What is the best approach for managing chronic wounds?

Management of Chronic Wounds

The best approach for managing chronic wounds involves five basic principles: offloading of plantar ulcerations, debridement of necrotic tissue, revascularization when necessary, management of infection, and use of physiologic topical dressings. 1

Initial Management Strategy

• Offloading of plantar ulcerations is essential to reduce pressure on the wound site and promote healing 1
• Debridement of necrotic, nonviable tissue converts a biologically chronic wound to an acute wound, accelerating the healing process 1
• Revascularization of ischemic wounds should be performed when necessary to improve blood supply to the affected area 1
• Management of infection (both soft tissue and bone) through appropriate antimicrobial therapy is crucial for wound healing 1
• Use of physiologic, topical dressings to maintain a moist wound environment while controlling exudate 1

Advanced Wound Therapy

When to consider advanced wound therapy:

• If a wound fails to show at least 50% reduction after 4 weeks of appropriate standard wound management 1
• Treatment of chronic wounds is best managed in a multidisciplinary/interprofessional setting 1

Advanced wound therapy options include:

1. Negative-pressure wound therapy

   • Especially useful for deep, large wounds and in preparation for skin grafts 1
   • Available in electrically powered and mechanically powered forms 1

2. Oxygen therapies

   • Topical oxygen therapy has shown efficacy in healing chronic diabetic foot ulcers at 12 weeks 1
   • Home-based therapy with high participation and few adverse events 1
   • Hyperbaric oxygen therapy may be considered for nonhealing diabetic foot ulcers after revascularization 1

3. Growth factors

   • Becaplermin (platelet-derived growth factor) promotes chemotactic recruitment and proliferation of cells involved in wound repair 2
   • FDA-approved for diabetic lower extremity ulcers but lacks efficacy in pressure ulcers and venous stasis ulcers 2

4. Biophysical modalities

   • Include electrical stimulation, ultrasound, and extracorporeal shock wave therapy 1
   • Most supporting studies are retrospective observational or poor-quality RCTs 1

5. Acellular matrix tissues and bioengineered cellular therapies

   • Commonly used for more superficial ulcerations 1
   • Include xenograft dermis, human dermis products, and bilayered skin equivalents 1

Special Considerations

• For diabetic foot ulcers (DFUs):

  • Proper pressure offloading is critical 1
  • After healing, patients should be enrolled in a formal comprehensive prevention program to reduce recurrence 1

• For venous leg ulcers (VLUs):

  • Adjunctive techniques like split-thickness skin grafting and cellular therapy should only be considered after 4-6 weeks of standard therapy failure 1
  • Surgical debridement helps convert chronic wounds to acute wounds 1

Common Pitfalls to Avoid

• Failing to reassess underlying pathology when wounds don't improve after 4 weeks 3
• Using advanced therapies without first addressing the five basic principles of wound care 1
• Overlooking the importance of treating the underlying cause of the chronic wound 4
• Using topical antimicrobial dressings without clear indication, as they have shown no benefit in venous ulcers 1
• Neglecting to evaluate for osteomyelitis in non-healing ulcers 1

Evidence Quality Considerations

• Evidence to support advanced wound therapy is challenging to produce and assess due to:

  • Difficulty in randomization of trial participants 1
  • Exclusion of certain cohorts (e.g., individuals with chronic renal disease) from RCTs 1
  • Challenges in blinding participants and clinicians 1

• Products or agents with robust RCTs or systematic reviews should generally be preferred over those without level 1 evidence 1