What is the recommended treatment for chronic wounds?

Treatment of Chronic Wounds

The cornerstone of chronic wound treatment is aggressive debridement of necrotic tissue combined with infection control, moisture balance, and appropriate wound edge management—collectively known as the TIME principle—with specific interventions tailored to wound etiology. 1, 2, 3

Initial Assessment and Foundation of Care

Before initiating treatment, determine the wound type (arterial, venous, diabetic, pressure) through:

• Vascular assessment including ankle-brachial index measurement 4
• Wound characteristics: location, size, depth, drainage, tissue type 1, 4
• Probe the wound after cleansing to assess depth and involvement 1
• Plain radiographs to evaluate for underlying osteomyelitis 1
• Obtain wound cultures only from infected wounds, using tissue specimens or curettage from the debrided ulcer base—never swab superficially 1

Core Treatment Algorithm: The TIME Principle

1. Tissue Management (Debridement)

Debridement is the single most critical intervention, converting biologically chronic wounds to acute wounds and accelerating healing. 2, 3

• Perform sharp surgical debridement initially and repeat as necessary 1, 2
• Remove all necrotic, nonviable tissue to reduce bacterial burden and stimulate healing 3, 5
• For diabetic foot ulcers, consider surgical resection of the ulcer combined with removal of underlying bone when indicated 1

2. Infection/Inflammation Control

Do NOT treat clinically uninfected wounds with antibiotics—reserve antimicrobial therapy only for wounds with clear signs of infection. 1

When infection is present:

• Classify severity: mild/moderate infections may be treated outpatient with oral antibiotics; severe infections require hospitalization and parenteral therapy 1
• Select antibiotics based on culture results and clinical severity 1
• Duration: 1-2 weeks for mild soft tissue infections, 2-3 weeks for moderate to severe infections 1
• Optimize glucose control and metabolic status in diabetic patients 1

Critical pitfall: Antimicrobial therapy does NOT accelerate healing of uninfected wounds regardless of bacterial "bioburden"—this approach increases antibiotic resistance and adverse effects without benefit. 1

3. Moisture Balance

• Use physiologic topical dressings to maintain moist wound environment while controlling exudate 2
• Avoid both desiccation and maceration 3

4. Edge Management (Non-advancing wounds)

If a wound fails to show at least 50% reduction after 4 weeks of appropriate standard care, escalate to advanced therapies. 6, 2

Advanced Therapies (When Standard Care Fails)

Negative Pressure Wound Therapy (NPWT)

NPWT is the most evidence-based advanced therapy and should be your first choice for appropriate wounds. 1, 6, 2

Use NPWT for:

• Post-surgical/post-amputation diabetic foot wounds (strong evidence for reduced healing time) 1
• Deep, large wounds requiring preparation for skin grafts or flaps 6, 2

Do NOT use NPWT for:

• Non-surgical chronic diabetic ulcers (insufficient evidence of benefit) 1

Mechanism: Increases blood supply, reduces edema, absorbs exudate, inhibits infection, promotes granulation tissue 1, 6

Topical Growth Factors (Becaplermin/REGRANEX)

For diabetic lower extremity ulcers only:

• Apply becaplermin gel 0.01% once daily to clean, debrided wounds 7
• Effective only for Stage III-IV diabetic neuropathic ulcers with adequate blood supply (TcPO₂ >30 mmHg) 7
• NOT effective for pressure ulcers or venous stasis ulcers 7
• Increases complete closure rates from 35% to 50% at 20 weeks when combined with good ulcer care 7

Other Advanced Therapies (in order of evidence strength)

1. Topical oxygen therapy: Multiple high-quality RCTs support efficacy for chronic diabetic foot ulcers 6, 2
2. Placental-derived products: Consider when standard care fails to reduce ulcer size 1
3. Electrical stimulation: Moderate-quality evidence as adjunctive therapy 6

Avoid ultrasound/UltraMist therapy: No convincing evidence of benefit despite marketing claims 6

Wound-Specific Interventions

Diabetic Foot Ulcers

• Mandatory offloading of plantar ulcerations (total contact casting or equivalent) 2, 4
• Revascularization if ischemic (ABI <0.9 or TcPO₂ <30 mmHg) 2, 4
• Consider hyperbaric oxygen after revascularization for non-healing ulcers 2

Venous Leg Ulcers

• Compression therapy and leg elevation are primary treatments 1, 4
• Exercise if tolerated 4

Arterial Ulcers

• Immediate vascular surgery referral—medical management alone is insufficient 4

Pressure Ulcers

• Complete offloading of affected area 4
• Reposition every 2 hours 4

Common Pitfalls to Avoid

1. Using advanced therapies without first optimizing the five basic principles (debridement, infection control, moisture balance, offloading, addressing underlying vascular disease) 6, 2
2. Treating uninfected wounds with antibiotics—this increases resistance without improving healing 1
3. Obtaining wound cultures by swabbing rather than tissue biopsy/curettage—swabs yield unreliable results 1
4. Choosing therapies with weak evidence (ultrasound) over those with strong evidence (NPWT, topical oxygen) 6
5. Failing to evaluate for osteomyelitis in non-healing ulcers—probe to bone and obtain imaging 1, 2

Multidisciplinary Management

Chronic wounds require coordinated care including:

• Wound care specialists 2
• Vascular surgeons (for arterial disease) 2, 4
• Infectious disease (for complex infections) 1
• Endocrinology (for diabetic patients) 1
• Physical therapy (for offloading and mobility) 2

After healing, enroll diabetic patients in formal prevention programs to reduce 30% recurrence rate. 7