Chronic Wounds

By Holly Hovan, MSN, GERO-BC, APRN, CWOCN-AP

Refractory wounds comprise a significant worldwide health problem, affecting 5 to 7 million people per year in the United States alone. Wounds that fail to heal not only impact quality of life but also impose a significant physical, psychosocial, and financial burden. Additionally, individuals with refractory wounds often experience significant morbidity and sometimes mortality. Wound infections and amputations are common in this population, and chronic conditions often exist as well.

Collagenase: An enzymes that breaks the peptide bonds in collagen. Collagenases aid in destroying extracellular structures. Collagenase is one of the most frequently used enzymatic debridement agents.

Enzymatic debridement: A topical treatment that uses naturally occurring proteolytic enzymes or proteinases, which break down and remove devitalized tissue by digesting and dissolving this tissue in the wound bed.

Keratotic tissue: Keratotic tissue is the development of horny growths (keratomas). These growths can appear at the edges of wounds and hinder healing. They are removed by debridement to promote healing.

By Ryan Cummings, FNP, CWS

Although the impact of depression on all aspects of health and healing is well known and has been researched in progressively greater detail over the last decade, the role depression plays in prolonging healing time in chronic wounds is still rarely addressed fully. Empirically, every wound care provider has witnessed depression in patients with chronic non-healing ulcerations, although rarely is this directly addressed in wound care training or in algorithmic treatment plans. Ongoing pain, odor, body image compromise, and lack of faith in one’s own ability to heal are only some of the issues that wound care patients are often forced to address, and we owe it to our patients to be prepared to both discuss and validate their experiences during their time in our care.

By Temple University School of Podiatric Medicine Journal Review Club

The challenges of treating lower extremity wounds for podiatrists can feel more often like a marathon than a sprint. Complex and chronic wounds can add further stress on the patient and physician alike and make this marathon feel entirely uphill. In suspiciously slow-healing chronic wounds, narrowing down the specific diagnosis, the presence of a neoplasm, and/or the bacterial load analysis can drastically alter the treatment options. A punch biopsy procedure is a useful and informative diagnostic technique that can be used to address all of the previously listed concerns and further focus the treatment of such challenging wounds. Although the punch biopsy seems as though it should be a standard diagnostic tool, many providers are hesitant to use it because it is an invasive procedure. Given that the patient’s safety is always of the upmost importance in creating a treatment plan, a multicenter clinical trial was designed to observe the incidence of complications associated with performing punch biopsy procedures in chronic open wounds.

By Temple University School of Podiatric Medicine Journal Review Club

A diabetic foot ulcer (DFU) is a wound that has a higher risk of becoming chronic, leading to amputation and, in some cases, even death. Currently, the Wagner and Texas classification are used worldwide to assess the extent of diabetic foot lesion. The authors of this article believe that there is a lack of wound treatment principles based on both classification systems. In the article, they have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification system. The STAGE principle refers to surgical intervention during wound treatment of a DFU. With a focus on the anatomical layers of the wound, the management of blood supply, layer by layer incision to the infected area, maintenance of adequate wound drainage, and step by step treatment of the wound. STAGE is the management of an ulcer through its anatomical layers. Skeleton, Tendon, Angiogenesis, Granulation, and Epithelialization.

Chronic wounds of the lower extremities impose an increasing burden on health care providers and systems, and they can have a devastating impact on patients and their families. These wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure injuries. The estimated socioeconomic cost of chronic wounds is 2% to 4% of the health budget in Western countries. Moreover, patient mortality in individuals with chronic wounds has been estimated at 28% over a two-year period, significantly higher than the 4% mortality rate reported for 75 to 79 year-olds without chronic wounds.

Chronic and non-healing wounds are those that do not progress through the healing process in a timely or predicted manner. They are a global problem and are becoming harder to treat. Medicare estimates that over 8 million Americans have chronic wounds that cost the national health care system between $18.1 and $96.8 billion dollars annually.

Angiogenesis: The complex process in which the growth of normal, stable, and functional vessels is critically dependent on the coordinated interplay in space and time of different cell types and growth factors. This process involves the forming of new blood vessels from preexisting vessels by invading the wound clot to organize in a microvascular network throughout granulation tissue.

Autologous cell therapy: A therapeutic intervention that uses an individual’s cells, which are cultured and expanded outside of the body and reintroduced into the donor as a bioengineered skin substitute to aid in wound closure.

Immunomodulation: Therapeutic interventions aimed at modifying the immune response. Healing in chronic and complex wounds can be enhanced with immunomodulating agents.

By Lauren Lazarevski, RN, BSN, CWOCN

Could metallic micronutrients be the missing link for your patient with a chronic wound? When we consider the nutrition required to optimize wound healing, protein supplementation is usually the star of the show. However, there are micronutrients involved in wound healing on a cellular level. Although the daily requirements may be small, they are mighty—and if deficient, they may be the missing step in healing a chronic wound.

By Cathy Wogamon, DNP, MSN, FNP-BC, CWON, CFCN

A pilonidal cyst is a pocket located at the top of the cleft of the buttocks that usually results from an embedded or stiff hair. This area may remain dormant for years and cause no major issues; however, often the embedded or stiff hair may cause the cyst to become inflamed and infected, resulting in an abscess that requires an incision to drain the infected material. These abscesses can recur, causing the patient to require surgical intervention to remove the cyst. After surgery, some patients tend not to heal well, and the result is a chronic, tracking wound in an area that is difficult to heal.