How should I manage a chronic wound that shows no signs of healing after four weeks of treatment?

For a chronic wound showing no signs of healing after four weeks of treatment, early specialist referral is recommended to ensure comprehensive assessment and advanced management options. Referral should be made to a vascular specialist, dermatologist, tissue viability nurse, or multidisciplinary foot care service depending on the wound type and patient factors NICE CKS.

Assessment should include detailed evaluation of wound size, depth, presence of necrotic tissue, infection signs, and underlying causes such as venous insufficiency, arterial disease, diabetes, or pressure damage NICE CKS,NICE NG19,NICE CG179.

Wound cleansing with tap water or saline is advised to remove debris without causing tissue damage; scrubbing should be avoided to prevent trauma NICE CKS,NICE CKS.

Debridement of necrotic or sloughy tissue is important to promote healing and can be performed by trained professionals using methods appropriate to the wound and patient tolerance, including autolytic, sharp (by specialists), enzymatic, mechanical, or biosurgical techniques NICE CKS,NICE CKS,NICE NG19,NICE CG179.

Dressing selection should aim to maintain a warm, moist wound environment, manage exudate, and address complications such as pain, infection, bleeding, or odor. Non-adherent dressings are preferred if pain is present, and antimicrobial dressings may be used if infection is suspected NICE CKS,NICE CKS,NICE CG179.

Compression therapy is essential for venous leg ulcers and should be applied by trained healthcare professionals; lack of healing after 2–4 weeks of adequate compression warrants specialist referral NICE CKS.

In diabetic foot ulcers, offloading pressure, controlling infection and ischemia, and specialist debridement are key components of management, with multidisciplinary input recommended NICE NG19.

Systemic antibiotics should only be used if there is clinical evidence of infection such as spreading cellulitis or osteomyelitis, not solely based on wound cultures NICE CKS,NICE CG179.

Nutritional assessment and optimization may support healing, especially in pressure ulcers or malnourished patients NICE CG179.

Recent literature emphasizes the importance of addressing local and systemic factors impeding healing and supports the use of advanced wound dressings tailored to the wound type and patient needs to enhance healing outcomes Uccioli et al. 2015.