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The wound care management is critical for patients with chronic ulcers, and many treatments have been proposed to facilitate the recovery. We propose to use four optical imaging technologies, polarizing visible light, 650nm red light, 940nm near infrared, and 8-12μm long wave thermal infrared imaging, to monitor the ulcer status. Detailed imaging setup is reported and the preliminary results show that several physiological features can be extracted via the multimodal imaging. More clinical data will be collected to establish sufficient statistics to determine the prognostic biomarkers. The goal of such imaging and feature extraction is to indicate whether an ulcer is developing, infected, or recovered before significantly visible change appears.

Objectives There are no well accepted animal models of chronic wounds, limiting advances in understanding and treatment of chronic ulcers. We developed a porcine wound model which combines multiple factors involved in chronic wounds to create a contaminated necrotic eschar and evaluated the debriding efficacy of a novel bromelain based enzymatic debriding agent (EscharEx). Methods Contaminated ischemic wounds were created on the flanks of domestic pigs by ‘sandwiching’ the skin between 2 ‘O’ rings (1 placed on the surface of the skin and the other underneath the skin) for 24 h prior to dermatomal excision of the necrotic eschar and its contamination with Staphylococcus aureus and Candida albicans. After confirming the development of infected eschars, additional animals were used to compare the effects of daily application of topical EscharEx or its hydrating vehicle on eschar debridement as a control. Results In all cases, application of the ‘O’ rings resulted in full thickness necrotic ecshars with invasive infections, which did not reepithelialize and sloughed off spontaneously within 14–21 days. All wounds reepithelialized within 28–42 days forming contracted scars. All EscharEx treated eschars were completely debrided within 7–9 days, while no debridement was evident in eschars treated with the control gel. Conclusions Our model simulates the initial phase of chronic wounds characterized by a contaminated necrotic eschar allowing evaluation of wound debriding agents, and that a bromelain-based debriding agent completely debrides the contaminated necrotic eschars within one week in this model.

Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.

In the coming years increasing numbers of patients with chronic ulcers and tumor wounds are to be expected, both of which are typically multifaceted diseases requiring complex and increasingly long-term ambulatory therapy. Therefore, in recent years special medical emphasis has been placed on efficacious therapies with good tolerability and also suitability regarding feasibility for outpatient treatment. Some of these methods, such as cold plasma therapy, extracorporeal shock wave therapy (ESWT), water-filtered infrared therapy (wIRA), electrostimulation (ES) and low level laser therapy (LLLT) have a good chance of success when applied as an adjuvant method in the multimodal treatment concept for patients with recalcitrant wounds. All of these methods have at least indirect antimicrobial properties which can be advantageous in cases of microbial infiltration of wounds. As for all other methods for treating recalcitrant wounds, the promising application of the aforementioned methods requires great expertise in wound healing together with a broad and continuous interdisciplinary diagnostics and therapy (wound center).

Treatment and management of chronic wounds is a large burden on the health sector and causes substantial suffering for the patients. We believe that 13 lactic acid bacteria (LAB) symbionts isolated from the honey crop of the honeybee are important players in the antimicrobial action of honey, by producing antimicrobial substances and can be used in combination with heather honey as an effective treatment in wound management. A total of 22 patients with chronic ulcers were included; culture-dependent and molecular-based (MALDI-MS and 16S rRNA gene sequencing) techniques were used to identify bacteria from chronic wounds. These clinical isolates were used for in vitro antimicrobial testing with standardised viable LAB and sterilised heather honey mixture. Twenty of the patients' wounds were polymicrobial and 42 different species were isolated. Patient isolates that were tested in vitro were inhibited by the LAB and honey combination with inhibitory zones comparable with different antibiotics. LAB and heather honey in combination presents a new topical option in chronic wound management because of the healing properties of honey, antimicrobial metabolite production from the LAB and their bactericidal effect on common chronic wound pathogens. This new treatment may be a stepping stone towards an alternative solution to antibiotics.

A bilayered artificial dermis (AD) composed of an upper silicone sheet and a lower collagen sponge has been widely applied for skin defects. After application, fibroblasts and capillaries infiltrate the AD and the collagen sponge is replaced by host dermal tissue within a few weeks. However, this delay and the high incidence of infection are concerns regarding the use of AD in the treatment of chronic ulcers. In this study, we compared the neovascularization of conventional AD seeded with autol- ogous fibroblasts (cultured dermis: CD) and collagen/gel- atin sponge (CGS), which is a novel artificial dermis capable of sustained release of basic fibroblast growth factor (bFGF) after application using laser Doppler imag- ing (LDI). CD (n = 5) and CGS impregnated with bFGF (n = 6) were applied to diabetic foot ulcers after debride- ment. Perfusion units (PUs) were measured just after, and 1, 2 and 3 weeks after application, and complete healing rates within 16 weeks were compared. No significant dif- ferences in PUs were seen 1, 2 and 3 weeks after appli- cation and in healing rates within 16 weeks between the two groups. This study suggested that CD and CGS treat- ments were effective, but there were no significant differ- ences between them in the treatment of diabetic ulcers.

Introduction and objectives Platelet-rich plasma (PRP) is used as an adjuvant in the treatment of chronic ulcers of the lower extremity and has shown particularly promising results in the case of neuropathic ulcers. There has been less research, however, into its use in venous and hypertensive ulcers. Our aim was to assess the safety and feasibility of using PRP in the treatment of chronic ulcers of the lower extremity and to evaluate its potential benefits in directed healing. Material and methods We prospectively selected 11 patients with nonischemic ulcers of the lower extremity that had been present for at least 6 weeks. PRP was injected subcutaneously into the perilesional tissue and applied topically in 4 sessions held at 1-week intervals. We assessed quality of life (SF-12 questionnaire), pain (visual analog scale), and the circumference of the ulcer before and after treatment. Results There was a predominance of women (8/11, 73%), and venous ulcers (7/11, 64%) were more common than hypertensive ulcers (4/11, 36%). The median age of the patients was 79 years and the median time since onset of the ulcer was 17 months (range, 6-108 months). We observed a significant reduction in pain (P

Diabetic patients frequently develop chronic ulcers of the lower extremities, which are a frequent cause for hospitalization and amputation, placing strain on patients, their families, and healthcare systems. Present therapies remain a challenge, with high recurrence rates. Photobiomodulation (PBM), which is the non-invasive application of light at specific wavelengths, has been shown to speed up healing of chronic wounds, including diabetic foot ulcers (DFUs). PBM produces photophysical and photochemical changes within cells without eliciting thermal damage. It has been shown to promote tissue regeneration and speed up wound repair by reducing inflammation and oxidative stress, accelerating cell migration and proliferation, and promoting extracellular matrix production and release of essential growth factors. The shortage of rigorous, well-designed clinical trials makes it challenging to assess the scientific impact of PBM on DFUs, and lack of understanding of the underlying mechanisms also hinders the conventional use of this therapy. This review gives a glimpse into diabetic wound healing and PBM, and the effects of PBM on diabetic wound healing.

Helicobacter pylori, responsible for chronic ulcers and most stomach cancers, infects half of the world&rsquo, s population. The Urea Breath Test (UBT) is one of the most accurate and reliable non-invasive methods for diagnosing active H. pylori infection. The objective was to use longitudinal, population-wide UBT data for Western Australia to look for H. pylori-related disease patterns. We collected 95,713 UBT results from 77,552 individuals for the years 2010&ndash, 2015, likely representing all of the UBT samples analysed in Western Australia. Data collected also included sex, age and residential postcode. Other data reported here were inferred via a comparison with the 2011 Australian Census using a specially written Python program. While women appear to have more H. pylori-related disease than men, there is no difference in the disease rates once women&rsquo, s higher rates of presentation for testing are taken into account. On the other hand, while the treatment strategy for H. pylori infection is generally very effective in Western Australia, failure of the first-line treatment is significantly more common in women than men. Migrants and Aboriginal Australians have elevated rates of H. pylori-related disease, while the rate for non-Aboriginal Australian-born West Australians is very low. However, no significant associations were found with other socio-economic indicators. We conclude that, for some people, H. pylori-related disease is not a solved problem.

Category: Basic Sciences/Biologics, Diabetes Introduction/Purpose: Bone infection in the foot is a challenging pathology that frequently leads to amputation and major disability. Agent identification and antimicrobial susceptibility-guided therapy is the key for a successful treatment. Standard culture methods for bone tissue have demonstrated poor sensitivity. It has been reported that synovial fluid culture sensitivity is enhanced when seeded into pediatric blood culture bottles (PBCB), however, its performance for bone infection has yet to be determined. The aim of this study was to evaluate a novel method to obtain and process infected bone tissue using PBCB and comparing it with the standard technique. Methods: Patients admitted at a single university hospital with foot osteomyelitis between 2008 and 2017 were recruited prospectively. The diagnosis was made by clinical, laboratory and imaging findings. A representative sample of infected bone tissue was obtained for each patient and simultaneously processed using the standard technique for solid tissue cultures (SCM) and a morselized bone sample that was seeded into a PBCB (BacT/ALERT® PF). Culture sensitivity and number of agents detected for each technique were compared using the McNemar and the Mann Whitney tests respectively. Results: Over the period studied, 107 patients fitted the inclusion criteria. Of these, 63 patients had a diabetic-related infection. The causative agent was identified in 60.7% using the SCM and in 97.2% using PBCB (p < 0.001). We detected a mean of 1.05 bacteria species using SCM and 1.67 using PBCB (pConclusion: In this cohort, culture technique using morselized bone tissue seeded in PBCB identified the causative agent in a significantly larger percentage than SCM. Additionally, this method identified a larger number of agents. These findings demonstrate that this novel, simple and reproducible technique for culturing bone tissue samples allows a better microbiological diagnosis, without additional intraoperative risks, compared with standard methods.

Background: The aim of this study is to evaluate the effect of hyperbaric oxygen therapy (HBOT) in healing of chronic foot ulcers in patients with type II diabetes mellitus.Methods: A case control study included 40 type II diabetic patients with chronic foot ulcers not healing for more than 4 weeks. It has been conducted at Naser Institute for Research and Treatment and Menoufia University Hospital during the period between April 2017 and September 2018. Patients with non-healing diabetic foot ulcers were referred by physicians and were also identified through a number of wound care clinics in various hospitals.Results: Most ulcers were observed in the sole and heel in both groups A and B (n=14 and 9 respectively), while the rest of ulcers were distributed in other areas of the foot, namely the medial and lateral malleoli, dorsum and toes. On comparing the wound related complications developing during the treatment period, no statistically significant difference was found between both groups (p=0.147). As regards Wagner's grade, 7 patients (17.5%) had grade 4 ulcers, 18 patients (45%) had grade 3 ulcers and 15 patients (37.5%) had grade 2 ulcers, showing no statistically significant difference between both groups before treatment (p=0.259).Conclusions: HBOT is a useful adjunct in the treatment of non-healing diabetic foot ulcers, and that the cost of HBOT itself will be reduced as it becomes more widely available in the clinical setting, and as further knowledge of its other advantages, such as limited side effects and relative safety, become more widely appreciated.

Venous ulcers are a common disease caused by circulatory insufficiency, having as characteristics slow healing and therefore a difficult treatment. Consequently, this disease has a high impact at personal, professional and social levels, representing large costs for both patients and healthcare system. The aim of the present pilot study was to evaluate the effectiveness of an alternative treatment for this specific type of wound, based on the use of autologous platelet-rich plasma gel (PRP) combined with biocompatible porous membranes produced with the polysaccharides chitosan (C) and alginate (A). The applicability, security and healing efficacy of this treatment was evaluated in four patients suffering from venous ulcers with an at least 6-month of evolution that did not heal after conventional treatments. The clinical evolution analysis during the treatment was performed by periodic measurement of the lesions area for an average of 5.4 months. The results attained showed that the use of this treatment led to completed reduction in the ulcers area as well as to pain decrease. Hence, the combination between autologous PRP gel and chitosan-alginate (CA) porous membranes could be a useful alternative to treat chronic skin ulcers in humans.

Chronic wounds are an expression of underlying complex pathologies and have a high incidence. Skin substitutes may represent an alternative approach to treat chronic ulcers. The aim of this retrospective observational study was to evaluate the wound reduction using skin substitutes based on allogenic fibroblasts or keratinocytes in 30 patients not responding to conventional therapy. Wound bed was prepared, then keratinocytes on Laserskin(®) to treat superficial wounds or fibroblasts on Hyalograft 3D(R) to treat deep leg ulcers were applied, and finally wounds were treated with a secondary dressing composed of nanocrystalline silver. Once a week constructs were removed and new bioengineered products were applied, as well as nanocrystalline silver medication. In none of the cases under examination did any complications arise relating to the treatment. We also achieved a reduction in wound dimension and exudates, and an increase in wound bed score. Postoperative assessment shows a degree of healing that is statistically higher in the group treated with keratinocytes as compared with the fibroblast group. This retrospective study improves our understanding and defines the clinical indications for the various uses of the two types of skin substitutes.

Significance: Electrical stimulation (ES) is a therapeutic intervention that may help specialists facilitate wound healing rates. The purpose of this section is to compile the available animal research regarding the effectiveness of ES on the injury potential, healing rate, cellular and molecular proliferation, mechanical properties, and survival rate of skin flaps. Recent Advances: Regardless of the type of ES current and polarity used, most of the animal experimental evidence suggests that application of ES can facilitate wound healing. However, treatment time should be sufficiently long to attain good mechanical strength of regenerated tissue, because tensile strength is not consistent with augmented collagen deposition. ES improves the survival rate and skin blood flow of animal flaps, but clinical studies are needed to substantiate the findings from these animal experiments. Critical Issues: Impaired or delayed healing is a major clinical problem that can lead to wound chronicity. ES with various strategies has been used to facilitate the healing process, but many aspects remain controversial. Despite much research, no consensus exists regarding the detailed effects of ES on wound healing. Nevertheless, ES has been approved by the Center for Medicare and Medicine Services for reimbursement of the treatment of some chronic ulcers. Future Directions: Exogenous ES may promote the directional migration of cells and signaling molecules via electrotaxis; however, its underlying mechanism is still poorly understood. Future studies that further elucidate the mechanisms regulating electrotaxis will be necessary to optimize the use of ES in different wound states.

There has been a recent spurt in application of platelet-rich plasma (PRP) in dermatology and aesthetic medicine. However, the details regarding use of PRP in various dermatological indications ranging from hair restoration to chronic ulcers are dispersed in literature, herein we have tried to focus all under one heading. Overall, PRP seems to be a promising therapeutic modality but the level of evidence as of now, from the available published data is low. This review will also stimulate readers to carry out well designed, larger population based trials, so as to validate its use in dermatology practice.

Background: Malignancies that arise from scars are referred to as Marjolin ulcers. The association between chronic ulcers and squamous cell carcinomas is well established. There are many case reports in the literature regarding Marjolin ulcer; however, randomized controlled clinical series that describe a thorough evaluation of these patients are rarely encountered. Objective: We present our clinic's 15 years of experience with 34 Marjolin ulcer patients and their treatment modalities. Methods: A retrospective analysis of 302 squamous cell carcinoma patients who were treated in the plastic surgery department between 1997 and 2011 was performed. Thirty-four (10.3%) histopathologically confirmed Marjolin ulcer patients were further analyzed. Results: Although burn scars represented 77% of the patients in the present study, unstable scars that formed following traffic accidents and fistula tracts are also among the commonly encountered etiologies. Based on our observations, squamous cell carcinoma, in addition to malignant melanoma and verrucous carcinoma, is frequently observed in cases of Marjolin ulcers. Conclusion: If the goal is to eradicate this clinical entity, all of the chronic ulcers that fail to heal require biopsies at regular intervals. Large excisional margins, lymphadenectomies in cases of palpable lymph nodes, and a well-defined oncology protocol are all essential in treating Marjolin ulcer.

It is important for caregivers and patients to know which wounds are at risk of prolonged wound healing to enable timely communication and treatment. Available prognostic models predict wound healing in chronic ulcers, but not in acute wounds, that is, originating after trauma or surgery. We developed a model to detect which factors can predict (prolonged) healing of complex acute wounds in patients treated in a large wound expertise centre (WEC). Using Cox and linear regression analyses, we determined which patient- and wound-related characteristics best predict time to complete wound healing and derived a prediction formula to estimate how long this may take. We selected 563 patients with acute wounds, documented in the WEC registry between 2007 and 2012. Wounds had existed for a median of 19 days (range 6-46 days). The majority of these were located on the leg (52%). Five significant independent predictors of prolonged wound healing were identified: wound location on the trunk [hazard ratio (HR) 0·565, 95% confidence interval (CI) 0·405-0·788; P = 0·001], wound infection (HR 0·728, 95% CI 0·534-0·991; P = 0·044), wound size (HR 0·993, 95% CI 0·988-0·997; P = 0·001), wound duration (HR 0·998, 95% CI 0·996-0·999; P = 0·005) and patient's age (HR 1·009, 95% CI 1·001-1·018; P = 0·020), but not diabetes. Awareness of the five factors predicting the healing of complex acute wounds, particularly wound infection and location on the trunk, may help caregivers to predict wound healing time and to detect, refer and focus on patients who need additional attention.

Epidermolysis bullosa (EB), a group of heritable skin fragility disorders, is characterized by blistering, erosions, and chronic ulcers of the skin and mucous membranes, associated with extracutaneous manifestations with considerable morbidity and mortality. Mutations in as many as 18 distinct genes are known to underlie different EB-like disorders. The progress in molecular genetics of this group of disorders has improved the accuracy of diagnostic subclassification and prognostication, and has formed the basis for prenatal and preimplantation genetic diagnosis. Quite recently, inroads have also been made toward the treatment of EB by gene therapy, protein replacement, and cell-based approaches. DEBRA International, the premiere patient-advocacy organization, sponsored the Triennial Research Conference in November 2012 in Marbella, Spain*. This Conference Report summarizes the presentations and discussions of this meeting, with emphasis on the most recent progress in EB research over the past 3 years.

Chronic ulcers ((arterio)venous, decubitus, or postoperative) have no tendency to heal within a period of at least 3 months despite optimal therapy according to internationally accepted guidelines. This retrospective study evaluates the safety and efficacy of an autologous, dermal-epidermal skin substitute (SS) for treating ulcers of various origins. Ulcers were treated within 7 Dutch centers over 5 years. Sixty-six ulcers (size: 0.75-150 cm²; duration: 0.25-32 years) with a follow-up time of 24 weeks after a single-skin substitute application were assessed. Wound-bed preparation consisted of vacuum-assisted-closure-therapy (5 days, hospitalized) or application of acellular dermis (5-7 days, outpatient). Time to heal, adverse events, and recurrence 1 year after complete healing were recorded. Complete ulcer healing occurred in 36 of 66 ulcers (55%) at 24 weeks. At that time point, a further 29% of ulcers showed decrease in ulcer size between 50 and 99%. No difference was observed between the hospitalized vs. outpatient treatment with complete healing. There were 32 of 36 healed ulcers that were available for follow-up 1 year after complete closure, of which 27 (84%) were still closed. Only two minor/moderate possibly related adverse events were recorded. This retrospective analysis shows that SS provides a safe and successful treatment for particularly chronic ulcers of various origins.

Human amnion/chorion tissue derived from the placenta is rich in cytokines and growth factors known to promote wound healing; however, preservation of the biological activities of therapeutic allografts during processing remains a challenge. In this study, PURION® (MiMedx, Marietta, GA) processed dehydrated human amnion/chorion tissue allografts (dHACM, EpiFix®, MiMedx) were evaluated for the presence of growth factors, interleukins (ILs) and tissue inhibitors of metalloproteinases (TIMPs). Enzyme-linked immunosorbent assays (ELISA) were performed on samples of dHACM and showed quantifiable levels of the following growth factors: platelet-derived growth factor-AA (PDGF-AA), PDGF-BB, transforming growth factor α (TGFα), TGFβ1, basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), placental growth factor (PLGF) and granulocyte colony-stimulating factor (GCSF). The ELISA assays also confirmed the presence of IL-4, 6, 8 and 10, and TIMP 1, 2 and 4. Moreover, the relative elution of growth factors into saline from the allograft ranged from 4% to 62%, indicating that there are bound and unbound fractions of these compounds within the allograft. dHACM retained biological activities that cause human dermal fibroblast proliferation and migration of human mesenchymal stem cells (MSCs) in vitro. An in vivo mouse model showed that dHACM when tested in a skin flap model caused mesenchymal progenitor cell recruitment to the site of implantation. The results from both the in vitro and in vivo experiments clearly established that dHACM contains one or more soluble factors capable of stimulating MSC migration and recruitment. In summary, PURION® processed dHACM retains its biological activities related to wound healing, including the potential to positively affect four distinct and pivotal physiological processes intimately involved in wound healing: cell proliferation, inflammation, metalloproteinase activity and recruitment of progenitor cells. This suggests a paracrine mechanism of action for dHACM when used for wound healing applications.

Malignant degeneration of wounds is rare and often misdiagnosed. Delay in diagnosis may result in a worse prognosis. The aim of this study is to determine the number of skin cancers associated with chronic skin ulcers in our facility over a period of 10 years. Between January 2002 and December 2012, a total of about 1000 patients had consulted with us for chronic wounds, especially of vascular, diabetic and traumatic origin and pressure ulcers. Thirteen skin cancers had been detected: seven squamous cell and five basal cell carcinomas and one melanoma. We highlight how important it is to be aware of the signs suggesting a malignant change and the importance of biopsy at regular intervals during the life cycle of any chronic wound.

The aim of this study was to evaluate the efficacy of the treatment of chronic ulcers with unfocused shock waves. Between March 2009 and February 2012 we studied a group of 124 patients, aged between 28 and 80 years, with serious wounds arisen over three months and who met the inclusion criteria for treatment. The patients were randomly divided into groups A and B, both treated with unfocused ESWT but with an average energy density for each impulse equal to 0.10 mJ/mm 2 in group A (total energy equal to 1.7 mJ for each shot) and an average energy density for each impulse equal to 0.04 mJ/mm 2 in group B (total energy equal to 3.3 mJ for each shot). The pulses were administered at a frequency of 4 Hz in both groups. Wounds were classified according to: location, width, length, percentage of granulation tissue, necrotic tissue, fibrous tissue, presence of bacterial exudation and pain (assessed by VAS). Their evolution was monitored by photo capture. The patients were treated with a frequency of 1 session every 7 days for 7 weeks. During the treatment period, the possible occurrence of side effects was monitored. Before treatment the wounds in group A had an average area equal to 3.85 cm 2 and the average value of the VAS pain scale was equal to 5.8 (range 2–9); the wounds in group B had an average area equal to 3.4 cm 2 and the average value of the VAS pain scale was equal to 5.7 (range 3–9). At the end of the treatment protocol the mean area in group A decreased by 80% (final mean area 0.93 cm 2 ), and the average pain on VAS scale dropped by 79%; the mean area in group B decreased by 67% (final mean area 1.2 cm 2 ) and the average score on VAS scale dropped by 48%. None of the treated patients experienced adverse reactions to treatment. None of the treated wounds developed infection during treatment. In conclusion, shock waves can act on difficult wounds, stimulating the reparative physiological process; therefore it represents an effective and safe procedure to accelerate the healing process, reducing the operating costs and avoiding more complex interventions.

Chronic wounds affect over 4 million individuals and pose a significant burden to the US healthcare system. Diabetes, venous stasis, radiation or paralysis are common risk factors for chronic wounds. Unfortunately, the current standard of care (SOC) has a high relapse rate and these wounds continue to adversely affect patients' quality of life. Fortunately, advances in tissue engineering have allowed for the development of cell-based wound dressings that promote wound healing by improving cell migration and differentiation. As the available options continue to increase in quantity and quality, physicians should have a user-friendly guide to reference when deciding which dressing to use. The objective of this review is to identify the currently available biologic dressings, describe their indications, and provide a framework for integration into clinical practice. This review included 53 studies consisting of prospective and retrospective cohorts as well as several randomized control trials. Three general categories of cell-based biologic dressings were identified and nine brands were included. Cell-based biologic dressings have shown efficacy in a broad range of scenarios, and studies examining their efficacy have improved our understanding of the pathophysiology of chronic wounds. Amniotic and placental membranes have the widest scope and can be used to treat all subtypes of chronic wounds. Human skin allografts and bioengineered skin substitutes can be used for chronic ulcers but generally require a vascularized wound bed. Autologous platelet rich plasma (PRP) has shown promise in venous stasis ulcers and decubitus ulcers that have failed conventional treatment. Overall, more research is necessary to determine if these novel therapeutic options will change the current SOC, but current studies demonstrate encouraging results in the treatment of chronic wounds.

Many vital processes of wound healing are oxygen-dependent, and therefore oxygen-based therapeutic strategies for damaged tissues should be based on an understanding of the area with anoxia, hypoxia, and normoxia. The authors discuss hyperbaric oxygen (HBO) for wound healing and its advantages, topical oxygen and topical hyperbaric oxygen (THBO), and transdermal continuous oxygen therapy (TCOT). The use of oxygen in the treatment of different chronic ulcers such as diabetic foot ulcers is very effective. Its application for patients with pressure ulcers requires further studies, although all the few studies on the effect of oxygen in the treatment of pressure ulcers indicated that this method will accelerate the healing process of pressure ulcers.

Con el paso de los años la esperanza de vida ha ido en incremento, provocando un envejecimiento de la población, y consigo mayor incidencia de enfermedades crónicas, aumentando así la prevalencia de ulceras crónicas cutáneas. Las úlceras crónicas cutáneas (UCC) son un problema mundial de salud, que afecta gran parte de población de todas las edades, y suponen uno de los principales recursos tanto económicos como humanos. Entre sus repercusiones se halla mayores estancias hospitalarias, así como un incremento de la morbimortalidad del paciente. El cuidado de las UCC está siendo un foco de interés por parte de enfermería, donde se investiga nuevos conocimientos clínicos para fundamentar su práctica. En este trabajo se analiza la efectividad de una nueva modalidad terapéutica: Plasma Rico en Plaquetas (PRP) que contiene factores de crecimiento que estimulan la reparación y / o la regeneración de diversos tejidos. La terapia con PRP, se propone como una alternativa de tratamiento, sobre todo en casos de úlceras cutáneas crónicas donde los tratamientos convencionales resulten improductivos. Over the years, life expectancy has been increasing, causing an aging population, and leading to a higher incidence of chronic diseases; thus increasing the prevalence of chronic skin ulcers. Chronic Skin Ulcers (CSU) are a global health disorder that affects a large part of the population of all ages requiring great deal of economic and human resources. Among its repercussions, longer hospital stays, as well as an increase in patient morbidity and mortality can be found between others. The treatment of the CSU is a focus of interest in the nursing field, where new clinical knowledge is being researched to serve as base during clinical practice. In this study the effectiveness of a new therapeutic modality is analysed: Platelet-rich plasma (PRP), rich in growth factors that stimulate the repair and/ or regeneration of various tissues. The therapy with PRP is proposed as an alternative treatment, especially in cases of chronic skin ulcers where conventional treatments are unproductive. Grado en Enfermería

The purpose of this uncontrolled study was to evaluate the clinical effectiveness of ReCell(®) system in the treatment of chronic ulcers. From October 2011 to July 2012, 20 patients, 8 men and 12 women with a mean age of 70 years, with chronic ulcers of different aetiology that were unresponsive to conventional therapies were recruited and treated using the ReCell(®) system. Patient pain rate, scar aesthetics and patient satisfaction were assessed using a Visual Analogue Scale, Manchester Scar Scale and the Rosenberg Self-Esteem Scale, respectively. Complete ulcer healing, defined as 100% reepithelialisation was observed between 40 and 60 days in 14 patients (70%) depending on the type of ulcer and comorbidity. At day 60 postprocedure, 80% reepithelialisation was present in five patients (25%), while one patient with concomitant psoriasis had 50% reepithelialisation. Pain scores improved by day 7 postprocedure. The function and aesthetics of the ReCell-treated patients were good. It is concluded that the ReCell technique may have provided the regenerative tissue stimulation necessary for the rapid healing of chronic ulcers, including those not responsive to more traditional methods.

Thromboangiitis obliterans (TAO) or Buerger's disease is associated with both distal ulcers in the extremities and the possibility of amputation. The only treatment that has been shown to be effective in TAO is complete abstention from smoking. In spite of this, the disease progresses in up to 30 percent of cases and finally results in limb amputation. Only a few pharmacological and surgical options are available to date to improve healing ulcers in TAO. The efficacy of prostaglandin analogues is controversial. This paper summarizes the current evidence for medical treatment with bosentan in chronic ulcers in TAO patients. These available data up to date allow us to conclude that the beneficial effects of bosentan on improving endothelial function, inflammatory processes, and selective vasodilatation of damaged vessels result in a clinical enhancement regarding healing and preventive digital ulcers in such patients. In any case, these promising findings have to be confirmed with larger randomised trials.

OBJETIVO: Avaliar Qualidade de Vida e autoestima de pacientes com úlcera crônica. MÉTODOS: Estudo analítico e transversal. Avaliaram-se, por seis meses, 150 pacientes, sendo 75 portadores de úlcera crônica. Foram incluídos pacientes dos dois gêneros, com mais de 18 anos, internados e atendidos em ambulatório, e com cognição preservada. RESULTADOS: Dentre os pacientes com úlcera, predominou o gênero masculino (p

Introduction: Chronic wounds are a major, functionally-limiting medical problem impairing quality of life for millions of people each year. Extracorporeal shock wave therapy (ESWT) may accelerate and improve wound repair. Some authors investigated the optimal session number of ESWT in rat models. Aim: Purpose of this study was to verify the effectiveness of two temporal modalities of ESWT administration in chronic ulcers. Materials and methods: 84 subjects with chronic ulcers were enrolled. They were divided into 2 groups according to the absence or presence of associated lymphedema. Each group was divided with a stratified randomization into two subgroups receiving the same total energy of ESWT (2640 Mj) but with different temporal modality during the week. Results: Our results show, at the end of the 5 weeks treatment, a statistically significant reductionof wounds area and pain in the groups which received the ESWT fractioned in 2 weekly steps (2 x 1320 Mj) and reduction of limb circumference in subjects with lymphedema. Discussion: By fractioning energy in 2 weekly steps probably there is greater regenerative activation. This type of application cannot be generalized, it could be a best choice in diabetic ulcers, even in the presence of lymphedema. The kwnoledge relative to the efficacy of ESWT in treatment of chronic wounds has had over the years a consolidation process, instead the modulation of time treatment can be considered as a new borders for clinical studies.

Background Chronic ulcers are a common problem, with chronic diabetic and venous ulcers forming a large proportion. This is the first case-control study to assess the effect of topical timolol on healing of chronic venous and chronic diabetic ulcers. Methods The study included 60 patients with chronic leg ulcers. The ulcers in the study group (n = 30) were treated with topical 0.5% timolol maleate solution along with antibiotics and dressings; those in the control group (n = 30) received only antibiotics and dressings. The ulcers in both groups were evaluated at 4, 8, and 12 weeks, and ulcer area was calculated. Healing rate was assessed by calculating the percentage change in ulcer area. Results The mean percentage change in area at 4, 8, and 12 weeks was 25.29, 43.77, and 61.79 in the study group and 11.92, 22.40, and 29.62 in the control group. Analysis showed that there were significant differences in percentage change in ulcer of the study and control groups at all three time points and also within the groups. The type of ulcer, history of alcohol consumption, and smoking did not affect the healing rates in the study group. Conclusions Topical β-blockade using timolol improves the healing of chronic leg ulcers.

Marjolin’s ulcer is a rare, aggressive skin cancer developing in scar tissue, chronic ulcers and areas affected by inflammations. Its incidence is estimated to range from 1% to 2% of all burn scars. It most frequently takes the form of squamous cell carcinoma which sometimes is diagnosed during examination of lesions developing in scars and hard-to-heal chronic wounds (pressure sores, leg ulcers). Therapeutic management of Marjolin’s ulcer requires well-designed treatment plan to ensure optimal medical care and good quality of life for the patient. The high risk of metastases and damage to the structure of vitally important organs determines the need for early diagnosis and prompt surgical intervention with supplementary therapy. The purpose of the study was to examine etiopathogenesis of Marjolin’s ulcer and principles of its treatment. The authors focused on the aspect of malignant degeneration in chronic wounds (leg ulcers, pressure sores) as a very rare, aggressive form of Marjolin’s ulcer. A review of the available literature on the issue of Marjolin ulcers was conducted using the key words; Marjolin ulcers, pressure sore, chronic wound. Malignant degeneration in chronic wounds is a very rare aggressive form of Marjolin ulcer. Increased oncological alertness should be displayed by nursing and medical personnel taking care of patients with chronic wounds.

Objective: Hyaluronic acid (HA) and its derivatives are used for chronic wounds, but evidence of their effectiveness remains unclear. The aim of this study was to provide more updated evidence for the effectiveness of HA (or its derivatives) compared with placebo or other agents for promoting healing in chronic wounds. Method: The Cochrane Central Register of Controlled Trials, MEDLINE via Ovid Online, CINAHL and the EMBASE via EBSCO host databases were searched. Drug companies and experts in wounds were also contacted. Randomised controlled trials of HA (or its derivatives) compared with control were eligible for inclusion. Results: We identified nine randomised controlled trials involving 865 participants with chronic wounds were included in the review. The reporting for mixed arterial and venous ulcers seems to be better quality than that for venous leg ulcers (VLUs) and diabetic foot ulcers (DFUs). Studies provided little evidence regarding the claimed effects of HA or its derivaties on healing of chronic wounds. However, there is some evidence on their effectiveness for reducing pain intensity for mixed arterial and venous ulcers, which involved 255 patients (MD=−6.78 [95% CI: –11.10 to –2.46]). Conclusion: Evidence to guide decisions regarding the use of HA or its derivatives to promote wound healing is still limited. More good-quality randomised controlled trials are warranted.

Primjena suportivnih obloga za rane važan je čimbenik za uspješan rezultat suvremenog liječenja kroničnog vrijeda. Pravilan odabir obloge ključan je za brži i kvalitetniji, te u konačnici i isplativiji ishod liječenja. S obzirom na izrazito veliki broj generičkih vrsta i njihovih varijanti, kao glavni element za pravilan odabir obloge najvažnije je poznavati mehanizme djelovanja i kliničke dokaze o učinkovitosti obloge, na što više lokalnih faktora u vrijedu koji odgađaju i otežavaju cijeljenje vrijeda. Pojava suportivne obloge koja ima svojstva djelovanja na klinički identificirana tri ključna lokalna faktora, koji u najvećoj mjeri otežavaju cijeljenje vrijeda, a to su eksudat, infekcija i biofi lm, dobiven je značajan iskorak u stvaranju optimalnih uvjeta za brže cijeljenje kroničnog vrijeda. Nove obloge, koje objedinjavaju hidrofi ber tehnologiju i Ag+ tehnologiju, omogućuju učinkovitu antimikrobnu kontrolu i istodobno preveniraju ponovno formiranje bofi lma, najtvrdokornijeg čimbenika koji podržava kroničnu upalnu reakciju i time značajno odgađa cijeljenje vrijeda., Application of supportive wound dressing is an important segment for successful result of modern treatment of chronic ulcers. The right choice of dressing is the key to faster, better, and ultimately more cost-effective treatment outcome. Due to the extremely large number of generic types and variants, the main element for proper dressing selection is to know the mechanisms of action and clinical evidence of the effectiveness because of many local factors that delay ulcer healing. The advent of wound dressing that is efficient at the three clinically identified key local factors that largely impede the healing of ulcers, i.e. exudate, infection and biofilm, has made a significant step forward in the creation of optimal conditions for faster healing of chronic ulcers. The complexity of the effects of new technologies, which integrate hidrofi ber technology and Ag + technology, provides effective antimicrobial control while at the same time preventing biofilm reformation.

Današnje spoznaje i dokazi o biofilmu, interakcije između različitih bakterijskih vrsta, te ukupna virulencija mikroba imaju utjecaj na odgođeno cijeljenje rane i razvoj infekcije. Kvalitetan opis kliničkih simptoma uz suvremena saznanja o mikrobima rane odličan su vodič za kreiranje strategije liječenja kroničnog vrijeda. Zbog sve boljeg razumijevanja uloge biofilma u produljenju vremena liječenja i znanja o sustavu i strukturi biofi lma istraživači su razvili Ag+tehnologiju. Ta tehnologija ima jake sinergističke učinke između općenite antimikrobne aktivnosti ionskog srebra i specifi čnih spojeva koji pomažu u učinkovitosti ometanja i uklanjanja biofilma., Current knowledge and proofs of biofilm, interactions between various bacterial species and overall virulence of microbes play a role in delayed healing of wound and development of infection. High quality description of clinical symptoms and current knowledge of microbes provide an excellent guideline for creating the strategy of wound treatment. Owing to better understanding of the role of biofilm in prolongation of healing time and facts about biofilm system and structure, scientists have developed the Ag+ technology. This technology has strong synergistic effects of the general and antimicrobial activity of ionic silver and specific compounds, which have proved efficient in biofilm obstruction and removal.

Introduction Patients with chronic ulcers have physical, social, and psychological changes that directly affect their quality of life. Objectives To evaluate the quality of life and analyze the association between personal and health characteristics in patient quality of life for those with chronic ulcers. Method A cross-sectional study, nonprobabilistic. The questionnaire to evaluate personal and health characteristics and the Ferrans and Power Quality of Life Index–Wound Version were used for the data collection. The sample consisted of 200 patients with chronic ulcers of several etiologies (venous ulcers, pressure ulcers, diabetic ulcers, and mixed) recruited at the basic health units in two cities in the South of Minas Gerais, Brazil. Results Overall, the study found that their quality of life was rated as good. There was a positive correlation between the different ages ( P = 0.0165), number of children ( P = 0.0083), and practice of religion ( P = 0.0394) with quality of life.

Foreign bodies are occasionally seen by family physicians. Plantar foreign bodies in particular pose a special challenge because they involve weight-bearing regions that are difficult to access. If left undetected long enough, these may lead to hospitalization, surgery, or even longstanding complications such as tumors, contractures, infections, and chronic ulcers. Dermoscopy of the cutaneous surface allows early detection of indwelling foreign bodies with a far greater degree of accuracy than with the naked eye. Furthermore, use of a polarized dermatoscope provides ideal illumination and 3-dimensional visualization of the involved site, and facilitates extraction of the penetrating object. This technique could be used for similar injuries involving other body surfaces.

Leprae, which is a forgotten infectious disease, presents with primary findings of skin lesions and peripheral nerve lesions. Neuropathic ulcers are frequently found and may cause deformities, particularly in the extremities. It should not be forgotten that malignant tumors seen on the floor of chronic ulcers can also be seen on the floor of neuropathic ulcers depending on leprae. In our study, a 61-year-old male patient with an ulcerated and unhealed lesion in the volar surface of the second finger of his right hand that existed for approximately 6 months is presented. Although leprae is not common these days, early defect repairs will prevent osteomyelitis and sequelae of amputation, depending on the malignancy in these patients. © 2016 Turkish Society of Plastic Reconstructive, and Aesthetic Surgery.

Chronic foot and leg ulcers are a serious medical problem requiring long-term treatment, often complicated by amputations and long-term disability. Balneological and physical methods complement the treatment of those patients who have completed optimal vascular and surgical treatment. The most common causes of ulcers are atherosclerosis, diabetes and venous insufficiency. In the thermal treatment we can effectively improve the treatment results using natural gases such as carbon dioxide and ozone, physical methods, kinesitherapy and treatment of diseases causing ulceration. The aim of our research was to evaluate the results of treatment of ulcers in patients with diabetes, atherosclerosis and venous insufficiency in the thermal center conditions. The material is a group of 46 patients with ulcers, in this group there were 18 women, the mean age was 63.5 years ± 9.8. The number of patients with diabetic, atherosclerotic and venous insufficiency type of ulcer was 56.5 and 17.4 had grade II, and another 3/4/5 respectively 23.2 / 14.2%. Treatment in addition to standard surgical care and antibiotic therapy included ozone-therapy, carbodioxide-therapy, kinesitherapy and physical treatments (pulsed magnetic field and laser therapy). The average duration of treatment was 46 days. The results of the treatment were assessed on a four-level scale: I complete recovery, II improvement with chance to full recovery, III minor improvement, and IV lack of the improvement. In addition, patients were evaluated for changes in metabolic control of diabetes, and lipid parameters were also evaluated. Full recovery was achieved in 32.9 improvement in the prognosis of recovery, small improvement in 24,6 of patients. In the subjective evaluation questionnaire, all patients reported improvement - generally reducing pain and swelling. In additional studies, the statistically significant level of total cholesterol, LDL-cholesterol, triglycerides and fibrinogen decreased. Based on the obtained results, we conclude that thermal treatment is a valuable method that improves treatment outcomes in patients with vascular and diabetic ulcers. For the full assessment of the method, it is necessary to plan further randomized trials comparing the thermal treatment to other reference methods of treatment of chronic foot and culves ulcers.

Dusta vranas (Chronic ulcers) are a frequ ently encountered problem in present era produced commonly as a complication of trauma or pathologic insult and it causes long - term agony to th e patient. The issue of chronic ulcers management with Ayurvedic panacea is one of the major areas of research an d has come under increased scrutiny. In the present study Nimbaadya Taila is selected which is cited by Acharya Bhela in the co ntext of vrana. It contains Nimba pallava, Aamra pallava, Aamalaki pallava, Bala, Yastimadhu and Gomaya rasa. These drugs posses s vrana shodhana and ropana properties. It was used topically in all types of chronic wounds once daily for 30 days or till the healing of the wound whichever is earlier. It is a single blind clinical study; where 20 patients were selected and divided into two groups of 10 patients each. Trial group patient’s ulcers were treated with dressing having Nimbaadya T aila. Control group patients ulcers were treated with Hydrogen peroxide and Eusol and dry gauze bandaging. It reduces pain, burning sensation, itchin g, decreases discharge, edema and helps in gradual improvement in floor and granulation tissue as compared to control group. Hence it can be speculated that Nimbaadya taila possess sufficient efficacy in vrana shodhana and vrana ropana without producing an y adverse effects.

A total of 263 angiosperm species under 210 genera and 79 families have been recorded from Dhamrai Upazila of Dhaka district. Of these, Magnoliopsida is represented by 200 species under 154 genera and 62 families while Liliopsida is represented by 63 species under 56 genera and 17 families. Asteraceae is the largest family in Magnoliopsida represented by 17 species, and Poaceae is the largest family in Liliopsida represented by 20 species. Habit analysis shows that herbs, shrubs and trees are represented by 166, 23 and 74 species, respectively. Sixty two medicinal plants have been documented with their uses for the cure of more than 30 diseases, and some of these are diabetes, jaundice, diarrhoea, dysentery, spleen and liver complaints, chronic ulcers, bronchitis, rheumatism, irregular menstruation, piles, urinary problems and heart diseases. Threats to the species have also been assessed and appropriate conservation measures suggested. DOI: http://dx.doi.org/10.3329/bjb.v41i1.11085 Bangladesh J. Bot. 41(1): 71-85, 2012 (June)

The purpose of this prospective experimental and clinical study is to evaluate the effectiveness of the intralesional injection of platelet-rich plasma (PRP), in the management of non-healing chronic wounds. Skin defects were created in the ears of 20 white New Zealand rabbits. In the study group, autologous PRP was injected intralesionally. The control group was treated conservatively. Nineteen out of 20 cases of the study group healed within a mean time of 24·9 days. In the control group, seven defects healed within a mean period of 26·7 days, seven ulcers did not heal at day 28 and in six cases a full thickness ear defect was recorded. For a 3-year period, 26 patients with chronic ulcers underwent surgical debridement and intralesional injection of PRP. A histological study was performed before and 7 days after PRP injection. Ten patients healed within a mean period of 7 weeks. In 16 cases, PRP prepared the wound bed for the final and simpler reconstructive procedure. Intralesional injection is a newly described method for application of PRP and represents an effective therapeutic option when dealing with non-healing wounds.

Over the last decade, maggot debridement therapy (MDT) has been recognized by many clinicians as a potential adjunct to conventional therapy, and many patients with non healing, chronic ulcers have been treated. Numerous case reports and case series have described the successful use of MDT in a variety of ulcers. However, comparative clinical trials and in particular randomized controlled trials investigating the efficacy of MDT are sparse. A systematic search in the literature showed three randomized clinical trials and five non randomized studies evaluating the efficacy of sterile Lucilia sericata applied on ulcers with various aetiologies. Of these, seven studies had debridement and/or healing as an outcome variable. When evaluating maggots as debriding agents, the studies report MDT as being significantly more effective than hydrogel or a mixture of conventional therapy modalities, including hydrocolloid, hydrogel and saline moistened gauze. However, the design of the studies was suboptimal, with important differences in the use of other therapies, such as compression, that may influence both debridement and healing between the compared groups, as well as inappropriately short follow-up times. The quality of the studies therefore makes it difficult to conclude that MDT shortens healing time. The poor quality of the data used for evaluating the efficacy of MDT highlights the need for more and better designed investigations.

Chronic ulceration of the leg represents a major, underestimated problem of modern health care, involving physical and cosmetic impairment and social stigma along with high community costs for patients' treatment. The increasing prevalence of chronic ulcers, currently reported to be as much as 0.3% in the general population, should stimulate identification of more efficacious therapeutic approaches to achieve complete healing. The strategies of regenerative medicine based on small molecules, biomimetic scaffolds, gene or cell therapy, and electromagnetic field manipulation represent some of the modern therapeutic alternatives for wound healing. Here we review in an integrated, interdisciplinary approach the modern cellular and molecular mechanistic concepts regarding the involvement of extremely low frequency electromagnetic fields (ELF-EMF) in the complex process of tissue repair, with particular focus on chronic wounds. The data analysis supports three main effects of electromagnetic fields on the wound healing pathways: 1) an antiinflammatory effect, by modulation of cytokine profile that induces the transition of the healing process from a chronic pro-inflammatory to an anti-inflammatory state; 2) a neo-angiogenic effect, by increased endothelial cells proliferation and tubulization and production of fibroblast growth factor (FGF)-2; and 3) a reepithelialization effect, by stimulation of collagen formation. We believe that utilization of ELF-EMF in larger clinical trials designed to optimize these functional parameters would facilitate a better understanding of ELFEMF- induced healing mechanisms and lead to improved therapeutic outcomes for this disabling condition which is often totally resistant to treatment.

Regenerative Medicine is an emerging field that combines basic research and clinical observations in order to identify the elements required to replace damaged tissues and organs in vivo and to stimulate the body's intrinsic regenerative capacity. Great benefits are expected in this field as researchers take advantage of the potential regenerative properties of both embryonic and adult stem cells, and more recently, of induced pluripotent stem cells. Bioengineered skin emerged mainly in response to a critical need for early permanent coverage of extensive burns. Later this technology was also applied to the treatment of chronic ulcers. Our group has established a humanized mouse model of skin grafting that involves the use of bioengineered human skin in immunodeficient mice. This model is suitable for the study of physiologic and pathologic cutaneous processes and the evaluation of treatment strategies for skin diseases, including protocols for gene and cell therapy and tissue engineering. Our work has been funded by the Spanish Department of Science and Innovation (SAF2007-61019 and SAF 2010-16976), by the Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), and by the Ministry of Health (Advanced Therapies Plan, TRA 0160).

Leg ulcers are the commonest cutaneous manifestation of sickle cell disease, typically running an indolent course. They commonly occur around the distal third of the leg, an area notorious for difficult-to-heal wounds. The vacuum-assisted closure (VAC) device has been found efficacious in the management of chronic ulcers of varying aetiologies. However, reports on its use in the management of sickle cell ulcers are at best scanty. The purpose of this study was to determine the usefulness of VAC therapy in the management of sickle cell ulcers. Over an 18-month period, consecutive patients presenting at the plastic surgery centre of the Imo State University Teaching Hospital were managed using VAC therapy and subsequent skin grafting for extensive ulcers. Data were extracted from the case records after completion of wound care and analysed using descriptive statistics. There were seven males and two females aged 14–34 years with 15 ulcers affecting the distal third of the leg. Ulcer duration before commencement of VAC care ranged from 2.5 to 84 months. All wounds showed remarkable reduction in size, had healthy granulation tissue and were ready for skin grafting within 6–10 days of VAC care. Graft take was 98% to 100%. Use of the VAC device is valuable in the management of sickle cell ulcers. This device rapidly improves the vascularity of the wound bed and permits early successful coverage of sickle cell ulcers.

Small- to medium-sized ulcers and wounds that are “difficult-to-close” constitute the bulk of wounds that cause problems in closure. Direct suture is the best-known option to treat wounds, but all wounds are not amenable for it. Such problem wounds require treatment techniques such as skin grafting and flap coverage. An external fixator, called “Joshi’s external stabilization system,” was used in this technique. Two Kirschner wires were attached to two specialized adjustable screws, called “distracters,” to construct the external fixator. One Kirschner wire each was passed intradermally on either side of a wound, and their ends were connected by the specialized screws, called the distracters. The knobs of these distracters were turned at regular intervals. With turning of the knobs each time, the Kirschner wires moved toward each other and brought the wound edges along with them. When the wound’s edges met each other, the wounds were closed with sutures, and the external fixator was removed. This technique was applied for 16 patients, for defects of 2.5–10 cm size, from head to foot, over a 3-year period, from January, 2008 to December, 2010. There were 11 male and five female patients, between ages 5 and 93 years. Treatment duration ranged from 10 to 28 days, and follow-up was from 3 to 24 months. This technique was found useful to attain direct closure of chronic ulcers and difficult-to-close wounds and obviate the need for, and render superior results compared to, skin grafting and flap coverage.