Overview of Treatment of Chronic Wounds

19/10/2020 Overview of treatment of chronic wounds - UpToDate
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Overview of treatment of chronic wounds

Authors: Karen Evans, MD, Paul J Kim, DPM, MS
Section Editors: Charles E Butler, MD, FACS, Russell S Berman, MD, Eduardo Bruera, MD
Deputy Editors: Kathryn A Collins, MD, PhD, FACS, Diane MF Savarese, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2020. | This topic last updated: Sep 01, 2020.
INTRODUCTION
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 [1].
Normal wound healing is described separately. (See "Risk factors for impaired wound healing and wound
complications", section on 'Impaired wound 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, measurable rate. Although there is no specific time frame that clearly differentiates an acute from a
chronic wound, 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 [2].
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
chronic wounds".)
LOCAL CARE OF CHRONIC WOUNDS
Local treatment is directed toward reducing pain and itching, minimizing infection and bleeding from the
wound, and dealing with the most troublesome chronic wound problems that affect the patient physically and
emotionally, such as excess exudate that can lead to unpleasant odors.
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.)
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Odor — Wound odor can be controlled with interval mechanical debridement to decrease the microbial
bioburden on the wound surface, with topical antimicrobial therapy (eg, metronidazole) [5-7] and/or with odor-
absorbing dressings such as those that have absorptive charcoal within the dressing (eg, Actisorb, Carboflex).
Soaks of acetic acid or Dakin solution can also help to minimize odor.
Bleeding — A nonadherent dressing can be placed directly on the friable wound to reduce bleeding and reduce
pain associated with dressing changes. A second layer of alginate dressings that contain coagulants can also
help to minimize bleeding ( table 1).
Chronic wounds that are prone to oozing from the ulcer bed (eg, malignant wounds that cannot be excised) can
be controlled with topical hemostatic agents or sucralfate [8] and gentle pressure in the form of elastic
bandages, with focal points of bleeding managed with silver nitrate, handheld cautery, or local anesthetic with
epinephrine. (See "Overview of topical hemostatic agents and tissue adhesives" and "Subcutaneous infiltration
of local anesthetics".)
Pruritus — Itching is a common complaint with chronic wounds. Itching is usually due to dry skin or contact
dermatitis. Keeping the skin moisturized and protected will help reduce itching, and, if necessary, topical
corticosteroid creams can be applied. (See "Irritant contact dermatitis in adults", section on 'Management'.)
Exudate — An absorptive dressing should be placed over the nonadherent dressing to control drainage and
reduce periwound maceration and tailored to the specific anatomic location and wound depth ( table 1).
Alternatively, wound drainage can be drawn away using a collecting device (eg, ostomy appliance, negative
pressure wound therapy device), provided there are no contraindications. (See "Basic principles of wound
management", section on 'Wound debridement' and "Basic principles of wound management", section on
'Wound dressings' and 'Negative pressure wound therapy' below.)
Pain — Pain associated with the wound, and specifically with dressing changes, should not be ignored. The
World Health Organization analgesic ladder, which was developed for the treatment of cancer-related pain, is
applicable to other types of chronic pain. For patients receiving stable doses of a long-acting opioid around the
clock, supplemental doses of a short-acting agent should be considered prior to dressing changes, if they are
painful. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management:
Adjuvant analgesics (coanalgesics)" and "Management of acute pain in the patient chronically using opioids for
non-cancer pain" and "Approach to the management of chronic non-cancer pain in adults".)
SURGICAL APPROACH
In general, surgical intervention of chronic wounds, which frequently requires multiple staged surgical
procedures, is used to prepare the wound bed first by managing infection and handling any underlying factors
contributing to wound chronicity (eg, bony deformities, foreign body, biomechanical instability), and then to
subsequent coverage of the wound, which may require surgical revascularization. If these are successful in
converting the chronic wound to an acute wound, provisional or definitive wound coverage can be performed.
(See 'Wound bed preparation' below and 'Wound coverage/closure' below.)
Chronic wounds from cutaneous ulceration that occur in the setting of systemic disease states such as
vasoocclusive, autoimmune, and inflammatory disorders (eg, rheumatoid arthritis, sickle cell disease, pyoderma

gangrenosum, scleroderma) are difficult to treat and are often colonized with antibiotic-resistant bacteria [9].
Appropriate medical management of the underlying condition must be addressed prior to any planned
definitive surgical procedure. As an example, pyoderma gangrenosum is a specific case of a chronic wound
where surgical intervention is not typically indicated unless appropriate medical management has first been
conducted. (See "Approach to the differential diagnosis of leg ulcers" and "Pyoderma gangrenosum: Treatment
and prognosis".)
Surgery has inherent risks associated with the procedure itself as well as anesthesia-related risks. Medical
optimization is important to decrease the risk of intraoperative and postoperative complications. The risks and
benefits of surgery should be assessed to determine if the surgical intervention is the best course of treatment.
Chronic wounds associated with malignancy can often be approached surgically if there are no prohibitive
comorbidities and doing so aligns with the patient's goals for care. Even with advanced systemic disease,
surgical debridement of the wound is possible.
Some patients may be too sick or disabled to undergo repeated procedures, which are often necessary to
achieve wound closure. For debilitated patients with chronic lower extremity ischemia or malignancy-related
wounds on the lower extremity, primary amputation may be a more appropriate course of action. (See "Lower
extremity amputation".)
WOUND BED PREPARATION
Wound bed preparation is defined as the process of removing local barriers to wound healing to maximize the
potential for successful healing. This is accomplished primarily through debridement. Adjunctive methods to
aid in preparing the chronic wound bed include negative pressure wound therapy and hyperbaric oxygen
therapy, which are discussed briefly below, and in more detail elsewhere. (See 'Operative debridement' below
and 'Adjunctive therapies' below.)
Cultures — Obtaining bacterial/fungal/acid fast bacilli cultures may be helpful if there are clinical signs of
infection. A random culture will most likely yield a positive result in a chronic wound environment even though
it may not be pathogenic [10]. This may lead to unnecessary antibiotic treatment. In addition, biofilm cannot be
detected through traditional agar culture methods. Other methods are necessary for biofilm detection such as
16S rDNA pyrosequencing [11]. If there is suspicion of infection (purulence, heavy drainage, clinical signs of
infection in the surrounding tissue), a tissue specimen should be obtained during debridement.
Operative debridement — Debridement removes nonviable tissue, pathogens (biofilm), contaminants, and

foreign (or other) material and also drains areas of infection. It is important that debridement includes the base
of the wound as well as the wound perimeter.
Chronic wounds may require serial debridement in the operating room to sufficiently prepare the wound bed
[12]. Clinic-based debridement often does not allow for sufficiently aggressive removal of nonviable tissue and
biofilm due to inadequate pain control and the limited ability to achieve hemostasis. The operating room is a
safer environment for the debridement of chronic wounds, which often require the management of deeper soft
tissue and bone-related issues. In some cases, it is more appropriate to debride the wounds in the operating
room, even if no definitive closure/coverage is planned, due to the degree of nonviable
tissue/contamination/infection.

For chronic wounds that appear infected, wound/tissue cultures should be obtained during operative
debridement to help direct antimicrobial therapy. If the etiology of the wound is unknown or the wound
displays atypical characteristics, an excisional biopsy of the wound and/or wound perimeter should be also be
obtained for histology.
Adjunctive therapies
Negative pressure wound therapy — Negative pressure wound therapy (NPWT), also called vacuum-
assisted wound closure, refers to wound dressing systems that continuously or intermittently apply
subatmospheric pressure to the surface of a wound. NPWT promotes the development of granulation tissue to
cover deeper exposed tissues [13]. NPWT is primarily used in situations where healing is expected. NPWT can
also provide programmable intermittent fluid irrigation between operations [14]. Information regarding the
mechanism of action and use of this device and contraindications (eg, malignancy in the wound) for its use is
reviewed elsewhere. (See "Negative pressure wound therapy".)
NPWT may improve the healing of some types of chronic wounds/ulceration provided that they are well
vascularized [15-17]. Patients with extremity wounds and inadequate peripheral pulses should undergo
noninvasive vascular testing to confirm adequate perfusion prior to instituting NPWT, especially patients with
diabetes or other risk factors for peripheral artery disease. (See "Noninvasive diagnosis of arterial disease".)
● Compared with conventional dressing changes, NPWT reduces time to closure of diabetic foot ulcers and
wounds resulting from diabetic foot surgery. In this population of patients, NPWT is also associated with
shorter length of hospitalization, decreased complication rates, and reduced costs. The use of NPWT in the
management of diabetic foot lesions is discussed in detail separately. (See 'Diabetic foot wounds' below.)
● Three randomized trials have evaluated the use of NPWT as an adjunctive therapy for the management of
pressure (decubitus) ulcers [15,18,19]. No significant differences were identified with respect to quantitative
wound healing measures (eg, wound surface area reduction). However, NPWT improved patient comfort
and was less labor intensive [20]. (See 'Pressure-induced skin and soft tissue injury' below.)
● NPWT has been used instead of traditional bolstering methods to provide skin graft fixation [21,22]. The
NPWT dressing distributes negative pressure uniformly over the surface of the fresh graft, immobilizing the
graft with less chance of shearing [23]. Improved qualitative skin graft take and quantitative improvements
in skin graft success (eg, reduced number of repeat grafts) have been described in observational studies
[24-27] and in two randomized trials [28,29]. In one of the trials, 60 patients were randomly assigned to
conventional bolster dressing or NPWT following split-thickness skin graft [28]. NPWT was associated with
significant reduction in the loss of graft area (0 versus 4.5 cm2 in the control group) and the median
duration of hospitalization (13.5 versus 17 days).
● The abdominal wall of patients undergoing exploration for severe abdominal trauma is frequently left open
to facilitate second-look operations [30,31]. In this patient population, NPWT improves the success of both
early and late (>9 days) fascial closure. A general discussion of the management of the open abdomen is
found elsewhere. (See 'Abdominal wounds' below.)
Hyperbaric oxygen therapy — Hyperbaric oxygen therapy (HBOT) has been used as an adjunct to wound
care in the treatment of chronic wounds [32-38]. HBOT has been shown to have in vitro effects on wound
healing [39]. HBOT may also aid wound bed preparation by increasing local tissue oxygen perfusion prior to the

definitive surgical procedure, which may be particularly important for wounds that develop as a late effect of
radiation therapy for the treatment of cancer [32,40-42]. (See "Hyperbaric oxygen therapy" and "Management
of late complications of head and neck cancer and its treatment", section on 'Hyperbaric oxygen'.)
Most studies of HBOT in chronic wounds are observational, and the few available trials are limited by small
sample size and low quality [43-45]. Systematic reviews have concluded that, although hyperbaric oxygen may
benefit some types of wounds (eg, postradiation therapy), there is insufficient evidence to support routine use
[46,47].
Although HBOT has been associated with more rapid ulcer healing in patients with diabetes, the indications for
hyperbaric oxygen in the treatment of nonhealing diabetic foot ulcers remain uncertain. Although a number of
series and randomized trials of various sizes and quality have suggested its utility, later studies suggest that
HBOT has no benefit for diabetic foot ulcer healing and limb salvage [48]. HBOT for the management of diabetic
foot ulceration is discussed in detail elsewhere. (See 'Diabetic foot wounds' below.)
Support for HBOT for venous or pressure ulcers, and wounds related to chronic ischemia due to peripheral
artery disease, is lacking. (See 'Venous stasis ulcers' below and 'Ischemic ulcers and gangrene' below.)
WOUND COVERAGE/CLOSURE
Surgical procedures that provide wound coverage/closure are briefly described below. It is important to address
the underlying etiology prior to performing the definitive procedure.
If the wound is relatively small, it can be completely excised and closed primarily (sutures/staples) provided
there is no to minimal skin tension. An understanding of appropriate tension and blood supply is paramount to
allow for healing. In a previously infected wound, we avoid placing absorbable sutures deeply within the
wound. In this situation, vertical mattress sutures may help bring the deep and superficial spaces together.
Larger or more complicated wounds may require graft or flap coverage. Procedures that provide coverage to
the chronic wound are listed below and discussed in more detail in the linked topics.
● Split-thickness skin graft – Split-thickness skin grafts (STSGs), also called partial-thickness grafts, are
autologous epidermal/dermal grafts. Chronic wounds with a good bed of granulation tissue and without
exposed tendon or bone are good candidates for skin grafting. STSGs may be complicated by secondary
contracture and should be avoided in areas around joint surfaces. (See "Skin autografting", section on 'Split-
thickness skin grafting'.)
● Full-thickness skin grafts – Full-thickness skin grafts (FTSGs) are autologous epidermal and full-thickness
dermal grafts. These grafts have a decreased incidence of secondary contracture. FTSG is appropriate when
a thicker autograft is necessary, such as for deeper wounds or in areas that require more durable tissue
(eg, foot). (See "Skin autografting", section on 'Full-thickness skin grafting'.)
● Xenografts/allografts – If an autologous graft is not possible, a xenograft or allograft can be used. One
strategy is to use a xenograft or allograft to build up a dermal tissue layer prior to STSG application. A
xenograft or allograft will be replaced by the host tissue over time. There are a variety of
xenografts/allografts that serve different purposes ( table 2). Porcine epidermis can be applied to the

wound surface as a litmus test to ensure that adequate debridement was performed prior to the definitive
closure/coverage procedure, or it can be used as a biologic dressing when there is low confidence in patient
compliance. Other xenografts, including bovine collagen, can be used to cover deeper soft tissue defects to
form a neodermis in preparation to receive a split-thickness skin graft. Allografts can be used for the same
purpose.
● Local tissue flaps – Local tissue rearrangement is useful in many circumstances when primary closure is not
possible. These techniques involve recruitment of skin from surrounding areas and transposing it into the
defect to allow for closure. Blood supply to the flap must be preserved. Common local tissue flaps include
V-to-Y advancement, rotation flaps, and advancement flaps. (See "Z-plasty" and "Overview of flaps for soft
tissue reconstruction", section on 'Skin'.)
● Pedicled flaps – Pedicled flaps are useful when muscle or fascia is needed to cover a large wound or deep
wound that has exposed tendon or bone. The blood supply to the harvested muscle must be preserved,
and the flap is rotated to cover the wound defect. Pedicled flaps include expendable muscles, such as the
abductor hallucis muscle flap for coverage of medial foot or ankle defects, or the hemigastrocnemius
muscle flap to cover knee defects. Another common flap is the soleus flap for coverage of mid-tibial
defects. (See "Overview of flaps for soft tissue reconstruction", section on 'Pedicled'.)
● Free tissue transfers – Free tissue transfer is an important technique for closure of larger soft tissue defects
that may not be amenable to pedicled or local advancement flaps. The muscle or fascia is harvested, with
or without the overlying skin, along its vascular pedicle. The free flap is placed into the defect and the
arterial and venous blood supply sutured to a local artery and vein nearby. (See "Overview of flaps for soft
tissue reconstruction", section on 'Skin'.)
Once a wound is closed or covered, careful surveillance is needed. Recurrence of the wound at the same site or
development of wounds at another location can occur after initial healing, especially in high-risk patients. As an
example, diabetic patients with peripheral neuropathy must be adequately protected with specialized
accommodative inserts, shoes, and braces. Thus, it is important to address as the initial reason for the chronic
wound.
SPECIFIC WOUND MANAGEMENT
Management of specific chronic wounds is briefly discussed below.
Diabetic foot wounds — The diabetic foot ulcer is a unique category of chronic wound that requires multiple
considerations ( algorithm 1). The general evaluation and management of diabetic foot ulcers is discussed
separately [49]. (See "Evaluation of the diabetic foot" and "Management of diabetic foot ulcers".)
Chronic diabetic foot ulcers are often colonized with a variety of pathogens. For patients who require operative
debridement, or incision and drainage for infection, initial empiric antibiotic therapy is transitioned to more
specific treatment based upon the results and sensitivities of intraoperative cultures. Prolonged antibiotic
therapy may be needed, particularly for the treatment of osteomyelitis [50]. Further, specific therapy, such as
negative pressure wound therapy, should be considered before surgery and in between surgical debridements
[51-53]. (See "Management of diabetic foot ulcers", section on 'Managing infection'.)

Special attention should also be given to identifying and correcting any underlying bony deformities or
biomechanical instability causing areas of focal pressure or shear stress as the source of delayed wound
healing. Correction may require adjunctive surgery (eg, Achilles tendon lengthening to offload the plantar
forefoot, free or pedicled flap to provide tissue durability) or more complex bony reconstruction/realignment.
(See "Management of diabetic foot ulcers", section on 'Mechanical offloading'.)
The weightbearing nature of the foot increases the risk for wound recurrence after closure/coverage,
particularly when a skin graft is used, since these are insensate. The surgical plan should address durability and
the demands of ambulation. The patient will also require long-term use of a custom shoe with an
accommodative orthotic. Bracing with an ankle-foot orthosis may also be necessary to reduce the risk for
recurrence [54]. (See "Management of diabetic foot ulcers", section on 'Mechanical offloading'.)
The following case examples illustrate different types of diabetic foot wounds.
● The pictures in the figure show the management of a diabetic patient with a diabetic foot infection (
picture 1). Following incision and drainage of the ankle joint and debridement of necrotic skin, the
postsurgical wound was managed with wound dressings, followed by skin grafting.
● The pictures in the figure show the management of a diabetic patient with a chronic sinus draining from
the plantar aspect of the foot that was present for over nine months. Following debridement, the wound
was dressed and treated with a matrix wound dressing to provide an appropriate wound bed for skin
grafting ( picture 2). After two weeks, the overlying silicone layer was removed and a skin graft was
placed ( picture 3).
Ischemic ulcers and gangrene — The presence of ischemia influences the timing of revascularization,
debridement, and definitive coverage/closure.
● For patients with wet gangrene or abscess ( picture 4), the wound should be debrided immediately
regardless of the need for revascularization. The dressing choice depends upon the level of anticipated
drainage and the size of the wound. Dead space is usually managed with gauze packing. The extremity
should be revascularized as soon as safely possible, if needed, after drainage/debridement and control of
the infection.
● For patients with dry gangrene without cellulitis ( picture 5), the limb should be revascularized first. The
wound dressing is protective, reducing the risk for trauma or infection. The wound should be lightly
wrapped with a bulky dry gauze bandage, avoiding excess pressure that could aggravate ischemia.
Following revascularization, the wound should be monitored closely for signs of healing or for tissue
necrosis/drainage that may indicate a need for further debridement.
Chronic orthopedic wounds — Large soft tissue defects of the extremities are often the result of trauma and
are frequently accompanied by bony fractures. When traumatic wounds become chronic, wound coverage
options are dictated by the severity of the initial injury and the anatomic location. (See "Severe lower extremity
injury in the adult patient".)
For traumatic wounds that required internal fixation, the chronicity of the wound may be due to an underlying
bone infection (osteomyelitis) or biofilm on a screw, plate, anchor, or heavy suture. Thus, removal of affected
materials will be necessary for definitive closure. Bone infection requires resection of the infected segment,

long-term antibiotics, and/or use of antibiotic-impregnated cement. The skeletal framework must be addressed
to provide stability of the overlying soft tissue envelope. Treatment of chronic or subacute osteomyelitis can
occur over many months with standard antibiotic treatment regimens lasting typically six weeks, following a
period of time off antibiotics, at which time bone culture is repeated. If the repeat culture or aspirate is
negative, definitive soft tissue closure/coverage can proceed. (See "Nonvertebral osteomyelitis in adults: Clinical
manifestations and diagnosis".)
Total joint implants pose a difficult problem. Expeditious soft tissue coverage or closure over noninfected joint
implants or internal fixation is important. Infected internal fixation constructs and joint implants may require
removal with subsequent reimplantation once the infection is resolved. Typically, these problems require
pedicled flaps or free tissue transfers for definitive coverage. (See 'Wound coverage/closure' above and "Skin
autografting".)
The following case examples illustrate different types of chronic orthopedic wounds.
● The pictures in the figure show the management of a patient with an infected total knee arthroplasty (
picture 6). Four weeks after the procedure, the incision site evidenced drainage and was opened.
Following debridement of necrotic tissue, a rotation flap was used to close the open knee defect, over
which a skin graft was placed to provide coverage of the muscle.
● The pictures in the figure show the management of a patient with a chronic draining sinus three years after
open reduction and internal fixation for a fibular fracture ( picture 7). After debridement and removal of
the previously placed fibular plate, a location rotation flap was used to cover the exposed bone, over which
a skin graft was placed to provide coverage of the residual exposed subcutaneous tissue.
● The pictures in the figure show the management of patient with a chronic draining sinus related to repair of
a prior calcaneal fracture one year previously ( picture 8). Following incision, drainage, debridement, and
removal of infected hardware, a free flap was placed.
● The pictures in the figure show the management of a patient with chronic draining sinus emanating from
osteomyelitis in a bone sequestrum following a prior traumatic injury ( picture 9). Following bone
debridement and removal of the sequestrum, the bone was packed with an antibiotic spacer and a free
muscle flap used to provide coverage, over which a skin graft was used to cover the muscle.
Abdominal wounds — A chronic open abdominal wound can occur following local skin separation, partial
fascial dehiscence, or complete fascial dehiscence leading to evisceration from an abdominal incision. More
often, open abdominal wounds result from intentionally leaving an abdominal incision open at the completion
of an abdominal procedure to prevent abdominal compartment syndrome. Rarely, large defects are the result
of traumatic injury (eg, shotgun blast).
If the wound is small and the fascia is intact, local wound care with bedside incision and drainage may be all
that is needed. Negative pressure wound therapy can aid the closure of clean abdominal wounds. For wounds
that are larger, those that have drainage, and those with abdominal wall necrosis, surgical debridement and
sequential second-look procedures are more optimal for achieving definitive closure ( algorithm 2). (See
"Surgical management of necrotizing soft tissue infections" and "Management of the open abdomen in
adults".)

The following case examples illustrate different types of chronic abdominal wounds.
● The pictures in the figure show the management of a patient with a necrotizing abdominal wall infection
related to a surgical site infection. Following debridement of infected and necrotic material ( picture 10),
including the fascial edges, the wound was able to be closed primarily.
● The pictures in the figure show the management of a child with a nonhealing abdominal wall wound that
was present for five months ( picture 11). The wound was treated with open dressings until a bed of
granulation tissue was present, after which a xenograft was initially placed to ensure that a skin graft would
take. Negative pressure wound therapy was used to secure the xenograft. A skin graft was placed five days
later with a good result.
Pressure-induced skin and soft tissue injury — Pressure-induced injury is due to chronic pressure in
susceptible areas that lead to ischemia and skin loss. Sacral, ischial, and trochanteric wounds occur primarily in
patients who are wheelchair- or bed-bound. Heel pressure ulcers can also occur in patients who are in bed for
prolonged periods of time without offloading devices to the heel. The treatment of pressure ulcers depends
upon the stage of the ulcer. (See "Clinical staging and management of pressure-induced skin and soft tissue
injury".)
The root cause of the pressure-induced chronic wound must be identified and addressed. If nothing is changed
to address the cause, surgical intervention is likely to fail. Prior to surgical flap closure, nutrition must be
optimized and the affected surfaces offloaded. For wounds in the perineal region, stool and urinary diversion
are a necessary adjunct to care. (See "Surgical management of pressure-induced skin and soft tissue injuries".)
Ulcerated and fungating malignancy-related wounds — The palliative treatment of malignancy-related (eg,

post radiation therapy) or ulcerating or fungating malignant wounds represents a clinical challenge without
evidence-based guidelines or established protocols. The clinician should establish goals for wound
management with the patient. Although symptom management strategies for comfort may work in tandem
with healing interventions with the goal of eventual wound closure, it is important to recognize when efforts
toward wound closure may become unrealistic or burdensome for the patient.
Topical wound care and specific dressings should be tailored to the individual wound and patient needs, and
the physician should appreciate that proper wound management can make a great deal of difference to the
patient and influence his or her ability to comfortably receive guests, participate in public events, and assist
with activities of daily living [55-58]. Simple wound care such as washing with soap and water and light
debridement can be helpful. Often, dressings, such as acetic acid or Dakin solution, are used to aid in odor
management. (See 'Local care of chronic wounds' above.)
If feasible, palliative oncologic approaches such as appropriate chemotherapy or radiation therapy can also aid
in decreasing tumor burden. If consistent with the goals of care, surgical management may be considered.
Surgical options for ulcerated and fungating malignancy-related wounds include surgical resection with
appropriate flap or graft reconstruction. Resection and closure may be especially helpful to maintain function
for malignant wounds in certain areas of the body, such as in the extremities or groin. However, the decision to
operate in such cases must be individualized and include careful consideration of the risks and potential
benefits of surgery in the context of the overall disease status and burden as well as the individual patient's

goals of care. (See "Benefits, services, and models of subspecialty palliative care", section on 'Establishing goals
of care' and "Discussing goals of care".)
The pictures in the figure show the management of a patient with a chronic wound following excision and
radiation treatment for invasive squamous carcinoma of the left lower extremity five years before presentation (
picture 12). Following 20 courses of hyperbaric oxygen therapy over 20 days, surgical debridement, and open
wound dressings, the wound started to heal.
Venous stasis ulcers — The mainstay of treatment for venous ulceration is local wound care and compression
therapy. Skin grafting may improve ulcer healing and is indicated for those who do not exhibit appropriate
wound healing after 12 months of medical care. (See "Medical management of lower extremity chronic venous
disease", section on 'Ulcer care'.)
Venous ulcers are typically colonized with gram-negative bacteria, which uncommonly become planktonic or
cause ascending infection or sepsis [59]. Clearance of biofilm, which is also particularly common in venous
stasis wounds, is important prior to definitive coverage or closure. Clearance of biofilm is suggested when there
is no odor, no discolored drainage, and the wound bed is pink with granulation tissue. Venous ulcers can be
very large or even circumferential around the extremity. Thus, surgical intervention often includes the use of
skin grafts. Graft adherence is a good sign that biofilm has been eradicated.
Compression therapy is necessary after surgical intervention, including long-term compression therapy to
prevent recurrence ( picture 13). Ablation of axial veins or perforating veins may be needed to eliminate
underlying superficial venous insufficiency [60]. (See "Compression therapy for the treatment of chronic venous
insufficiency" and "Approach to treating symptomatic superficial venous insufficiency".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Chronic wound management".)
SUMMARY AND RECOMMENDATIONS
● A chronic wound may be defined as one that is physiologically impaired due to a disruption of the wound
healing cycle. Wound healing normally progresses at a sustained, measurable rate. A chronic state is
defined by some as a less than 15 percent reduction of the surface area of the wound over one week, or
less than 50 percent reduction over one month. (See 'Introduction' above.)
● Local care of chronic wounds includes debridement and proper wound dressings. 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 minimizing infection.
Adjuncts to wound healing may include negative pressure wound therapy and hyperbaric oxygen therapy,
provided there are no contraindications for their use. (See 'Local care of chronic wounds' above and
'Negative pressure wound therapy' above and 'Hyperbaric oxygen therapy' above.)

● In general, surgical intervention for chronic wounds may be necessary to manage infection, handle any
underlying factors that are contributing to the chronic wound state (eg, bony deformities, foreign body,
biomechanical instability), and prepare the wound bed for subsequent coverage, which may require
repeated procedures and sometimes surgical revascularization. (See 'Surgical approach' above.)
● Limited chronic wounds may be amenable to complete excision and primary closure (sutures/staples),
provided there is no to minimal skin tension. Larger or more complicated wounds may require skin graft or
skin/muscle flap coverage. (See 'Wound coverage/closure' above.)
● The management of specific chronic wounds, including diabetic foot wounds, chronic orthopedic wounds,
chronic abdominal wounds, pressure ulcers, ulcerated and fungating malignancy-related wounds, and
venous ulcers, is briefly reviewed above. (See 'Specific wound management' above.)
● Clinical follow-up and wound surveillance are needed once the chronic wound has been closed or covered.
Wound recurrence can occur after initial healing, particularly in high-risk populations, such as in patients
with diabetic foot wounds. To prevent recurrence, it is important to address the factors that were
responsible for the development of the wound. (See 'Wound coverage/closure' above.)
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REFERENCES
1. Golinko MS, Clark S, Rennert R, et al. Wound emergencies: the importance of assessment, documentation,
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43. Kessler L, Bilbault P, Ortéga F, et al. Hyperbaric oxygenation accelerates the healing rate of nonischemic
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the literature. Arch Surg 2003; 138:272.
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Database Syst Rev 2012; :CD004123.
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treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes Care 2013;
36:1961.
49. 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.
50. 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.
51. Kim PJ, Attinger CE, Steinberg JS, Evans KK. Negative Pressure Wound Therapy with Instillation: Past,
Present, and Future. Surg Technol Int 2015; 26:51.
52. Dalla Paola L. Diabetic foot wounds: the value of negative pressure wound therapy with instillation. Int
Wound J 2013; 10 Suppl 1:25.
53. 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.
54. 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.
55. Seaman S. Management of malignant fungating wounds in advanced cancer. Semin Oncol Nurs 2006;
22:185.
56. Merz T, Klein C, Uebach B, et al. Fungating Wounds - Multidimensional Challenge in Palliative Care. Breast
Care (Basel) 2011; 6:21.
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10-year prospective study. Pain 1995; 63:65.

58. Adderley UJ, Holt IG. Topical agents and dressings for fungating wounds. Cochrane Database Syst Rev
2014; :CD003948.
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healing venous ulcers. Eur J Dermatol 2012; 22:751.
60. 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.
Topic 99040 Version 12.0

GRAPHICS
Wound management dressing guide
Treatment options
Type of tissue in
Therapeutic goal Role of dressing Wound bed
the wound Primary dressing Secondary dressing
preparation
Necrotic, black, dry Remove devitalized Hydration of Surgical or Hydrogel Polyurethane film
tissue wound bed mechanical Honey dressing
Do not attempt Promote autolytic debridement
debridement if debridement
vascular
insufficiency
suspected
Keep dry and refer
for vascular
assessment
Sloughy, yellow, Remove slough Rehydrate wound Surgical or Hydrogel Polyurethane film
brown, black or Provide clean bed mechanical Honey dressing
grey wound bed for Control moisture debridement if Low adherent
Dry to low exudate granulation tissue balance appropriate (silicone) dressing
Promote autolytic Wound cleansing
debridement (consider antiseptic
wound cleansing
solution)
Sloughy, yellow, Remove slough Absorb excess fluid Surgical or Absorbent dressing Retention bandage
brown, black or Provide clean Protect periwound mechanical (alginate/CMC/foam) or polyurethane
grey wound bed for skin to prevent debridement if For deep wounds, film dressing
Moderate to high granulation tissue maceration appropriate use cavity strips, rope
exudate Exudate Promote autolytic Wound cleansing or ribbon versions
management debridement (consider antiseptic
wound cleansing
solution)
Consider barrier
products
Granulating, clean, Promote Maintain moisture Wound cleansing Hydrogel Pad and/or
red granulation balance Low adherent retention bandage
Dry to low exudate Provide healthy Protect new tissue (silicone) dressing Avoid bandages
wound bed for growth For deep wounds use that may cause
epithelialization cavity strips, rope or occlusion and
ribbon versions maceration
Tapes should be
Granulating, clean, Exudate Maintain moisture Wound cleansing Absorbent dressing used with caution
red management balance Consider barrier (alginate/CMC/foam) due to allergy
Moderate to high Provide healthy Protect new tissue products Low adherent potential and
exudate wound bed for growth (silicone) dressing secondary
epithelialization For deep wounds, complications
use cavity strips, rope
or ribbon versions
Epithelializing, red, Promote Protect new tissue Hydrocolloid (thin)

pink epithelialization growth Polyurethane film
No to low exudate and wound dressing
maturation Low adherent
(contraction) (silicone) dressing
Infected Reduce bacterial Antimicrobial Wound cleansing Antimicrobial

Low to high load action (consider antiseptic dressing
exudate Exudate Moist wound wound cleansing
management healing solution)
Odor control Odor absorption Consider barrier
products
The purpose of this table is to provide guidance about appropriate dressings and should be used in conjunction with clinical judgement and local
protocols. Where wounds contain mixed tissue types, it is important to consider the predominant factors affecting healing and address accordingly.

Where infection is suspected, it is important to regularly inspect the wound and to change the dressing frequently. Wound dressings should be used
in combination with appropriate wound bed preparation, systemic antibiotic therapy, pressure offloading, and diabetic control.
CMC: carboxymethyl cellulose.
Reproduced with permission from: McCardle J, Chadwick P, Edmonds M, et al. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds
International, 2013. Copyright © 2013 Schofield Healthcare Media LTD. Available from: www.woundsinternational.com.
Graphic 101893 Version 2.0

Allografts
Tissue source Manufacturer Product Preservation Crosslinking Sterilization
Fascia lata Coloplast Suspend Δ, Tutoplast Δ Solvent dehydrated No Irradiation
Dermis LifeCell AlloDerm ◊ Freeze dried No Irradiation
Boston Scientific Repliform ◊ Lyophilized No Ethylene oxide
Coloplast Axis Solvent dehydrated No Irradiation
* Freeze-dried under vacuum.

¶ Gamma radiation.
Δ Tutoplast refers to a sterilization process used by RTI Surgical to process various allografts. Although the literature refers to a Tutoplast and Suspend allograft,
these are the same fascia lata material.
◊ AlloDerm and Repliform are the same material.

Management of diabetic foot wounds

SVS: Society for Vascular Surgery; WIfI: Wound, Ischemia, and foot Infection; ABI: ankle-brachial index; I&D: incision and drainage; MRI: magnetic resonance imaging;
MRSA: methicillin-resistant Staphylococcus aureus.
* Signs of severe infection include severe cellulitis, fever, hemodynamic instability, and purulent drainage.
¶ Plain foot radiographs may demonstrate gas in the tissues, osteomyelitis, or the presence of a foreign body. Other foot imaging (eg, MRI) may be needed to
identify fluid collections or osteomyelitis not detected on physical exam.
Δ Severe ischemia is manifest on clinical examination as severely diminished or absent pedal pulses, dependent rubor, ABI <0.40, or toe pressure <30 mmHg.
Vascular imaging is warranted for those with obvious limb ischemia. Tissue loss can manifest as ischemic ulceration or as wet or dry gangrene. Patients with stable,
dry gangrene do not require immediate debridement; vascular imaging and revascularization are preferentially performed before debridement.
◊ For severe infections, broad-spectrum antimicrobial therapy should be initiated and adjusted depending upon the results of tissue culture and sensitivity. For mild-
to-moderate infection, antimicrobial therapy should target aerobic gram-positive cocci. For patients with a prior history of MRSA infection or when the local
prevalence of MRSA colonization or infection is high, empiric therapy should also be directed against MRSA. The duration of antimicrobial therapy depends upon the
severity of infection and organism. Residual infected bone following debridement of necrotic bone may require four to six weeks of treatment or longer.
§ All ulcers subjected to excessive pressure benefit from pressure reduction, which is accomplished with mechanical offloading. Foot deformities include hammertoe,
bunion, rocker bottom deformity, and Charcot arthropathy. Optimizing foot biomechanics may include Achilles tendon or gastrocnemius tendon lengthening or
tendon transfer procedures, among others.
¥ Some patients with mild ischemia may also require revascularization to achieve wound healing.
References:
1. Mills JL, 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.
2. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the
American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 2016; 63:3S.
3. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot
infections. Clin Infect Dis 2012; 54:e132.

Management of diabetic foot abscess
The pictures show the management of a 30-year-old patient with a diabetic foot infection. The patient presented with a five-day history of
ankle swelling, fever, and chills. At the time of incision and drainage, a large deep abscess was found within the ankle joint.
Following debridement, the skin and soft tissue defect involved the anterior and lateral lower leg (A). The extensor tendons were exposed
(B), and following interim care with wound dressings, a free flap was used to cover the anterior ankle defect (preferred to prevent later joint
contracture), and a split-thickness skin graft was placed on the lateral wound (C). Four weeks postoperatively, the wounds were healed and
the patient was able to ambulate without difficulty (D).


Provisional wound coverage of diabetic plantar infection
The pictures in the figure show the management of a diabetic patient with a chronic sinus draining from the plantar
aspect of the foot that was present for over nine months. Following debridement (A), the wound was dressed and
treated with an interim matrix wound dressing to create a neodermis to serve as wound bed for skin grafting (B).
After two weeks, the overlying silicone layer was removed (C), and a skin graft was placed.

Definitive wound coverage following diabetic plantar infection
The pictures in the figure show the management of a diabetic patient with a chronic sinus draining from the plantar aspect of the foot that was
present for over 9 months. Following debridement, the wound was dressed and treated with an interim matrix wound dressing to provide an
appropriate wound bed for skin-grafting. The appearance of the foot following placement of a split-thickness skin graft (A), and healed appearance
four weeks later (B) are shown.

Wet gangrene of the right foot
This picture shows a patient with vascular compromise (occluded anterior tibial artery) and infection of the dorsum of the foot. Note the
exposed tendons and deep fascia with liquefied subcutaneous tissue, which indicates an active soft tissue infection. Compared with the left
foot, the right foot is darker in color and is edematous. The patient underwent multiple excisional debridements but ultimately required a
midfoot amputation.
Courtesy of Paul Kim, DPM, MS.

Ischemic wound lateral foot
The picture depicts the clinical appearance of an ischemic wound on the lateral forefoot,
specifically at the plantar aspect of the 5th metatarsal-phalangeal joint. Note the wound
appearance of fibrotic tissue mixed with eschar in an area of increased pressure near a
bony prominence.

Management of wound dehiscence over total knee arthroplasty
The pictures show the management of a patient with an infected total knee arthroplasty. Four weeks after the procedure, the incision site
evidenced drainage and was opened. Following debridement of necrotic tissue (A), a medial hemigastrocnemius rotation flap was
performed to close the defect (B), over which a skin graft was placed to provide coverage of the muscle. The appearance of the healed
wound is shown (C).

Management of infected orthopedic fibular plate
The pictures show the management of a 53-year-old patient with a chronic draining sinus three years following open reduction and
internal fixation for a fibular fracture (A). After debridement and removal of the previously placed fibular plate, a local flap based
proximally off of peroneal perforators was rotated in to cover the exposed bone. A skin graft was placed to provide coverage of the
residual exposed subcutaneous tissue (B). The appearance of the healed wounds is shown (C).

Chronic draining sinus tract treatment
The pictures show the management of a patient with a chronic draining sinus related to repair of a prior calcaneal fracture one
year previously. Incision, drainage, debridement, and removal of infected hardware resulted in an anterior leg wound and
lateral foot defect (A). An arteriogram showed perfusion to the foot via only the anterior tibial artery (B). A free gracilis muscle
flap was placed into the defect with the anterior tibial vessels used as recipient vessels (C). The appearance of the healed free
muscle flap is shown (D).

Healing of tibial draining sinus with chronic osteomyelitis
The pictures in the figure show the management of a 30-year-old patient with chronic drainage following a prior
traumatic injury (A). Chronic osteomyelitis was seen in a bony sequestrum on magnetic resonance imaging (B) and
plain films (C). Following bone debridement and removal of the sequestrum, the bone was packed with an antibiotic
spacer and a free muscle flap used to fill the space, over which a skin graft was used to provide coverage of the
muscle. The early postoperative appearance of the free flap is shown (D).

Management of abdominal compartment syndrome and open abdomen
IAP: intra-abdominal pressure; OR: operating room.

* Severe injury, severe burns, liver transplantation, prolonged open surgery, massive resuscitation.
¶ For at-risk patients, bladder pressure measurements are obtained every four to six hours.
Δ Abdominal decompression can be considered in the absence of other obvious causes of organ dysfunction.
◊ Bladder pressure should be rechecked for new clinical findings (eg, abdominal tension, organ dysfunction).

Midline dehiscence healed with negative pressure wound therapy
These pictures are of a 60-year-old woman with a previously infected abdominal wall wound and failed hernia
repair. The wound was located in the midline portion of a large pannus. It was debrided but not repaired due
to medical comorbidities. After medical optimization, a negative pressure wound therapy device was placed
with a sponge placed over the hernia sac. The area healed in by secondary intention over a period of 12 weeks.

Chronic abdominal wound in child
Chronic sinus tracts within a midline abdominal scar (A). On closer inspection (B), residual suture material can be seen within the more cranially
located sinus tract. Such wounds will not heal until the suture is removed.

Healing of radiated-induced chronic leg wound
The pictures show the management of a patient with a chronic wound following excision and radiation treatment for invasive
squamous carcinoma of the left lower extremity five years before presentation. The anterior tibial tendon was exposed (A).
Following 20 days of daily hyperbaric oxygen therapy, surgical debridement, and open wound dressings, the wound began to
heal (B).

Chronic venous stasis ulcer healing
The pictures show the management of a patient with a laterally-located chronic venous stasis ulcer that was present for six months (A).
Following local wound care and compression therapy, a xenograft and later skin grafting led to wound closure over a six-week period of
time (B).

Contributor Disclosures
Karen Evans, MD Nothing to disclose Paul J Kim, DPM, MS Grant/Research/Clinical Trial Support: Acelity [Wound care];
Integra [Wound care]. Consultant/Advisory Boards: Acelity [Wound care]; Integra [Wound care]. Charles E Butler, MD,
FACS Consultant/Advisory Boards: ECM Biosurgery [Abdominal wall reconstruction]; Tela Bio [Abdominal wall & breast
reconstruction]. Russell S Berman, MD Nothing to disclose Eduardo Bruera, MD Grant/Research/Clinical Trial Support:
Helsinn Healthcare SA [Nausea, cachexia (Netupitant, anamorelin)]. Kathryn A Collins, MD, PhD, FACS Nothing to
disclose Diane MF Savarese, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy

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LOCAL CARE OF CHRONIC WOUNDS

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WOUND BED PREPARATION

Operative debridement — Debridement removes nonviable tissue, pathogens (biofilm), contaminants, and

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SPECIFIC WOUND MANAGEMENT

Management of specific chronic wounds is briefly discussed below.

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Ulcerated and fungating malignancy-related wounds — The palliative treatment of malignancy-related (eg,

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SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

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Use of UpToDate is subject to the Subscription and License Agreement.

7. Ashford R, Plant G, Maher J, Teare L. Double-blind trial of metronidazole in malodorous ulcerating

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Topic 99040 Version 12.0

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Wound management dressing guide

Epithelializing, red, Promote Protect new tissue Hydrocolloid (thin)

Infected Reduce bacterial Antimicrobial Wound cleansing Antimicrobial

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CMC: carboxymethyl cellulose.

Graphic 101893 Version 2.0

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Tissue source Manufacturer Product Preservation Crosslinking Sterilization

Fascia lata Coloplast Suspend Δ, Tutoplast Δ Solvent dehydrated No Irradiation

Dermis LifeCell AlloDerm ◊ Freeze dried No Irradiation

Boston Scientific Repliform ◊ Lyophilized No Ethylene oxide

Coloplast Axis Solvent dehydrated No Irradiation

* Freeze-dried under vacuum.

Graphic 63852 Version 5.0

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Management of diabetic foot wounds

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Graphic 103017 Version 1.0

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Management of diabetic foot abscess

Graphic 105175 Version 1.0

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Provisional wound coverage of diabetic plantar infection

Graphic 106137 Version 2.0

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Definitive wound coverage following diabetic plantar infection

Graphic 105178 Version 1.0

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Wet gangrene of the right foot

Courtesy of Paul Kim, DPM, MS.

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Ischemic wound lateral foot

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