What is the recommended treatment for chronic wounds?

Treatment of Chronic Wounds

Treat chronic wounds using the TIME principle (Tissue debridement, Infection control, Moisture balance, Edge management) as the foundation, escalating to negative pressure wound therapy if the wound fails to show 50% reduction after 4 weeks of standard care. 1

Initial Assessment

Before initiating treatment, perform these essential evaluations:

• Determine wound characteristics: location, size, depth, drainage, and tissue type to classify the wound properly 1
• Probe the wound after cleansing to assess true depth and involvement of underlying structures 1
• Obtain plain radiographs to evaluate for osteomyelitis, particularly in non-healing ulcers 1
• Culture only infected wounds using tissue specimens or curettage from the debrided ulcer base—never use superficial swabs 1

Core Treatment Algorithm: The TIME Principle

1. Tissue Management (Debridement)

Perform sharp surgical debridement initially and repeat as necessary to convert the biologically chronic wound into an acute wound, which accelerates healing. 1, 2

• For diabetic foot ulcers with bone involvement, consider surgical resection of the ulcer combined with removal of underlying bone 1
• Debridement removes necrotic tissue that harbors bacteria and impairs healing 2

2. Infection/Inflammation Control

Do NOT treat clinically uninfected wounds with antibiotics—this is a critical pitfall to avoid. 1

• Classify infection severity: mild/moderate infections can be treated outpatient with oral antibiotics; severe infections require hospitalization and parenteral therapy 1
• Select antibiotics based on culture results and clinical severity 1
• In diabetic patients, optimize glucose control and metabolic status 1

3. Moisture Balance

• Use physiologic topical dressings to maintain a moist wound environment while controlling exudate 1, 2
• Avoid both excessive dryness and maceration 1

4. Edge Management

If a wound fails to show at least 50% reduction after 4 weeks of appropriate standard care, escalate to advanced therapies. 1, 2

Wound-Specific Interventions

Diabetic Foot Ulcers

• Mandatory offloading of plantar ulcerations using total contact casting or other pressure-relieving devices 1, 2
• Revascularization if ischemic—assess vascular status and refer to vascular surgery when indicated 1, 2
• Consider becaplermin gel (REGRANEX 0.01%) for Stage III-IV diabetic neuropathic ulcers with adequate blood supply (TcpO2 >30 mmHg) as an adjunct to good ulcer care 3
• After healing, enroll patients in a formal comprehensive prevention program to reduce recurrence 2

Venous Leg Ulcers

• Compression therapy and leg elevation are the primary treatments 1
• Exercise if tolerated to improve venous return 4

Pressure Ulcers

• Offloading the affected area is essential—reposition patients regularly and use pressure-redistributing surfaces 2
• Note: Becaplermin showed no benefit for pressure ulcers (15% vs 12% healing, not significant) 3

Advanced Therapies (When Standard Care Fails After 4 Weeks)

Use this hierarchy based on evidence strength:

First-Line Advanced Therapy: Negative Pressure Wound Therapy (NPWT)

NPWT is the most evidence-based advanced therapy and should be the first choice for appropriate wounds. 1, 5

• Use NPWT for: post-surgical/post-amputation diabetic foot wounds, deep large wounds, and wound preparation for skin grafts and flaps 1, 5, 2
• Do NOT use NPWT for: non-surgical chronic diabetic ulcers 1
• NPWT increases blood supply, tissue perfusion, reduces edema, absorbs exudate, inhibits infection, and promotes granulation tissue 5

Second-Line: Topical Oxygen Therapy

• Multiple high-quality RCTs support efficacy for chronic diabetic foot ulcers 1, 5
• Consider when NPWT is not appropriate or has failed 5

Third-Line: Electrical Stimulation

• Moderate-quality evidence as adjunctive therapy for accelerating wound healing 1, 5

Fourth-Line: Placental-Derived Products

• Consider when standard care fails to reduce ulcer size 1
• Less robust evidence compared to above therapies 1

Therapies NOT Recommended

• Ultrasound therapy (including UltraMist): The International Working Group on the Diabetic Foot does not recommend routine use due to lack of convincing evidence 5
• Becaplermin for pressure ulcers or venous stasis ulcers: FDA trials showed no efficacy 3

Common Pitfalls to Avoid

• Using advanced therapies without first optimizing the five basic principles (debridement, infection control, moisture balance, offloading, addressing underlying causes) 1, 2
• Treating uninfected wounds with antibiotics—this promotes resistance without benefit 1
• Obtaining wound cultures by swabbing rather than tissue biopsy/curettage—swabs yield unreliable results 1
• Choosing therapies with weak evidence (like ultrasound) over those with strong evidence (like NPWT) 1, 5
• Failing to evaluate for osteomyelitis in non-healing ulcers—always obtain radiographs 1, 2
• Neglecting vascular assessment—all patients with nonhealing lower extremity ulcers need ankle-brachial index measurement and pedal pulse palpation 4

Multidisciplinary Management

Chronic wounds require coordinated care including wound care specialists, vascular surgeons, infectious disease specialists, endocrinologists, and physical therapists. 1, 2

This team-based approach addresses the multiple factors contributing to impaired healing and optimizes outcomes. 1