Classification and Management of Chronic Wounds

Introduction

Every acute wound has the potential to transition into a chronic phase. The primary categories of chronic wounds include arterial, venous, and diabetic ulcers, as well as pressure ulcers. A special group consists of so-called atypical wounds. These are located in abnormal sites, exhibit an abnormal appearance, and do not heal after 3-6 months of standard therapy. For atypical wounds, a biopsy is recommended to assess the etiopathogenesis of the wound and potentially refer for specialized examination.

Understanding the pathogenesis of skin integrity disruption plays a crucial role in therapy. The specific therapy is guided by the etiology of the chronic wound, addressing the underlying cause. An essential part of treatment is local therapy, which includes wound assessment, debridement, and the application of moist wound healing. The choice of specific dressing depends on the nature of the wound.

Commonly used local methods of moist wound healing include hydrocolloids and hydrogels. Hydrocolloid dressings contain hydrophilic colloid particles that slowly absorb fluid from the wound, transforming into a gel-like mass. This creates a moist environment in the wound, stimulating autolytic debridement, granulation, and epithelialization. The absorption of wound exudate ensures wound closure, and the gel layer prevents secondary infection from entering the wound. Hydrogels, which are gel dressings based on hydrophilic polymers with a high water content, work on a similar principle.

Management of Chronic Wounds

Systemic therapy is dictated by the wound’s etiology, while local therapy shares several common aspects. Local therapy should initially follow the TIME principle (Tissue debridement, Infection control, Moisture balance, Edges of the wound). Careful wound debridement should be the foundation of therapy for all types of chronic wounds, except for arterial ulcers. It involves the removal of dead tissue, and according to studies, it significantly affects the speed and success of wound healing.

Williams et al., for example, demonstrated in their study that aggressive debridement doubles the likelihood of successful wound healing. Debridement removes not only necrotic tissue but also invisible biofilm, which can maintain the inflammatory phase in the wound and impede healing. A report from the U.S. National Institutes of Health’s Center for Integrative Biology and Infectious Diseases indicates that 80% of wound infections are caused by biofilm. Debridement is most commonly performed surgically, but autolytic debridement can also be utilized in moist wound healing using active cleansing dressings, hydrocolloid, and hydrogel dressings.

Preventing and treating wound infection is essential, whether through local therapy or systemic antibiotic therapy. Maintaining a moist environment in the wound is another crucial component of treatment, contrary to the previous erroneous recommendation of “drying” the wound for healing.

Moist wound healing accelerates wound healing and reduces the likelihood of infection through a complex mechanism, such as the absorption of exudate or barrier function. The specific method of moist wound healing depends on the appearance of the wound. Hydrocolloid and hydrogel dressings are used for wounds with mild to moderate exudation, dry and necrotic wounds. The final important aspect is the care of the wound edges – they should not be undermined. If the wound edges are undermined or rolled, excision is necessary to allow epithelialization from the wound edges.

Conclusion

Chronic wounds are a common problem whose management is often underestimated. Successful therapy requires understanding the etiopathogenesis of chronic wounds, treating the underlying cause, and careful local therapy following the TIME principle.

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Sources:

1. Bowers S., Franco E. Chronic wounds: evaluation and management. Am Fam Physician 2020 Feb 1; 101 (3): 159-166.
2. Williams D., Enoch S., Miller D. et al. Effect of sharp debridement using curette on recalcitrant nonhealing venous leg ulcers: a concurrently controlled, prospective cohort study. Wound Repair Regen 2005; 13 (2): 131-137, doi: 10.1111/j.1067-1927.2005.130203.x.