Background

• A chronic wound is defined as a break in the skin of greater than 6 weeks
• Multiple factors contribute to poor wound healing including chronic disease, vascular insufficiency, diabetes, advanced age, neurologic defects, nutritional deficiencies, and edema
• Wound care requires a provider to consider every aspect interfering with wound healing in a particular patient

Signs and Symptoms

Differential Diagnosis

Evaluation

1. Take a focused history:
   1. Description of how the wound occurred
   2. Past history of wounds, including previous diagnoses and response to treatment
   3. Dermatologic conditions that predispose to ulceration (e.g. vasculitis) or wounds (e.g. edema)
   4. Presence or absence of pain and pain quality, precipitating and ameliorating factors
   5. Systemic conditions that may predispose to wound development/poor healing (e.g. HIV, rheumatologic diseases, chemotherapy, illicit drug use, nutritional deficiency, inflammatory conditions such as IBD)
   6. Previous hospitalizations and surgeries, including insertion of mesh, prostheses
   7. Current medications with a focus on immunosuppressive medications and topical therapies (e.g. neomycin, bacitracin) that can cause hypersensitivity reactions
2. Social history including home environment, capabilities and support and tobacco, alcohol, and IV drug use
3. Then do a focused physical exam:
   1. Examine the extremity. Look for signs of predisposing systemic disease (e.g. edema, hemosiderosis, lipodermatosclerosis, and varicosities suggest venous disease; cool extremities with slow capillary refill and dependent rubor reflect arterial disease; compromised lower extremity sensation reflects neuropathy)
   2. Clean the ulcer. Remove all slough, eschar, and debris so you can see the borders, base, and surrounding skin. Do this with a syringe filled with warm water or normal saline and a sterile blade or scissors, if needed.
   3. Examine the ulcer. Note the characteristics of the borders, the color and texture of the ulcer base, and the appearance and quantity of wound exudate.
3. Order laboratory evaluations on a case-by-case basis. Often no labs are indicated. If venous or arterial vascular disease is suspected, consider ultrasounds and/or ABI testing to confirm and assess severity.

Treatment

Generally, the goal is to clean and debride the wound, determine if the wound is infected, and choose an appropriate bandage.

• Cleansing: fill a syringe with warm water or normal saline and irrigate copiously. This has been shown to reduce the bacterial load and clears away wound-healing debris
• Debridement: to do sharp debridement use a scalpel, forceps, or scissors to remove nonviable tissue and debris around venous, pressure, and diabetic ulcers. If limited by pain then use a local anesthetic (e.g. 1% lidocaine subcutaneous or benzocaine spray); second line debridement includes wet-to-dry and enzymatic debridement. To use the wet-to-dry method apply a moistened gauze over debris. Once the gauze is dry, removing this gauze will also result in the removal of adhered nonviable tissue. This is typically not recommended as it causes significant pain and removes components valuable to healing (e.g. fibroblasts, keratinocytes). Finally, small studies suggest Papin-urea may provide more extensive debridement than collagenase.
• Colonization versus infection. If increased erythema, edema, warmth, pain, exudate, malodor, or systemic signs then suspect infection. Infection is often polymicrobial with staph aureus and anaerobes most common. Mycobacterial and fungal infections may lack intense signs of inflammation; suspect these in wounds with inexplicable failure to heal. Whenever possible culture the wound
• Bandage the wound. Choose a bandage based on the amount of exudate, patient capabilities, and available supplies. Use the table below to help choose a product. Remember an expensive dressing may cost less overall given faster healing and fewer complications.

Adjuncts to Wound Care

Compression: this is the first-line treatment for venous ulcers. Numerous reports have indicated that compression therapy is superior to dressings as it relieves edema and stasis. Before ordering an Unna boot rule out arterial insufficiency, as the compression can worsen outcomes. If the ABI is below 0.6 or above 1.2 (suggesting noncompressible vessels) then refer to vascular surgery prior to compression.

When to refer

• If more advanced care (e.g. surgical debridement) or expertise is needed. Often wounds are managed completely by podiatry, dermatology, or vascular surgery; consider resuming care once recommendations are in place.

References

Fonder, M et al. “Treating the chronic wound: A practical approach to the care of nonhealing wounds and wound care dressings.” J Am Acad Dermatol, Feb 2008: 185-206.