Dressings and topical agents for treating venous leg ulcers

Updating Wound Care Algorithms: A Systematic, Focused Review

PURPOSE

The purpose of this project was to update the underlying evidence base for basic wound care in the Solutions Wound Care Algorithms and revise this resource as needed.

METHODS

The 14 major algorithm goals, guidelines, and outcomes of patient care and 34 detailed qualifying assessment and management statements/steps were reconstructed to encompass 21 qualifying statements/steps and aligned with their most recent (2013) levels of evidence. Next, a systematic, focused review of the literature was conducted to update the evidence levels using the Strength of Recommendation Taxonomy.

SEARCH STRATEGY

An English language search of CINAHL, Medline, Cochrane Library, and Joanna Briggs Institute (JBI) electronic databases was conducted for the years 2015-2023. For each wound type, the following search terms were used: meta-analysis, systematic review, randomized controlled trial, clinical practice guideline, clinical trial, and wound care/healing and dressings. Publications not focused on the patient population or qualifying statements were excluded.

FINDINGS

The search retrieved 59 elements that met the predetermined criteria for analysis and leveling. All qualifying statements and steps remain evidence-based. Higher quality evidence became available for nutritional status assessment, exercise to reduce risk factors for various types of lower extremity ulcers, using tap water to cleanse wounds; that delayed wound healing may be a sign of infection, and that silver-containing dressings are effective when used appropriately. No basic patient and wound care steps have the highest level of evidence (level 1) and strength of recommendation (A).

CONCLUSION

Compared to previous updates, we found fewer clinical trials indicating a need for research to improve evidence levels for various steps of basic wound assessment and care processes.

Pilot Implementation of a Primary Care Disease Management Concept for Venous Leg Ulceration: Results of a Mixed-Methods Process Evaluation

BACKGROUND

Within the project "Ulcus Cruris Care", a disease management intervention to improve general practice care for patients with venous leg ulcer was developed, comprising online teaching for practice teams, standardized patient education, and case management. Implementation of the intervention was piloted and evaluated via a process evaluation. This study aims to evaluate contentedness with the intervention, implementation effort, implementation determinants, intervention fidelity, and perceived intervention effects using a mixed-methods process evaluation.

METHODS

The mixed-methods process evaluation explored the views of general practitioners, medical assistants and patients regarding the intervention components. Data were collected through semi-structured telephone interviews and a survey questionnaire. Qualitative data were first analyzed inductively, followed by a deductive-inductive approach based on the Theoretical Domains Framework. Survey data were analyzed descriptively.

RESULTS

Participants (n = 21) reported a strong contentedness with the intervention, high intervention fidelity, low implementation effort, and a change in perception of compression therapy as the central treatment element. Healthcare professionals emphasized increased patient education and patient and family involvement. Patients reported feeling better informed and empowered to take an active role in their treatment, primarily due to increased knowledge and skills in compression therapy. As a result, they were more content with their care and reported positive experiences with wound healing since trial participation.

CONCLUSIONS

The Ulcus Cruris Care intervention can lead to a noticeable change in knowledge and potentially influence practice teams' approach to venous leg ulcer management, facilitating a significantly more frequent use of compression therapy in VLU care. A confirmatory evaluation of potential effects in a definitive RCT seems warranted.

Venous Insufficiency: Wound Management

PURPOSE OF REVIEW

Venous leg ulcers (VLUs) are one of the most common forms of chronic wounds and with nearly half the people having recurrent episodes, this significantly impacts a patient's quality of life. As such, VLU is a chronic disease that requires lifelong maintenance and awareness. A correct diagnosis of VLU is essential for management.

RECENT FINDINGS

VLUs can be of mixed etiology and treatment should be aimed at optimizing the underlying venous hypertension based on its cause. If there is an anatomical venous reflux contributing to the non-healing of the VLU, early treatment of incompetent veins can improve healing rates. All aspects contributing to the patient's ongoing venous hypertension should be addressed to provide appropriate treatment. This can include venous interventions but also through conservative measures. Patient education and their engagement in their own care is essential for good outcomes.

Impact of Silver Dressings on Wound Healing Rate in Patients with Lower Extremity Ulcers: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The ulcers of lower extremities, both venous and diabetic, impose a massive burden on sufferers globally. This meta-analysis evaluates the efficacy of silver dressings in improving healing rate of these ulcers.

METHODS

We carried out comprehensive searches in PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Internet (CNKI) up to March 2024. Two reviewers independently screened the study and extracted data. While the primary outcome was wound healing rate, secondary outcomes included wound healing area and recurrence rate. Data were analyzed using Stata 16.0 software.

RESULTS

A total of 18 studies involving 1,825 participants were included. Silver dressings demonstrated statistically significant effects in improving healing rates for diabetic foot ulcers (DFUs) (OR 2.14, 95% CI: 1.52, 3.00, p = 0.00), whereas the effects were not statistically significant for venous leg ulcers (VLUs) (OR 1.32, 95% CI: 0.97, 1.78, p = 0.07). Silver dressings also reduced ulcer area by 27.44 cm2 (95% CI: 6.96-47.92) and recurrence rate by 45% (95% CI: 0.11-1.79). Subgroup analysis revealed that the Asia-Pacific region and treatments of 6 weeks or less exhibited higher healing rates than their respective counterparts, although there was no statistical significance.

CONCLUSIONS

This study indicated a statistically significant benefit of the treatment for DFU. However, the effect on VLU, though positive, did not reach statistical significance. This distinction should be considered in clinical application and further research.

OBJECTIVE

The ulcers of lower extremities, both venous and diabetic, impose a massive burden on sufferers globally. This meta-analysis evaluates the efficacy of silver dressings in improving healing rate of these ulcers.

METHODS

We carried out comprehensive searches in PubMed, Embase, Web of Science, the Cochrane Library, and China National Knowledge Internet (CNKI) up to March 2024. Two reviewers independently screened the study and extracted data. While the primary outcome was wound healing rate, secondary outcomes included wound healing area and recurrence rate. Data were analyzed using Stata 16.0 software.

RESULTS

A total of 18 studies involving 1,825 participants were included. Silver dressings demonstrated statistically significant effects in improving healing rates for diabetic foot ulcers (DFUs) (OR 2.14, 95% CI: 1.52, 3.00, p = 0.00), whereas the effects were not statistically significant for venous leg ulcers (VLUs) (OR 1.32, 95% CI: 0.97, 1.78, p = 0.07). Silver dressings also reduced ulcer area by 27.44 cm2 (95% CI: 6.96-47.92) and recurrence rate by 45% (95% CI: 0.11-1.79). Subgroup analysis revealed that the Asia-Pacific region and treatments of 6 weeks or less exhibited higher healing rates than their respective counterparts, although there was no statistical significance.

CONCLUSIONS

This study indicated a statistically significant benefit of the treatment for DFU. However, the effect on VLU, though positive, did not reach statistical significance. This distinction should be considered in clinical application and further research.

A critical overview of challenging roles of medicinal plants in improvement of wound healing technology

PURPOSE

Chronic diseases often hinder the natural healing process, making wound infections a prevalent clinical concern. In severe cases, complications can arise, potentially leading to fatal outcomes. While allopathic treatments offer numerous options for wound repair and management, the enduring popularity of herbal medications may be attributed to their perceived minimal side effects. Hence, this review aims to investigate the potential of herbal remedies in efficiently treating wounds, presenting a promising alternative for consideration.

METHODS

A literature search was done including research, reviews, systematic literature review, meta-analysis, and clinical trials considered. Search engines such as Pubmed, Google Scholar, and Scopus were used while retrieving data. Keywords like Wound healing 'Wound healing and herbal combinations', 'Herbal wound dressing', Nanotechnology and Wound dressing were used.

RESULT

This review provides valuable insights into the role of natural products and technology-based formulations in the treatment of wound infections. It evaluates the use of herbal remedies as an effective approach. Various active principles from herbs, categorized as flavonoids, glycosides, saponins, and phenolic compounds, have shown effectiveness in promoting wound closure. A multitude of herbal remedies have demonstrated significant efficacy in wound management, offering an additional avenue for care. The review encompasses a total of 72 studies, involving 127 distinct herbs (excluding any common herbs shared between studies), primarily belonging to the families Asteraceae, Fabaceae, and Apiaceae. In research, rat models were predominantly utilized to assess wound healing activities. Furthermore, advancements in herbal-based formulations using nanotechnology-based wound dressing materials, such as nanofibers, nanoemulsions, nanofiber mats, polymeric fibers, and hydrogel-based microneedles, are underway. These innovations aim to enhance targeted drug delivery and expedite recovery. Several clinical-based experimental studies have already been documented, evaluating the efficacy of various natural products for wound care and management. This signifies a promising direction in the field of wound treatment.

CONCLUSION

In recent years, scientists have increasingly utilized evidence-based medicine and advanced scientific techniques to validate the efficacy of herbal medicines and delve into the underlying mechanisms of their actions. However, there remains a critical need for further research to thoroughly understand how isolated chemicals extracted from herbs contribute to the healing process of intricate wounds, which may have life-threatening consequences. This ongoing research endeavor holds great promise in not only advancing our understanding but also in the development of innovative formulations that expedite the recovery process.

Effectiveness of the Use of the Human Recombinant Epidermal Growth Factor in the Subsidized Regime vs The Contributive Regime in Patients with Venous Ulcers in Bogotá

Introduction

Vascular ulcers constitute a serious global public health problem, responsible for causing a significant social and economic impact due to their recurrent, disabling nature and the need for prolonged therapies to cure them.

Objective

To evaluate the use and efficacy of the rhEGF in the epithelialization of patients with a diagnosis of CEAP stage 6 venous insufficiency, in the two regimes of the health system in Colombia, the contributive (equivalent to a health system where citizens with payment capacity contribute a percentage of their salary) and the subsidized (equivalent to a health system where the state covers the vulnerable population and low socioeconomic level) versus the other treatments used.

Methodology

Observational, descriptive, retrospective, multicenter study, in which 105 medical records with 139 ulcers were reviewed, in 2 centers, one belonging to the subsidized system and the other to the contributive system in Colombia.

Results

The association with the epithelialization variable of the different treatment groups for ulcers according to the application of the mixed effect model test, for both regimes was for the Biologicals (EC 34.401/p = 0.000), Bioactive Agents (Hydrogels) (EC 24.735/p = 0.005) groups; for the rest of the treatment groups, the results were neither associated nor statistically significant.

Conclusion

Intra- and perilesional therapy with rhEGF expands the therapeutic spectrum in patients with venous ulcers, regardless of the type of health system in which it will be applied, shortening the healing time and reaching a possible therapeutic goal, which according to this study there is an association with epithelialization regardless of the regime applied.

Pyolytics as a product of the physical–chemical repurposing of antiseptics and an alternative to larval therapy for chronic wounds

The traditional treatment of chronic wounds involves daily cleansing of the wound surface from purulent necrotic masses using mechanical and medicinal methods, accompanied by regular replacement of wound dressing. In this case, medicinal wound cleansing lasts 10–15 mins from the time of replacement of the old wound dressing with the new one. According to established practice, medicinal sanitation of infected and purulent wounds during dressing involves irrigation of the wound surface with cleansing solutions, antiseptics, and/or antibiotics. In severe cases, the above therapy is supplemented with live larvae of the necrophage fly, which are injected into purulent necrotic masses and left in them under wound dressing until wounds are completely cleansed from pus. Nevertheless, the generally accepted course of treatment of chronic wounds remains ineffective. The use of pyolytics and their supplementation with wound dressings in the form of warm wet compresses, which create a local greenhouse effect in wounds, was reported to accelerate the healing of chronic wounds. Pyolytics are a group of antiseptics developed in Russia. They are warm alkaline solutions of hydrogen peroxide; when they interact with purulent necrotic masses, these solutions dissolve very quickly and foam them. Because of the interaction with pyolytics, thick purulent masses immediately turn into fluffy oxygenated foam. Pyolytics have been developed because of the physicochemical repurposing of aqueous solutions of sodium hydrogen carbonate and hydrogen peroxide. To accelerate the healing of chronic wounds, a recommendation was to irrigate the surface of chronic wounds with 3% hydrogen peroxide and 2–10% sodium bicarbonate solutions, heated to 37–45°C, which have alkaline activity at pH 8.4–8.5 and are enriched with dissolved carbon dioxide or oxygen (due to excess pressure of 0.2 atm). This study presented the importance of treating chronic wounds using politics and treatment outcomes using pyolytics along with warm moist dressing compresses, demonstrating a wound-healing effect. Consequently, physical and chemical reprofiling of antiseptics may make them effective pyolytics, and the combination of pyolytics with warm wound dressings such as warm moist compresses, which create a local greenhouse effect on wounds, accelerates the healing of chronic wounds.

A robotic venous leg ulcer system reveals the benefits of negative pressure wound therapy in effective fluid handling

We applied a market-leading, single-use negative pressure wound therapy device to a robotic venous leg ulcer system and compared its fluid handling performance with that of standard of care, superabsorbent and foam dressings and compression therapy. For each tested product, we determined a metrics of retained, residual, evaporated and (potential) leaked fluid shares, for three exudate flow regimes representing different possible clinically relevant scenarios. The single-use negative pressure wound therapy system under investigation emerged as the leading treatment option in the aspects of adequate fluid handling and consistent delivery of therapeutic-level wound-bed pressures. The superabsorbent dressing performed reasonably in fluid handling (resulting in some pooling but no leakage), however, it quickly caused excessive wound-bed pressures due to swelling, after less than a day of simulated use. The foam dressing exhibited the poorest fluid handling performance, that is, pooling in the wound-bed as well as occasional leakage, indicating potential inflammation and peri-wound skin maceration risks under real-world clinical use conditions. These laboratory findings highlight the importance of advanced robotic technology as contemporary means to simulate patient and wound behaviours and inform selection of wound care technologies and products, in ways that are impossible to achieve if relying solely on clinical trials and experience.

Dressings and topical agents containing hyaluronic acid for chronic wound healing

BACKGROUND

Hyaluronic acid is synthesised in plasma membranes and can be found in extracellular tissues. It has been suggested that the application of hyaluronic acid to chronic wounds may promote healing, and the mechanism may be due to its ability to maintain a moist wound environment which helps cell migration in the wound bed.

OBJECTIVES

To evaluate the effects of hyaluronic acid (and its derivatives) on the healing of chronic wounds.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2022.

SELECTION CRITERIA

We included randomised controlled trials that compared the effects of hyaluronic acid (as a dressing or topical agent) with other dressings on the healing of pressure, venous, arterial, or mixed-aetiology ulcers and foot ulcers in people with diabetes.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 12 trials (13 articles) in a qualitative synthesis, and were able to combine data from four trials in a quantitative analysis. Overall, the included trials involved 1108 participants (mean age 69.60 years) presenting 178 pressure ulcers, 54 diabetic foot ulcers, and 896 leg ulcers. Sex was reported for 1022 participants (57.24% female). Pressure ulcers It is uncertain whether there is a difference in complete healing (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.58 to 2.35); change in ulcer size (mean difference (MD) 25.60, 95% CI 6.18 to 45.02); or adverse events (none reported) between platelet-rich growth factor (PRGF) + hyaluronic acid and PRGF because the certainty of evidence is very low (1 trial, 65 participants). It is also uncertain whether there is a difference in complete healing between lysine hyaluronate and sodium hyaluronate because the certainty of evidence is very low (RR 2.50, 95% CI 0.71 to 8.83; 1 trial, 14 ulcers from 10 participants). Foot ulcers in people with diabetes It is uncertain whether there is a difference in time to complete healing between hyaluronic acid and lyophilised collagen because the certainty of evidence is very low (MD 16.60, 95% CI 7.95 to 25.25; 1 study, 20 participants). It is uncertain whether there is a difference in complete ulcer healing (RR 2.20, 95% CI 0.97 to 4.97; 1 study, 34 participants) or change in ulcer size (MD -0.80, 95% CI -3.58 to 1.98; 1 study, 25 participants) between hyaluronic acid and conventional dressings because the certainty of evidence is very low. Leg ulcers We are uncertain whether there is a difference in complete wound healing (RR 0.98, 95% CI 0.26 to 3.76), percentage of adverse events (RR 0.79, 95% CI 0.22 to 2.80), pain (MD 2.10, 95% CI -5.81 to 10.01), or change in ulcer size (RR 2.11, 95% CI 0.92 to 4.82) between hyaluronic acid + hydrocolloid and hydrocolloid because the certainty of evidence is very low (1 study, 125 participants). It is uncertain whether there is a difference in change in ulcer size between hyaluronic acid and hydrocolloid because the certainty of evidence is very low (RR 1.02, 95% CI 0.84 to 1.25; 1 study, 143 participants). We are uncertain whether there is a difference in complete wound healing between hyaluronic acid and paraffin gauze because the certainty of evidence is very low (RR 2.00, 95% CI 0.21 to 19.23; 1 study, 24 ulcers from 17 participants). When compared with neutral vehicle, hyaluronic acid probably improves complete ulcer healing (RR 2.11, 95% CI 1.46 to 3.07; 4 studies, 526 participants; moderate-certainty evidence); may slightly increase the reduction in pain from baseline (MD -8.55, 95% CI -14.77 to -2.34; 3 studies, 337 participants); and may slightly increase change in ulcer size, measured as mean reduction from baseline to 45 days (MD 30.44%, 95% CI 15.57 to 45.31; 2 studies, 190 participants). It is uncertain if hyaluronic acid alters incidence of infection when compared with neutral vehicle (RR 0.89, 95% CI 0.53 to 1.49; 3 studies, 425 participants). We are uncertain whether there is a difference in change in ulcer size (cm2) between hyaluronic acid and dextranomer because the certainty of evidence is very low (MD 5.80, 95% CI -10.0 to 21.60; 1 study, 50 participants). We downgraded the certainty of evidence due to risk of bias or imprecision, or both, for all of the above comparisons. No trial reported health-related quality of life or wound recurrence. Measurement of change in ulcer size was not homogeneous among studies, and missing data precluded further analysis for some comparisons.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine the effectiveness of hyaluronic acid dressings in the healing of pressure ulcers or foot ulcers in people with diabetes. We found evidence that hyaluronic acid probably improves complete ulcer healing and may slightly decrease pain and increase change in ulcer size when compared with neutral vehicle. Future research into the effects of hyaluronic acid in the healing of chronic wounds should consider higher sample size and blinding to minimise bias and improve the quality of evidence.

SCI-QOL and WOUND-Q Have the Best Patient-reported Outcome Measure Design: A Systematic Literature Review of PROMs Used in Chronic Wounds

Chronic wounds are a significant burden on healthcare systems due to high costs of care (2%-4% total healthcare cost) and a considerable burden on patient's quality of life. Patient-reported outcome measures (PROMs) are questionnaires developed to enable patient self-assessments of their outcomes. A gap in knowledge exists because previous reviews on wound-specific PROMs did not evaluate the quality of the development. The main question is which PROM has the best quality development properties and should be used in clinical care and research.

Methods

PubMed, Embase, and CINAHL were searched from their inception through December 2021. Studies that included patients aged 18 years or older, with chronic wounds, and who reported using a condition-specific PROM for wounds were extracted. We excluded generic PROMs, comments, guidelines, and editorial letters. The COSMIN-guidelines were used to evaluate the quality of the PROMs.

Results

Of the 16,356 articles, a total of 251 articles describing 33 condition-specific PROMs for wounds were used. In total, 17 of 33 (52%) PROMs were developed for specific wound types, and nine of 33 (27%) PROMs were developed for any type of wound. Two of 33 (6%) PROMs were not rated because no development article was available. Only the SCI-QOL (Spinal Cord Injury-QOL) and the WOUND-Q rated "very good" in PROM design.

Conclusions

Thirty-three condition-specific PROMs were found. Only the SCI-QOL and the WOUND-Q rated very good in PROM design. The WOUND-Q is the only condition-specific PROM, which can be used in all types of chronic wounds in any anatomic location.

Evaluating polymeric biomaterials to improve next generation wound dressing design

Wound healing is a dynamic series of interconnected events with the ultimate goal of promoting neotissue formation and restoration of anatomical function. Yet, the complexity of wound healing can often result in development of complex, chronic wounds, which currently results in a significant strain and burden to our healthcare system. The advancement of new and effective wound care therapies remains a critical issue, with the current therapeutic modalities often remaining inadequate. Notably, the field of tissue engineering has grown significantly in the last several years, in part, due to the diverse properties and applications of polymeric biomaterials. The interdisciplinary cohesion of the chemical, biological, physical, and material sciences is pertinent to advancing our current understanding of biomaterials and generating new wound care modalities. However, there is still room for closing the gap between the clinical and material science realms in order to more effectively develop novel wound care therapies that aid in the treatment of complex wounds. Thus, in this review, we discuss key material science principles in the context of polymeric biomaterials, provide a clinical breadth to discuss how these properties affect wound dressing design, and the role of polymeric biomaterials in the innovation and design of the next generation of wound dressings.

SELF-ASSESSMENT OF PRIMARY CARE NURSES ABOUT CARE FOR PEOPLE WITH VENOUS ULCERS: A CROSS-CUTTING STUDY

Objective: To identify the self-knowledge of primary care nurses about care for people with venous ulcers. Method: This is a cross-sectional study with 40 nurses working in health units. Two data collection instruments were used: characterization, developed by the author, and self-assessment on venous ulcers. Results: All questions of the self-assessment instrument reached medians classified as little level of knowledge, except questions related to the application of elastic compression therapy, with the median = 3 (moderate), and the evaluation of lower limbs to investigate arterial involvement, with 3.50, between little and moderate. The item cleaning the lesion stood out, which obtained median = 4 (little) and the highest average found in the responses, 4.03 (little). Conclusion:The nurse’s self-assessment reached moderate and low scores of clinical practice in terms of knowing (theoretical knowledge) and doing (practical knowledge) in the care of people with venous ulcers. Venous ulcer is a complex wound and requires knowledge from nurses about the pathophysiology and appropriate treatment, interfering with the improvement of the person’s quality of life. It is believed that this study can encourage the reflection of this professional and education actions in the services.

AUTOAVALIAÇÃO DE ENFERMEIROS DA ATENÇÃO PRIMÁRIA SOBRE ASSISTÊNCIA À PESSOA COM ÚLCERAS VENOSAS: UM ESTUDO DE CORTE TRANSVERSA

Objetivo:Identificar o autoconhecimento de enfermeiros da atenção primária sobre assistência à pessoa com úlceras venosas. Método: Trata-se de um estudo de corte transversal com 40 enfermeiros lotados em unidades de saúde. Utilizaram-se dois instrumentos de coleta de dados: caracterização, elaborada pelo autor, e autoavaliação sobre úlcera venosa. Resultados: Todas as questões do instrumento autoavaliativo alcançaram medianas classificadas como nível de conhecimento pouco, à exceção das questões relativas à aplicação de terapia compressiva elástica com mediana = 3 (moderado) e à avaliação de membros inferiores para investigar comprometimento arterial, 3,50, entre pouco e moderado. Destacou-se o item limpeza da lesão, o qual obteve a mediana = 4 (pouco) e a maior média encontrada das respostas, 4,03 (pouco). Conclusão: A autoavaliação do enfermeiro atingiu os escores moderado e pouco da prática clínica no que tange ao saber (conhecimento teórico) e ao fazer (conhecimento prático) no cuidado à pessoa com úlcera venosa. A úlcera venosa é uma ferida complexa e exige do enfermeiro conhecimento sobre a fisiopatologia e o tratamento adequado, interferindo na melhora da qualidade de vida dessa pessoa. Acredita-se que este estudo possa fomentar a reflexão desse profissional e ações de educação nos serviços.

Hydrogel dressings for venous leg ulcers

BACKGROUND

Venous leg ulcers are a chronic health problem that cause considerable economic impact and affect quality of life for those who have them. Primary wound contact dressings are usually applied to ulcers beneath compression therapy to aid healing, promote comfort and control exudate. There are numerous dressing products available for venous leg ulcers and hydrogel is often prescribed for this condition; however, the evidence base to guide dressing choice is sparse.

OBJECTIVES

To assess the effects of hydrogel wound dressings on the healing of venous leg ulcers in any care setting.

SEARCH METHODS

In May 2021, we searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE, Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), either published or unpublished, that compared the effects of hydrogel dressing with other dressings on the healing of venous leg ulcers. We excluded trials evaluating hydrogel dressings impregnated with antimicrobial, antiseptic or analgesic agents as these interventions are evaluated in other Cochrane Reviews.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included four RCTs (10 articles) in a qualitative analysis. Overall, 272 participants were randomised, in sample sizes ranging from 20 to 156 participants. The mean age of the included population in the trials ranged from 55 to 68 years, 37% were women based on studies that reported the sex of participants. The studies compared hydrogel dressings with the following: gauze and saline, alginate dressing, manuka honey and hydrocolloid. Two studies were multicentre and the others were single-centre trials. Length of treatment using hydrogel dressing was four weeks in three studies and two weeks in one study. The follow-up period was the same as the duration of treatment in three studies and in one study the follow-up for wound healing was at 12 weeks after four weeks of treatment. Overall risk of bias was high for all trials because at least one of the three key criteria (selection bias, detection bias and attrition bias) was at high risk. Hydrogel compared with gauze and saline It is uncertain whether there is a difference in complete wound healing (risk ratio (RR) 5.33, 95% confidence interval (CI) 1.73 to 16.42; 1 trial, 60 participants) or change in ulcer size (mean difference (MD) -1.50, 95% CI -1.86 to -1.14; 1 trial, 60 participants) between interventions because the certainty of the evidence is very low. Data reported from one trial were incomplete for time-to-ulcer healing. Hydrogel compared with alginate dressing It is uncertain whether there is a difference in change in ulcer size between hydrogel and alginate gel because the certainty of the evidence is very low (MD -41.80, 95% CI -63.95 to -19.65; 1 trial, 20 participants). Hydrogel compared with manuka honey It is uncertain whether there is a difference in complete wound healing (RR 0.75, 95% CI 0.46 to 1.21; 1 trial, 108 participants) or incidence of wound infection (RR 2.00, 95% CI 0.81 to 4.94; 1 trial, 108 participants) between interventions because the certainty of the evidence is very low. Hydrogel compared with hydrocolloid One study (84 participants) reported on change in ulcer size between hydrogel and hydrocolloid; however, further analysis was not possible because authors did not report standard errors or any other measurement of variance of a set of data from the means. Therefore, it is also uncertain whether there is a difference in change in ulcer size between hydrogel and hydrocolloid because the certainty of the evidence is very low. No studies provided evidence for the outcomes: recurrence of ulcer, health-related quality of life, pain and costs. Overall, independent of the comparison, the certainty of evidence is very low and downgraded twice due to risk of bias and once or twice due to imprecision for all comparisons and outcomes.

AUTHORS' CONCLUSIONS

There is inconclusive evidence to determine the effectiveness of hydrogel dressings compared with gauze and saline, alginate dressing, manuka honey or hydrocolloid on venous leg ulcer healing. Practitioners may, therefore, consider other characteristics such as costs and symptom management when choosing between dressings. Any future studies assessing the effects of hydrogel on venous wound healing should consider using all the steps from CONSORT, and consider key points such as appropriate sample size with the power to detect expected differences, appropriate outcomes (such as time-to-event analysis) and adverse effects. If time-to-event analysis is not used, at least a longer follow-up (e.g. 12 weeks and above) should be adopted. Future studies should also address important outcomes that the studies we included did not investigate, such as health-related quality of life, pain and wound recurrence.

A meta-review of the impact of compression therapy on venous leg ulcer healing

This meta-review aimed to appraise and synthesise findings from existing systematic reviews that measured the impact of compression therapy on venous leg ulcers healing. We searched five databases to identify potential papers; three authors extracted data, and a fourth author adjudicated the findings. The AMSTAR-2 tool was used for quality appraisal and the certainty of the evidence was appraised using GRADEpro. Data analysis was undertaken using RevMan. We identified 12 systematic reviews published between 1997 and 2021. AMSTAR-2 assessment identified three as high quality, five as moderate quality, and four as low quality. Seven comparisons were reported, with a meta-analysis undertaken for five of these comparisons: compression vs no compression (risk ratio [RR]: 1.55; 95% confidence interval [CI] 1.34-1.78; P < .00001; moderate-certainty evidence); elastic compression vs inelastic compression (RR: 1.02; 95% CI: 0.96-1.08; P < .61 moderate-certainty evidence); four layer vs <four-layer bandage systems (RR: 1.07; 95% CI: 0.82-1.40; P < .63; moderate-certainty evidence); comparison between different four-layer bandage systems (RR: 1.08; 95% CI: 0.93-1.25; P = .34; moderate-certainty evidence); compression bandage vs compression stocking (RR 0.95; 95% CI 0.87-1.03; P = .18; moderate-certainty evidence). The main conclusion from this review is that there is a statistically significant difference in healing rates when compression is used compared with no compression, with moderate-certainty evidence. Otherwise, there is no statistically different difference in healing rates using elastic compression vs inelastic compression, four layer vs <four-layer bandage systems, different four-layer bandage systems, or compression bandages vs compression stockings.

Randomized, double-blind clinical trial comparing the healing of stasis ulcers in lower limbs with standard hydrocolloid gel dressings and with dressings with Syzygium cumini extract

Objective

To evaluate the healing of venous ulcers in the lower limbs (VLU) using dressings with hydrocolloid gel associated with Syzygium cumini extract (SHG) compared to standard hydrocolloid gel dressings (HG).

Method

This prospective, double-blind, randomized trial recruited 90 patients with VLU divided into: dressings with SHG ( n = 44) and dressings with HG ( n = 46). Primary endpoint was healing in the 14th visit. Secondary endpoints were healing rate, complete healing during follow-up, and improvement in the pain scale and in quality of life.

Results

There were no significant between-group differences in healing ( p = 0.15). The wound area made healing difficult ( p = 0.008). Age, body mass index, and wound time demonstrated a tendency to worsen the healing. Positive culture for Pseudomonas aeruginosa resulted in 88% reduction in the healing risk ( p < 0.0001).

Conclusion

There was no difference between the dressings evaluated. The presence of Pseudomonas aeruginosa significantly impaired wound healing.

Biological autologous excised varicose vein dressing compared to conservative dressing on the ulcer bed during endovenous ablation

Objective

To compare the use of biological autologous excised varicose vein dressing ( VenoDress) compared to conservative dressing on the ulcer bed during endovenous ablation

Methods

This retrospective non-blinded study included all consecutive patients with primary or recurrent venous leg ulcers (VLU) with superficial varices treated in one center between September 2019 and October 2020. They all underwent venous ablation, wound debridement, and when needed phlebectomy. On the study group, the excised veins were incised, formed into a sheet, and applied onto the debrided wound bed with the endothelial side facing the wound bed. Adhesion was assessed weekly for 3 weeks. The study group was compared to a control group that underwent similar procedures but with the debrided wound bed treated with low-adherent paraffin dressing. The primary outcome was complete wound healing at 1 and 3 months, and the secondary outcomes were wound-related pain and leg edema.

Results

Complete wound closure was documented in 17/26 study group patients at 1 month (65%) and in 25/26 (96%) at 3 months. Complete wound closure was documented in 37/82 patients in the control group (45%) and in 67/82 (82%) at 3 months. The 1-month healing rates were significantly in favor of the VenoDress group when adjusted to sex and diabetes: odds ratio = 2.81 (1.05–7.532), p = .04. The preoperative pain level of the study group (as measured by a visual analog scale VAS (0–10) decreased from 4.96 ± 2.71 to 0.73 ± 1.36 at 1 week and that of the control group from 4.8 ± 2 to 1.35 ± 1.38 at 1 week ( p < .001).

Conclusion

the use of autologous varicose veins as dressing effectively reduced pain in VLU patients compared to conventional techniques. Although its effects on wound closure appear highly promising, further validation is warranted in a randomized comparative study.

[Venous ulcus cruris-Surgical treatment]

Venous ulcus cruris is usually a chronic disease and an extreme burden for patients and their families. An analysis based on a random statutory health insurance sample of the AOK Hessen/KV Hessen estimated the number of affected people to be 400,000 in Germany. A venous ulcus cruris is always caused by an underlying chronic venous insufficiency (CVI). A spontaneous healing of this chronic disease without treatment is not to be expected. The conservative treatment includes an adequate compression treatment and exudate management. Surgical treatment is based on three pillars: an open surgical or endovenous approach to resolve the pathological venous reflux, uIcer surgery and in rare cases the various procedures of fascia surgery as well as defect coverage by a combination of negative pressure wound therapy and skin transplantation.

Effective high-throughput isolation of enriched platelets and circulating pro-angiogenic cells to accelerate skin-wound healing

Delayed wound healing and chronic skin lesions represent a major health problem. Over the past years, growth factors mediated by platelet-rich plasma (PRP) and cell-based therapies were developed as effective and affordable treatment able to improve wound healing capacity. We have advanced existing concepts to develop a highly efficient high-throughput protocol with proven application for the isolation of PRP and pro-angiogenic cells (Angio^PRP). This protocol outlines the effectiveness of Angio^PRP in promoting the critical healing process including wound closure, re-epithelialization, granulation tissue growth, and blood vessel regeneration. We coupled this effect with normalization of mechanical properties of rescued mouse wounds, which is sustained by a correct arrangement of elastin and collagen fibers. Proteomic analysis of treated wounds demonstrated a fingerprint of Angio^PRP based on the up-regulation of detoxification pathway of glutathione metabolism, correlated to a decrease in inflammatory response. Overall, these results have enabled us to provide a framework for how Angio^PRP supports wound healing, opening avenues for further clinical advances.

Superiority of a Novel Multifunctional Amorphous Hydrogel Containing Olea europaea Leaf Extract (EHO-85) for the Treatment of Skin Ulcers: A Randomized, Active-Controlled Clinical Trial

This 8-week, multicenter, randomized, active-controlled, observer-blinded clinical trial was designed to demonstrate the accelerating effect on wound healing of the novel Olea europaea leaf extract hydrogel (EHO-85) by comparing it to a widely used amorphous hydrogel. Results showed that EHO-85 significantly accelerated wound healing, regardless of ulcer etiology (pressure, venous leg or diabetic foot) and prognosis, doubling the median wound area reduction compared with a reference amorphous hydrogel (79.4% vs. 39.7%; difference: −39.7%, 95% CI: −71.1 to −21.3%; p < 0.001). The intention-to-treat analysis was conducted on 195 patients from 23 Spanish health centers/nursing homes. This novel treatment balances the ulcer microenvironment by modulating reactive oxygen species and pH. These actions complement the moistening and barrier functions inherent to amorphous hydrogels, whilst also conferring EHO-85 its documented granulation formation and pain relief properties. Furthermore, efficacy was achieved safely and in a cost-efficient manner due to its multi-dose format, which reduced the amount of product needed by 85.8% over 8 weeks compared to single-use hydrogel. The present randomized controlled trial is a relevant milestone in evidence-based practice for being the first to demonstrate (i) the effectiveness of an amorphous hydrogel in accelerating wound healing and (ii) the superiority of a specific hydrogel over another.

Primary care disease management for venous leg ulceration—study protocol for the Ulcus Cruris Care [UCC] randomized controlled trial (DRKS00026126)

Background

Venous leg ulcers (VLU) have a prevalence of 1–2% in developed countries, and affected patients are severely and long-term impaired in daily activities, work, and social participation. Evidence-based outpatient treatment based on compression therapy is frequently not implemented. The “Ulcus Cruris Care” project was established to develop a disease management concept to improve outpatient treatment for patients with VLU in German primary care. For this purpose, a multifaceted intervention was conceived consisting of an online training for general practitioners and medical assistants, standardized treatment recommendations, e-learning and print-based information for patients, and a software support for case management. The main aims of the Ulcus Cruris Care intervention are to promote standardized treatment according to current scientific knowledge, to facilitate case management for VLU patients exerted by medical assistants, and to support patient education and participation in the treatment process. The UCC trial was designed to evaluate the effectiveness of the Ulcus Cruris Care intervention.

Methods

The UCC trial is a prospective cluster-randomized controlled multicenter trial. Fifty GP practices are intended to be recruited and randomized 1:1 to intervention or control arm. Patients with venous leg ulcers will be recruited by participating GP practices, to include a total of 63 patients in each arm. The primary outcome is time to ulcer healing. Secondary outcomes comprise number and sizes of ulcers, recurrence, pain intensity according to the visual analog scale, health-related quality of life according to EQ-5D-5L, depressiveness according to Patient Health Questionnaire (PHQ-9), patient satisfaction according to the Patient Assessment of Chronic Illness Care (PACIC-5A) query, and adherence to VLU treatment. The outcome analysis of the UCC trial is accompanied by a health economic analysis and a process evaluation.

Discussion

The UCC trial will evaluate whether the Ulcus Cruris Care intervention may lead to faster wound healing, higher health-related quality of life, and lower use of medical resources. If the intervention turns out to have a positive impact on assessed outcomes, comprehensive implementation in primary care may be considered.

Trial registration

The trial protocol (version 1 as of July 19, 2021) has been registered in the German Clinical Trials Register on August 30, 2021 (DRKS00026126).

Hydrocolloid dressing versus conventional wound care after dermatologic surgery

Background

Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries.

Objective

To examine whether a one-time HCD application after dermatologic surgery results in greater patient satisfaction and improved postoperative outcomes compared with conventional daily dressings (CDD).

Methods

We examined patients who underwent Mohs or standard surgical excision with linear closure followed by HCD. The patients additionally had a history of excisional surgery with CDD in the past 5 years. A modified version of the validated Bluebelle Wound Healing Questionnaire was administered.

Results

The survey response rate was 74.4% (64/86). Compared with CDD, HCD rated higher in comfort, convenience, scar appearance, and simplicity of wound care instructions (P < .0001). Nearly all patients (96.8%) preferred HCD over CDD.

Limitations

Variability in time from prior dermatologic surgery may introduce recall bias. Prior surgeries involving CDD were sometimes performed by a different surgeon, which could introduce other confounding factors.

Conclusions

A simplified wound care regimen involving HCD can potentially lead to increased comfort, convenience, simplicity, and a subjective improvement in scar appearance, though additional studies are needed.

A pilot study using cell-mixed sheets of autologous fibroblast cells and peripheral blood mononuclear cells to treat refractory cutaneous ulcers

BACKGROUND/AIMS

We invented a cell-mixed sheet consisting of autologous fibroblast cells and peripheral blood mononuclear cells (PBMNCs) to treat refractory cutaneous ulcers. These sheets secrete the growth factors needed throughout the wound healing process in animal models.

METHODS

We performed this study as a pilot phase I clinical trial (UMIN-CTR: UMIN000031645). Fibroblast cells were isolated and cultured from the oral tissue, and PBMNCs were collected by apheresis. A cell-mixed sheet was prepared by co-culturing these collected cells for 3 days. The primary observation index was safety, including all adverse events. Additional observation indices were wound healing over 1, 3, and 6 months; wound healing rate at 7 days and 1, 3, and 6 months.

RESULTS

Six patients with venous leg ulcers (VLUs) were enrolled in the study, including three patients who were treated with the cell-mixed sheet transplantation. One patient was excluded because no fibroblast cells grew from the oral tissue culture, and other two were excluded because the growth factor secreted from mixed-cell sheets did not reach the reference value. The VLUs of two patients who received the cell-mixed sheet transplantation healed, and the VLU in one patient decreased in size.

CONCLUSIONS

This pilot study demonstrated that cell-mixed sheets might be a new topical intervention to treat VLUs. However, it was also suggested that this treatment might be limited when using autologous cells collected from patients with VLUs. Therefore, it may be necessary to use high-quality allogeneic cells instead of autologous cells to improve the feasibility of this treatment.

Towards User-Oriented Recommendations for Local Therapy of Leg and Foot Ulcers-An Update of a S3-German Guideline

Background: The German S3- guideline on local therapy of leg ulcers and diabetic foot ulcers is in the process of being updated. Major goals are to improve the guidelines’ applicability and to take steps towards a living guideline according to current methodological standards. The aim of this article is to describe the main measures to achieve these goals. Methods: The context of the guideline in the field of local wound care and the stakeholder requirements are briefly described. Based on a derived framework, the project team adjusted the methods for the guideline. Results: Main adjustments are more specific inclusion criteria, online consensus meetings and the use of an authoring and publication platform to provide information in a multi-layered format. A new set of practice-oriented key questions were defined by the guideline panel to foster the formulation of action-oriented recommendations. Conclusions: The set of new key questions addressing practical problems and patients’ preferences as well as the adjustments made to improve not only the guidelines’ applicability, but also the feasibility of the further dynamic updating processes in the sense of a living guideline, should be steps in the right direction.

Compression bandages or stockings versus no compression for treating venous leg ulcers

BACKGROUND

Leg ulcers are open skin wounds on the lower leg that can last weeks, months or even years. Most leg ulcers are the result of venous diseases. First-line treatment options often include the use of compression bandages or stockings.

OBJECTIVES

To assess the effects of using compression bandages or stockings, compared with no compression, on the healing of venous leg ulcers in any setting and population.

SEARCH METHODS

In June 2020 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions by language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials that compared any types of compression bandages or stockings with no compression in participants with venous leg ulcers in any setting.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed studies using predetermined inclusion criteria. We carried out data extraction, and risk-of-bias assessment using the Cochrane risk-of-bias tool. We assessed the certainty of the evidence according to GRADE methodology.

MAIN RESULTS

We included 14 studies (1391 participants) in the review. Most studies were small (median study sample size: 51 participants). Participants were recruited from acute-care settings, outpatient settings and community settings, and a large proportion (65.9%; 917/1391) of participants had a confirmed history or clinical evidence of chronic venous disease, a confirmed cause of chronic venous insufficiency, or an ankle pressure/brachial pressure ratio of greater than 0.8 or 0.9. The average age of participants ranged from 58.0 to 76.5 years (median: 70.1 years). The average duration of their leg ulcers ranged from 9.0 weeks to 31.6 months (median: 22.0 months), and a large proportion of participants (64.8%; 901/1391) had ulcers with an area between 5 and 20 cm2. Studies had a median follow-up of 12 weeks. Compression bandages or stockings applied included short-stretch bandage, four-layer compression bandage, and Unna's boot (a type of inelastic gauze bandage impregnated with zinc oxide), and comparator groups used included 'usual care', pharmacological treatment, a variety of dressings, and a variety of treatments where some participants received compression (but it was not the norm). Of the 14 included studies, 10 (71.4%) presented findings which we consider to be at high overall risk of bias. Primary outcomes There is moderate-certainty evidence (downgraded once for risk of bias) (1) that there is probably a shorter time to complete healing of venous leg ulcers in people wearing compression bandages or stockings compared with those not wearing compression (pooled hazard ratio for time-to-complete healing 2.17, 95% confidence interval (CI) 1.52 to 3.10; I2 = 59%; 5 studies, 733 participants); and (2) that people treated using compression bandages or stockings are more likely to experience complete ulcer healing within 12 months compared with people with no compression (10 studies, 1215 participants): risk ratio for complete healing 1.77, 95% CI 1.41 to 2.21; I2 = 65% (8 studies with analysable data, 1120 participants); synthesis without meta-analysis suggests more completely-healed ulcers in compression bandages or stockings than in no compression (2 studies without analysable data, 95 participants). It is uncertain whether there is any difference in rates of adverse events between using compression bandages or stockings and no compression (very low-certainty evidence; 3 studies, 585 participants). Secondary outcomes Moderate-certainty evidence suggests that people using compression bandages or stockings probably have a lower mean pain score than those not using compression (four studies with 859 participants and another study with 69 ulcers): pooled mean difference -1.39, 95% CI -1.79 to -0.98; I2 = 65% (two studies with 426 participants and another study with 69 ulcers having analysable data); synthesis without meta-analysis suggests a reduction in leg ulcer pain in compression bandages or stockings, compared with no compression (two studies without analysable data, 433 participants). Compression bandages or stockings versus no compression may improve disease-specific quality of life, but not all aspects of general health status during the follow-up of 12 weeks to 12 months (four studies with 859 participants; low-certainty evidence). It is uncertain if the use of compression bandages or stockings is more cost-effective than not using them (three studies with 486 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

If using compression bandages or stockings, people with venous leg ulcers probably experience complete wound healing more quickly, and more people have wounds completely healed. The use of compression bandages or stockings probably reduces pain and may improve disease-specific quality of life. There is uncertainty about adverse effects, and cost effectiveness. Future research should focus on comparing alternative bandages and stockings with the primary endpoint of time to complete wound healing alongside adverse events including pain score, and health-related quality of life, and should incorporate cost-effectiveness analysis where possible. Future studies should adhere to international standards of trial conduct and reporting.

Bacterial cellulose an effective material in the treatment of chronic venous ulcers of the lower limbs

Chronic venous ulcers (CVU) of the lower limbs (LL) are common and cause psychological changes and significant social impact, as they make the patient susceptible to pain, absence from work and social bonds. Some materials are suggested as dressings for the treatment of CVU, but they are expensive and are generally not available for use in public health services. To evaluate the efficacy of the treatment for lower limbs (LL) chronic venous ulcer (CVU) using bacterial cellulose (BC), gel and multi-perforated film associated. A randomized controlled clinical-intervention study was performed among participants with LL CVU, divided into two groups: experimental (EG), treated with BC wound dressing and control (CG), treated with a cellulose acetate mesh impregnated with essential fatty acids (Rayon®). The participants were followed for 180 days, evaluated according to the MEASURE methodology. Thirty-nine patients were treated, 20 from the EG and 19 from the CG. In both groups, the wound area decreased significantly (p < 0.001), the healing rate was similar to the CG. The mean number of dressing changes in the SG was 18.33 ± 11.78, while in the CG it was 55.24 ± 25.81, p < 0.001. The healing dressing of bacterial cellulose, gel and associated film, when stimulating the epithelization of the lesions, showed a significant reduction in the initial area, with a percentage of cure similar to the Rayon® coverage. In addition to requiring less direct manipulation of ulcers.

Wound Care for Venous Ulceration

Venous leg ulcers (VLUs) affect as many as 20% of patients with advanced chronic venous insufficiency and are associated with significant morbidity and health care costs. VLUs are the most common cause of leg ulcers; however, other etiologies of lower extremity ulcerations should be investigated, most notably arterial insufficiency, to ensure appropriate therapy. Careful clinical examination, standardized documentation, and ultrasound evaluation are needed for diagnosis and treatment success. Reduction of edema and venous hypertension through compression therapy, local wound care, and treatment of venous reflux or obstruction is the foundation of therapy. As key providers in venous disease, interventional radiologists should be aware of current standardized disease classification and scoring systems as well as treatment and wound care guidelines for venous ulcers.

International study to develop the WOUND-Q patient-reported outcome measure for all types of chronic wounds

Patient‐reported outcome measures (PROMs) for chronic wounds mainly focus on specific types of wounds. Our team developed the WOUND‐Q for use with all types of wounds in any anatomic location. We conducted 60 concept elicitation interviews with patients in Canada, Denmark, the Netherlands, and the United States. Analysis identified concepts of interest to patients and scales were formed and refined through cognitive interviews with 20 patients and input from 26 wound care experts. Scales were translated into Danish and Dutch. An international field‐test study collected data from 881 patients (1020 assessments) with chronic wounds. Rasch measurement theory (RMT) analysis was used to refine the scales and examine psychometric properties. RMT analysis supported the reliability and validity of 13 WOUND‐Q scales that measure wound characteristics (assessment, discharge, and smell), health‐related quality of life (life impact, psychological, sleep impact, and social), experience of care (information, home care nurses, medical team, and office staff), and wound treatment (dressing and suction device). The WOUND‐Q can be used to measure outcomes in research and clinical practice from the perspective of patients with any type of wound.

Antimicrobial stewardship of antiseptics that are pertinent to wounds: the need for a united approach

Long before the nature of infection was recognized, or the significance of biofilms in delayed healing was understood, antimicrobial agents were being used in wound care. In the last 70 years, antibiotics have provided an effective means to control wound infection, but the continued emergence of antibiotic-resistant strains and the documented antibiotic tolerance of biofilms has reduced their effectiveness. A range of wound dressings containing an antimicrobial (antibiotic or non-antibiotic compound) has been developed. Whereas standardized methods for determining the efficacy of non-antibiotic antimicrobials in bacterial suspension tests were developed in the early twentieth century, standardized ways of evaluating the efficacy of antimicrobial dressings against microbial suspensions and biofilms are not available. Resistance to non-antibiotic antimicrobials and cross-resistance with antibiotics has been reported, but consensus on breakpoints is absent and surveillance is impossible. Antimicrobial stewardship is therefore in jeopardy. This review highlights these difficulties and in particular the efficacy of current non-antibiotic antimicrobials used in dressings, their efficacy, and the challenges of translating in vitro efficacy data to the efficacy of dressings in patients. This review calls for a unified approach to developing standardized methods of evaluating antimicrobial dressings that will provide an improved basis for practitioners to make informed choices in wound care.

Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.

Medicine and Phlebolymphology: Time to Change?

Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

Antibacterial Activity of Silver and Its Application in Dentistry, Cardiology and Dermatology

The problem of antimicrobial resistance is increasingly present and requires the discovery of new antimicrobial agents. Although the healing features of silver have been recognized since ancient times, silver has not been used due to newly discovered antibiotics. Thanks to technology development, a significant step forward has been made in silver nanoparticles research. Nowadays, silver nanoparticles are a frequent target of researchers to find new and better drugs. Namely, there is a need for silver nanoparticles as alternative antibacterial nanobiotics. Silver nanoparticles (AgNPs), depending on their size and shape, also have different antimicrobial activity. In addition to their apparent antibacterial activity, AgNPs can serve as drug delivery systems and have anti-thrombogenic, anti-platelet, and anti-hypertensive properties. Today they are increasingly used in clinical medicine and dental medicine. This paper presents silver antimicrobial activity and its use in dentistry, cardiology, and dermatology, where it has an extensive range of effects.

Open-label Venous Leg Ulcer Pilot Study Using a Novel Autolologous Homologous Skin Construct

Venous leg ulcers (VLUs) are often refractory to compression therapy, and their prevalence is increasing. An autologous homologous skin construct (AHSC) that uses the endogenous regenerative capacity of healthy skin has been developed to treat cutaneous defects, with a single application. The ability of AHSC to close VLUs with a single treatment was evaluated in an open-label, single-arm feasibility study to test the hypothesis that AHSC treatment will result in wound closure by providing healthy autologous tissue to the wound bed.

METHODS

Ten VLUs were treated with a single application of AHSC. A 1.5 cm2 full-thickness skin harvest from the proximal calf was collected and sent to a Food and Drug Administration-registered facility, where it was processed into AHSC and returned to the provider within 48 hours. AHSC was spread evenly across the wound and dressed with silicone. The primary endpoint was wound closure rate at 12 weeks. Wound closure was followed with 3-dimensional planimetry, and closure was confirmed by a panel of plastic surgeons. Additional endpoints followed for 12 weeks included graft take, harvest site closure, adverse event rate, complications, and patient-reported pain.

RESULTS

All 10 VLUs demonstrated successful graft take as evidenced by graft persisting in wound and harvest site closure. Eight VLUs exhibited complete closure within 12 weeks. One VLU that failed to heal with a prior split thickness skin graft closed within 13.5 weeks with AHSC. The mean time of closure was 34 days (95% confidence interval, 14-53). Pain improved by closure confirmation visit. There was 1 serious adverse event unrelated to the product or procedure.

CONCLUSION

This pilot study demonstrated that AHSC may be a viable single-application topical intervention for VLUs and warrants further investigation in larger, controlled studies.

A Systematic Review of Model-Based Economic Evaluations of Treatments for Venous Leg Ulcers

OBJECTIVE

The aim of this review was to identify, and assess the quality of, published model-based economic evaluations relating to treatments for patients with venous leg ulcers to help inform future decision-analytic models in this clinical area.

METHODS

A systematic literature search was performed on six electronic databases, from database inception until 21 May 2018. Search results were screened against predefined criteria by two independent reviewers. Data was then extracted from the included studies using a standardised form, whilst the decision-analytic model-specific Philips Checklist was used to assess quality and to inform model critique.

RESULTS

A total of 23 models were identified, 12 studies used a Markov modelling approach, five used decision trees and six studies did not detail the model type. Studies were predominantly from the National Health Service (NHS)/payer perspective, with only two taking a societal perspective. Interventions were wide ranging, but dressing technologies (11/23) were most common. The intervention studied was found to be dominant in 22/23 studies. The reporting quality of papers was mostly low, with evidence behind model structures, time horizons and data selection consistently underreported across the included papers.

CONCLUSIONS

This review has identified a sizeable literature of model-based economic evaluations, evaluating treatments for venous leg ulcers. However, the methods used to conduct such studies were generally poorly reported. In particular, the reporting of evidence surrounding the model structure, justification of the time horizon used and the rationale for selecting data inputs should be focused on in any future models developed.

Electrospun Fibers and Sorbents as a Possible Basis for Effective Composite Wound Dressings

Skin burns and ulcers are considered hard-to-heal wounds due to their high infection risk. For this reason, designing new options for wound dressings is a growing need. The objective of this work is to investigate the properties of poly (ε-caprolactone)/poly (vinyl-pyrrolidone) (PCL/PVP) microfibers produced via electrospinning along with sorbents loaded with Argovit™ silver nanoparticles (Ag-Si/Al2O3) as constituent components for composite wound dressings. The physicochemical properties of the fibers and sorbents were characterized using scanning electron microscopy (SEM), differential scanning calorimetry (DSC), Fourier transform infrared spectroscopy (FTIR) and inductively coupled plasma optical emission spectroscopy (ICP-OES). The mechanical properties of the fibers were also evaluated. The results of this work showed that the tested fibrous scaffolds have melting temperatures suitable for wound dressings design (58-60 °C). In addition, they demonstrated to be stable even after seven days in physiological solution, showing no macroscopic damage due to PVP release at the microscopic scale. Pelletized sorbents with the higher particle size demonstrated to have the best water uptake capabilities. Both, fibers and sorbents showed antimicrobial activity against Gram-negative bacteria Pseudomona aeruginosa and Escherichia coli, Gram-positive Staphylococcus aureus and the fungus Candida albicans. The best physicochemical properties were obtained with a scaffold produced with a PCL/PVP ratio of 85:15, this polymeric scaffold demonstrated the most antimicrobial activity without affecting the cell viability of human fibroblast. Pelletized Ag/Si-Al2O3-3 sorbent possessed the best water uptake capability and the higher antimicrobial activity, over time between all the sorbents tested. The combination of PCL/PVP 85:15 microfibers with the chosen Ag/Si-Al2O3-3 sorbent will be used in the following work for creation of wound dressings possessing exudate retention, biocompatibility and antimicrobial activity.

International mixed methods study protocol to develop a patient-reported outcome measure for all types of chronic wounds (the WOUND-Q)

INTRODUCTION

Most patient-reported outcome measures (PROM) for chronic wounds are specific to a single wound type (eg, pressure ulcer) or part of the body. A barrier to outcome assessment in wound care and research is the lack of a rigorously designed PROM that can be used across wound types and locations. This mixed method study describes the protocol for an international collaboration to develop and validate a new PROM called the WOUND-Q for adults with chronic wounds.

METHODS AND ANALYSIS

In phase I, the qualitative approach of interpretive description is used to elicit concepts important to people with wounds regarding outcome. Participants from Canada, Denmark, the Netherlands, and the USA are aged 18 years and older and have a wound that has lasted 3 months or longer. Interviews are digitally recorded, transcribed and coded. A conceptual framework and preliminary item pool are developed from the qualitative dataset. Draft scales are formed to cover important themes in the conceptual framework. These scales are refined using feedback from people with chronic wounds and wound care experts. After refinement, the scales are translated into Danish and Dutch, following rigorous methods, to prepare for an international field-test study. In phase II, data are collected in Canada, Denmark, the Netherlands, and the USA. An international sample of people with a large variety of chronic wounds complete the WOUND-Q. Rasch Measurement Theory analysis is used to identify the best subset of items to retain for each scale and to examine reliability and validity.

ETHICS AND DISSEMINATION

This study is coordinated at Brigham and Women's Hospital (Boston, USA). Ethics board approval was received at each participating site for both study phases. Findings will be published in peer-reviewed journals and presented at national and international conferences and meetings.

Negative pressure wound therapy compared with standard moist wound care on diabetic foot ulcers in real-life clinical practice: results of the German DiaFu-RCT

OBJECTIVES

The aim of the DiaFu study was to evaluate effectiveness and safety of negative pressure wound therapy (NPWT) in patients with diabetic foot wounds in clinical practice.

DESIGN

In this controlled clinical superiority trial with blinded outcome assessment patients were randomised in a 1:1 ratio stratified by study site and ulcer severity grade using a web-based-tool.

SETTING

This German national study was conducted in 40 surgical and internal medicine inpatient and outpatient facilities specialised in diabetes foot care.

PARTICIPANTS

368 patients were randomised and 345 participants were included in the modified intention-to-treat (ITT) population. Adult patients suffering from a diabetic foot ulcer at least for 4 weeks and without contraindication for NPWT were allowed to be included.

INTERVENTIONS

NPWT was compared with standard moist wound care (SMWC) according to local standards and guidelines.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was wound closure within 16 weeks. Secondary outcomes were wound-related and treatment-related adverse events (AEs), amputations, time until optimal wound bed preparation, wound size and wound tissue composition, pain and quality of life (QoL) within 16 weeks, and recurrences and wound closure within 6 months.

RESULTS

In the ITT population, neither the wound closure rate (difference: n=4 (2.5% (95% CI-4.7% - 9.7%); p=0.53)) nor the time to wound closure (p=0.244) was significantly different between the treatment arms. 191 participants (NPWT 127; SMWC 64) had missing endpoint documentations, premature therapy ends or unauthorised treatment changes. 96 participants in the NPWT arm and 72 participants in the SMWC arm had at least one AE (p=0.007), but only 16 AEs were related to NPWT.

CONCLUSIONS

NPWT was not superior to SMWC in diabetic foot wounds in German clinical practice. Overall, wound closure rate was low. Documentation deficits and deviations from treatment guidelines negatively impacted the outcome wound closure.

TRIAL REGISTRATION NUMBERS

NCT01480362 and DRKS00003347.

Selection of Appropriate Wound Dressing for Various Wounds

There are many factors involved in wound healing, and the healing process is not static. The therapeutic effect of modern wound dressings in the clinical management of wounds is documented. However, there are few reports regarding the reasonable selection of dressings for certain types of wounds in the clinic. In this article, we retrospect the history of wound dressing development and the classification of modern wound dressings. In addition, the pros and cons of mainstream modern wound dressings for the healing of different wounds, such as diabetic foot ulcers, pressure ulcers, burns and scalds, and chronic leg ulcers, as well as the physiological mechanisms involved in wound healing are summarized. This article provides a clinical guideline for selecting suitable wound dressings according to the types of wounds.

First-Line Interactive Wound Dressing Update: A Comprehensive Review of the Evidence

Wound management is a significant and growing issue worldwide. Knowledge of dressing products and clinical expertise in dressing selection are two major components in holistic wound management to ensure evidence-based wound care. With expanding global market of dressing products, there is need to update clinician knowledge of dressing properties in wound care. Optimal wound management depends on accurate patient assessment, wound diagnosis, clinicians’ knowledge of the wound healing process and properties of wound dressings. We conducted a comprehensive review of the physical properties of wound dressing products, including the advantages and disadvantages, indications and contraindications and effectiveness of first-line interactive/bioactive dressing groups commonly used in clinical practice. These include semipermeable films, foams, hydroactives, alginates, hydrofibers, hydrocolloids, and hydrogels. In making decisions regarding dressing product selection, clinicians need to ensure a holistic assessment of patient and wound etiology, and understand dressing properties when making clinical decisions using wound management guidelines to ensure optimal patient outcomes. This review has highlighted there is lack of high quality evidence and the need for future well designed trials.

Internal consistency and reliability of the Swiss-French translation of the venous leg ulcer self efficacy tool (VeLUSET)

OBJECTIVE

This study was conducted to assess the psychometric properties of the translated and adapted Venous Leg Ulcer Self Efficacy Tool (VeLUSET) in the new cultural context.

DESIGN

Validation study SETTING: Three outpatient clinics in Western Switzerland.

PARTICIPANTS

32 consecutive persons with venous leg ulcers (VLU).

MAIN OUTCOME MEASURES

To determine the internal consistency and reliability of the VeLUSET for use in a Swiss-French speaking venous leg ulcer population.

RESULTS

Overall, the Cronbach alpha for the VeLUSET-FR was 0.96 (95% CI 0.93 to 0.98) on test and retest. Lin's concordance correlation coefficient of test and retest scores was 0.93 (95% CI 0.86 to 0.96).

CONCLUSION

The results indicate that the VeLUSET-FR is a valid and reliable instrument for measuring self-efficacy among Swiss-French persons affected by a venous leg ulcer. Our findings show that the psychometric properties are similar to those of the original tool. Therefore, we suggest that the VeLUSET-FR can be effectively used for measuring self-efficacy in Swiss-French persons with VLU.

Interventions for maintenance of surgically induced remission in Crohn's disease: a network meta-analysis

BACKGROUND

Crohn's disease (CD) is a chronic disease of the gut. About 75% of people with CD undergo surgery at least once in their lifetime to induce remission. However, as there is no known cure for the disease, patients usually experience a recurrence even after surgery. Different interventions are routinely used in maintaining postsurgical remission. There is currently no consensus on which treatment is the most effective.

OBJECTIVES

To assess the effects and harms of interventions for the maintenance of surgically induced remission in Crohn's disease and rank the treatments in order of effectiveness.

SEARCH METHODS

We searched the Cochrane IBD Group Specialized Register, CENTRAL, MEDLINE, and Embase from inception to 15 January 2019. We also searched reference lists of relevant articles, abstracts from major gastroenterology meetings, ClinicalTrials.gov, and the WHO ICTRP. There was no restriction on language, date, or publication status.

SELECTION CRITERIA

We considered for inclusion randomised controlled trials (RCTs) that compared different interventions used for maintaining surgically induced remission in people with CD who were in postsurgical remission. Participants had to have received maintenance treatment for at least three months. We excluded studies assessing enteral diet, diet manipulation, herbal medicine, and nutritional supplementation.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected relevant studies, extracted data, and assessed the risk of bias. Any disagreements were resolved by discussion or by arbitration of a third review author when necessary. We conducted a network meta-analysis (NMA) using a Bayesian approach through Markov Chain Monte Carlo (MCMC) simulation. For the pairwise comparisons carried out in Review Manager 5, we calculated risk ratios (RR) with their corresponding 95% confidence intervals (95% CI). For the NMA, we presented hazard ratios (HR) with corresponding 95% credible intervals (95% CrI) and reported ranking probabilities for each intervention. For the NMA, we focused on three main outcomes: clinical relapse, endoscopic relapse, and withdrawals due to adverse events. Data were insufficient to assess time to relapse and histologic relapse. Adverse events and serious adverse events were not sufficiently or objectively reported to permit an NMA. We used CINeMA (Confidence in Network Meta-Analysis) methods to evaluate our confidence in the findings within networks, and GRADE for entire networks.

MAIN RESULTS

We included 35 RCTs (3249 participants) in the review. The average age of study participants ranged between 33.6 and 38.8 years. Risk of bias was high in 18 studies, low in four studies, and unclear in 13 studies. Of the 35 included RCTs, 26 studies (2581 participants; 9 interventions) were considered eligible for inclusion in the NMA. The interventions studied included 5-aminosalicylic acid (5-ASA), adalimumab, antibiotics, budesonide, infliximab, probiotics, purine analogues, sulfasalazine, and a combination of sulfasalazine and prednisolone. This resulted in 30 direct contrasts, which informed 102 mixed-treatment contrasts.The evidence for the clinical relapse network (21 studies; 2245 participants) and endoscopic relapse (12 studies; 1128 participants) were of low certainty while the evidence for withdrawal due to adverse events (15 studies; 1498 participants) was of very low certainty. This assessment was due to high risk of bias in most of the studies, inconsistency, and imprecision across networks. We mainly judged individual contrasts as of low or very low certainty, except 5-ASA versus placebo, the evidence for which was judged as of moderate certainty.We ranked the treatments based on effectiveness and the certainty of the evidence. For clinical relapse, the five most highly ranked treatments were adalimumab, infliximab, budesonide, 5-ASA, and purine analogues. We found some evidence that adalimumab (HR 0.11, 95% Crl 0.02 to 0.33; low-certainty evidence) and 5-ASA may reduce the probability of clinical relapse compared to placebo (HR 0.69, 95% Crl 0.53 to 0.87; moderate-certainty evidence). However, budesonide may not be effective in preventing clinical relapse (HR 0.66, 95% CrI 0.27 to 1.34; low-certainty evidence). We are less confident about the effectiveness of infliximab (HR 0.36, 95% CrI 0.02 to 1.74; very low-certainty evidence) and purine analogues (HR 0.75, 95% CrI 0.55 to 1.00; low-certainty evidence). It was unclear whether the other interventions reduced the probability of a clinical relapse, as the certainty of the evidence was very low.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing endoscopic relapse. Whilst there might be some evidence of prevention of endoscopic relapse with adalimumab (HR 0.10, 95% CrI 0.01 to 0.32; low-certainty evidence), no other intervention studied appeared to be effective.Due to high risk of bias and limited data across the network, we are uncertain about the effectiveness of interventions for preventing withdrawal due to adverse events. Withdrawal due to adverse events appeared to be least likely with sulfasalazine (HR 1.96, 95% Crl 0.00 to 8.90; very low-certainty evidence) and most likely with antibiotics (HR 53.92, 95% Crl 0.43 to 259.80; very low-certainty evidence). When considering the network as a whole, two adverse events leading to study withdrawal (i.e. pancreatitis and leukopenia) occurred in more than 1% of participants treated with an intervention. Pancreatitis occurred in 2.8% (11/399) of purine analogue participants compared to 0.17% (2/1210) of all other groups studied. Leukopenia occurred in 2.5% (10/399) of purine analogue participants compared to 0.08% (1/1210) of all other groups studied.

AUTHORS' CONCLUSIONS

Due to low-certainty evidence in the networks, we are unable to draw conclusions on which treatment is most effective for preventing clinical relapse and endoscopic relapse. Evidence on the safety of the interventions was inconclusive, however cases of pancreatitis and leukopenia from purine analogues were evident in the studies. Larger trials are needed to further understand the effect of the interventions on endoscopic relapse.

"Wounds Home Alone"-Why and How Venous Leg Ulcer Patients Self-Treat Their Ulcer: A Qualitative Content Study

BACKGROUND

Venous leg ulcers (VLUs), the most common type of leg ulcerations, have long healing times and high recurrence rates; reimbursement rules and a general shortage of nursing staff have put self-treatment into focus. The study aimed to investigate why and how patients with VLUs self-treat their ulcers.

METHODS

Patients with VLUs (N = 32) were selected by criterion sampling for a multicentric qualitative study using semi-structured interviews. The interviews were analyzed via inductive qualitative content analysis.

RESULTS

More than two-thirds of participants sometimes self-treated VLU and one quarter changed their prescribed treatment. Experiences were expressed through four themes as follows: (a) current local VLU therapy; (b) VLU self-treatment; (c) patient education; and (d) psychosocial issues. The main reasons for self-treatment were a lack of healthcare resources, reimbursement restrictions, and dissatisfaction with conventional treatment together with insufficient knowledge about the wound-healing process and possible side effects. No educational materials were provided for patients or caregivers. Many patients adopted homemade remedies.

CONCLUSION

Patients with VLUs practice self-care due to limited healthcare availability, a low awareness of the causes of their condition, and the effects of therapy on VLU healing. Future educational intervention is needed to enhance self-treatment.