Continuing medical educationWound healing and treating wounds: Chronic wound care and management
Introduction
In the United States, chronic wounds affect >6 million people, with increasing numbers anticipated because of our aging population and the high prevalence of diabetes mellitus. A 2004 analysis found that chronic wounds are the largest direct medical cost center of all human skin diseases, costing $9.7 billion in the United States in 1 year alone.1 Chronic wounds can impact quality of life as profoundly as renal and heart disease.2 Mortality for some patients with chronic wounds now rivals that of cancer patients.3
Healing wounds is historically one of the most basic and essential practices of human civilization. From Egyptian papyri to the battlefields of Crimea, there are accounts of wound care from preventing infection to creating bandages and homemade dressings with honey, grease, and lint.4 Today, there is a growing body of literature to inform these and more technologically advanced practices.
Once the underlying disease has been addressed (see part I of this 2-part continuing medical education article and Table I), wound bed preparation is a critical concept. Chronic wounds tend to be stuck in the inflammatory phase of wound healing.5 To optimize wound healing, the wound should be clean, with a healthy granulating base, and free of infection. Dressings should be chosen to keep the wound moist but not too wet or too dry. If the wound fails to heal after addressing these issues, advanced technologies can be considered. Tissue, infection, moisture imbalance, and edge advancement (TIME), which addresses important barriers to wound healing, was developed in 2002 by a wound care consensus group.6 We advocate following TIME guidelines for the treatment of chronic wounds.
Section snippets
Tissue
Key points Removal of devitalized tissue is essential for wound healing to occur. Debridement, which facilitates removal of this devitalized tissue, can be accomplished using surgical, mechanical, autolytic, enzymatic, and biologic techniques.
Infection
Key points Addressing local infection using cleansing agents and topical antimicrobials can improve healing Cadexomer iodine has antimicrobial activity and is helpful in healing chronic venous ulcers and decubitus ulcers Dilute vinegar topical soaks may reduce recurrent bacterial colonization in chronic wounds, especially for pseudomonas In frequently infected wounds or those at high risk, silver-impregnated dressings may be given a two-week trial period for efficacy. For deep infection, systemic treatment is
Moisture balance
Key points Adequate moisture balance promotes keratinocyte migration and wound healing A dressing that will keep the wound moist but not too wet or too dry should be chosen While there are multiple types of moisture retentive dressings, the 5 basic categories are films, foams, hydrocolloids, alginates, and hydrogels Negative pressure therapy appears to be effective in postsurgical wounds.
Edge of wound
Key points Biologic skin substitutes mimic the architecture of normal skin and activate healing cascades within the patient The 3 main categories of biologic skin substitutes include epidermal, dermal, and dermoepidermal combination constructs. Hyperbaric oxygen is most helpful in patients with diabetic foot ulcers Becaplermin gel is approved by the US Food and Drug Administration for the treatment of diabetic foot ulcers
Advancing the edges of any wound requires addressing not only local but also systemic
Disease-specific medical management
Key points Compression therapy is the cornerstone of treatment of venous ulcers. Pressure relief with proper footwear and contact casting, correction of arterial disease, treatment of infection, and wound debridement are mainstays of diabetic foot ulcer treatment. Frequent repositioning with specialized support surfaces and pressure-reducing mattresses are key interventions in the treatment and prevention of pressure ulcers.
Disease-specific, medical management of chronic wounds is discussed below. Treatment
References (141)
- et al.
The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology
J Am Acad Dermatol
(2006) - et al.
Clinical and economic assessment of diabetic foot ulcer debridement with collagenase: results of a randomized controlled study
Clin Ther
(2013) - et al.
Oxygen embolism after hydrogen peroxide irrigation of a vulvar abscess
Br J Anaesth
(2002) - et al.
Laceration management
Ann Emerg Med
(1999) - et al.
A comparison of postprocedural wound care treatments: do antibiotic-based ointments improve outcomes?
J Am Acad Dermatol
(2011) - et al.
Double-blind trial of metronidazole in malodorous ulcerating tumours
Lancet
(1984) - et al.
A double-blind study of the efficacy of metronidazole gel in the treatment of malodorous fungating tumours
Eur J Cancer
(1992) - et al.
Silver treatments and silver-impregnated dressings for the healing of leg wounds and ulcers: a systematic review and meta-analysis
J Am Acad Dermatol
(2010) - et al.
A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers
J Vasc Surg
(1992) - et al.
Split-thickness skin graft donor site care: a quantitative synthesis of the research
Appl Nurs Res
(1998)
Meta-analysis of randomized controlled trials on hydrocolloid occlusive dressing versus conventional gauze dressing in the healing of chronic wounds
Asian J Surg
A review of topical negative pressure therapy in wound healing: sufficient evidence?
Am J Surg
Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial
J Vasc Surg
The effect of a tissue engineered bilayered living skin analog, over meshed split-thickness autografts on the healing of excised burn wounds. The Apligraf Burn Study Group
Burns
The clinical effectiveness in wound healing with extracellular matrix derived from porcine urinary bladder matrix: a case series on severe chronic wounds
J Am Col Certif Wound Spec
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy
J Vasc Surg
Management of lower extremity wounds in patients with peripheral arterial disease: a stratified conservative approach
Ann Vasc Surg
Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial
Lancet
Off-loading the diabetic foot for ulcer prevention and healing
J Vasc Surg
Pressure ulcers
J Am Acad Dermatol
Associations between chronic disease, age and physical and mental health status
Chronic Dis Can
Guest Editorial: are diabetes-related wounds and amputations worse than cancer?
Int Wound J
A brief history of wound care
Plast Reconstr Surg
Classifications for wound bed preparation and stimulation of chronic wounds
Wound Repair Regen
Wound bed preparation: a systematic approach to wound management
Wound Repair Regen
Frequency of debridements and time to heal: a retrospective cohort study of 312 744 wounds
JAMA Dermatol
Practical guidelines on the management and prevention of the diabetic foot 2011
Diabetes Metab Res Rev
Bioactive peptides derived from vascular endothelial cell extracellular matrices promote microvascular morphogenesis and wound healing in vitro
Wound Repair Regen
Multicenter clinical trial on the performance and tolerability of the Hyaluronic acid-collagenase ointment for the treatment of chronic venous ulcers: a preliminary pilot study
Eur Rev Med Pharmacol Sci
Enzymatic wound debridement
J Wound Ostomy Continence Nurs
Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: a randomised controlled trial
Phlebology
A randomized controlled trial of larval therapy for the debridement of leg ulcers: results of a multicenter, randomized, controlled, open, observer blind, parallel group study
Wound Repair Regen
Defined and refined: criteria for identifying wound infection revisited
Br J Community Nurs
Current management of acute cutaneous wounds
N Engl J Med
Water for wound cleansing
Cochrane Database Syst Rev
A multicenter comparison of tap water versus sterile saline for wound irrigation
Acad Emerg Med
Tissue toxicity of antiseptic solutions. A study of rabbit articular and periarticular tissues
J Trauma
Evaluation of bactericidal effect of three antiseptics on bacteria isolated from wounds
J Wound Care
Antimicrobial susceptibility pattern of bacterial isolates from wound infection and their sensitivity to alternative topical agents at Jimma University Specialized Hospital, South-West Ethiopia
Ann Clin Microbiol Antimicrob
Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial
JAMA
Gentamicin ointment versus petrolatum for management of auricular wounds
Dermatol Surg
Using the TIME framework in wound bed preparation
Br J Community Nurs
Antibiotics and antiseptics for venous leg ulcers
Cochrane Database Syst Rev
A randomized trial of cadexomer iodine in decubitus ulcers
J Am Geriatr Soc
A topical metronidazole gel used to treat malodorous wounds
Br J Nurs
Appropriate use of silver dressings in wounds: international consensus document
Int Wound J
Silver based wound dressings and topical agents for treating diabetic foot ulcers
Cochrane Database Syst Rev
Topical antimicrobial therapy for treating chronic wounds
Clin Infect Dis
Honey as a topical treatment for wounds
Cochrane Database Syst Rev
Faster healing and less pain in skin biopsy sites treated with an occlusive dressing
Arch Dermatol
Cited by (387)
Microenvironment-responsive smart hydrogels with antibacterial activity and immune regulation for accelerating chronic wound healing
2024, Journal of Controlled ReleaseLentinan-loaded GelMA hydrogel accelerates diabetic wound healing through enhanced angiogenesis and immune microenvironment modulation
2024, International Journal of Biological MacromoleculesCollaborative biofluid analysis based multi-channel integrated wearable detection system for the monitoring of wound infection
2024, Biosensors and Bioelectronics: XThe advancement of intelligent dressings for monitoring chronic wound infections
2024, Chemical Engineering JournalMelt electrowriting (MEW)-PCL composite Three-Dimensional exosome hydrogel scaffold for wound healing
2024, Materials and Design
Drs Powers and Higham contributed equally to this work.
Funding sources: None.
Conflicts of interest: None declared.
Date of release: April 2016
Expiration date: April 2019