Pearls for Practice: A Stepwise Approach to Care of the Chronic Wound
Most individuals take wound healing for granted,1 but many local and systemic factors can disturb the multiple repair processes and slow the healing trajectory.2
The Wound Healing Society3 defined an acute wound as one that proceeds through an orderly and timely reparative process and results in a sustained restoration of anatomic and functional integrity. A chronic wound has either failed to proceed in an orderly and timely manner or has failed to establish a sustained result. In chronic wounds, the healing process is prolonged and incomplete, proceeding in an uncoordinated manner and often resulting in a poor outcome.3,4
Although a common pathway of persistent inflammatory stimuli has been suggested for all chronic wounds,4 outwardly and clinically, chronic wounds appear to have heterogeneous clinical causes.2 Despite their heterogenous underlying pathology (eg, diabetes mellitus, venous insufficiency, or prolonged pressure), we have instituted a stepwise approach to the care of all chronic wounds. This approach is based on a treatment paradigm reported by Winkler and Steadman5 grounded on the principles of removing deterrents to wound healing while simultaneously avoiding agents that might be detrimental to the cellular and humoral processes of healing. Many agents, devices, and dressings reportedly used in the care of chronic wounds have been demonstrated to be harmful to the wound and cytotoxic to cells such as fibroblasts and keratinocytes that are necessary for the wound to progress to a healing trajectory.
The paradigm outlined by Winkler and Steadman is designed around meticulous wound bed preparation to allow the wound to proceed to endogenous healing or to set the stage for successful wound closure with autologous tissue.5,6 The paradigm included 3 new products that could be used synergistically to fulfill the principles without doing harm to the healing wound. We have adopted those products into our stepwise approach and incorporated them into a simple algorithm that can be followed when determining treatment for any chronic wound in our wound clinic. The algorithm allows one to ask the patient straightforward yes or no questions and then follows a stepwise treatment plan to achieve optimal wound bed preparation and eventual wound closure (see Figure 1).
To prepare the wound bed, first necrotic tissue, debris, or slough needs to be removed from the wound. Surgical, enzymatic, osmotic, and mechanical methods are used to effect debridement. We have found that once any thick, dry eschar has been removed, a hypochlorous acid wound cleanser (Vashe Wound Cleanser, SteadMed Medical LLC, Fort Worth, TX) placed onto the wound as a soak and then wiped off effectively removes debris and slough; Vashe Wound Cleanser also disrupts biofilm in the wound.7 Following debridement, a hydroconductive dressing (Drawtex Hydroconductive Dressing, SteadMed Medical LLC, Fort Worth, TX) is used to draw off any remaining debris, slough, bacteria, and deleterious cytokines to complete wound bed preparation.8 If wound bed preparation has been optimal after treatment with Vashe and Drawtex Hydroconductive Dressing, spontaneous healing can occur or closure with autologous epidermis and dermis can be performed. To close the wound, we use micro-autografting with the Xpansion Micro-autografting Kit (SteadMed Medical LLC, Fort Worth, TX) in the clinic under local anesthesia, eliminating the need to be admitted to the hospital and undergo a trip to the operating room.9
In cases where wound bed preparation is not optimal, other methods may be required. Hyperbaric oxygen (HBO) can be used if the criteria for HBO treatment are met. Using HBO often can help mitigate the stalled wound bed preparation or set the wound for another application of Drawtex. When wound bed preparation is complete and closure with autologous tissue is not necessary because the wound is small or the patient does not agree to an operative procedure such as a micro-autograft, 1 or 2 applications of a collagen dressing or skin substitute may complete spontaneous closure of the wound.
We have been using this stepwise approach for chronic wound treatment for 1 year and have found it useful; the algorithm is easy for team members to follow. Cases demonstrating the approach include a woman in her 30s with a venous stasis ulcer of her leg. Following debridement, she was treated with Vashe and Drawtex to prepare the wound bed (see Figure 2a). Once optimal wound bed preparation was achieved (see Figure 2b), Xpansion micro-autografting was performed. The wound completely healed and remained so as of her last follow-up visit 8 weeks later (see Figure 2c). Another patient was a man in his 70s with a venous stasis ulcer who presented with eschar and slough covering the ulcer (see Figure 3a). The wound was soaked with Vashe and wiped with gauze for a soft debridement. Drawtex dressings then were applied to complete wound bed preparation (see Figure 3b). The wound was closed with Xpansion micro-autografts and went on to complete closure (see Figure 3c).
An algorithm is useful for demonstrating a stepwise approach and as shown in the 2 cases presented, this approach can result in rapid healing of chronic wounds.
1. Robson MC. Wound infection: a failure of wound healing caused by an imbalance of bacteria. Surg Clin N Amer.1997;77(3):637–650.
2. Robson MC, Steed DL, Franz MG. Wound healing: biologic features and approaches to maximize healing trajectories. Curr Prob Surg. 2001;38(2):61–140.
3. Lazurus GS, Cooper DM, Knighton DR, Margolis DJ, Pecararo RE, Rodeheaver G, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994;130(4):489–493.
4. Nwomeh BC, Yager DR, Cohen IK. Physiology of the chronic wound. Clin Plast Surg. 1998;25(3):341–356.
5. Winkler M, Steadman ME. Removing deterrents without adding potentially harmful agents: a new paradigm for effective wound healing. Today’s Wound Clinic. 2014;8(3):1–2.
6. Robson MC. Advancing the science of wound bed preparation for chronic wounds. Ostomy Wound Manage. 2012;58(11):10–12.
7. Robson MC. Treating chronic wounds with hypochlorous acid disrupts biofilm. Today’s Wound Clinic. 2014;8(9):21–22.
8. Robson MC (ed). Innovations for wound bed preparation: the role of Drawtex Hydroconductive Dressings. Wounds. 2012;24(9 suppl):1–27.
9. Smith DJ. Achieving efficient wound closure with autologous skin. Today’s Wound Clinic. 2014;8(1):23–24.
Pearls for Practice is made possible through the support of SteadMed Medical, LLC, Fort Worth, TX (www.steadmed.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of SteadMed Medical, LLC; OWM; or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.