Continuing medical education
Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings

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Chronic wounds are a major healthcare problem costing the United States billions of dollars a year. The American Academy of Dermatology has underscored the significance of wound care in dermatological practice. It is critical for all dermatologists to understand the elements of diagnosis and therapy. We emphasize major aspects of diagnosis and present a simple classification of wound dressings with guidelines for usage and relative cost data.

Learning objective

After completing this learning activity, participants should be able to diagnose common types of chronic wounds, formulate a therapeutic plan, and describe the major classes of topical therapies and dressings for the chronic wound.

Section snippets

Physiologic wound healing

Normal wound healing requires proper circulation, nutrition, immune status, and avoidance of negative mechanical forces. The process usually takes 3 to 14 days to complete and has three phases: inflammation, proliferation, and remodeling with wound contraction8, 9, 10 (Fig 1). During the inflammatory phase, neutrophils and macrophages appear in the wounded area to phagocytize bacteria and debris. A functioning immune system and adequate supply of growth factors are necessary in this phase of

Approach to the patient with a nonhealing wound

A thorough medical history and physical examination are essential to every patient evaluation. Healthy patients usually heal in a timely manner, while patients with chronic wounds almost always have factors that impair the ability to heal. Thus, the clinician must assess the patient's general health status. History-taking should address:

  • 1.

    Description of how the wound occurred

  • 2.

    Past history of wounds, including previous diagnoses and response to treatment

  • 3.

    Family history of chronic wounds and/or poor

Venous ulcers

Venous stasis ulcers account for more than half of all lower extremity chronic wounds.27 Approximately 1% to 2% of the adult population has a history of active or healed venous ulceration.4, 5 It is not unusual for this type of wound to persist for 5 years or longer.6 Venous stasis ulcers are more common in women than men and increase in incidence with age.4

Venous ulcers usually occur in the setting of longstanding venous hypertension and insufficiency, and are a consequence of venous

Moisture and occlusion

The Greek physician Galen of Pergamum (120-201 A.D.) noted empirically that wounds heal optimally in a moist environment.48 Nevertheless, for nearly 2000 years, therapeutic efforts focused on drying the wound site, with absorptive gauzes a mainstay of wound management.49 It was not until the 1960s that Winter proved the critical role of moisture in healing, when he demonstrated that acute wounds covered with moisture-retentive occlusive dressings healed twice as rapidly as similar wounds left

Past to present

Translations of the ancient Egyptian Ebers Papyrus (1550 B.C.) reveal descriptions of wound dressings composed of lint (vegetable fibers), grease (animal fats), and honey. Modern day scholars believe that the lint may have been used for its absorbency, the grease for its barrier properties, and the honey for its antibacterial effects.48 Thus, even the earliest wound dressings appear to have been designed to manipulate the wound environment in purposeful ways. This same approach is utilized in

Compression

Compression therapy is considered the first-line treatment for venous ulcers. Numerous reports have indicated that compression therapy is superior to virtually any other type of dressing for the treatment of these wounds.155, 156, 157 Compression relieves edema and stasis by reducing distention in superficial veins and assisting the calf muscle pump.155 Compressive dressings also stimulate healthier granulation tissue.158

Because many patients with venous disease have concomitant arterial

Global approach to wound care

The treatment of patients with chronic wounds requires a team approach. There must be a partnership between the patient, the patient's family, the medical team, and outpatient support agencies, with clear communication and an understanding of the fundamentals of care between all individuals. Even the most expert wound care team will fail if communication with the patient and the patient's family is faulty. In order to be successful, there must also be knowledgeable collaboration between wound

Conclusion

Medicine generally and dermatology specifically must place great emphasis on quality wound care. In order to remedy the dearth of wound care expertise among physicians in the United States, we must modify how we teach medical students, residents, and colleagues. We are in major need of evidence-based wound care. Often, wound therapy is anecdotal and predicated upon the “dressing of the month.” Medicine must establish suitable protocols that allow us to quantifiably determine which materials are

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    Funding sources: None.

    Conflicts of interest: None declared.

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