Chronic Wounds

Chronic wounds — those failing to progress through orderly healing within about a month — afflict 1-2% of people across a lifetime and a far higher share of the elderly and diabetic, consuming an estimated 2-4% of health budgets in developed systems, overwhelmingly through nursing time and complications rather than dressings. Three conditions dominate: venous leg ulcers (the majority of leg ulcers, born of venous hypertension), diabetic foot ulcers (neuropathy plus vascular disease plus pressure), and pressure injuries (unrelieved load over bone in the immobile). The unspoken statistic reframes all of it: a diabetic foot ulcer marks five-year mortality around 50% — worse than breast or prostate cancer — because it flags systemic vascular disease; wounds are not a skin nuisance but a vital sign. Their unfashionability — chronic, elderly, unglamorous — is precisely why evidence-poor commerce fills the attention gap.

Wound care's scandal is inverse adoption: the interventions with the strongest evidence are systematically underused while premium products flow. Venous ulcers: compression therapy is the treatment — healing most ulcers within months in trials — yet substantial fractions of patients receive none; and early endovenous ablation of reflux (the EVRA trial) accelerates healing and cuts recurrence, still unevenly offered. Diabetic feet: offloading pressure from the ulcer (total contact casts the gold standard) is the equivalent keystone, and the removable-device compromise most patients actually get is measurably inferior when worn as poorly as it usually is. Pressure injuries: repositioning schedules and proper support surfaces do the preventive work. Across all: debridement, infection control judged clinically (all chronic wounds are colonised — swabs treat cultures, not patients), and arterial assessment before anyone compresses a leg. The discipline is logistics and physiology, not product selection.

Around this evidence vacuum grew a marketplace the evidence cannot justify: thousands of dressing products with trials too small and biased for Cochrane reviews to rank them beyond keep it moist and match the exudate; and, at the extreme, the US skin-substitute economy — bioengineered and placental-tissue grafts whose Medicare spending exploded past ten billion dollars a year by 2024-25 amid price-inflation schemes, per-application billing incentives and fraud prosecutions, on an evidence base of mostly industry-funded trials against inadequate standard care. The clinical translation: skin substitutes have legitimate niche roles in refractory, well-prepared wounds under specialist care; as first-line revenue devices applied weekly to uncompressed venous ulcers and unoffloaded diabetic feet, they are the emblem of everything wrong. Adjacent tools earn calibrated verdicts: negative-pressure therapy (useful in selected acute and post-surgical wounds; chronic-wound evidence thinner than its ubiquity), hyperbaric oxygen (mixed trials, narrow indications), maggot debridement (effective at what it does), and growth factors (marginal).

The evidence-based pathway is systematic rather than exotic. Diagnose the wound: aetiology (venous, arterial, mixed, diabetic-neuropathic, pressure, and the atypical minority — vasculitis, pyoderma gangrenosum, malignancy — that punish assumption), perfusion (ankle-brachial index before compression, vascular referral when ischaemic), and the patient (glycaemia, nutrition, oedema, medications, smoking). Treat the cause: compression or ablation for venous disease, offloading and revascularisation for diabetic feet, pressure redistribution for pressure injuries. Prepare the wound bed: debridement of devitalised tissue, moisture balance with unglamorous dressings, infection treated on clinical signs. Escalate on trajectory: a wound not measurably smaller by four weeks is a referral trigger — to vascular surgery, diabetic foot MDT or dermatology — not a cue for a costlier dressing. And prevent the sequel: compression hosiery after venous healing, lifelong foot surveillance after a diabetic ulcer, because recurrence, not healing, is the default.

Chronic wounds tax lives in ways clinics undercount: dressing-change pain routinely undertreated, exudate and odour policing patients into isolation, mobility and work eroded for months, and the depression-healing loop running both directions. Care that works engages this layer — analgesia planned around dressing changes, odour-management dressings, and the social prescription of keeping people moving and connected. Prevention deserves equal billing because each pathway has one: venous — treat varicose disease and oedema early, compress after any ulcer; diabetic — annual foot screening, daily self-checks, immediate care for breaks in insensate skin (the amputation cascade usually starts with a blister nobody felt); pressure — repositioning, surfaces and nutrition for anyone immobile, with most hospital-acquired injuries considered preventable and tracked as quality failures. The cheapest wound remains the one that never opens.

For a leg ulcer: insist on a diagnosis and an ankle-brachial index — then, if venous, compression from day one and the question about vein ablation asked; no compression, no plan. For a diabetic foot ulcer: same-day contact with a diabetic foot service, offloading treated as the prescription it is, vascular status assessed, and the five-year seriousness understood as motivation, not fatalism. For anyone immobile at home or in care: repositioning schedules, pressure-redistributing surfaces and skin checks are the family-enforceable standard. For every wound: measurable shrinkage by four weeks or referral — and deep scepticism toward any clinic whose answer to a non-healing wound is a premium product rather than a cause found and treated. The boring fundamentals heal; the brochure mostly bills.