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