Wound Care and Healing — Principles of Acute and Chronic Wound Management

Wound assessment and classification

Accurate wound assessment requires identification of the underlying etiology, as treatment differs fundamentally between wound types. Venous ulcers are typically shallow, in the gaiter area, with associated edema and hemosiderin staining. Arterial ulcers are typically on pressure points (toe tips, lateral malleolus), pale/painful, with absent pulses. Diabetic foot ulcers are typically on the plantar surface under metatarsal heads, neuropathic and painless. Pressure ulcers occur over bony prominences and are staged by depth (Stage I through Stage IV, unstageable, and deep tissue injury). The TIME framework provides a systematic wound bed assessment.

• Venous ulcer: shallow, medial leg, gaiter area, hemosiderin staining, edema — compression is primary treatment
• Arterial ulcer: toe tips, lateral malleolus, pale/painful, cool skin, absent pulses — vascular referral
• Diabetic ulcer: plantar surface, painless (neuropathic), callus rim — offloading is primary treatment
• Pressure ulcer: bony prominence, staged by depth (I–IV, unstageable, deep tissue injury)
• TIME framework: Tissue (granulation, slough, necrosis), Infection, Moisture balance, Edge (advancing or stalled)
• Peri-wound assessment: maceration, callus, edema, erythema — indicates dressing or compression failure

Treatment principles and dressing selection

Wound bed preparation follows the TIME framework: debridement of necrotic tissue and slough (surgical, autolytic, enzymatic, or mechanical), infection control (topical antiseptics for critical colonization, systemic antibiotics for spreading/cellulitis), moisture balance (absorbent dressings for exudative wounds, hydrogels for dry wounds), and wound edge advancement (addressing edema, callus, and mechanical factors). Compression (multi-layer bandaging for venous ulcers) and offloading (total contact casting for diabetic plantar ulcers) are the cornerstones of their respective wound types. Adjunct therapies (negative pressure wound therapy, bioengineered skin substitutes, hyperbaric oxygen) are considered for complex wounds failing standard care.

• Surgical debridement: sharp debridement of necrotic tissue — most effective for wound bed preparation
• Autolytic debridement: moist wound healing with hydrogels or hydrocolloids for sloughy wounds
• Infection management: topical (silver, cadexomer iodine) for critical colonization; systemic for cellulitis
• Moisture balance: foam dressings for moderate exudate, alginates for heavy exudate, hydrogels for dry wounds
• Compression: 4-layer bandaging for venous ulcers — 40 mmHg at ankle, 30 mmHg at calf, 20 mmHg at knee
• Negative pressure wound therapy: for complex open wounds, surgical dehiscence, and flap donor sites

Guidelines referenced:

• NICE guideline NG19 — Diabetic foot problems: prevention and management
• Wounds International: best practice guidelines for wound management
• EWMA Document: Wound bed preparation in practice