ROLF PAULSON, MD, Medical Director, Chronic Wound Care Clinic, Altru Clinic and Hospital; Clinical Professor of Internal Medicine, University
of North Dakota School of Medicine and Health Sciences, Grand Forks, ND.
PAT GUTHMILLER, RN, BSN CWOCN, Wound and ostomy nurse, Altru Clinic and Hospital, Grand Forks, ND.
DAN RUSTVANG, RN, MSN, FNP-C, Technical Director, Chronic Wound Clinic, Altru Clinic and Hospital, Grand Forks, ND.
This article was contributed by Dr Paulson, Ms Guthmiller, and Mr Rustvang and edited by Julia M. Russell.
The authors disclose that they have no financial relationships with any manufacturer in this area of medicine.
The diagnosis and treatment of chronic wounds has received inadequate attention in medical schools and primary care residencies.
Attention to wound management, especially the care of chronic cutaneous ulcers, is generally scattered throughout medical
and surgical specialties, rehabilitation medicine, podiatry, dermatology, and primary care.
We have a 4-step protocol currently in use at our institution for the management of chronic cutaneous ulcers. The first and
most important step is to determine and address the cause of the wound. Edema secondary to venous valvular incompetence, for
example, can cause stasis ulcers; diabetes is a frequent cause of neuropathic ulcers; and arterial insufficiency often causes
ulcers that lead to gangrene.
The next step is to evaluate any comorbidities that may interfere with wound healing, such as arterial insufficiency that
is preventing resolution of a heel ulcer caused by immobility, infection that is complicating healing of a statis ulcer, or
neuropathy, arterial insufficiency, and infection all complicating healing of a ulcer.
Third, we evaluate how well the patient understands the nature of the ulcer and the healing process, their motivation to improve,
and the need for resources, such as caregivers, money or insurance for dressings or equipment, and transportation. A positive
outlook and healing environment will optimize the outcome. The fourth and last step is to evaluate the wound and determine
the appropriate treatment, type of dressing needed, and the need for debridement.
History and physical examination
At our institution, patients with chronic ulcers undergo a thorough history taking, physical examination, and, when appropriate,
special studies. A complete history puts the wound in context; a history of arterial or venous disease or vasculitis is particularly
important in the patient with a nonhealing leg ulcer. How was the initial wound treated? What treatments for previous ulcers
have been successful? Has the patient undergone skin grafts or vascular bypass? What caused immobility that led to the decubitus
ulcers? Does the patient appear well nourished?
During the wound examination, note the appearance of the wound itself and the surrounding skin and the presence and absence
of pulses, edema, and other clues to the underlying cause. Measure the wound and note any necrosis, slough, or granulation
tissue. Probe any fissures or deep aspects to the wound. Document the size and composition of the wound, including granulation
tissue, eschar, or slough with both a flow chart and a digital camera. Images are excellent documentation for both the clinical
staff and the patient; many patients with sacral or heel ulcers have never seen their wound.
A clinical suspicion of inadequate arterial supply that is suggested by the ankle-brachial ratio warrants formal arterial
Doppler flow studies. Laboratory studies including serum albumin level, WBC count, and ESR may give evidence of inflammation
and the patient's nutritional status. A suspicion of osteomyelitis warrants consideration of a bone scan or MRI. A biopsy
may be in order if the history and examination are inconclusive regarding the type of ulcer.
Treatment
Ulcer treatment occurs in 2 phases; first, the ulcer is prepared for healing, and then healing is promoted (see "Treating
specific ulcers"). Because healing will not occur until granulation tissue has formed, the first step is to debride necrotic
tissue or slough. Sharp debridement using a scalpel or scissors to remove necrotic tissue can be performed in the operating
room or in the office. Mechanical debridement involves the use of a whirlpool, abrasive treatment, or wet-to-dry dressings
to mechanically remove debris. Enzymatic debridement requires the use of a topical agent such as collagenase to remove and
dissolve the slough. Autolytic debridement, or moist wound healing, involves the use of hydrocolloids, transparent films,
and hydrogels to enable the body's own enzymes to eliminate devitalized tissue and encourage growth of granulation tissue.
Advantages of autolytic debridement include less pain, less frequent dressing changes, and faster healing. Moist wound healing
consists of occluding the wound, keeping the surface moist, keeping the edges dry, and removing exudate.
TABLE 1. Dressings for ulcer care
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Among the many available dressings, those used most commonly for ulcer treatment fall into either moisture-retentive or drying
agents. Made of nonwoven fibers derived from seaweed, alginate dressings form an absorbent gel on contact with wound exudate.
They are typically used for wounds with moderate to heavy drainage. Hydrocolloid dressings are composed of gelatin and gel-forming
agents such as sodium carboxymethylcellulose. They also form an absorbent gel on contact with exudate and are used for wounds
with light to moderate drainage. Hydrogel dressings contain a gel composed primarily of water and are used for wounds with
minimal or no exudate (see Table 1). Wounds with extreme exudate may benefit from the use of vacuum-assisted closure.
SUGGESTED READING
Baranoski S, Ayello E. Wound Care Essentials: Practice Principles. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004.
Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice: neuropathic diabetic foot ulcers. N Engl J Med. 2004;351:48-55.
de Araujo T, Valencia I, Federman DG, et al. Managing the patient with venous ulcers. Ann Intern Med. 2003;138:326-334.
Lyder CH. Pressure ulcer prevention and management. JAMA. 2003;289: 223-226.
Sumpio BE. Foot ulcers. N Engl J Med. 2000;343:787-793.
Takahashi PY, Kiemele LJ, Jones JP Jr. Wound care for elderly patients: advances and clinical applications for practicing
physicians. Mayo Clin Proc. 2004;79:260-267.
Treating specific ulcers
IMAGES: ROLF PAULSON, MD
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Stasis ulcers
The appearance of stasis ulcers, the most common type of chronic ulcer, is typically one of a shallow, irregularly shaped
wound that is often hyperpigmented and usually occurs on the medial or lateral malleolus. Effective management of the constant
edema is the key to treatment. At our institution, treatment using a 4-layer compression bandage system is often successful;
patients tolerate the 4-layer compression bandages much better than they do the Unna boot dressings.
A wound dressing can be used under the 4-layer bandage. The initial 4-layer dressing is usually changed after 3 or 4 days
and then weekly thereafter. Compression should only be initiated with adequate circulation. Stockings typically exert 30 to
40 mm of compression, although a greater degree of compression is often used in obese patients. We have found that antiembolism
stockings provide inadequate compression in a wound care setting.
Healing a stasis ulcer is often easier than keeping it healed. Patients must understand the consequences of discontinuing
compression.
Arterial ulcers
These often painful ulcers caused by arterial insufficiency can occur anywhere, but appear most often in the feet. Gangrene
of the toes or foot is a worrisome presentation of arterial insufficiency. Treatment is aimed at restoring blood flow, and
options include revascularization by surgery or angioplasty. Amputation is a last resort.
Diabetic foot ulcers
These painless neurotrophic or neuropathic ulcers typically occur on the plantar surface of the foot below the first metatarsal
head, at the heel, or at the top of the toes. Treatment involves eliminating the pressure that caused the ulcer and addressing
any arterial deficiencies or infection; the latter can be complex and require complicated antibiotic regimens. Osteomyelitis
is assessed by exam, x-ray studies, bone scan, or MRI and treated appropriately with antibiotics, surgery, or both.
Decubitus ulcers
The crucial element of treating these ulcers is relieving the pressure, or offloading. As for heel or other pressure ulcers,
observe the patient in both the sitting and supine positions in the chair or mattress used regularly to determine the best
way to alleviate pressure. The appropriate dressing depends on staging (see Table 1). In stage 1 decubitus ulcers, the skin
is unbroken but red or otherwise discolored that does not fade within 30 minutes of the pressure being relieved. Stage 2 ulcers
are characterized by a torn or broken top layer of skin that creates a shallow, open wound. Stage 3 ulcers are deeper than
stage 2, and the wound extends through the fatty tissue. Stage 4 ulcers extend into the muscle and necrotic tissue, and drainage
is often noted.
CLINICAL PEARLS - Examine dressings removed from wound, and note type and consistency of exudate.
- Limit or modify use of adhesive dressings on fragile skin.
- The silver-based dressings are antimicrobial and are appropriate for methicillin-resistant Staphylococcus aureus wounds.
- Ischemic pain is extremely difficult to control. If pain is controlled and surgery is considered too risky, observation is
a reasonable approach, with the understanding that thewound will not heal. Uncontrolled pain or infection warrants urgent
revascularization or amputation.
- Debridement is not an emergency, and the clinical situation may worsen when the patient with inadequate circulation undergoes
debridement.
- Get help! As difficult as it is to be mindful of the available dressings, it is more difficult to have them available and
have the right reimbursement codes at the ready. Teaming with an RN or certified wound ostomy care nurse (CWOCN) works very
well in our chronic wound care setting.
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