Definition and Causes
Chronic, complex, or problem wounds are skin ulcers or sores that do not heal without special treatment. Wounds that fail
to heal in three months are usually considered chronic. Some take years to heal or never do. Common chronic wounds include
venous ulcers (leg), arterial ulcers (foot), diabetic ulcers (leg and foot), and pressure ulcers (bedsores on elbows, back,
ankles, hips, and heels). Wound care specialists classify chronic wounds into stages or grades. Diabetic foot ulcers are
classified using the Wagner Grade Scale (See
Diabetic Ulcers).
Pressure ulcers are classified into stages developed by the
National Pressure Ulcer Advisory Panel (NPUAP):
-
Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to
damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm,
mushy, boggy, warmer, or cooler as compared to adjacent tissue.
-
Stage I: Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin
may not have visible blanching; its color may differ from the surrounding area.
-
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
May also present as an intact or open/ruptured serum-filled blister.
-
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough
may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
-
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts
of the wound bed. Often include undermining and tunneling.
-
Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green,
or brown) and/or eschar (tan, brown, or black) in the wound bed.
Chronic wounds require a healthy, oxygenated wound bed to heal. A lack of sufficient oxygen (hypoxia) in the wound bed slows
or stops the normal healing process. Healing is notably difficult in patients with poor general or circulatory health.
Diabetes, in particular, may inhibit wound healing and increase the risk of infection and amputation. Wounds resulting from
trauma, surgery, burns, skin grafting, and radiation therapy may also become problem wounds. Chronic wounds are especially
prone to serious bacterial infections that threaten life and limb.
Hyperbaric Oxygen Approval Status
Read the
Arterial Insufficiencies: Enhancement of Healing in Selected Problem Wounds
page in the Undersea and Hyperbaric Medical Society resource library to learn more about wound evaluation, hypoxia, measures of
wound oxygenation, the mechanisms and efficacy of hyperbaric oxygen, and future areas for research.
Treatment with Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy (HBOT) is an effective adjunct to traditional wound care therapies, including topical cleaning;
surgical removal (debridement) of dead skin and tissue; application of dressings, ointments, and biologics; and use of
compression boots or stockings, vacuum or negative pressure wound therapy (NPWT) pumps, ultrasound, laser, and other emerging
technologies. HBOT helps repair wounds and enhance healing by improving blood circulation, encouraging the formation of new
capillary blood vessels (angiogenesis), supplying more oxygen to tissue in the wound bed, and stimulating the growth and
distribution of stem cells. Hyperbaric oxygen also helps kill the anaerobic bacteria that cause some of the worst infections
in chronic wounds. Evidence for HBOT is especially strong in diabetic foot ulcers classified Wagner Grade 3 or higher, for
which hyperbaric oxygen is widely considered standard therapy.
hyperbariclink commentary
Hyperbaric oxygen plays an increasingly important role in the treatment of problem wounds and limb salvage. But access to
accredited hyperbaric facilities and certified hyperbaric physicians and technicians is a public health problem. In 2004
as many as two-thirds of nursing home patients with NPUAP Stage II or worse pressure ulcers were not enrolled in wound care
treatment programs
[NCHS, 2011].
In diabetes-related wounds alone, US hospitals performed 66,000 toe, foot, and leg amputations
in 2006
[CDC, 2011],
for which health economists have estimated a cost of $3 billion per year
[ACA, 2008]. More and more
hospitals and health networks today are opening advanced wound care and hyperbaric centers to serve this unmet clinical need.
Even if chronic wounds were its only indicated use, HBOT would be assured a place in evidence-based medicine for quality and
cost-effective healthcare.
Patient Resources
HyperbaricLink recommends the following websites for anyone seeking authoritative information, patient advocacy, and
community support for chronic wounds.
Presented by insurance company Aetna and reviewed by Harvard Medical School faculty, the InteliHealth foot ulcers page
provides a good overview of symptoms, treatments, and prevention.
Presented by device manufacturer Healthpoint Biotherapeutics, this interactive program clearly explains the different types
of chronic wounds with easy-to-understand graphics, audio, and text in English and Spanish.
The chronic wound entry in Wikipedia provides good basic information about the different types of wounds and their causes
and treatments.
Clinical Resources
Start with the following resources to explore current research activities and the peer-reviewed medical literature on
hyperbaric oxygen therapy for chronic wounds.
The ACHM is a professional organization working to develop an image of hyperbaric oxygen therapy as a distinct medical
specialty, often requiring full-time practice. ACHM has a strong focus on wound care and offers a credentialing and fellowship
track for physicians, a Certified Hyperbaric and Wound Specialist (CHWS) program for hyperbaric technologists, and a Wound
Care Boot Camp online training course.
The preeminent multidisciplinary organization for wound care, AAWC is a nonprofit association open to everyone involved in
wound care. Its mission is to spread awareness by promoting excellence in education, clinical practice, public policy, and
research.
A nonprofit organization welcoming all wound care professionals, the APWCA combines the structure of a credentialing college
and a full-service medical association. Its mission is to decrease the rate of complications from wounds all types. APWCA
provides ACHM-recognized physician and technician certification programs in conjunction with the Council for Medical Education
and Testing (CMET).
ClinicalTrials.gov keeps the official list of human clinical trials currently enrolling, in progress, and recently completed.
One may reasonably question the size and legitimacy of any study not listed here.
Search ClinicalTrials.gov for current studies of wound + hyperbaric oxygen therapy
An independent, international, nongovernmental organization, the Cochrane Collaboration is a powerful force in evidence-based
medicine. One may consider a Cochrane Reviews article on any HBOT topic required hyperbaric reading.
Read the Cochrane Reviews article "Hyperbaric oxygen therapy for chronic wounds"
A specialized Google search engine, Google Scholar indexes scholarly articles, patents, and legal opinions and journals.
Google Scholar may generate excessive search results, but entries provide easy access to full-text journal articles.
Search Google Scholar for "chronic wounds" + "hyperbaric oxygen"
HBOEvidence uses computerized tools to appraise the key randomized controlled trials (RCTs) in the hyperbaric medical
literature. One may reasonably question the overall strength of HBOT evidence for any disease or condition not covered here.
Read the HBOEvidence appraisals for treatment of nonhealing wounds with hyperbaric oxygen therapy
PubMed.gov
US National Library of Medicine
National Institutes of Health
PubMed keeps the official list of scientific papers published in reputable peer-reviewed medical journals. One may reasonably question the importance and
legitimacy of any study not listed here.
Search PubMed.gov for journal articles relating to chronic wounds and hyperbaric oxygen therapy
An international nonprofit organization serving some 2,400 members in 50 countries, the UHMS is the chief accrediting body
and the primary source of scientific information for diving and hyperbaric medicine physiology.
Read the UHMS statement on the Medicare Arterial Insufficiency Ulcer Issue
Related Terms
- Amputation
- Arterial ulcer
- Bedsore
- Bony necrosis
- Clostridial myonecrosis
- Clostridial myositis
- Decubitus ulcer
-
Delayed radiation injury »
- Diabetes
- Diabetic foot
- Diabetic foot ulcer
- Gas gangrene
- Hypoxia
- Leg ulcer
- Limb salvage
- Necrotizing fasciitis
- Necrotizing infection
- Nonhealing wound
- Osteomyelitis
- Osteonecrosis
- Pressure ulcer
-
Radionecrosis »
- Selected problem wounds
- Slow-healing wound
- Soft tissue necrosis
- Venous stasis ulcer
- Venous ulcer
- Wagner ulcer grade classification scale