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Chronic Wound Management in the Ambulatory Setting

Despite low supportive evidence, certain advanced wound therapies may benefit patients.

A PPM Brief

Following a wound, tissue repair occurs along a spectrum ranging from underhealing (chronic wounds) to overhealing (fibrosis). Arterial or venous insufficiency, diabetes, undue skin pressure, presence of a foreign body, and infection are all possible pathologic states that result in chronic wound development. In a clinical review,1 researchers looked at chronic wound management in the ambulatory setting, with its multitude of treatment approaches.

Dressing Selection

Wound dressings are typically selected based on clinical assessment and may deliver debriding or antimicrobial agents. Dressing selection has a wide market and a lack of high-quality evidence regarding their effective use, therefore, clinicians often rely on personal and professional experience to make their selections. Products aim to be easily accessible, cost-effective, and confirm to patient preference. Goals include:

  • maintaining a moist wound environment
  • preventing or treating infection
  • minimizing skin irritation or friction between the wound (clothing, devices such as wheelchairs).

In the United States, it is estimated that as many as 4.5 million people have chronic wounds, resulting in substantial economic and psychosocial costs. (Source: 123RF)

Standard Gauze

Wet-to-dry packing consists of moistened gauze placed into the wound with daily changing, which provides debridement. Although popular, this technique may result in a dehydrated wound bed, preventing granulation and matrix regeneration (dry wounds can cause the patient pain and discomfort). Wet-to-dry packing should not be in contact with the adjacent intact skin around the wound due to maceration of healthy tissue, which may enlarge the wound.

Negative-Pressure Wound Therapy (NPWT)

Vacuum devices deliver NPWT, composed of a sterile foam dressing that covers the wound, enclosed by an occlusive film that adheres to the adjacent, normal skin. Suction is applied to the dressing and a drainage tube connects to a portable vacuum canister. Evidence2 has shown that NPWT reduces wound exudate, debris, and bacterial contamination while increasing vascular perfusion and granulation. A meta-analysis3 in particular showed that NPWT, compared with standard wound care, was associated with decreased wound size and shorter time to healing.

Advanced Dressings

Alginates and foams (to absorb excess exudate); hydrocolloids (to prevent tissue dehydration); and hydrogels (to hydrate dry wounds and absorb exudate in moist wounds), may be used; however, limited evidence suggests that patient comfort is improved. Topical antimicrobial agents, iodine, and silver-based preparations may be used as well. Other approaches include:

  • honey and methylene blue (little evidence)
  • protease-modulating matrices such as oxidized regenerated cellulose (to reduce wound bed inflammation)
  • skin substitutes for temporary wound coverage (mostly for specialty wound care settings)
  • porcine collagen products
  • human-derived products such as cadaver acellular dermal matrix and allogenic fibroblasts
  • combination materials such as bovine collagen matrix underlying human epidermal cells.

Adjuvant Wound Therapies

  • Compression therapy: For venous stasis ulcers, 8 randomized clinical trials showed improved time to healing with compression vs no compression treatment.4
  • Foam alternatives: A meta-analysis suggested that foam alternatives such as egg crate foam overlays to standard hospital mattresses was associated with reducing the incidence of pressure ulcers in at-risk patients.5
  • Hyperbaric oxygen therapy: The uncertain benefits, limited availability, and cost of hyperbaric oxygen therapy may limit its usefulness for managing chronic wounds.6

Effective care for chronic wounds requires a multimodal treatment approach, including but not limited to wound bed optimization, management of presenting medical conditions, and consistent follow-up. The advanced wound therapies described below may benefit some patients, but evidence is limited according to the published review. Due to expense, cost-effectiveness is a key consideration for dressings, although some products may decrease dressing change frequency and improve healing, which in turn can lead to overall cost reductions.

Last updated on: August 2, 2019
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Treatment of Painful Cutaneous Wounds
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