Chronic wounds

A chronic wound is one that has failed to go through the normal stages of healing in the order and timeframe you would typically expect. Usually the timepoint is 3 months, although a wound can be classed as chronic if it has shown no significant progress towards healing in 1 month (Chadwick, 2020; Couch, 2021).

The normal wound healing process is marked by four stages (DermNet, 2009; WoundSource, 2016):

• Haemostasis – the process that stops blood flow and encourages clotting
• Inflammation – the way in which the tissue responds to the injury or disease, normally marked by a combination of redness, swelling, pain, itchiness and feeling hot
• Proliferation – new tissue cells grow so the wound can be ‘rebuilt’
• Repair – collagen reforms to provide the structure for the wound to close (also known as the ‘remodelling’ or ‘maturation’ phase).

Chronic wounds are often stalled at the inflammation stage of

Aetiology and symptoms

The aetiology and signs and symptoms of a chronic wound vary according to the type of wound.

As described, a chronic wound is identified by its failure to heal over an expected period of time rather than by a set of symptoms. However, most chronic wounds share a number of characteristics:

• high levels of proteases (enzymes that break down proteins and peptides)
• elevated inflammatory markers
• reduced activity of growth factors (components that control the growth, differentiation and metabolism of cells that are essential to tissue repair)
• reduced cell proliferation (Phan, 2021)

Visible signs of a chronic wound might include a raised wound margin; inflammation around the wound; discolouration of the surrounding skin; pain (sometimes constant); weeping from the wound (InformedHealth, 2018).

A significant risk with a chronic wound of any aetiology is infection, which occurs because the body’s external defence – the skin – is compromised and

A chronic wound is diagnosed based on a visual assessment, consideration of how long the wound has been present with no sign of healing, and a thorough patient history together with identification of individual risk factors, all of which are outlined above.

A commonly used, standardised method of assessing a chronic wound is the TIMES principle, an acronym that summarises clinical features of a wound bed and can help clinicians determine how to treat and manage a wound (Wounds UK, 2017).

• T – Tissue. The overall appearance of the wound bed is key in determining how healthy the tissue is and whether there are signs of necrosis, which encourages bacteria growth. Dead tissue indicates that debridement (removal of such tissue) is necessary.
• I – Infection/inflammation. Bacteria can multiply and cause infection, slow healing and increase pain and pus and/or discharge.
• M – Moisture. If there is excessive or deficient moisture

The exact treatment plan will depend on the type of chronic wound, its severity, whether infection is present, the patient’s individual circumstances and other influencing factors (such as comorbidities, health status), and local guidelines.

In general, chronic wound treatment and management typically involves:

Dressing the wound: many different types of dressings are available and will depend on the wound and patient needs and preferences. Dressings should be changed frequently.

Moisturising the skin: In some cases, moisturising topic treatments can be applied to the wound edge and surrounding skin.

Cleaning: This entails rinsing the wound and removing dead or deeply damaged tissue, called debridement. Anaesthetic may be used to minimise pain during this procedure.

Managing infection: If infection is present, particularly if it has spread beyond the localise wound area, oral or intravenous antibiotics can be prescribed.

Relieving pressure/offloading: If a patient with a pressure ulcer is bedridden or wheelchair bound,

References

Adderley, U. The National Wound Care Strategy Programme. 2021. www.woundcare-today.com/journals/issue/wound-care-today/article/national-wound-care-strategy-programme (accessed 1 December 2021)

Chadwick, P. Spotlight on managing chronic wounds, diabetic foot ulcers and pressure ulcers. 2020. www.bjfm.co.uk/spotlight-on-managing-chronic-wounds-diabetic-foot-ulcers-and-pressure-ulcers (accessed 1 December 2021)

Cleveland Clinic. Diabetic Feet. 2021 www.my.clevelandclinic.org/health/diseases/21510-diabetic-feet#symptoms-and-causes (accessed 1 December 2021)

Couch, K. Chronic Wounds. 2021. www.woundsource.com/patientcondition/chronic-wounds (accessed 1 December 2021)

DermNet NZ. Wound healing – normal wound healing. 2009. www.dermnetnz.org/cme/wound-healing/normal-wound-healing (accessed 1 December 2021)

Diabetes UK. Peripheral neuropathy (nerve damage). 2021. www.diabetes.org.uk/guide-to-diabetes/complications/nerves_neuropathy (accessed 1 December 2021)

Fryberg, R and Banks, J. Challenges in the treatment of chronic wounds. 2015. www.ncbi.nlm.nih.gov/pmc/articles/PMC4528992/ (accessed 1 December 2021)

InformedHealth. Chronic wounds: Overview. 2018. www.ncbi.nlm.nih.gov/books/NBK326431/ (accessed 1 December 2021)

InformedHealth. What are the treatment options for chronic wounds? 2018b. www.ncbi.nlm.nih.gov/books/NBK326436/ (accessed 1 December 2021)

McGuire, J. Diabetic Neuropathic Foot Ulcers. 2021. www.woundsource.com/patientcondition/diabetic-neuropathic-foot-ulcers (accessed 1 December 2021)

Monteira-Soares, M, Russell, D et al. IWGDF Guideline on the classifcation of diabetic foot ulcers. 2019. International Working Group on the Diabetic Foot.