BOTTOM LINE ✔ In order to heal a chronic wound must have adequate vascular supply, be free of dead tissue, clear of infection, and moist. In clinic, your job is to optimize the wound for healing with the provision of full care or appropriate referral. |
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
|
Venous ulcer |
Arterial ulcer |
Diabetic foot ulcer |
Location |
Most common site: medial malleolus. Can occur anywhere there is reflux between the deep and superficial venous systems |
Distal leg often over boney prominences |
Foot |
Appearance |
Borders usually irregular/ill-defined, wound bed usually shallow, surrounding skin often exhibits induration, hemosiderosis, pitting edema |
Round with sharply demarcated border, surrounding skin shiny, hairless, atrophic |
Callus precursor, then ulceration; structural foot deformities |
Common complaint |
Swelling/aching legs worse at end of the day, improves with elevation |
Often significant pain, worse with leg elevation |
Loss of sensation |
Other |
Not unusual if persists for 5 years or longer |
Ulceration of mixed arterial and venous etiology is not uncommon |
|
Differential Diagnosis
|
Pyoderma gangrenosum |
Pressure ulcer |
Vasculitis |
Location |
Most common site: pretibial, but can occur anywhere. |
Skin overlying boney prominences (sacrum, malleoli, hips, heals) |
Often over-dependent areas |
Appearance |
Begin as pustules, expand into sharply circumscribed ulcers, violaceous, undermined borders |
Blanching erythema of intact skin, progression to full-thickness skin loss |
Begin as palpable purpura, can progress to ulceration, look for purpura at the ulcer edge |
Common complaint |
Pustule is tender |
Immobility |
Maybe very painful, often systemic symptoms/evidence of infection, autoimmune disease, culprit medication, or malignancy |
Evaluation
- Take a focused history:
- Description of how the wound occurred
- Past history of wounds, including previous diagnoses and response to treatment
- Dermatologic conditions that predispose to ulceration (e.g. vasculitis) or wounds (e.g. edema)
- Presence or absence of pain and pain quality, precipitating and ameliorating factors
- 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)
- Previous hospitalizations and surgeries, including insertion of mesh, prostheses
- Current medications with a focus on immunosuppressive medications and topical therapies (e.g. neomycin, bacitracin) that can cause hypersensitivity reactions
- Social history including home environment, capabilities and support and tobacco, alcohol, and IV drug use
- Then do a focused physical exam:
- 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)
- 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.
- 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.
- 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.
Product (e.g and cost/wk) |
Advantages |
Disadvantages |
Indications |
Comment |
Gauzes
|
Inexpensive Accessible |
Drying Poor barrier |
Packing deep wounds |
Change every 12-24 hours |
Films
|
Moisture-retentive Transparent Semiocclusive Protects wounds from contamination |
No absorption Fluid trapping |
Wounds with minimal exudate |
Can leave in place for 7 days or until fluid leaks
|
Hydrogels
|
Moisture-retentive Non-traumatic removal Pain relief |
May overhydrate |
Dry wounds Painful wounds |
Change every 1-3 days |
Hydrocolloids
|
Long wear-time Absorbent Occlusive Protects wound from contamination |
Opaque Fluid trapping Malodorous discharge |
Wounds with light to moderate exudate |
Can leave in place for 7 days or until fluid leaks |
Alginates and hydrofibers
|
Highly absorbent Hemostatic |
Fibrous debris
|
Wounds with moderate to heavy exudate Mild hemostasis |
Can leave in place until soaked with exudate |
Foams
|
Absorbent Thermal insulation Occlusive |
Opaque Malodorous discharge |
Wounds with light to moderate exudate |
Change every 3 days |
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.