.
  • Diabetic foot ulcers: offloading the foot and, if necessary, treating the underlying peripheral arterial disease 6.
  • Pressure ulcers: offloading the affected area 6.
• Skin substitutes are an advanced therapy recommended for wounds that fail to show decrease in size with standard care 5, 7.
• Emerging advances in treatment approaches include novel therapies (stem cells, microRNAs, and nanocarrier-based delivery systems) and multifunctional biological dressings 8.