When Not To Use Advanced Wound Care Modalities

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Author(s): 
Gary M. Rothenberg, DPM, CDE, CWS

   In light of these issues, we should give consideration to stopping therapy when there is a lack of response or even forgoing utilization of advanced modalities in cases in which wound closure and, more importantly, the ability to maintain closure is futile.

   In regard to contraindications with biologic skin equivalents, Apligraf is contraindicated for use on clinically infected wounds.3 Apligraf is also contraindicated in patients with known allergies to bovine collagen or the components to the Apligraf agarose shipping medium. Likewise, Dermagraft is contraindicated for use in ulcers that have signs of clinical infection or ulcers with sinus tracts.4 Additionally, Dermagraft is contraindicated in patients with known hypersensitivity to bovine products.

   The pivotal trials for each of these products excluded patients with compromised vascular status or Charcot arthropathy. However, these are not listed as contraindications for use. In fact, several algorithms exist to help guide therapy and it is often recommended that high-risk patients such as those with previous history of ulceration or amputation or those with Charcot arthropathy receive advanced wound care modalities even earlier.5 The rationale behind this faster movement to advanced modalities is justified by the known potential for difficult wound healing and associated morbidity in this patient population.

   In the absence of any other studies in the advanced comorbid patient population, one should hopefully observe the same trajectories toward healing. Clinically, there may be a slower response but the same principles of weekly reassessment and critical examination for response to therapy are mandatory. The critical question still remains when to stop advanced modalities because the reality is that we will not be able to heal all wounds nor should clinicians be utilizing these resources in certain clinical scenarios.

Should You Consider Palliative Wound Care?

Chronic wound maintenance or the “palliative wound care” model provides appropriate, standard care and maintains accepted tenets for treatment including pain management, offloading, infection prevention and a dignified quality of life.6 This may involve regular home healthcare visits for dressing changes and less frequent face-to-face visits. This has the added benefit of keeping patients in their homes and not overburdening caregivers with frequent travel to and from clinics.

   The criteria for inclusion in this type of protocol may include patients who have received advanced wound therapies for a reasonable period (six to eight weeks) with no progression towards healing. Additionally, a small percentage of wounds may not heal without surgical intervention. There may be cases in which the deformity underlying the etiology of the wound is too rigid and one is unable to accommodate it with external offloading. However, when it comes to patients who refuse or are deemed too sick or medically unstable to undergo surgical intervention for wound healing or amputation, clinicians may consider palliative wound care. Other potential “red flag” patients for whom advanced modalities may not be appropriate include smokers, the homeless, those with unstable mental illness and people with significantly elevated HbA1c.

   Little is written about stopping advanced therapy use in wound care. As clinicians dedicated to healing patients, we often see it as a failure when we are unable to achieve wound closure. Ultimately, success should not be defined by the ability to close a wound but rather in providing the patient with optimal quality of life.

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