What are the best practices for managing a chronic unhealed wound?

Management of Chronic Unhealed Wounds

Clean the wound regularly with water or saline, perform sharp debridement to remove all necrotic tissue and callus, and dress with simple absorbent dressings selected based on exudate control, comfort, and cost—avoiding expensive antimicrobial or biologic agents that lack evidence for improved healing. 1

Initial Assessment and Vascular Evaluation

Before initiating wound care, you must determine if the wound has adequate perfusion to heal. 2, 3

• Palpate pedal pulses and measure ankle-brachial index (ABI) in all patients with chronic leg wounds. 2, 3
• Obtain toe pressures and transcutaneous oxygen pressure (TcPO2) if available. 2, 3
• Critical thresholds requiring urgent vascular surgery referral: ABI <0.5, ankle pressure <50 mmHg, toe pressure <30 mmHg, or TcPO2 <25 mmHg. 2, 3
• Revascularization must occur before or concurrent with wound healing efforts—inadequate perfusion prevents healing regardless of other interventions. 2, 3

Core Wound Care Protocol

Debridement Strategy

Sharp debridement is the preferred method and should be performed aggressively at each visit. 1

• Remove all slough, necrotic tissue, and surrounding callus using sharp debridement. 1
• Take relative contraindications into account: severe ischemia (requiring revascularization first) or significant pain. 1
• Do not let concerns about the residual defect limit your debridement—aggressive removal of nonviable tissue is essential to convert chronic wounds into acute wounds that can progress through normal healing stages. 4
• Avoid expensive alternative debridement methods (hydrogels, enzymatic agents, larval therapy) as they lack robust evidence of superiority over sharp debridement. 1

The evidence for sharp debridement is surprisingly limited (low quality), but professional consensus strongly supports it as essential wound care. 1

Wound Cleansing and Dressing Selection

Use simple, cost-effective dressings rather than expensive advanced products. 1, 5

• Clean wounds regularly with clean water or saline to remove debris from the wound surface. 1, 5
• Select dressings primarily based on exudate control, comfort, and cost. 1, 5
• For heavily exuding wounds causing maceration, use absorbent dressings such as foam dressings or alginates that draw moisture away from periwound skin. 5
• Maintain a warm, moist environment with sterile, inert dressings to promote healing. 1
• Avoid occlusive dressings if maceration is present. 5

What NOT to Use

Do not use antimicrobial dressings (silver, iodine, honey) with the goal of improving wound healing or preventing secondary infection. 1, 5 This is a strong recommendation with moderate quality evidence—these expensive dressings do not accelerate healing in noninfected wounds. 1

Do not select growth factors, bioengineered skin products, electrical stimulation, ultrasound, or systemic herbal therapies in preference to standard care. 1 Despite marketing claims, these interventions lack evidence of superiority over basic wound care principles. 1

Infection Management

Treat clinically infected wounds with systemic antibiotics and surgical debridement, not antimicrobial dressings alone. 2, 3

• Obtain wound cultures from the debrided tissue base, not surface swabs. 2, 3
• For severe infections, switch to parenteral broad-spectrum antibiotics covering gram-positive organisms (including MRSA) and gram-negative bacteria. 2
• Continue antibiotics for 2-4 weeks depending on adequacy of debridement and wound vascularity. 2
• Monitor daily for signs of infection (fever, spreading erythema, purulent drainage), which can be exacerbated by maceration. 5, 2

Advanced Therapies: Limited Role

Consider negative pressure wound therapy (NPWT) only for post-operative wounds or heavily exuding wounds after revascularization—its effectiveness and cost-effectiveness remain unestablished. 1, 5 The 2018 World Journal of Emergency Surgery suggests NPWT may help after complete necrosis removal in necrotizing infections, but evidence of superiority over conventional dressings is lacking. 1

Consider hyperbaric oxygen therapy in select cases, though further trials are needed to confirm cost-effectiveness and identify which patients benefit most. 1

One exception: Sucrose-octasulfate–impregnated dressing may be considered as adjunctive treatment for noninfected, neuro-ischemic diabetic foot ulcers that are difficult to heal (weak recommendation, moderate evidence). 1

Medical Optimization

Address systemic factors that impair healing: 2, 3

• Smoking cessation is mandatory and non-negotiable—smoking profoundly impairs wound healing through vasoconstriction and tissue hypoxia. 2
• Optimize glycemic control if diabetic (target HbA1c <7%). 2
• Ensure adequate nutrition, pain control, and edema management. 2, 3
• Modify cardiovascular risk factors. 2, 3

Specific Wound Types

Venous Leg Ulcers

Compression therapy (30-40 mmHg) is the cornerstone of treatment, combined with leg elevation and exercise. 3

Diabetic Foot Ulcers

Pressure offloading is essential in addition to appropriate moisture management and debridement. 5, 2

Arterial/Ischemic Wounds

Immediate vascular surgery referral for revascularization is the priority—wound care alone will fail without adequate perfusion. 2, 3

Follow-Up and Reassessment

Perform wound reassessment at least weekly to evaluate healing progress and adjust treatment. 2

If wounds fail to achieve sufficient healing after 4 weeks of standard care, reassess underlying pathology and consider whether vascular insufficiency, uncontrolled infection, or systemic factors are preventing healing. 6 Do not simply add expensive advanced therapies without addressing the root cause. 5

Coordinate care through an interdisciplinary team including vascular surgery, infectious disease, wound care specialists, and podiatry as needed. 2, 3

Common Pitfalls

• Failing to address underlying vascular insufficiency will result in continued wound failure despite optimal local wound care. 5, 2, 3
• Using antimicrobial dressings routinely wastes resources without improving outcomes in noninfected wounds. 1, 5
• Inadequate debridement leaves chronic wounds in a perpetual inflammatory state—be aggressive. 4, 7
• Applying wet dressings for >24-48 hours can cause maceration of surrounding skin. 8