Recurrence of Chronic Ulcers

There is an extraordinarily high rate of recurrence of chronic wounds. 1,2,3,4 This is due in great part to the very slow strengthening process during the remodeling stage of wound healing. 5,6,7 By protecting the fragile skin at this stage, the rate of recurrence might be decreased. 8,9,10,11,12,13

The remodeling phase is an overlooked and critical stage of wound healing
Remodeling is the final phase of wound healing after re-epithelialization. During this phase, the healing wound gains tensile strength as new collagen is formed into increasingly larger bundles with more intermolecular crosslinks. 14,15,16 It includes a reorganization of new collagen fibers, forming a more organized lattice structure that progressively continues to increase wound tensile strength. The remodeling process continues for up to two years.5,6,7 This is a particularly vulnerable period for reulceration because the newly healed ulcer is not fully mature and is not yet able to withstand the vertical and shear stresses placed on it.13

The skin is very fragile during the remodeling stage

Recurrence rates are high during the remodeling phase
Depending on the population studied, recurrence rates for chronic wounds in adults are between 13% and 83%.1,2,3,4
Examples of recurrence rates:

70% The three year recurrence rate of diabetic foot ulcers, once healed. 17
36-50% The one year recurrence rate of pressure ulcers in people with SCI. 18,19
82% Recurrence rate of pressure ulcers in paraplegics. 20
13-83% Recurrence rate of pressure ulcers in entire adult population.1,2,3,4
30-57% Recurrence rate of patients with diabetes mellitus (DM) and peripheral neuropathy.9,10,11,12,13
72% Recurrence rate of patients with venous ulcers. 21
33-43% Two to twelve year recurrence rate of pressure ulcers that had been treated with cutaneous or musculocutaneous flaps. 22,23

Prevention of recurrence
Although all extrinsic factors should be addressed in the prevention of ulceration, the factors that affect the fragility of skin the most during the remodeling phase must be minimized to prevent recurrence.13 Pressure, shear and friction forces have a severely detrimental effect on new and healing skin, and their reduction has a significant potential to reduce recurrence rates. 24,25,26,27,28,29,30,31,32 For example, a study evaluating pressure offloading using orthopedic shoes resulted in a drop of recurrence rate for diabetic ulcers from 83% to 17%. 33

Conclusion
Chronic ulcer recurrence is a serious and largely unaddressed problem. By continuing treatment during the remodeling phase, a large number of chronic wounds could be prevented.

References
1 WOCN Guideline for Prevention and Management of Pressure Ulcers. 2003
2 Relander, M., & Palmer, B. (1988). Recurrence of surgically treated pressure sores. Scandinavian Journal of Plastic and Reconstructive Surgery, 22, 89–92.
3 Schryvers, O.I., Stranc, M.F., & Nance, P.W. (2000). Surgical treatment of pressure ulcers: 20-year experience. Archives of Physical Medicine and Rehabilitation, 81,1556–1562.
4 Thomas DR. Prevention and Treatment of Pressure Ulcers. J Am Med Dir Assoc 2006; 7: 46–59.
5 Clark, R.A.F. and Singer, A. (2000) Wound Repair: Basic biology to tissue engineering. In “Principles of Tissue Engineering” second edition, pp. 857-878. Academic Press.
6 Richard Salcido, MD. The Cicatrix: The Critical Functional Stage of Wound Healing. ADVANCES IN SKIN & WOUND CARE & VOL. 21 NO. 9
7 Mercandetti M., Cohen A.J. (2005). Wound Healing: Healing and Repair. Emedicine.com.
8 Presentation by David Thomas, MD (Professor of Internal Medicine & Geriatric Medicine at Saint Louis University) at the 2001 AMDA Convention
9 Mueller et al. Use of Computed Tomography and Plantar Pressure Measurement for Management of Neuropathic Ulcers in Patients With Diabetes. Phys Ther. 79 (3): 296.
10 Apelqvist J, Castenfors J, Larsson J, et al. Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers. Diabet Med.1989; 6:526–530.
11 Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med.1993; 233:485–491.
12 Helm PA, Walker SC, Pullium GF. Recurrence of neuropathic ulceration following healing in a total contact cast. Arch Phys Med Rehabil.1991; 72:967–970.
13 Sinacore DR. Total contact casting for diabetic neuropathic ulcers. Phys Ther.1996; 76:296–301.
14 LeBoeuf H, Calhoun KH, Quinn FB. Prevention and Revision of the Cicatrix Grand Rounds, Department of Otolaryngology, University of Texas Medical Branch, Galveston, Texas: November 19, 1997.
15 Understanding Wounds. http://www.angio.org/providers/woundcare/understandingWounds.html The Angiogenesis Foundation, Cambridge, Massachusetts
16 Douglas MacKay ND, Alan L. Miller ND. Nutritional Support for Wound Healing. Alternative Medicine Review 2003 (Nov);8(4):359–377
17 Thomas Miller, MD, Scott A. Clark, DPM, and Barry Stults, MD. Managing and Preventing Diabetic Foot Ulcers. Emerg Med 36(8):14-23, 2004
18 Carlson et al., 1992; Fuhrer et al., 1993; Goldstein, 1998; Niazi et al., 1997; Salzberg et al. 1998.
19 Consortium for Spinal Cord Medicine. Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. August 2000.
20 Evans GR; Dufresne CR; Manson PN. Surgical correction of pressure ulcers in an urban center: is it efficacious? Adv Wound Care. 1994; 7(1):40-6
21 Valencia IC, Falabella A, Kirsner RS, Eaglstein WH. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol. 2001 Mar;44(3):401-21; quiz 422-4.
22 RK Vohra, CN McCollum. Pressure Sores. BMJ 1994;309:853-7
23 Hilton Marc Kaplan & Anne-Caroline Dupont Salter. BIONTM Neuromuscular Stimulation for Pressure Ulcer Prevention. Alfred Mann Institute, University of Southern California
24 Naylor PFD (1955a): The skin surface and friction. Brit. J Dermatol, 67: 239-248.
25 Naylor PFD (1955): Experimental friction blisters. Brit. J Dermatol, 67: 327-344.
26 Herring KM, Richie DH (1990): Friction Blisters and Sock Fiber Composition. Journal of the Am Podiatric Medical Assoc. 80 (2): 63-71.
27 Reichel SM (1958): Shearing force as a factor in decubitus ulcers in paraplegics. JAMA, 166: 762 763.
28 Guttmann L (1976): The prevention and treatment of pressure sores. In: Bed Sore Biomechanics: Proceedings of a Seminar on the Viability and Clinical Applications, RM Kenedi, JM Cowden, JT Scales, eds. MacMillan: London: 153-159.
29 Dinsdale SM (1974): Decubitus ulcers: Role of pressure and friction in causation. Arch Phys Med Rehabil, 55: 147-151.
30 Bennett L, Kavner D, Lee BK, Trainor FA (1979): Shear vs. pressure as causative factors in skin blood flow occlusion. Arch Phys Med Rehabil, 60: 309-314.
31 Brand PW (1976): Pressure sores - The problem. In: Bed Sore Biomechanics: Proceedings of a Seminar on the Viability and Clinical Applications, RM Kenedi, JM Cowden, JT Scales, eds. MacMillan: London: 19 23.
32 Roaf R (1976): The causation and prevention of bed sores. In: Bed Sore Biomechanics: Proceedings of a Seminar on the Viability and Clinical Applications, RM Kenedi, JM Cowden, JT Scales, eds. MacMillan: London: 5-9.
33 Presentation by David Thomas, MD (Professor of Internal Medicine & Geriatric Medicine at Saint Louis University) at the 2001 AMDA Convention
34 Stadelmann WK, Digenis AG, Tobin GR. Physiology and healing dynamics of chronic cutaneous wounds. Am J Surg 1998;176:26S-38S.
35 Dix K. Wound Care. Infection Control Today. 05/01/2006

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Recurrence_of_Chronic_Ulcers.pdf