A systematic review of 66 research papers focused on the treatment of skin ulcers suggests that most are so technically flawed that their results are unreliable. And even of those that pass muster, there is only weak evidence that some treatments work better than standard compression therapy or special stockings.
The research review team, led by investigators at the Johns Hopkins Evidence-Based Practice Center and the Johns Hopkins Wound Healing Center, noted than an estimated $25 billion is spent annually in the United States treating chronic skin wounds related mostly to poor blood circulation, disorders known as venous ulcers. Their prevalence is rising along with rates of diabetes and obesity, and the review was undertaken in an effort to inform physicians about the treatment options.
In 2011, the Agency for Healthcare Research and Quality awarded the Johns Hopkins Evidence-Based Practice Center a $475,000 project to carry out the research, which was led by Gerald Lazarus, M.D., founder of the Johns Hopkins Wound Healing Center and professor of dermatology and medicine at Johns Hopkins Bayview Medical Center; and Jonathan Zenilman, M.D., scientific director of the Wound Healing Center and professor of medicine and chief of the Division of Infectious Diseases at Johns Hopkins Bayview.
The research review team began by identifying 10,066 citations that were possibly related to wound care. They found that only 66 of these papers specifically addressed their questions about the effectiveness of treatments for chronic venous leg ulcers.
For the study, the investigators analyzed clinical outcomes involving wound dressings, antibiotics and venous surgery.
Overall results found that dressings that used living human cells increased wound healing. Results suggested that cadexomer iodine and collagen may also increase healing, says Lazarus. "That doesn't mean that other types of dressings don't work. It just means that there is no evidence yet on which treatments work the best," says Lazarus. Support stockings, he adds, must for now remain the standard of care for treating chronic venous ulcers.
Lazarus says the review also showed evidence is inconclusive about using systemic antibiotics unless there are demonstrated signs of infection. And it is also inconclusive about such surgical treatments as radiofrequency ablation, endovenous laser treatment and sclerotherapy helped healing, although surgical correction of underlying pathology did decrease recurrence of ulcers.
"There is a critical need for well-designed research studies to compare the current minimally invasive surgical interventions to the gold standard of care, compression therapy," he says.
The Johns Hopkins researchers enlisted input from a panel of 14 experts in wound care in their review of the data.
Chronic wounds are a global problem, the researchers say. In addition to obesity and diabetes worldwide, skin ulcers occur as a consequence of neurological problems, rheumatological illnesses, blood vessel inflammation and infection. Nonhealing wounds cause not only pain, but also loss of mobility and a general decline in physical and emotional well-being. Patients can become disabled, unable to work and dependent on care from others.
Lazarus says, "The review should serve as a means to bring the wound healing community together to improve the situation." Christine Chang, M.D., M.P.H., medical officer of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality, adds, "Our hope is that this evidence report provides patients and providers with the best information available to make well-informed decisions about care."
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A systematic review of 66 research papers focused on the treatment of skin ulcers suggests that most are so technically flawed that their results are unreliable. And even of those that pass muster, there is only weak evidence that some treatments work better than standard compression therapy or special stockings.
The research review team, led by investigators at the Johns Hopkins Evidence-Based Practice Center and the Johns Hopkins Wound Healing Center, noted than an estimated $25 billion is spent annually in the United States treating chronic skin wounds related mostly to poor blood circulation, disorders known as venous ulcers. Their prevalence is rising along with rates of diabetes and obesity, and the review was undertaken in an effort to inform physicians about the treatment options.
In 2011, the Agency for Healthcare Research and Quality awarded the Johns Hopkins Evidence-Based Practice Center a $475,000 project to carry out the research, which was led by Gerald Lazarus, M.D., founder of the Johns Hopkins Wound Healing Center and professor of dermatology and medicine at Johns Hopkins Bayview Medical Center; and Jonathan Zenilman, M.D., scientific director of the Wound Healing Center and professor of medicine and chief of the Division of Infectious Diseases at Johns Hopkins Bayview.
The research review team began by identifying 10,066 citations that were possibly related to wound care. They found that only 66 of these papers specifically addressed their questions about the effectiveness of treatments for chronic venous leg ulcers.
For the study, the investigators analyzed clinical outcomes involving wound dressings, antibiotics and venous surgery.
Overall results found that dressings that used living human cells increased wound healing. Results suggested that cadexomer iodine and collagen may also increase healing, says Lazarus. "That doesn't mean that other types of dressings don't work. It just means that there is no evidence yet on which treatments work the best," says Lazarus. Support stockings, he adds, must for now remain the standard of care for treating chronic venous ulcers.
Lazarus says the review also showed evidence is inconclusive about using systemic antibiotics unless there are demonstrated signs of infection. And it is also inconclusive about such surgical treatments as radiofrequency ablation, endovenous laser treatment and sclerotherapy helped healing, although surgical correction of underlying pathology did decrease recurrence of ulcers.
"There is a critical need for well-designed research studies to compare the current minimally invasive surgical interventions to the gold standard of care, compression therapy," he says.
The Johns Hopkins researchers enlisted input from a panel of 14 experts in wound care in their review of the data.
Chronic wounds are a global problem, the researchers say. In addition to obesity and diabetes worldwide, skin ulcers occur as a consequence of neurological problems, rheumatological illnesses, blood vessel inflammation and infection. Nonhealing wounds cause not only pain, but also loss of mobility and a general decline in physical and emotional well-being. Patients can become disabled, unable to work and dependent on care from others.
Lazarus says, "The review should serve as a means to bring the wound healing community together to improve the situation." Christine Chang, M.D., M.P.H., medical officer of the Center for Outcomes and Evidence at the Agency for Healthcare Research and Quality, adds, "Our hope is that this evidence report provides patients and providers with the best information available to make well-informed decisions about care."
Explore further: Human skin wound dressings to treat cutaneous ulcers
Medical Xpress on facebook
Related Stories
Human skin wound dressings to treat cutaneous ulcers
Oct 02, 2013
Researchers from Université Laval's Faculty of Medicine and CHU de Québec have shown that it is possible to treat venous ulcers unresponsive to conventional treatment with wound dressings made from human skin grown in vitro. ...
Stockings perform better than bandages to treat leg ulcers
Dec 05, 2013
A new study has found that leg ulcers take the same time to heal when people wear compression stockings rather than traditional bandages.
New finding may help accelerate diabetic wound healing
Oct 30, 2013
University of Notre Dame researchers have, for the first time, identified the enzymes that are detrimental to diabetic wound healing and those that are beneficial to repair the wound.
Wound care meta-review draws firm conclusions from Cochrane published studies
Jul 09, 2012
Robust evidence exists for some wound care interventions, but there are still gaps in current knowledge requiring international consensus and further high-level clinical evidence, according to a paper published online by ...
'Spray-on skin' could revolutionize treatment of venous leg ulcers
Aug 02, 2012
The treatment, which consists of skin cells (keratinocytes and fibroblasts) suspended in a mixture of different types of proteins associated with blood clotting, was tested on a group of 228 patients suffering from venous ...
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