Overview of treatment of chronic wounds
- Karen Evans, MD
Karen Evans, MD
- Associate Professor
- Georgetown University Medical Center
- Paul Kim, DPM, MS
Paul Kim, DPM, MS
- Associate Professor
- Department of Plastic Surgery
- Georgetown University School of Medicine
- Section Editors
- Charles E Butler, MD, FACS
Charles E Butler, MD, FACS
- Section Editor — Plastic and Reconstructive Surgery
- The University of Texas, MD Anderson Cancer Center
- Russell S Berman, MD
Russell S Berman, MD
- Section Editor — Skin and Soft Tissue Surgery
- Chief of Surgical Oncology
- New York University Langone Medical Center
- Eduardo Bruera, MD
Eduardo Bruera, MD
- Section Editor — Non Pain Symptoms: Assessment and Management
- Professor of Oncology
- University of Texas, MD Anderson Cancer Center at Houston
A chronic wound may be defined as one that is physiologically impaired due to a disruption of the wound healing cycle as a result of impaired angiogenesis, innervation, or cellular migration, among other reasons . Normal wound healing is described separately. (See "Wound healing and risk factors for non-healing", section on 'Impaired wound healing' and "Wound healing and risk factors for non-healing", section on 'Risk factors for non-healing'.)
The precise timeline for complete epithelialization varies depending on numerous factors including comorbidities (eg, diabetes, autoimmune disease, peripheral artery disease), increased body mass index, anatomic location, and medications. However, regardless of etiology, wound healing normally progresses at a sustained, measureable rate. Some suggest that the lack of approximately 15 percent reduction weekly or approximately 50 percent reduction of the surface area of the wound over a one-month period indicates a chronic state .
Examples of chronic wounds include nonhealing or infected surgical or traumatic wounds, venous ulcers, pressure ulcers, diabetic foot ulcers, and ischemic ulcers. Chronic wounds related to malignancy require appropriate treatment of the malignancy, but in some cases, palliation may be all that can be offered [3,4]. The clinical assessment and differentiation of these wounds is reviewed elsewhere. (See "Clinical assessment of wounds".)
LOCAL CARE OF CHRONIC WOUNDS
As with acute wounds, local care of chronic wounds includes debridement and proper wound dressings. Frankly necrotic debris should be aggressively removed. Proper local care is an important element of preparing the wound bed to accept a skin graft or flap, or for closure, when indicated. (See "Basic principles of wound management", section on 'Wound debridement' and "Basic principles of wound management", section on 'Wound dressings' and 'Wound bed preparation' below.)
Local treatment should also be directed toward dealing with the most troublesome chronic wound problems that affect the patient physically and emotionally, such as odor, bleeding, itching, excess exudate, pain, and also toward minimizing infection.
- Golinko MS, Clark S, Rennert R, et al. Wound emergencies: the importance of assessment, documentation, and early treatment using a wound electronic medical record. Ostomy Wound Manage 2009; 55:54.
- Sheehan P, Jones P, Giurini JM, et al. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Plast Reconstr Surg 2006; 117:239S.
- Brem H, Balledux J, Bloom T, et al. Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing. Arch Surg 2000; 135:627.
- Brem H, Jacobs T, Vileikyte L, et al. Wound-healing protocols for diabetic foot and pressure ulcers. Surg Technol Int 2003; 11:85.
- Wood DK. The draining malignant ulceration. Palliative management in advanced cancer. JAMA 1980; 244:820.
- Finlay IG, Bowszyc J, Ramlau C, Gwiezdzinski Z. The effect of topical 0.75% metronidazole gel on malodorous cutaneous ulcers. J Pain Symptom Manage 1996; 11:158.
- Ashford R, Plant G, Maher J, Teare L. Double-blind trial of metronidazole in malodorous ulcerating tumours. Lancet 1984; 1:1232.
- Masuelli L, Tumino G, Turriziani M, et al. Topical use of sucralfate in epithelial wound healing: clinical evidences and molecular mechanisms of action. Recent Pat Inflamm Allergy Drug Discov 2010; 4:25.
- Shanmugam VK, Schilling A, Germinario A, et al. Prevalence of immune disease in patients with wounds presenting to a tertiary wound healing centre. Int Wound J 2012; 9:403.
- Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003; 11 Suppl 1:S1.
- Armstrong DG, Lavery LA, Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366:1704.
- Kim PJ, Attinger CE, Steinberg JS, et al. The impact of negative-pressure wound therapy with instillation compared with standard negative-pressure wound therapy: a retrospective, historical, cohort, controlled study. Plast Reconstr Surg 2014; 133:709.
- Joseph E, Hamori CA, Berman S, et al. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic non-healing wounds. Wounds 2000; 12:60.
- Kanakaris NK, Thanasas C, Keramaris N, et al. The efficacy of negative pressure wound therapy in the management of lower extremity trauma: review of clinical evidence. Injury 2007; 38 Suppl 5:S9.
- Vuerstaek JD, Vainas T, Wuite J, et al. State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg 2006; 44:1029.
- Ford CN, Reinhard ER, Yeh D, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg 2002; 49:55.
- Wanner MB, Schwarzl F, Strub B, et al. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: a prospective study. Scand J Plast Reconstr Surg Hand Surg 2003; 37:28.
- Mandal A. Role of topical negative pressure in pressure ulcer management. J Wound Care 2007; 16:33.
- Bovill E, Banwell PE, Teot L, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J 2008; 5:511.
- Jeschke MG, Rose C, Angele P, et al. Development of new reconstructive techniques: use of Integra in combination with fibrin glue and negative-pressure therapy for reconstruction of acute and chronic wounds. Plast Reconstr Surg 2004; 113:525.
- Schneider AM, Morykwas MJ, Argenta LC. A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg 1998; 102:1195.
- Barendse-Hofmann MG, van Doorn L, Steenvoorde P. Circumferential application of VAC on a large degloving injury on the lower extremity. J Wound Care 2009; 18:79.
- DeFranzo AJ, Marks MW, Argenta LC, Genecov DG. Vacuum-assisted closure for the treatment of degloving injuries. Plast Reconstr Surg 1999; 104:2145.
- Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg 2000; 105:174.
- Scherer LA, Shiver S, Chang M, et al. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg 2002; 137:930.
- Llanos S, Danilla S, Barraza C, et al. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann Surg 2006; 244:700.
- Moisidis E, Heath T, Boorer C, et al. A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting. Plast Reconstr Surg 2004; 114:917.
- Stevens P. Vacuum-assisted closure of laparostomy wounds: a critical review of the literature. Int Wound J 2009; 6:259.
- Rotondo MF, Schwab CW, McGonigal MD, et al. 'Damage control': an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35:375.
- Niezgoda JA, Serena TE, Carter MJ. Outcomes of Radiation Injuries Using Hyperbaric Oxygen Therapy: An Observational Cohort Study. Adv Skin Wound Care 2016; 29:12.
- Tibbles PM, Edelsberg JS. Hyperbaric-oxygen therapy. N Engl J Med 1996; 334:1642.
- Wattel F, Mathieu D, Nevière R, Bocquillon N. Acute peripheral ischaemia and compartment syndromes: a role for hyperbaric oxygenation. Anaesthesia 1998; 53 Suppl 2:63.
- Leach RM, Rees PJ, Wilmshurst P. Hyperbaric oxygen therapy. BMJ 1998; 317:1140.
- Oriani, G, Meazza, D, Favales, F, et al. Hyperbaric therapy in diabetic gangrene. J Hyperb Med 1990; 5:171.
- Hammarlund C, Sundberg T. Hyperbaric oxygen reduced size of chronic leg ulcers: a randomized double-blind study. Plast Reconstr Surg 1994; 93:829.
- Löndahl M, Katzman P, Nilsson A, et al. A prospective study: hyperbaric oxygen therapy in diabetics with chronic foot ulcers. J Wound Care 2006; 15:457.
- Thom SR. Hyperbaric oxygen: its mechanisms and efficacy. Plast Reconstr Surg 2011; 127 Suppl 1:131S.
- Bennett MH, Feldmeier J, Hampson N, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev 2005; :CD005005.
- Bennett MH, Feldmeier J, Hampson N, et al. Hyperbaric oxygen therapy for late radiation tissue injury. Cochrane Database Syst Rev 2012; :CD005005.
- Hoggan BL, Cameron AL. Systematic review of hyperbaric oxygen therapy for the treatment of non-neurological soft tissue radiation-related injuries. Support Care Cancer 2014; 22:1715.
- Kessler L, Bilbault P, Ortéga F, et al. Hyperbaric oxygenation accelerates the healing rate of nonischemic chronic diabetic foot ulcers: a prospective randomized study. Diabetes Care 2003; 26:2378.
- Duzgun AP, Satir HZ, Ozozan O, et al. Effect of hyperbaric oxygen therapy on healing of diabetic foot ulcers. J Foot Ankle Surg 2008; 47:515.
- Abidia A, Laden G, Kuhan G, et al. The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: a double-blind randomised-controlled trial. Eur J Vasc Endovasc Surg 2003; 25:513.
- Wang C, Schwaitzberg S, Berliner E, et al. Hyperbaric oxygen for treating wounds: a systematic review of the literature. Arch Surg 2003; 138:272.
- Kranke P, Bennett MH, Martyn-St James M, et al. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2012; :CD004123.
- Margolis DJ, Gupta J, Hoffstad O, et al. Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care 2013; 36:1961.
- Mills JL Sr, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59:220.
- Lipsky BA, Berendt AR, Cornia PB, et al. Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:1679.
- Kim PJ, Attinger CE, Steinberg JS, Evans KK. Negative Pressure Wound Therapy with Instillation: Past, Present, and Future. Surg Technol Int 2015; 26:51.
- Dalla Paola L. Diabetic foot wounds: the value of negative pressure wound therapy with instillation. Int Wound J 2013; 10 Suppl 1:25.
- Kim PJ, Attinger CE, Oliver N, et al. Comparison of Outcomes for Normal Saline and an Antiseptic Solution for Negative-Pressure Wound Therapy with Instillation. Plast Reconstr Surg 2015; 136:657e.
- Paton J, Bruce G, Jones R, Stenhouse E. Effectiveness of insoles used for the prevention of ulceration in the neuropathic diabetic foot: a systematic review. J Diabetes Complications 2011; 25:52.
- Seaman S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs 2006; 22:185.
- Merz T, Klein C, Uebach B, et al. Fungating Wounds - Multidimensional Challenge in Palliative Care. Breast Care (Basel) 2011; 6:21.
- Zech DF, Grond S, Lynch J, et al. Validation of World Health Organization Guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63:65.
- Adderley UJ, Holt IG. Topical agents and dressings for fungating wounds. Cochrane Database Syst Rev 2014; :CD003948.
- Renner R, Sticherling M, Rüger R, Simon J. Persistence of bacteria like Pseudomonas aeruginosa in non-healing venous ulcers. Eur J Dermatol 2012; 22:751.
- Thakral G, La Fontaine J, Kim P, et al. Treatment options for venous leg ulcers: effectiveness of vascular surgery, bioengineered tissue, and electrical stimulation. Adv Skin Wound Care 2015; 28:164.
- LOCAL CARE OF CHRONIC WOUNDS
- SURGICAL INTERVENTION
- Wound bed preparation
- - Operative debridement
- - Negative pressure wound therapy
- - Hyperbaric oxygen therapy
- Wound coverage/closure
- SPECIFIC WOUND MANAGEMENT
- Diabetic foot wounds
- Ischemic ulcers and gangrene
- Chronic orthopedic wounds
- Abdominal wounds
- Pressure ulcers
- Ulcerated and fungating malignancy-related wounds
- Venous stasis ulcers
- SUMMARY AND RECOMMENDATIONS