Chronic Ulcer (Non-Healing Wound)

Why chronic ulcers do not heal

Normal wounds pass through stages of clotting, inflammation, new tissue formation and remodeling over a few weeks. Chronic ulcers get stuck in the inflammatory stage. Common reasons:

• Poor blood supply: not enough oxygen and nutrients reach the tissue.
• High venous pressure: fluid and proteins leak into tissue, causing swelling and skin breakdown.
• Repeated pressure or friction: the wound keeps being re-injured.
• Nerve damage: people do not feel injury, so they keep walking on it.
• Infection and biofilm: bacteria form protective layers that resist healing.
• Diabetes: high blood sugar impairs immune cells and healing.
• Poor nutrition, especially low protein, and smoking.
• Medicines such as long-term steroids.

Types of chronic ulcers

Venous leg ulcers

The most common type, making up about 70% of leg ulcers. Damaged valves in leg veins (venous insufficiency) let blood pool, raising pressure in the lower leg. The skin becomes stained, hard and itchy before breaking down.

Diabetic foot ulcers

Diabetes can damage nerves (so injuries go unnoticed), reduce blood flow and slow healing. Ulcers can become infected and spread to bone (osteomyelitis). They are a leading cause of amputation, which is why prompt care matters.

Pressure ulcers

Sustained pressure on skin over bones cuts off blood flow. They can develop within hours in people who cannot move. They are staged 1 to 4 by depth.

Arterial ulcers

Peripheral artery disease reduces blood flow to the legs. Ulcers are painful, often worse when the legs are raised, and heal poorly without restoring circulation.

Other causes

• Skin cancer: squamous cell carcinoma, basal cell carcinoma or melanoma can look like an ulcer. A long-standing ulcer can also turn cancerous (Marjolin ulcer).
• Inflammatory conditions: pyoderma gangrenosum, vasculitis.
• Infections: such as atypical mycobacteria.
• Sickle cell disease.

Diagnosis

A doctor or wound specialist will examine the wound's size, depth, edges and base, and the surrounding skin, and check pulses and sensation. Tests include:

• Ankle-brachial index (ABI): compares blood pressure at the ankle and arm to detect arterial disease. Essential before compression therapy.
• Duplex ultrasound of veins or arteries.
• Blood tests: blood sugar and HbA1c, blood count, kidney function, nutrition markers.
• Wound swab or tissue culture if infection is suspected.
• X-ray or MRI to look for bone infection.
• Biopsy of ulcers that look unusual or do not heal after 3 months of appropriate care.

Treatment

Treat the cause

• Venous: compression bandages or stockings, the key treatment; leg elevation; walking; and procedures to close faulty veins, which speed healing and reduce recurrence.
• Diabetic: offloading pressure with special boots or casts, blood sugar control, removal of callus and dead tissue, and infection treatment.
• Pressure: repositioning at least every 2 hours, pressure-relieving mattresses and cushions, nutrition support.
• Arterial: restoring blood flow by angioplasty, stenting or bypass surgery. Compression is avoided in significant arterial disease.

Wound care

• Cleaning with saline or water at each dressing change.
• Debridement: removing dead tissue and callus.
• Dressings chosen to keep the wound moist but not wet: foams, hydrocolloids, alginates, hydrogels and others.
• Infection treatment: antibiotics for spreading infection; antiseptic dressings for local infection.
• Advanced therapies for resistant wounds: negative pressure wound therapy, skin substitutes and grafts, and hyperbaric oxygen for selected diabetic foot ulcers.

Support healing

• stop smoking
• improve nutrition, especially protein
• control blood sugar
• keep active as able

Outlook

Venous ulcers often heal within 3 to 6 months with good compression but recur frequently without ongoing stockings. Diabetic foot ulcers heal in most people with expert care, but recurrence is common and amputation risk is significant if infection or poor circulation is not addressed. Pressure ulcers can heal with pressure relief and care, though deep ones may need surgery.

Frequently asked questions

What is a chronic ulcer?

A chronic ulcer is an open skin wound that has not healed after 4 to 12 weeks. Most occur on the legs and feet and are caused by vein problems, diabetes, pressure or poor arterial blood flow, which stop the normal healing process.

Why won't my wound heal?

Common reasons are poor circulation, high vein pressure and leg swelling, diabetes, infection, repeated pressure, smoking and poor nutrition. A doctor can find the cause with an exam, an ankle-brachial index and blood tests, and correct it.

How are venous leg ulcers treated?

Compression therapy with bandages or stockings is the most important treatment, along with leg elevation, walking, and wound dressings. Treating the faulty leg veins with procedures speeds healing and reduces the chance of the ulcer coming back.

Can a chronic ulcer become cancer?

Rarely, a long-standing ulcer or scar can develop into skin cancer, called a Marjolin ulcer. Also, some skin cancers look like ulcers. A wound that does not heal after 3 months of good care, or has raised, irregular edges, should be biopsied.