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For patients with chronic ulcers, the primary management goal, when possible, is complete wound healing. When this is not possible, palliative wound care provides a patient-centered alternative. Malnutrition is a risk factor for pressure ulcer development, but it is unclear whether interventions improve wound healing or other outcomes. Debridement is the removal of nonviable tissue, foreign bodies, and biofilm from the wound bed to eliminate physical and microbiologic impediments to healing. Nonsurgical debridement options include autolytic, enzymatic, biologic, and mechanical methods. The ideal dressing provides moisture to the wound and dryness to the periwound area. Choice of dressing is based primarily on exudate management properties. Pressure offloading is considered the primary therapy for pressure ulcers but strong evidence to support its use is lacking. For patients with venous leg ulcers (VLUs), unless contraindicated, compression therapy is a recommended component of the management plan. There is insufficient or poor-quality evidence supporting the effectiveness of negative pressure wound therapy and hyperbaric oxygen therapy in the management of pressure ulcers, VLUs, and arterial ulcers. Family physicians play a central role in the management of chronic ulcers, providing aggressive risk factor modification, control of chronic conditions, and prompt referral when indicated.

Case 2. Awinita is a 55-year-old American Indian woman with chronic bilateral leg hyperpigmentation and varicosities. She comes to your office because of an 8-week history of right anterior leg ulcer. She has been self-treating the ulcer but has not noticed significant improvement.

Management Goals

Wound Healing

Given the great patient and societal burden of chronic ulcers, the primary management goal, when possible, is complete wound healing. Biological determinants of wound healing should be addressed, including blood flow, clinical infection, bone involvement, and the wound microenvironment.1

Management of chronic ulcers requires the physician to address wound cleansing; debridement; choice of dressing; compression therapy; pressure offloading; and the use of topical, systemic, and physical therapies.1 Psychosocial barriers to management, including barriers to care access, mental health conditions, food insecurity, poor living conditions, prohibitive cost of dressings and medical supplies, and other barriers, should be considered by the care team.

Palliative Care

In many cases, complete wound healing is not possible. Patients who are elderly, frail, or have severe neurocognitive disorders, advanced malignancies, nonrevascularizable limbs, severe malnutrition, or poor mobility may have difficulty healing. In these situations, realistic goals of wound care should be discussed and shared decision-making should guide management.

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