What is the best approach to manage a non-healing ulcer?

Management of Non-Healing Ulcers

The best approach to manage a non-healing ulcer is a systematic treatment strategy that includes thorough assessment of the underlying cause, appropriate debridement, infection control, optimizing wound environment, offloading pressure, and considering advanced therapies when standard care fails to show improvement after 4-6 weeks.

Initial Assessment and Classification

• Evaluate the ulcer for location, size, depth, presence of necrotic tissue, exudate, odor, and signs of infection 1
• Assess for peripheral artery disease (PAD) by taking history, palpating foot pulses, and measuring ankle-brachial index (ABI) or toe pressure 1
• Determine ulcer etiology (neuropathic, ischemic, venous, or mixed) as this guides treatment approach 1
• Document baseline characteristics to monitor progress over time 1

Core Treatment Components

Debridement

• Remove slough, necrotic tissue, and surrounding callus with sharp debridement as the preferred method, considering contraindications such as pain or severe ischemia 1
• Debride neuropathic ulcers with callus and necrosis as soon as possible to enable adequate assessment 1
• Consider alternative debridement methods (enzymatic, autolytic) for non-urgent cases 1

Infection Control

• Diagnose infection based on clinical signs (redness, warmth, induration, pain/tenderness, or purulent secretions) 1
• For superficial infections, cleanse, debride necrotic tissue, and start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 1
• For deep infections, consider urgent surgical intervention, assess for PAD, and initiate broad-spectrum antibiotics 1

Wound Dressing Selection

• Select dressings primarily based on exudate control, comfort, and cost 1
• Maintain a moist wound environment to promote healing 1
• Do not routinely use dressings containing antimicrobial agents solely to accelerate healing 1

Pressure Offloading (for plantar ulcers)

• For neuropathic plantar ulcers, use a non-removable knee-high offloading device (total contact cast or irremovable walker) as the preferred treatment 1
• When non-removable devices are contraindicated, use a removable device 1
• For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing and walking, and use crutches if necessary 1

Vascular Assessment and Management

• Consider urgent vascular imaging and revascularization in patients with toe pressure <30 mmHg or transcutaneous oxygen pressure (TcPO2) <25 mmHg 1
• In patients with ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 1
• Consider vascular imaging and revascularization when an ulcer does not improve within 6 weeks despite optimal management 1
• The aim of revascularization is to restore direct flow to at least one of the foot arteries, preferably the one supplying the anatomical region of the wound 1

Advanced Therapies for Non-Healing Ulcers

When standard care fails to show improvement after 4-6 weeks, consider the following advanced therapies:

Recommended Advanced Therapies

• Consider sucrose-octasulfate impregnated dressings for non-infected, neuro-ischemic ulcers that are difficult to heal 1
• Consider autologous combined leucocyte, platelet, and fibrin patch as an adjunctive treatment for non-infected diabetic foot ulcers that are difficult to heal 1
• Consider systemic hyperbaric oxygen therapy as an adjunctive treatment for non-healing ischemic diabetic foot ulcers 1
• Consider negative pressure wound therapy to reduce wound size for post-operative wounds 1
• Consider placental-derived products as adjunctive treatment when standard care has failed to reduce wound size 1

Not Recommended

• Do not use topical oxygen therapy as primary or adjunctive intervention 1
• Do not use growth factors, autologous platelet gels (except the specific leucocyte-platelet-fibrin patch), or bioengineered skin products in preference to standard care 1
• Do not use interventions involving electricity, magnetism, ultrasound, or shockwaves 1
• Do not use interventions aimed at correcting nutritional status with the aim of improving healing 1

Monitoring and Follow-up

• If the ulcer is not showing signs of healing within 6 weeks despite optimal management, reassess treatment approach 1
• Monitor for signs of infection, deterioration, or complications 1
• Educate patients and caregivers on appropriate self-care and how to recognize signs of worsening infection 1

Prevention of Recurrence

• Once healed, include the patient in an integrated foot-care program with ongoing observation, professional foot treatment, adequate footwear, and education 1
• The foot should never return to the same shoe that caused the ulcer 1

Special Considerations

• For diabetic foot ulcers, a multidisciplinary approach involving diabetologists, surgeons, vascular specialists, podiatrists, and nurses is essential 1
• For ulcers with underlying systemic diseases (like vasculitis associated with HCV), treating the underlying condition may be necessary for healing 2
• Consider surgical reconstruction by an experienced foot surgeon for complex deformities that contribute to ulceration 1

By following this systematic approach and adjusting treatment based on ulcer characteristics and patient response, most non-healing ulcers can be effectively managed and brought to complete healing.