Chronic wound repair and healing in older adults: current status and future research.

The incidence of chronic wounds is increased among older adults, and the impact of chronic wounds on quality of life is particularly profound in this population. It is well established that wound healing slows with age. However, the basic biology underlying chronic wounds and the influence of age-associated changes on wound healing are poorly understood. Most studies have used in vitro approaches and various animal models, but observed changes translate poorly to human healing conditions. The impact of age and accompanying multi-morbidity on the effectiveness of existing and emerging treatment approaches for chronic wounds is also unknown, and older adults tend to be excluded from randomized clinical trials. Poorly defined outcomes and variables, lack of standardization in data collection, and variations in the definition, measurement, and treatment of wounds also hamper clinical studies. The Association of Specialty Professors, in conjunction with the National Institute on Aging and the Wound Healing Society, held a workshop, summarized in this paper, to explore the current state of knowledge and research challenges, engage investigators across disciplines, and identify key research questions to guide future study of age-associated changes in chronic wound healing.

Protocol for treatment of diabetic foot ulcers.

Each year, 82,000 limb amputations are performed in patients with diabetes mellitus. The majority of these amputations could be avoided by following strict protocols. The collective experience treating patients with neuropathic diabetic foot ulcers of 4 major diabetic foot programs in the United States and Europe were analyzed. The following protocol has been developed for patients with diabetic foot ulcers: (1) measurement of the wound by planimetry; (2) optimal glucose control; (3) surgical debridement of all hyperkeratotic, infected, and nonviable tissue; (4) systemic antibiotics for deep infection, drainage, and cellulitis; (5) offloading; (6) moist-wound environment; and (7) treatment with growth factors and/or cellular therapy if the wound is not healing after 2 weeks with this protocol and a new epithelial layer is not forming. In addition, the pathogenesis of diabetic foot ulcers is discussed, as well as the associated costs and complications, including amputation. Debridement, wound-bed preparation, antibiotics, various types of dressings, biological therapies, growth factors, and offloading are described as treatment modalities for patients with diabetic foot ulcers. In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensure rapid healing and minimize morbidity, mortality, and costs, as well as eliminate amputation in the absence of ischemia and osteomyelitis.

Wound-healing protocols for diabetic foot and pressure ulcers.

Diabetic foot and pressure ulcers are chronic wounds by definition. They share similar pathogeneses; i.e., a combination of increased pressure and decreased angiogenic response. Neuropathy, trauma, and deformity also often contribute to development of both types of ulcers. Early intervention and proper treatment should result in complete healing of non-ischemic diabetic foot and pressure ulcers, as defined by 100% epithelialization and no drainage (if no osteomyelitis is present). The authors developed the following paradigm, which has proved to be highly effective for complete healing of these wounds: 1) recognition that all patients with limited mobility are at risk for a sacral, ischial, trochanteric, or heel pressure ulcer; 2) daily self-examination of the sacral, ischium, buttocks, hips, and heels of all bed-bound patients and the feet of patients with diabetes with risk factors (e.g., neuropathy); 3) initiation of a treatment protocol immediately upon recognition of a break in the skin (i.e., emergence of a new wound); 4) objective measurement by planimetry of every wound (at a minimum, weekly) and documentation of its progress; 5) establishment of a moist wound-healing environment; 6) relief of pressure from the wound; 7) debridement of all non-viable tissue in the wound; 8) elimination of all drainage and cellulitis; 9) cellular therapy or growth factors for patients with wounds that do not heal rapidly after initial treatment; and 10) continuous physical and psychosocial support for all patients. If this paradigm is followed, most diabetic foot and pressure ulcers are expected to heal.