Bringing Wound Care Back to the Future

  The majority of patients afflicted with chronic wounds suffer from lower extremity ulcers caused by chronic venous insufficiency (CVI) that affects approximately 2.5 million people in the US. It has been estimated that approximately 600,000 people seek treatment for venous leg ulcers on an annual basis and given the relationship between age and venous ulceration that number most likely will continue to grow as the population ages. Tremendous effort has been expended by many organizations to define the standard of care for venous ulcerations.

  Data show that following guidelines improves patient outcomes. With regard to venous ulceration, guidelines are focused on the provision of appropriate compression. Margolis1,2 reported that appropriate limb compression resulted in healing rates of 30% to 60% at 24 weeks and 70% to 85% at 1 year. In a 2006 study of wound healing trajectories in 232 patients conducted in eight trials over 10 years, Steed3 showed that 60% of patients were healed on average at 20 weeks. Thus, when appropriate compression is applied, the overall healing rate in venous ulcers approaches 80% and has remained unchanged for the past 20 years.

The Frustrating 15%

  In the 1990s, product choice was relatively limited and the standard of care at the time was the “Duke Boot,” popularized by Dr. Claude Burton of Duke University.4 In 1993, this author reviewed data from 300 consecutive patients treated at Memorial Hermann Hospital, Houston, Tex using Dr. Burton’s approach that comprised use of a hydrocolloid dressing and an Unna’s boot (we used Gelocast™ Unna's Boot Dressing (Biersdorf Jobst, Inc., Charlotte, NC) covered with an elastic wrap (ACE® or Coban 3M™, St. Paul, Minn). The overall healing rate was 85% within approximately 6 months. What was interesting was that among the “frustrating 15%” (who had not healed), all had either diabetes or rheumatoid arthritis or both, most of the latter were on prednisone. When the author performed a similar data review 15 years later, despite the plethora of new options available for dressings and compression, the “frustrating 15%” remained; overall healing rates continued to be 85%, simply by implementing consistently good compression. When so much changed in the wound care industry between the years 1990 and 2006, how could so little have changed in terms of outcome for stasis patients?

Plotting The Trajectories

  Numerous studies have shown that dressing or bandage choice has no significant impact on time of healing or healing rates in stasis ulcer patients provided with good compression.5,6 However, when Steed’s data were separated into two categories—ie, patients who healed by 20 weeks and patients who did not—plotting the wound-healing trajectories revealed very different curves. This suggested that the latter group’s underlying comorbidities interfered with healing. It is this latter group that may benefit from advanced technology. For example, a randomized controlled trial (RCT) of human skin equivalent (HSE)7 showed that 63% of patients receiving HSE were healed at 6 months compared to 49% for the control group. Likewise, for an RCT of the OASIS extracellular matrix graft (Healthpoint, Fort Worth, Tex), at 12 weeks the experimental group was 55% healed versus 34% for the control group.8

Identifying the Hard-to-Heal Patient

  Most experienced industry professionals would like to think that over a career of practice, they have gotten better at screening for vascular disease, diagnosing vasculitis or atypical ulcerations, and controlling the other factors that negatively affect healing like poor nutrition, bacterial bioburden, or out-of-control diabetes. But the fact is that the majority of venous ulcer patients do well with little more than good, basic compression. That is why it does not take a lifetime of experience to do a good job with these patients. However, a small percentage of patients will fall into a hard-to-heal category; clinicians should now recognize the criteria early rather than waiting for them to fail after several months of conservative care. These patients may have chronic or large wounds or certain “red flag” comorbid conditions. In some cases, these wounds should be diagnosed on the day of consultation or, as suggested by Falanga,9 within 4 weeks of care when they fail to meet projected healing milestones.

Bringing Back the Past

  No other intervention in the field of wound care may have a greater evidence base for use than compression in the treatment of venous ulcerations. Applied correctly and consistently, compression can heal up to 85% of patients, a success rate that has held steady for 20 years. Recent scientific advances allow clinicians to expediently identify patients with limited healing potential and provide them with advanced technologies aimed at correcting their specific underlying healing barriers. However, the great irony of healthcare in the 21st century is that reimbursement problems threaten the wound care professional’s ability to provide the most basic compression; regional Medicare carriers quibble over how and when such compression can be provided to the growing number of patients who need it.10

  Utilizing new technologies in the care of compromised patients is exciting. Still, the future challenge for venous ulcer management may be how to provide the same care that was available in the past.

References

1. Margolis DJ, Berlin JA, Strom BL. Risk factors associated with the failure of a venous leg ulcer to heal. Arch. Dermatol. (1999); 135(8):920–926.

2. Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. Brit. Med. J. (1997); 315(7108):576–580.

3. Steed DL, Hill DP, Woodske ME, Payne WG, Robson MC. Wound-healing trajectories as outcome measures of venous stasis ulcer treatment. Int. Wound J. (2006); 3(1):40-47.

4. Burton CS: Venous ulcers. Am J Surgery. (1994); 167(1A): 37S–41S.

5. Cullun MN. Evaluation of treatments for wounds in clinical trials. J Wound Care (1996);5(1):8–9.

6. Duby T, Hoffman D, Cameron J, Brown D, Chewy G, Ryan T. A randomized trial in the treatment of venous leg ulcer comparing short stretch bandages, four layer bandage system and a long stretch-paste bandage system. Wounds. (1993);5:276-279.

7. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Arch. Dermatol. (1998); 134(3):293-300.

8. Mostow EN, Haraway GD, Dalsing M, Hodde JP, King D. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J. Vasc. Surg. (2005);41(5):837–843.

9. Falanga V, Sabolinski M. Wound Repair and Regeneration. Vasc Surg. 1999; 7(4)201–207.

10. Fife C. Walker D, Thomson B, Carter M Limitations of daily living activities in patients with venous stasis ulcers undergoing compression bandaging: Problems with the concept of self-bandaging. Wounds. (2007)10(19):255–257 Fla: Taylor & Francis Group 2005:423–437.