What are the next steps for a wound that is not healing with standard of care?

Management of Non-Healing Diabetic Foot Ulcers

For diabetic foot ulcers failing standard care after 2 weeks, consider sucrose-octasulfate dressings for non-infected neuro-ischemic ulcers, autologous leucocyte/platelet/fibrin patch, placental-derived products, hyperbaric oxygen for ischemic ulcers, or topical oxygen therapy—but only where resources exist and after confirming optimal sharp debridement and offloading are in place. 1

First: Verify True Standard of Care Failure

Before adding adjunctive therapies, confirm these fundamentals are optimized:

• Sharp debridement must be aggressive and regular to remove all callus, slough, and necrotic tissue—this is the single most important modifiable factor 1, 2
• Offloading must be adequate: total contact cast is gold standard for plantar ulcers; if contraindicated, use irremovable walker 2
• Basic moisture-retentive dressings should be in place (hydrogels for dry wounds, absorptive dressings for exudative wounds) 1, 2
• Vascular assessment must confirm adequate perfusion or revascularization has been attempted 2
• Infection control should be addressed if present 3

The IWGDF defines "failure" as insufficient change in ulcer area after at least 2 weeks of best standard care. 1

Evidence-Based Adjunctive Therapies (When Standard Care Fails)

For Non-Infected Neuro-Ischemic Ulcers:

• Sucrose-octasulfate impregnated dressings can be considered as adjunctive treatment (Conditional recommendation; Moderate quality evidence) 1
  • This is one of the few dressings with conditional support from IWGDF 2024 guidelines
  • Only use after 2+ weeks of failed standard care including proper offloading

For Ischemic Ulcers:

• Hyperbaric oxygen therapy may be considered where standard care has failed and resources exist (Conditional; Low quality evidence) 1, 2

  • Should only be used after revascularization attempts 2
  • Requires existing infrastructure to support intervention

• Topical oxygen therapy can be considered where standard care has failed and resources exist (Conditional; Low quality evidence) 1

For Difficult-to-Heal Ulcers (General):

• Autologous leucocyte, platelet, and fibrin patch is the only platelet-based therapy with conditional support (Conditional; Moderate quality evidence) 1

  • Requires resources and expertise for regular venepuncture
  • All other platelet therapies are NOT recommended 1

• Placental-derived products can be considered as adjunctive therapy (Conditional; Low quality evidence) 1

For Post-Surgical Wounds Only:

• Negative Pressure Wound Therapy (NPWT) should be considered for post-operative wounds after surgical debridement or amputation (Conditional; Low quality evidence) 1
  • Critical pitfall: Do NOT use NPWT on non-surgical diabetic foot ulcers—this is contraindicated and can cause harm by removing moisture from dry wounds (Strong recommendation against) 1, 2

What NOT to Use (Strong Recommendations Against)

The IWGDF 2024 guidelines provide strong recommendations AGAINST many commonly used interventions:

• Do NOT use antimicrobial/antiseptic dressings, honey, collagen, or alginate dressings (Strong; Moderate to Low evidence) 1, 2
• Do NOT use growth factor therapy as routine adjunct (Conditional against; Low evidence) 1
• Do NOT use cellular or acellular skin substitutes as routine adjuncts (Conditional against; Low evidence) 1
• Do NOT use pharmacological agents promoting angiogenesis, vitamins/trace elements, or protein supplementation (Strong; Low evidence) 1
• Do NOT use physical therapies including ultrasound, shockwaves, electricity, or magnetism (Strong; Low evidence) 1
• Do NOT use enzymatic, ultrasonic, or surgical debridement over sharp debridement (Strong; Low evidence) 1

Clinical Algorithm for Non-Healing Wounds

Week 0-2:

1. Ensure aggressive sharp debridement at appropriate frequency 1, 2
2. Optimize offloading (total contact cast for plantar ulcers) 2
3. Apply appropriate moisture-retentive dressing 1, 2
4. Assess and address vascular insufficiency 2
5. Control infection if present 3

Week 2-4: If insufficient ulcer area reduction:

1. Reassess and re-optimize all standard care elements 4
2. Consider one evidence-supported adjunctive therapy based on ulcer characteristics:
   • Non-infected neuro-ischemic: sucrose-octasulfate dressing 1
   • Ischemic (post-revascularization): hyperbaric or topical oxygen 1, 2
   • Post-surgical: NPWT 1
   • Other difficult-to-heal: autologous leucocyte/platelet/fibrin patch or placental products 1

Week 4+: If still not healing:

1. Repeat comprehensive reassessment of underlying pathology 4, 5
2. Consider alternative adjunctive therapy from evidence-supported options 1
3. Evaluate for surgical intervention if appropriate 1

Critical Pitfalls to Avoid

• Jumping to expensive biologics before optimizing debridement and offloading—this is the most common error 2
• Using silver/antimicrobial dressings on non-infected wounds—does not accelerate healing and wastes resources 2
• Applying NPWT to non-surgical, dry wounds—this is contraindicated and harmful 2
• Failing to reassess after 4 weeks—wounds not responding by this point require systematic re-evaluation of underlying pathology 4, 5
• Using multiple unproven therapies simultaneously—stick to evidence-based interventions with at least conditional support 1

The evidence base remains limited with mostly low-quality studies, but the 2024 IWGDF guidelines represent the most comprehensive and recent synthesis of available data. 1