SHORT COMMUNICATION 157
ActaDV ActaDV
Advances in dermatology and venereology Acta Dermato-Venereologica
Need for Improved Definition of “ Chronic Wounds ” in Clinical Studies *
Bhone Myint KYAW 1 , Krister JÄRBRINK 1 , Laura MARTINENGO 1 , Josip CAR 1 , 2 , Keith HARDING 3 and Artur SCHMIDTCHEN 4 , 5
1
Centre for Population Health Sciences ( CePHaS ), Lee Kong Chian School of Medicine , Nanyang Technological University , Singapore , Singapore ,
2
Global eHealth Unit , Department of Primary Care and Public Health , School of Public Health , Imperial College London , London , 3 Division of Population Medicine , Cardiff University School of Medicine , Health Park , Cardiff , UK , 4 Dermatology and Skin Biology Programme , Lee Kong Chian School of Medicine , Nanyang Technological University , 59 Nanyang Drive , Experimental Medicine Building , Singapore 636921 , Singapore , and 5 Division of Dermatology , Department of Clinical Sciences , Lund University , Lund , Sweden . * E-mail : artur . schmidtchen @ ntu . edu . sg Accepted Sep 7 , 2017 ; Epub ahead of print Sep 7 , 2017
The term “ chronic wound ” was first used in the literature in the 1950s , to refer to wounds that were difficult to heal or did not follow a normal healing process ( 1 , 2 ). However , the term has met criticism for its uncertainty regarding the duration of chronicity ( 3 ). Various alternative terminologies have been suggested , such as hard-to-heal wounds , difficult to heal wounds , non-healing wounds and complex wounds ( 4 , 5 ). “ Chronic wounds ” are commonly defined as “ wounds that have not proceeded through an orderly and timely reparation to produce anatomic and functional integrity after 3 months ” ( 6 ). However , Martin & Nunan ( 7 ) defined a “ chronic wound ” as a barrier defect that has not healed in 3 months , and Leaper & Durani ( 8 ) defined it as a wound that lacks a 20 – 40 % reduction in size after 2 – 4 weeks of optimal treatment or when there is not complete healing after 6 weeks . Recent reviews have also highlighted the lack of consensus regarding the definition of a “ chronic wound ” and the need for further research in this area ( 9 , 10 ).
The increasing prevalence of non-communicable diseases and the ageing population have put the spotlight on wound care and the considerable societal burden of wounds ( 11 , 12 ). However , the lack of a common terminology when sharing and applying scientific research implies a risk of inaccuracy , with serious consequences for patients with wounds . For instance , the great disparity in the definitions of “ chronic wounds ”, leading to only a few studies being included in 2 systematic reviews ( 3 , 9 ), may , at a later stage , have a negative impact on the management and care of “ chronic wounds ”. Moreover , the undefined terminology may also hamper future comparisons between separate clinical retrospective or prospective studies .
The aim of this study is to highlight the wide heterogeneity in the definitions and reference staging of “ chronic wounds ”, and along with the review by Gould et al . ( 9 ), discuss this problem according to category of wound .
METHODS
Based on the published search strategy applied in a systematic review on the prevalence of chronic wounds ( 13 ), we reviewed the full-text of the included titles ( in the title / abstract stage ) for
* The Editor-in-Chief has not had responsibility for this article ; it has been handled fully by the Co-Editor , who made the decision to accept it . the definition of chronic wounds used by the different authors . We classified the studies , by aetiology , into the following groups : pressure ulcers ( PU ), venous ulcers ( VU ), arterial insufficiency ulcers ( AIU ) and diabetic foot ulcers ( DFU ), implying also that studies on ulcers of mixed aetiologies were excluded , as the purpose was to describe chronicity by ulcer group .
RESULTS
A total of 669 articles on chronic wounds that met the review criteria ( 13 ) were identified ( Fig . S1 1 ), of which 400 articles corresponded to PUs ( 60 %), 238 to DFUs ( 36 %), and 28 to VUs ( 4 %) ( despite this being one of the most common causes of chronic wounds ), and 3 to AIUs .
Sixty-three percent of the articles describing PUs did not provide a definition or a staging system . One hundred and forty-seven articles ( 37 %) provided either a reference staging system or a definition . Details are shown in Fig . 1 . No studies mentioned the duration of chronic PU in their definitions .
Only 53 of 238 articles on DFUs provided a definition or a staging system , of which 33 ( 22 %) used the Wagner classification of diabetic ulcer ( 1979 – 1981 ) without providing any information on the duration ( Fig . 1 ). Only 6 articles provided duration in their definition of a chronic DFU , with a cut-off range for defining chronicity varying from 2 to 8 weeks .
Of the 28 papers on VUs , 10 ( 36 %) used a staging system or provided a definition . The most commonly cited classification system was Comprehensive Classification System for Chronic Venous Disorders ( CEAP ), which was cited in 4 papers without any specified duration of the ulcer . Another 3 articles defined VU based exclusively on clinical and pathophysiological findings . Only 3 articles defined VU using the duration of the ulcer as part of their definitions , applying a range from 6 weeks to 2 months . Two of the 3 articles on AIUs cited the Rutherford grading system for the definition without integrating the duration in their definitions .
DISCUSSION
This study examined the preliminary stages of including articles in a systematic review on prevalence of “ chronic
1 https :// www . medicaljournals . se / acta / content / abstract / 10.2340 / 00015555-2786
This is an open access article under the CC BY-NC license . www . medicaljournals . se / acta Journal Compilation © 2018 Acta Dermato-Venereologica . doi : 10.2340 / 00015555-2786 Acta Derm Venereol 2018 ; 98 : 157 – 158