Overview of treatment of chronic wounds

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 or nonviable tissue 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.)

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 dilute acetic acid, hypochlorous acid, or Dakin solution can also help to minimize odor. Long-term frequent use of potentially locally cytotoxic agents such as Dakin solution is not recommended.

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 can be a complaint with chronic wounds. Itching and irritation are usually due to dry or wet skin or contact dermatitis. Keeping a proper moisture balance and the skin protected will help reduce itching and skin irritation, 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, reduce periwound maceration, and control the amount of exudate in the wound and should be 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. Topical exudate-absorbing topicals including cadexomer iodine and medicinal honey formulations may be helpful in removing scant to moderate exudate from the wound surface. (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. Topical or local anesthetics can be used but may have limited effect. (See "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Role of 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 may require 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 prior 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]. The degree of impact of biofilm on chronic wounds has not been fully elucidated. If there is suspicion of infection (purulence, heavy drainage, clinical signs of infection in the surrounding tissue), a culture should be obtained. Cultures should be obtained from the deepest margins of the wound, and if possible, include tissue from the wound base. The bacterial flora may evolve to a more resistant bacterial phenotype over time. Thus, cultures should be obtained serially if warranted.

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. Innovations include NPWT with instillation (NPWTi). This therapy combines the benefits of traditional NPWT and irrigation. In the acute care setting, NPWTi can expedite wound bed preparation [15]. (See "Negative pressure wound therapy".)

NPWT may improve the healing of some types of chronic wounds/ulceration provided that they are well vascularized [16-18]. 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 upper and lower extremity 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 [16,19,20]. 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 [21]. (See 'Pressure-induced skin and soft tissue injury' below.)

●NPWT has been used instead of traditional bolstering methods to provide skin graft fixation [22,23]. The NPWT dressing distributes negative pressure uniformly over the surface of the fresh graft, immobilizing the graft with less chance of shearing [24]. Improved qualitative skin graft take and quantitative improvements in skin graft success (eg, reduced number of repeat grafts) have been described in observational studies [25-28] and in two randomized trials [29,30]. In one of the trials, 60 patients were randomly assigned to conventional bolster dressing or NPWT following split-thickness skin graft [29]. 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 [31,32]. 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/topical oxygen therapy — Hyperbaric oxygen therapy (HBOT) has been used as an adjunct to wound care in the treatment of chronic wounds [33-39]. HBOT has been shown to have in vitro effects on wound healing [40]. 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 [33,41-43]. (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 [44-46]. 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 [47,48].

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 [49]. 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.)

There is increasing evidence to support the use of topical oxygen therapy [50]. Topical oxygen therapy provides localized oxygen delivery directly to the wound bed and periwound surfaces. This option may be more acceptable to patients who are not candidates for HBOT or who find the frequency of HBOT cumbersome. To date there are no peer-reviewed studies directly comparing the outcomes of HBOT with topical oxygen therapy.

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 "Surgical reconstruction of the lower extremity" and "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 [51]. (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 [52]. Further, specific therapy, such as negative pressure wound therapy, should be considered before surgery and in between surgical debridements [53-55]. (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 [56]. (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. (See "Management of chronic limb-threatening ischemia", section on 'Initial management'.)

●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" and "Surgical reconstruction of the lower extremity".)

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" and "Surgical reconstruction of the lower extremity".)

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 require the use of a wheelchair or who must stay in bed. 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 general management of pressure-induced skin and soft tissue injury" and "Local care 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.

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 "Evaluation and management of chronic venous insufficiency including venous leg ulcer", section on 'Ulcer care'.)

Venous ulcers are typically colonized with gram-negative bacteria, which uncommonly become planktonic or cause ascending infection or sepsis [57]. 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 12). Ablation of axial veins or perforating veins may be needed to eliminate underlying superficial venous insufficiency [58]. (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

●Chronic wound – 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 – 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/topical oxygen therapy' above.)

●Surgical care – In general, surgical intervention 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 and 'Wound bed preparation' above and 'Wound coverage/closure' 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.

•Once the chronic wound has been closed or covered, clinical follow-up and wound surveillance are necessary. Wounds can recur 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.

●Specific chronic wounds – 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.)