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Prevention, Diagnosis, and Management of Chronic Wounds in Older Adults

      Abstract

      Chronic wounds are common, disproportionately affect older adults, and are likely to be encountered by providers across all specialties and care settings. All providers should be familiar with basic wound prevention, identification, classification, and treatment approach, all of which are outlined in this article.

      Abbreviations and Acronyms:

      ABI (ankle-brachial index), ACP (American College of Physicians), CLI (critical limb ischemia), DVT (deep vein thrombosis), HBOT (hyperbaric oxygen therapy), IC (intermittent claudication), IPC (intermittent pneumatic compression), NPUAP (National Pressure Ulcer Advisory Panel), NSAIDs (nonsteroidal anti-inflammatory drugs), PAD (peripheral arterial disease), PT (physical therapy), VAC (vacuum-assisted closure)
      Article Highlights
      • Chronic wounds are common, costly, and are more likely to affect older adults.
      • Venous ulcers, neuropathic ulcers, ischemic ulcers, and pressure injuries each necessitate unique prevention and treatment strategies.
      • With the evidence and pragmatic guidance provided herein, providers will have the working knowledge to successfully manage chronic wounds.
      Appropriate prevention, diagnosis, and treatment of chronic wounds is important for providers across specialties. Wounds affect patients in all care settings and result in significant cost and morbidity. The burden of this condition falls largely on older adults, for whom the incidence of chronic wounds far exceeds that of younger populations.
      • Gould L.
      • Abadir P.
      • Brem H.
      • et al.
      Chronic wound repair and healing in older adults: current status and future research.
      ,
      • Cheung C.
      Older adults and ulcers: chronic wounds in the geriatric population.
      Medicare costs for wound care in 2014 were estimated at greater than $28 billion, and the prevalence for most wound types was greatest in patients aged 75 or older.
      • Nussbaum S.R.
      • Carter M.J.
      • Fife C.E.
      • et al.
      An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds.
      Venous ulcers are the most common lower extremity wound type, comprising 45% to 60% of all wounds, followed by neuropathic ulcers (15% to 25%), ischemic ulcers (10% to 20%), and mixed ulcers (10% to 15%).
      • Mekkes J.R.
      • Loots M.A.
      • Van Der Wal A.C.
      • Bos J.D.
      Causes, investigation and treatment of leg ulceration.
      Fortunately, new wound-treatment modalities continue to emerge. This review summarizes the latest information regarding prevention, identification, classification, and treatment of chronic wounds. Guidance on management of major wound types and pearls regarding dressing selection are provided.

      Pressure Injuries

      Pressure injuries (formerly termed pressure ulcers) result from tissue trauma occurring at sites of increased mechanical force (pressure, shear, or friction).
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Most commonly, pressure injuries are found on bony prominences, where force is increased upon the adjacent tissues, particularly the sacrum and heel.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Prevalence of pressure injuries in US care facilities was estimated at 8.8% in 2015.
      • VanGilder C.
      • Lachenbruch C.
      • Algrim-Boyle C.
      • Meyer S.
      The International Pressure Ulcer Prevalence Survey: 2006-2015: A 10-year pressure injury prevalence and demographic trend analysis by care setting.
      Pressure injuries can be classified into 4 stages of increasing depth and severity using the National Pressure Ulcer Advisory Panel (NPUAP) staging system.
      National Pressure Ulcer Advisory Panel, Haesler E, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance
      Prevention and Treatment of Pressure Ulcers.
      ,
      • Edsberg L.E.
      • Black J.M.
      • Goldberg M.
      • McNichol L.
      • Moore L.
      • Sieggreen M.
      Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System.
      Two additional stages exist in this classification system: unstageable injuries, covered by dead tissue or eschar that obscures the ulcer base, and deep tissue injuries, characterized by purple discoloration and indicating unknown depth. Further, 2 additional definitions are worth noting: medical-device–related pressure injury, which typically conforms to the shape of the device and should be staged using the aforementioned staging system, and mucosal membrane pressure injury, which typically also relates to medical-device use, but cannot be staged because of the anatomy of mucosal tissues.
      Prevention of pressure injuries begins with identification of at-risk patients. Immobility, the health of the affected tissue, and tissue perfusion are all directly associated with development of pressure injury.
      • Coleman S.
      • Nixon J.
      • Keen J.
      • et al.
      A new pressure ulcer conceptual framework.
      Additional factors, such as nutrition, moisture, diabetes, and low albumin, may contribute.
      • Coleman S.
      • Nixon J.
      • Keen J.
      • et al.
      A new pressure ulcer conceptual framework.
      Routine risk assessment is recommended by multiple national advisory boards.
      National Pressure Ulcer Advisory Panel, Haesler E, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance
      Prevention and Treatment of Pressure Ulcers.
      ,
      • Qaseem A.
      • Mir T.P.
      • Starkey M.
      • Denberg T.D.
      Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians.
      ,

      National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler,ed. Osborne Park, Western Australia: Cambridge Media: 2014.

      Performance of risk assessment is recommended as an initial screening tool upon admission to both acute- and long-term–care settings, with periodic reassessment thereafter.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Frequently used standardized risk assessment tools include the Braden and Norton scales.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Multiple interventions may prevent development of pressure injury. Frequent mobilization and repositioning are commonly used, although limited evidence to support this practice exists.
      • Gillespie B.M.
      • Chaboyer W.P.
      • McInnes E.
      • Kent B.
      • Whitty J.A.
      • Thalib L.
      Repositioning for pressure ulcer prevention in adults.
      ,
      • Reddy M.
      • Gill S.S.
      • Rochon P.A.
      Preventing pressure ulcers: a systematic review.
      Pressure offloading is another common prevention tool. Several specialized mattresses are superior to standard hospital mattresses in preventing formation of pressure injury.
      • Qaseem A.
      • Mir T.P.
      • Starkey M.
      • Denberg T.D.
      Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians.
      ,
      • Reddy M.
      • Gill S.S.
      • Rochon P.A.
      Preventing pressure ulcers: a systematic review.
      • Shi C.
      • Dumville J.C.
      • Cullum N.
      Support surfaces for pressure ulcer prevention: a network meta-analysis.
      • McInnes E.
      • Jammali-Blasi A.
      • Bell-Syer S.E.
      • Dumville J.C.
      • Middleton V.
      • Cullum N.
      Support surfaces for pressure ulcer prevention.
      Additional preventive measures include avoidance of excessive moisture or dryness and optimization of nutrition.

      National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler,ed. Osborne Park, Western Australia: Cambridge Media: 2014.

      ,
      • Reddy M.
      • Gill S.S.
      • Rochon P.A.
      Preventing pressure ulcers: a systematic review.
      Offloading of pressure from the affected site is the cornerstone of treatment for pressure injuries. Depending on the site of the wound, this may be accomplished with a cushion, specialized mattress, or heel-protection boots. In patients who remain largely immobile, and particularly in those that are bed or chair bound, frequent repositioning is commonly practiced, although there is not, at present, robust evidence that this improves healing outcomes.
      • Moore Z.E.
      • Cowman S.
      Repositioning for treating pressure ulcers.
      When feasible, physical therapy (PT) is appropriate to improve mobility, although its effect on pressure injury healing specifically is not known.
      Beyond measures to offload pressure, it is important to employ local wound-care measures, including debridement.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Eschar and slough, however, should not be removed from unstageable injuries, as they provide a natural protective barrier.
      National Pressure Ulcer Advisory Panel, Haesler E, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance
      Prevention and Treatment of Pressure Ulcers.
      ,

      National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler,ed. Osborne Park, Western Australia: Cambridge Media: 2014.

      Ensuring adequate wound hydration is important. This can be accomplished with dressings, including hydrocolloid or foam.
      • Qaseem A.
      • Humphrey L.L.
      • Forciea M.A.
      • Starkey M.
      • Denberg T.D.
      Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians.
      Nutritional supplementation is another important consideration. Supplementation of protein has been associated with improved wound healing and is recommended by the American College of Physicians (ACP) and the 2014 NPUAP Clinical Practice Guidelines.
      National Pressure Ulcer Advisory Panel, Haesler E, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance
      Prevention and Treatment of Pressure Ulcers.
      ,

      National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler,ed. Osborne Park, Western Australia: Cambridge Media: 2014.

      ,
      • Qaseem A.
      • Humphrey L.L.
      • Forciea M.A.
      • Starkey M.
      • Denberg T.D.
      Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians.
      Although optimal amount, timing, and formulation remain to be clarified, current general guidelines for calorie and protein intake, respectively, are 30 to 35 kcal/kg/day and 1.25 to 1.5 grams/kg/day. One recent well-designed randomized controlled trial in malnourished patients demonstrated increased reduction in injury area at 8 weeks with a high-calorie, high-protein supplement, augmented with amino acids and antioxidants.
      • Cereda E.
      • Klersy C.
      • Serioli M.
      • Crespi A.
      • D'Andrea F.
      A nutritional formula enriched with arginine, zinc, and antioxidants for the healing of pressure ulcers: a randomized trial.
      However, the overall evidence regarding the role of amino acids and antioxidants remains inconclusive. A general guideline regarding vitamin supplementation is to limit use to patients with nutritional deficiencies.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      At this time, there is insufficient evidence to recommend zinc for pressure-injury healing.
      • Smith M.E.
      • Totten A.
      • Hickam D.H.
      • et al.
      Pressure ulcer treatment strategies: a systematic comparative effectiveness review.
      Vitamin C has not been shown to improve healing.
      • Smith M.E.
      • Totten A.
      • Hickam D.H.
      • et al.
      Pressure ulcer treatment strategies: a systematic comparative effectiveness review.
      Beyond pressure offloading, local wound care, and nutrition, many other modalities have been investigated in pressure-injury healing. Electrical stimulation may accelerate wound healing, whereas radiant-heat therapy, electromagnetic therapy, light therapy, and laser therapy are not supported by current evidence.
      • Qaseem A.
      • Humphrey L.L.
      • Forciea M.A.
      • Starkey M.
      • Denberg T.D.
      Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians.
      ,
      • Smith M.E.
      • Totten A.
      • Hickam D.H.
      • et al.
      Pressure ulcer treatment strategies: a systematic comparative effectiveness review.
      Vacuum-assisted closure therapy, which uses negative pressure on the surface of the wound to promote healing, has been shown to have beneficial effects with regard to treatment response as well as healing time.
      • Smith N.
      The benefits of VAC therapy in the management of pressure ulcers.
      Surgical flap repair is occasionally used, although benefits are unclear, given high rates of complications and wound recurrence following surgery.
      • Bates-Jensen B.M.
      • Patlan A.
      Pressure ulcers.
      Biological agents have been studied in a limited fashion in pressure-injury treatment. Although low-strength evidence exists to support improved healing of Stage 3 and 4 injuries with the use of platelet-derived growth factor, its use remains off label, and it carries a black-box warning for increased risk of malignancy; thus, its use cannot be recommended. There is little evidence to support the use of other biological agents.
      • Smith M.E.
      • Totten A.
      • Hickam D.H.
      • et al.
      Pressure ulcer treatment strategies: a systematic comparative effectiveness review.

      Venous Ulcers

      Venous ulcers of the leg result from chronic venous insufficiency and consequent edema. They are the most common wound type and likely affect millions of people in the United States at any given point in time.
      • Vivas A.
      • Lev-Tov H.
      • Kirsner R.S.
      Venous leg ulcers.
      Clinical course is often chronic, with prolonged healing time and significant risk for recurrence.
      • Valencia I.C.
      • Falabella A.
      • Kirsner R.S.
      • Eaglstein W.H.
      Chronic venous insufficiency and venous leg ulceration.
      Venous ulcers have a marked impact on health-related quality of life as well as significant financial impact at both patient and societal levels, with an estimated yearly cost to US taxpayers of $14.9 billion.
      • Rice J.B.
      • Desai U.
      • Cummings A.K.
      • Birnbaum H.G.
      • Skornicki M.
      • Parsons N.
      Burden of venous leg ulcers in the United States.
      ,
      • Phillips T.
      • Stanton B.
      • Provan A.
      • Lew R.
      A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications.
      Venous ulcers typically occur in areas of dependent edema, most often the medial or lateral malleoli or calf. Significant maceration and drainage are usually present. Pain may be present but generally to a lesser degree than with ischemic ulcers. To manage venous ulcers, underlying conditions that cause leg edema should be investigated and, if present, treated. These include venous insufficiency, heart failure, cirrhosis, chronic kidney disease, and deep vein thrombosis, among others. Review of the medication list should be undertaken, with particular focus on calcium-channel blockers, nonsteroidal anti-inflammatory drugs (NSAIDS), and certain oral hypoglycemics, all of which can cause leg edema.
      The cornerstone of prevention and treatment of venous ulcers is control of edema. This is accomplished via mechanical compression, which is supported by robust evidence indicating improved healing outcomes, including shortened time to healing.
      • O'Meara S.
      • Cullum N.
      • Nelson E.A.
      • Dumville J.C.
      Compression for venous leg ulcers.
      Numerous strategies to achieve reduction of edema via mechanical compression exist, including wraps/bandages, stockings, and boots. Although there is insufficient evidence to definitively recommend a “gold standard” strategy for reduction of edema, a number of randomized controlled trials have investigated the comparative effectiveness of different compression strategies. Available evidence suggests that multi-layer bandages are superior to single-layer bandages, and that systems including an elastic component are superior to predominantly inelastic systems, with 1 study showing a 3.5 times higher chance of complete ulcer healing at 1 year with an elastic system.
      • Danielsen L.
      • Madsen S.M.
      • Henriksen L.
      Healing of venous leg ulcers: a randomized prospective study of a long-stretch versus short-stretch compression bandage.
      High-compression stockings also appear effective, although often impractical when a wound dressing is present.
      • O'Meara S.
      • Cullum N.
      • Nelson E.A.
      • Dumville J.C.
      Compression for venous leg ulcers.
      Intermittent pneumatic compression (IPC) has shown somewhat promising results when added to usual compression strategies but requires further study before it can be routinely recommended.
      • Nelson E.A.
      • Hillman A.
      • Thomas K.
      Intermittent pneumatic compression for treating venous leg ulcers.
      Practically, a 2-layer bandage with an elastic component can be used until the ulcer has healed, with subsequent transition to high-compression elastic stockings for maintenance of edema control.
      Local wound care is also important in management of venous ulcers. A number of dressing types have no proven benefit vs plain nonadherent dressings. These include alginates, foam, hydrocolloids, hydrofiber, and paraffin gauze.
      • O'Meara S.
      • Martyn-St James M.
      • Adderley U.J.
      Alginate dressings for venous leg ulcers.
      • O'Meara S.
      • Martyn-St James M.
      Foam dressings for venous leg ulcers.
      • Saco M.
      • Howe N.
      • Nathoo R.
      • Cherpelis B.
      Comparing the efficacies of alginate, foam, hydrocolloid, hydrofiber, and hydrogel dressings in the management of diabetic foot ulcers and venous leg ulcers: a systematic review and meta-analysis examining how to dress for success.
      Practically, an absorbent dressing, such as alginate or foam, to manage wound drainage optimally and avoid periwound maceration, should be chosen. Once an ulcer is healing, is superficial, and has minimal drainage, a plain nonadherent dressing can be used. There is generally low-quality evidence that certain topical antimicrobials, particularly silver and cadexamer iodine, may improve healing vs standard care.
      • Norman G.
      • Westby M.J.
      • Rithalia A.D.
      • Stubbs N.
      • Soares M.O.
      • Dumville J.C.
      Dressings and topical agents for treating venous leg ulcers.
      ,
      • O'Meara S.
      • Al-Kurdi D.
      • Ologun Y.
      • Ovington L.G.
      • Martyn-St James M.
      • Richardson R.
      Antibiotics and antiseptics for venous leg ulcers.
      These approaches can be considered, taking into account pragmatic factors including cost, availability, ease of use, and patient preference. Various debridement strategies (autolytic, enzymatic, biosurgical) have been assessed in randomized trials, although these are generally of low quality and do not have follow-up to healing.
      • Gethin G.
      • Cowman S.
      • Kolbach D.N.
      Debridement for venous leg ulcers.
      Evidence is insufficient to recommend any debridement strategy strongly, although, practically, debridement of necrotic tissue is typically a component of venous ulcer care. Sharp debridement can be used when slough or other devitalized material is present in the wound bed. If this is not possible, an enzymatic debriding ointment can be used.
      Several novel therapeutic options for venous ulcers exist, although most remain relatively poorly studied. Pentoxifylline, when combined with compression treatment, leads to increased rates of complete ulcer healing vs compression alone.
      • Jull A.B.
      • Arroll B.
      • Parag V.
      • Waters J.
      Pentoxifylline for treating venous leg ulcers.
      It warrants consideration as an adjunct, although patients should be monitored for gastrointestinal side effects. Sulodexide, a naturally occurring glycosaminoglycan with antithrombotic and fibrinolytic properties, may improve rate of wound healing when combined with control of edema and local wound care, although lack of availability in the United States limits its use.
      • Wu B.
      • Lu J.
      • Yang M.
      • Xu T.
      Sulodexide for treating venous leg ulcers.
      Using bioengineered cellular and tissue products is supported by moderate-quality evidence, although cost (more than $1000 per application) limits its utility to some extent.
      • Jones J.E.
      • Nelson E.A.
      • Al-Hity A.
      Skin grafting for venous leg ulcers.
      It is best considered as an alternative management option for refractory ulcers. Systemic antibiotics have generally been ineffective at improving healing outcomes in trials.
      • O'Meara S.
      • Al-Kurdi D.
      • Ologun Y.
      • Ovington L.G.
      • Martyn-St James M.
      • Richardson R.
      Antibiotics and antiseptics for venous leg ulcers.
      Given increasing issues with antibiotic resistance, their use should be confined to cases of clinical wound infection. The following novel treatment approaches cannot be recommended at present as a routine part of venous ulcer management owing to lack of supporting evidence: electromagnetic therapy, flavonoids, aspirin, zinc, and therapeutic ultrasound.
      • Aziz Z.
      • Cullum N.
      Electromagnetic therapy for treating venous leg ulcers.
      • Scallon C.
      • Bell-Syer S.E.
      • Aziz Z.
      Flavonoids for treating venous leg ulcers.
      • Cullum N.
      • Liu Z.
      Therapeutic ultrasound for venous leg ulcers.
      • Wilkinson E.A.
      Oral zinc for arterial and venous leg ulcers.
      • de Oliveira Carvalho P.E.
      • Magolbo N.G.
      • De Aquino R.F.
      • Weller C.D.
      Oral aspirin for treating venous leg ulcers.

      Neuropathic Ulcers

      Neuropathic ulcers commonly occur in the feet of patients with sensory loss, often caused by peripheral neuropathy. They are frequently found on the toes or metatarsal heads and may be preceded by formation of callus in areas of pressure. Pain is characteristically absent. Neuropathic ulcers frequently occur in the context of diabetes, and ulcers account for much of the morbidity associated with this illness. Diabetes can cause both neuropathy and ischemic disease; as a result, many ulcers have a multifactorial etiology. When a neuropathic ulcer is diagnosed, arterial blood flow, structural foot deformity, and clinical presence of infection should be assessed.
      • Peters E.J.
      • Lavery L.A.
      Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot.
      Active ischemia or infection will affect the plan of treatment significantly.
      Strategies for addressing the underlying causative factors for neuropathic ulcers include treating ischemia (if present) and offloading pressure.
      • Hingorani A.
      • LaMuraglia G.M.
      • 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.
      Acutely, the foot should be completely offloaded, with total contact casting being the gold standard method to accomplish this. For prevention, definitive footwear and custom orthotics are often the most appropriate method of long-term management for patients who have experienced previous neuropathic ulcers.
      • Bus S.A.
      • van Deursen R.W.
      • Armstrong D.G.
      • Lewis J.E.
      • Caravaggi C.F.
      • Cavanagh P.R.
      Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review.
      Insurance coverage for specialized footwear may be available for patients with diabetes.
      • Brunner J.E.
      Does your patient need diabetic therapeutic footwear? (where benefit, evidence, and bureaucracy collide).
      When ongoing infection—such as cellulitis, osteomyelitis, or septic arthritis—is present, providers should prescribe appropriate antimicrobial agents. Patients with nonhealing or chronically infected neuropathic ulcers may consider amputation as a treatment option.
      • Peter-Riesch B.
      The diabetic foot: the never-ending challenge.
      Local treatment of neuropathic ulcers involves debridement of the ulcer and callus,
      • Elraiyah T.
      • Domecq J.P.
      • Prutsky G.
      • et al.
      A systematic review and meta-analysis of debridement methods for chronic diabetic foot ulcers.
      which is often accomplished via sharp debridement with scissors or scalpel. Other forms of debridement, such as mechanical or enzymatic, may be appropriate in certain circumstances involving necrotic material; however, the efficacy of these approaches has not been proved.
      • Patry J.
      • Blanchette V.
      Enzymatic debridement with collagenase in wounds and ulcers: a systematic review and meta-analysis.
      There is no conclusive evidence that any particular dressing is superior to another.
      • Bergin S.M.
      • Wraight P.
      Silver based wound dressings and topical agents for treating diabetic foot ulcers.
      • Dumville J.C.
      • Deshpande S.
      • O'Meara S.
      • Speak K.
      Hydrocolloid dressings for healing diabetic foot ulcers.
      • Dumville J.C.
      • Lipsky B.A.
      • Hoey C.
      • Cruciani M.
      • Fiscon M.
      • Xia J.
      Topical antimicrobial agents for treating foot ulcers in people with diabetes.
      Thus, the practical provider prescribes a dressing that accounts for cost, convenience, and general wound principles. For patients exhibiting ischemic limbs in addition to neuropathic components (mixed ulcers), treating the ulcer as an ischemic wound is generally preferred. In patients with both intact blood flow and no infection, maintaining a moist wound environment (hydrogel, hydrocolloid, or saline) is often an appropriate option. For patients experiencing infection with intact blood flow, one must consider treating the infection systemically. There is no conclusive evidence supporting the use of topical antimicrobials in this context.
      • Bergin S.M.
      • Wraight P.
      Silver based wound dressings and topical agents for treating diabetic foot ulcers.
      ,
      • Dumville J.C.
      • Lipsky B.A.
      • Hoey C.
      • Cruciani M.
      • Fiscon M.
      • Xia J.
      Topical antimicrobial agents for treating foot ulcers in people with diabetes.
      The role of advanced therapies for neuropathic ulcers remains largely inconclusive based on published evidence. Hyperbaric oxygen therapy (HBOT) has been studied in the context of diabetic foot ulcers, where it appears to improve wound healing in the short term but not at 1 year.
      • Perren S.
      • Gatt A.
      • Papanas N.
      • Formosa C.
      Hyperbaric oxygen therapy in ischaemic foot ulcers in type 2 diabetes: a clinical trial.
      ,
      • Kranke P.
      • Bennett M.H.
      • Martyn-St James M.
      • Schnabel A.
      • Debus S.E.
      • Weibel S.
      Hyperbaric oxygen therapy for chronic wounds.
      A nonstatistically significant trend toward reduced amputation has been demonstrated, particularly in patients who are able to complete a full HBOT protocol.
      • Santema K.T.B.
      • Stoekenbroek R.M.
      • Koelemay M.J.W.
      • et al.
      Hyperbaric oxygen therapy in the treatment of ischemic lower-extremity ulcers in patients with diabetes: results of the DAMO2CLES Multicenter Randomized Clinical Trial.
      Cost and availability limit its use.
      • Kranke P.
      • Bennett M.H.
      • Martyn-St James M.
      • Schnabel A.
      • Debus S.E.
      • Weibel S.
      Hyperbaric oxygen therapy for chronic wounds.
      Vacuum-assisted closure (VAC) therapy can potentially improve wound healing,
      • Liu S.
      • He C.Z.
      • Cai Y.T.
      • et al.
      Evaluation of negative-pressure wound therapy for patients with diabetic foot ulcers: systematic review and meta-analysis.
      but its application and maintenance requires specifically trained staff. Remaining adjuvant treatments for neuropathic ulcers are not strongly supported by evidence.
      • Elraiyah T.
      • Tsapas A.
      • Prutsky G.
      • et al.
      A systematic review and meta-analysis of adjunctive therapies in diabetic foot ulcers.

      Ischemic Ulcers

      Ischemic ulcers of the leg most often occur in the context of peripheral arterial disease (PAD). They are frequently seen in patients with cardiovascular risk factors (smoking, diabetes mellitus, hypertension, hyperlipidemia, advanced age, family history of atherosclerotic vascular disease), and thus aggressive modification of these risk factors, particularly in patients who already have known PAD, is the best preventive strategy. Aspirin, for example, delays progression of PAD and reduces need for revascularization.
      • Hopf H.W.
      • Ueno C.
      • Aslam R.
      • et al.
      Guidelines for the prevention of lower extremity arterial ulcers.
      The characteristic symptom of PAD is distal leg pain with ambulation (intermittent claudication [IC]). Rest pain, particularly at night, can develop as ischemia worsens. Pain may be severe. Dependent rubor and elevation pallor are often observed. Affected limbs appear pale, dry, and relatively hairless. When ischemic ulcers develop, they are typically black in appearance because of necrotic tissue at the base and have well-demarcated borders. They often occur distally, such as on the tips or dorsal surface of toes, and are characteristically painful.
      Although PAD is the most common cause of lower-limb arterial insufficiency, other causes, both anatomic and functional, are possible. Thrombosis, embolism, and vasculitis are examples of anatomic causes, whereas conditions such as Raynaud disease can lead to functional obstruction. Trauma, fistulas, and aneurysms are other causes of impaired arterial flow.
      • Hess C.T.
      Clinical order sets for arterial ulcers.
      Regardless of cause, an objective test for identifying arterial insufficiency is measurement of the ankle-brachial index (ABI). If the ABI is below 0.9, there is arterial insufficiency, although, notably, this finding has suboptimal sensitivity, particularly in patients with diabetes or distal lesions, so clinical suspicion with normal ABI should prompt further investigation with Doppler ultrasound studies or angiography.
      • Nam S.C.
      • Han S.H.
      • Lim S.H.
      • et al.
      Factors affecting the validity of ankle-brachial index in the diagnosis of peripheral arterial obstructive disease.
      Patients with ulcers as a result of arterial insufficiency often have ABIs lower than 0.5.
      Once PAD has developed, there is significant risk for progression despite medical management. Over 5 years, approximately 7% of patients with asymptomatic PAD will progress to IC, and approximately 21% of those with IC will experience worsening of their symptoms (including progression to critical limb ischemia [CLI]). Estimates of the incidence of amputation over 5 years in patients with IC vary widely, ranging from 4% to 27%; risk is likely higher in patients with CLI.
      • Sigvant B.
      • Lundin F.
      • Wahlberg E.
      The risk of disease progression in peripheral arterial disease is higher than expected: a meta-analysis of mortality and disease progression in peripheral arterial disease.
      The cornerstone of management for ischemic ulcers is reestablishment of arterial blood flow. Several studies have investigated ischemic ulcer healing outcomes in CLI after revascularization. All are observational and most are single-center retrospective studies. The majority of enrolled patients have diabetes. Reported complete ulcer healing at 1 year post-revascularization ranges from 52% to 87% and does not appear to vary based on revascularization method (bypass vs endovascular), although only 1 study has specifically reported this difference.
      • Azuma N.
      • Koya A.
      • Uchida D.
      • Saito Y.
      • Uchida H.
      Ulcer healing after peripheral intervention: can we predict it before revascularization?.
      Local wound care, although important, has limited benefit for ulcer healing. A main goal is to keep the ulcer and overlying eschar dry and protected until blood flow is reestablished. This can be accomplished by covering the wound with dry gauze or topical films. To prevent wet gangrene, hydrating dressings—including hydrocolloids, hydrogels, alginates, and foam—should be avoided.
      • Sieggreen M.Y.
      • Kline R.A.
      Arterial insufficiency and ulceration: diagnosis and treatment options.
      Several novel treatment options for ischemic ulcers exist. HBOT (discussed in more detail in Neuropathic Ulcer section) is sometimes used despite limited supporting evidence. Some retrospective studies suggest that wound healing is improved and amputation decreased with IPC in patients with CLI; however, the quality of evidence is low.
      • Moran P.S.
      • Teljeur C.
      • Harrington P.
      • Ryan M.
      A systematic review of intermittent pneumatic compression for critical limb ischaemia.
      Larvae therapy, which decreases wound bioburden, debrides nonviable tissue, and improves wound healing by facilitating the remodeling process, is a consideration for infected wounds.
      • Rafter L.
      Larval therapy applied to a large arterial ulcer: an effective outcome.
      The strength of evidence to support the use of low-frequency ultrasound therapy in ischemic ulcers is low.
      • Kavros S.J.
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      Diagnostic and therapeutic ultrasound on venous and arterial ulcers: a focused review.
      B vitamins and folate have no benefit.
      • Hopf H.W.
      • Ueno C.
      • Aslam R.
      • et al.
      Guidelines for the prevention of lower extremity arterial ulcers.

      Choice of Wound Dressing

      Healing of any wound is a highly organized and complex process involving hemostasis, inflammatory response, proliferation, and remodeling. For wound healing to occur, multiple factors—including adequate tissue perfusion, an intact immune system, appropriate level of wound hydration, removal of necrotic/nonviable tissue, and management of infection, if present—must be addressed. These factors heavily influence dressing choice. Other factors to consider include protecting periwound skin, forming an effective bacterial barrier that conforms to the wound shape, producing minimal pain during dressing changes, avoiding introducing nonbiodegradable fibers into the wound, and maintaining optimal wound temperature and pH.
      • Sood A.
      • Granick M.S.
      • Tomaselli N.L.
      Wound dressings and comparative effectiveness data.
      It is essential to remember that dressings do not heal the wound; the body heals the wound. Dressings augment this process and can only be properly selected after thorough wound assessment and with knowledge of the capabilities of various dressing products. A summary of the most commonly used wound dressings, their indications/contraindications, and advantages/disadvantages, along with several examples of each dressing type, is provided in the Table. Our suggested approach to treating each wound type, based on evidence (when available) and our clinical experience, is outlined in Figure 1, Figure 2, Figure 3 to 4.
      TableCommon Wound Dressings and Their Use
      All images, courtesy of the Mayo Clinic Wound Clinic.
      DressingProductsIndicationsContraindicationsAdvantagesDisadvantagesComments
      Gauze



      Gauze squares, ribbon, padsDeep wounds, especially with tunneling and undermining; can be used for most every wound typeCan traumatize certain woundsInexpensive; readily available; nonocclusive and highly absorbent; absorbs exudate; mechanically debrides wounds. Can be used for infected and noninfected woundsFibers can be retained in wound bed; dried out dressings can reinjure a wound upon removal; requires frequent dressing changesNeeds to be remoistened often to maintain a moist wound environment.
      Foam



      Allevyn, Aquacel, Biatain, Cutimed Cavity, Cutimed Siltec, Hydrofera Blue, Kendall Foam, Lyofoam, Mepilex, Mepilex Transfer, Microfoam, Optifoam, Polymem, Restore,Tegaderm Foam High Performance, TielleLow to moderately exudative wounds; granulating wounds; slough-covered wounds; full-thickness and partial-thickness wounds; diabetic foot ulcersExcessive wound drainage; dry wound base; eschar; deep or tunneling woundMaintains wound moisture; highly absorbable; provides thermal insulation; provides some mechanical debridement; available with silverCan be cost-prohibitive; can cause wound desiccationAtraumatic to periwound margins with removal; can be changed every 4 to 7 days. If changed daily, can be used on infected wounds.
      Hydrogels

      Curafil, Curagel, Cutimed Gel, DuoDERM Hydroactive Gel, Hypergel, NU-GEL, Purilon, Skintegrity Gel, Tegaderm Hydrogel, TegagelPressure ulcers; full-thickness and partial-thickness ulcers; vascular ulcersWound maceration; excessively draining woundsEases pain by improving wound hydration; autolytic debridement; fills dead space; promotes granulationRequires a secondary dressing; not occlusive; macerates periwound margins; not efficacious in highly exudative or infected woundsStays moist longer than saline; reduces adherence of gauze to wound bed; must control for maceration; better than hydrocolloids and gauze for pressure ulcers.
      Transparent Films

      BIOCLUSIVE Plus, Hypafix,Mepitel Film, Opsite, Polyskin, Suresite,TegadermSurgical incisions; superficial wounds; skin-graft donor sites; areas of frictionExudative wounds; bacterial or fungal skin infectionsPermeable to water vapor; impermeable to bacteria; provides moist wound environmentCan cause further skin damage if removed incorrectly; no absorptive propertiesCannot be used on infected or heavily-draining wounds.
      Alginates



      Algicell, Algisite M, Aquacel, Aquacel Ag,Biatain Alginate, Curasorb Cutinova Hydro, Exufiber, Kaltostat, Maxorb, Maxorb Extra Ag, Melgisorb Plus, Nu-Derm Alginate, Opticell, Restore, SorbsanPressure injuries; vascular ulcers; sinus tracts; infected wounds; exposed tendonsDry, minimally draining, or superficial woundsMaintains wound moisture; nonadherent; used on infected wounds; absorb excessive drainage; fill dead space; autolytic debridementCan dehydrate a drier wound; needs a secondary dressing; ineffective for dry escharKeep dressing within wound borders; requires secondary dressing; control for wound maceration.
      Hydrocolloids

      Comfeel Plus, DuoDERM, Exuderm, Granuflex, NU-DERM, Primacol, Restore, Tegaderm, UltecPartial- and full-thickness wounds with low-to-moderate exudate; granulating wounds; minor burns; pressure injuries.Poor skin integrity; infected ulcers; deep/tunneling woundsMalleable; insulates wound; provides moist wound environment; prevents contamination; promotes autolytic debridement; no secondary dressing required; less frequent dressing changesCannot be used on highly-exudative wounds, over sinus tracks, exposed bone/tendon, fragile periwound tissue or on infected wounds; macerates healthy skinCan be used to “frame” a wound to secure dressing; can apply over alginate to control drainage.
      Collagen



      Biostep, CellerateRX Powder, Cutimed Epiona, FIBRACOL Plus, PROMOGRAN Matrix, Puracol Plus, SkinTemp,Stimulen Collagen GelExudative, full- and partial-thickness wounds; pressure injuries; venous ulcers; mixed vascular ulcers; diabetic foot ulcers; second-degree burns; donor sites; wounds healing by secondary intention; wound dehiscenceInfected wounds; osteomyelitis; cellulitis; wounds covered with escharAvailable as particles, hydrogel or sheets; stimulates healing beyond growth factorsVasculitis, third-degree burnsWound base must be clean, free of infection and debris; cannot be used with debriding agents; derived from bovine and porcine collagen: avoid use for religious or allergic reasons.
      Antimicrobial

      Acetic acid 0.25%, DABS solution, Dakin’s Solution, MediHoney, TheraHoney, Inadine, Iodoflex, Iodosorb Gel, Kendall AMD Antimicrobial Foam, silver sulfadiazine 1%Inhibits microbes in chronic wounds without using antibioticsWorsening infection; hypersensitivity/reaction to the antimicrobial productEasy to use; readily available; less costly than antibiotics; available without a prescription; less risk of resistance; effective at reducing wound bioburdenWill not eradicate a wound infection; alternative treatment may be neededAntimicrobial dressings should be continued until the wound improves.
      Silver Dressings

      Acticoat 7, Allevyn AG, Aquacel Ag, Biatain AG, Maxorb Extra AG, Mepilex AG, Opticell AG Optifoam AG, Polymem AG, Restore with Silver, SilvercelMalodorous, highly-exudative, slow-healing wounds; increased wound bioburdenCellulitis; systemic infectionHas antibacterial, antifungal and antiviral properties; improves wound hygieneMay cause silver staining on the skinAvailable in almost every dressing type; no effect on bacteria that has penetrated a wound bed.
      Cellular/Tissue-based Products

      Apligraf, Cytal Wound Matrix,

      Dermagraft,

      EpiFix, Grafix,

      Graftjacket, Integra, Wound Matrix, Kerecis Omega3,

      NuShield, Oasis Wound Matrix, TheraSkin
      Diabetic foot or venous stasis ulcers that have failed to heal after 4 weeks of standard wound careInfected wounds; significant drainage; osteomyelitis; cellulitis; tunneling or eschar that prevents graft adherence, arterial diseaseProvides wound coverage to complete wound closure; reduces healing time and pain; improves appearance and function; improves quality of life; less invasive than skin graftingExpensive; best applied by a skilled clinician; may not be covered by certain commercial insurance carriers; most products must be applied every 1 to 2 weeksProvides a temporary biologic barrier to augment wound healing by stimulating the recipient's own skin cells.

      Conclusion

      Chronic wounds are common and disproportionately affect older adults. Proper treatment requires identification, appropriate classification of the etiology, management of underlying contributing conditions, local therapies/dressings, and consideration of adjunctive therapies. Both primary and secondary prevention are also important. Providers in multiple specialties and across care settings, especially those caring for older adults, are likely to encounter chronic wounds and thus should be comfortable with these steps for all major wound types.

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