Continuing medical education
Wound healing and treating wounds: Chronic wound care and management

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In the United States, chronic ulcers—including decubitus, vascular, inflammatory, and rheumatologic subtypes—affect >6 million people, with increasing numbers anticipated in our growing elderly and diabetic populations. These wounds cause significant morbidity and mortality and lead to significant medical costs. Preventative and treatment measures include disease-specific approaches and the use of moisture retentive dressings and adjunctive topical therapies to promote healing. In this article, we discuss recent advances in wound care technology and current management guidelines for the treatment of wounds and ulcers.

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

  1. Removal of devitalized tissue is essential for wound healing to occur.

  2. Debridement, which facilitates removal of this devitalized tissue, can be accomplished using surgical, mechanical, autolytic, enzymatic, and biologic techniques.

Infection

Key points

  1. Addressing local infection using cleansing agents and topical antimicrobials can improve healing

  2. Cadexomer iodine has antimicrobial activity and is helpful in healing chronic venous ulcers and decubitus ulcers

  3. Dilute vinegar topical soaks may reduce recurrent bacterial colonization in chronic wounds, especially for pseudomonas

  4. In frequently infected wounds or those at high risk, silver-impregnated dressings may be given a two-week trial period for efficacy.

  5. For deep infection, systemic treatment is

Moisture balance

Key points

  1. Adequate moisture balance promotes keratinocyte migration and wound healing

  2. A dressing that will keep the wound moist but not too wet or too dry should be chosen

  3. While there are multiple types of moisture retentive dressings, the 5 basic categories are films, foams, hydrocolloids, alginates, and hydrogels

  4. Negative pressure therapy appears to be effective in postsurgical wounds.

Edge of wound

Key points

  1. Biologic skin substitutes mimic the architecture of normal skin and activate healing cascades within the patient

  2. The 3 main categories of biologic skin substitutes include epidermal, dermal, and dermoepidermal combination constructs.

  3. Hyperbaric oxygen is most helpful in patients with diabetic foot ulcers

  4. 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

  1. Compression therapy is the cornerstone of treatment of venous ulcers.

  2. 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.

  3. 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)

  • A. Singh et al.

    Meta-analysis of randomized controlled trials on hydrocolloid occlusive dressing versus conventional gauze dressing in the healing of chronic wounds

    Asian J Surg

    (2004)
  • C.M. Moues et al.

    A review of topical negative pressure therapy in wound healing: sufficient evidence?

    Am J Surg

    (2011)
  • E.N. Mostow et al.

    Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial

    J Vasc Surg

    (2005)
  • P. Waymack et al.

    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

    (2000)
  • H. Kimmel et al.

    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

    (2010)
  • A.W. Bradbury et al.

    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

    (2010)
  • J. Chiriano et al.

    Management of lower extremity wounds in patients with peripheral arterial disease: a stratified conservative approach

    Ann Vasc Surg

    (2010)
  • J.R. Barwell et al.

    Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial

    Lancet

    (2004)
  • P.R. Cavanagh et al.

    Off-loading the diabetic foot for ulcer prevention and healing

    J Vasc Surg

    (2010)
  • L.F. Kanj et al.

    Pressure ulcers

    J Am Acad Dermatol

    (1998)
  • W.M. Hopman et al.

    Associations between chronic disease, age and physical and mental health status

    Chronic Dis Can

    (2009)
  • D.G. Armstrong et al.

    Guest Editorial: are diabetes-related wounds and amputations worse than cancer?

    Int Wound J

    (2007)
  • G. Broughton et al.

    A brief history of wound care

    Plast Reconstr Surg

    (2006)
  • V. Falanga

    Classifications for wound bed preparation and stimulation of chronic wounds

    Wound Repair Regen

    (2000)
  • G.S. Schultz et al.

    Wound bed preparation: a systematic approach to wound management

    Wound Repair Regen

    (2003)
  • J.R. Wilcox et al.

    Frequency of debridements and time to heal: a retrospective cohort study of 312 744 wounds

    JAMA Dermatol

    (2013)
  • K. Bakker et al.

    Practical guidelines on the management and prevention of the diabetic foot 2011

    Diabetes Metab Res Rev

    (2012)
  • T.N. Demidova-Rice et al.

    Bioactive peptides derived from vascular endothelial cell extracellular matrices promote microvascular morphogenesis and wound healing in vitro

    Wound Repair Regen

    (2011)
  • G. Gravante et al.

    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

    (2013)
  • J. Ramundo et al.

    Enzymatic wound debridement

    J Wound Ostomy Continence Nurs

    (2008)
  • C.E. Davies et al.

    Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: a randomised controlled trial

    Phlebology

    (2015)
  • E. Mudge et al.

    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

    (2014)
  • K.F. Cutting et al.

    Defined and refined: criteria for identifying wound infection revisited

    Br J Community Nurs

    (2004)
  • A.J. Singer et al.

    Current management of acute cutaneous wounds

    N Engl J Med

    (2008)
  • R. Fernandez et al.

    Water for wound cleansing

    Cochrane Database Syst Rev

    (2012)
  • R.M. Moscati et al.

    A multicenter comparison of tap water versus sterile saline for wound irrigation

    Acad Emerg Med

    (2007)
  • D. Faddis et al.

    Tissue toxicity of antiseptic solutions. A study of rabbit articular and periarticular tissues

    J Trauma

    (1977)
  • D.U. Kumara et al.

    Evaluation of bactericidal effect of three antiseptics on bacteria isolated from wounds

    J Wound Care

    (2015)
  • M. Mama et al.

    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

    (2014)
  • D.P. Smack et al.

    Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment. A randomized controlled trial

    JAMA

    (1996)
  • R.M. Campbell et al.

    Gentamicin ointment versus petrolatum for management of auricular wounds

    Dermatol Surg

    (2005)
  • C. Dowsett

    Using the TIME framework in wound bed preparation

    Br J Community Nurs

    (2008)
  • S. O’Meara et al.

    Antibiotics and antiseptics for venous leg ulcers

    Cochrane Database Syst Rev

    (2010)
  • S. Moberg et al.

    A randomized trial of cadexomer iodine in decubitus ulcers

    J Am Geriatr Soc

    (1983)
  • S. Bale et al.

    A topical metronidazole gel used to treat malodorous wounds

    Br J Nurs

    (2004)
  • D. Leaper

    Appropriate use of silver dressings in wounds: international consensus document

    Int Wound J

    (2012)
  • S.M. Bergin et al.

    Silver based wound dressings and topical agents for treating diabetic foot ulcers

    Cochrane Database Syst Rev

    (2006)
  • B.A. Lipsky et al.

    Topical antimicrobial therapy for treating chronic wounds

    Clin Infect Dis

    (2009)
  • A.B. Jull et al.

    Honey as a topical treatment for wounds

    Cochrane Database Syst Rev

    (2015)
  • A.J. Nemeth et al.

    Faster healing and less pain in skin biopsy sites treated with an occlusive dressing

    Arch Dermatol

    (1991)
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    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

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