The wound care reference
for people who actually do it.

• Length × Width × Depth, in centimetres. Length is head-to-toe (12→6 o'clock); width is perpendicular (9→3); depth is the deepest point.
• Use the same convention every time. Mixing "head-to-toe" with "longest regardless of axis" produces false trend data.
• Clock method: 12 o'clock = toward the patient's head, always anchored to anatomy, never to the bed.
• Undermining = destruction under intact skin edges. Tunnelling = a narrow channel in one direction. Document as range + depth + position: "Undermining 1.5 cm from 12 to 3 o'clock; tunnelling 4.0 cm at 7 o'clock."
• Undermining and tunnelling are invisible on photographs. The written record is the only record of the wound's true extent.

← swipe table →

Switching tools mid-course destroys trendability. Use one per episode of care.

Non-blanchable erythema, IAD erythema and cellulitis are all under-detected in darker skin. Assess for colour difference from surrounding skin (darker, purple, deep red, yellowish — not "red"), and weight temperature, induration, boggy or firm texture, and patient-reported pain more heavily than visual colour. Use the Skin Tone Tool (Dhoonmoon et al., 2021).

ISTAP 2025 and the 2026 IAD Best Practice Update both make this an explicit competency.

• Written consent at admission plus verbal consent reaffirmed at each capture. Clinical use and teaching/publication are separate permissions.
• Facility-owned device only. Never a personal phone unless written policy explicitly permits it.
• Same position, distance, angle and lighting each time; lens square to the wound plane.
• Include a scale in frame with a non-identifiable patient code, date/time and anatomical label. Exclude face, tattoos, jewellery.
• Encrypted, access-controlled storage. Never personal drives, consumer cloud, or messaging apps.

Photographs supplement and never replace clinical assessment. A photo cannot capture depth, undermining, odour, temperature, induration or pain.

IMI National Guidelines: Wound Management Photography (2019); IAD Best Practice Update 2026, Box 4.

• Full assessment including measurement and photo: at least every 7 days.
• Partial assessment at every dressing change.
• Immediately, regardless of schedule: new or worsening pain, new odour, increased exudate, periwound erythema or induration, systemic signs, bleeding.
• Escalate if the wound hasn't shrunk ~40–50% in 4 weeks — reassess the diagnosis, not just the dressing.

← swipe table →

• Depth varies by anatomical location. The bridge of the nose, ear, occiput and malleolus have no subcutaneous tissue — Stage 3 there can be shallow. Areas of significant adiposity develop deep wounds.

NPUAP/NPIAP Pressure Injury Stages, revised April 2016 (npiap.com). Reproduced in NPIAP/EPUAP/PPPIA International Guideline, 3rd ed, 2019, Classification Systems.

• Medical Device-Related Pressure Injury (MDRPI) — this describes an aetiology, not a stage. Results from devices applied for diagnostic or therapeutic purposes. The injury generally conforms to the pattern or shape of the device. Stage it using the normal staging system.
• Mucosal Membrane Pressure Injury — CANNOT be staged. Found on mucous membranes with a history of a device in use at that location (ETT, NG tube, urinary catheter, bite block). Due to the anatomy of the tissue these ulcers cannot be staged. Document as "mucosal membrane pressure injury" with site and device — never as Stage 2.
• An individual is at risk the moment a device is applied. Independent risk factors for device-related injury include oedema, vasopressors, surgery, ventilator use, prone positioning, higher APACHE II/III and SOFA scores, longer device duration and greater total number of devices.
• Devices are the leading cause of pressure injury in the paediatric population.

NPUAP Pressure Injury Stages, 2016. NPIAP/EPUAP/PPPIA International Guideline 4th ed, Quick Reference Guide (Prevention), 25 February 2026 — RISK6.3, RISK6.6.

• Stage 2 is not a catch-all for shallow wounds. The 2016 definition explicitly excludes: moisture-associated skin damage (MASD) including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), and traumatic wounds (skin tears, burns, abrasions). If it is IAD or a skin tear, it is not a pressure injury at all — do not stage it.
• IAD vs Stage 2: IAD is diffuse, ill-defined, occurs where urine/stool contact the skin (perineum, buttocks, groin folds), often with satellite lesions. Pressure injury is localised over a bony prominence with distinct edges.
• Slough does not automatically mean Unstageable. Slough and eschar may be visible in Stage 3 and Stage 4. The test is whether it obscures the extent of tissue loss. If it obscures — Unstageable. If you can still see fat (Stage 3) or palpate bone (Stage 4), stage it.
• Slough in a "Stage 2" means you have staged it wrong. Granulation, slough and eschar are not present in Stage 2 by definition — so any slough means at least Stage 3, or Unstageable if depth is obscured.
• Stage 1 vs DTPI is decided by colour. Stage 1 colour changes do not include purple or maroon. Persistent deep red, maroon or purple = DTPI, and it carries a far worse prognosis — deep damage at the bone–muscle interface presenting through intact skin.
• DTPI that reveals deeper structures is no longer a DTPI. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures become visible, it is a full-thickness injury — Unstageable, Stage 3 or Stage 4.
• Blanchable erythema is not Stage 1. Press it. If it blanches, it is not a Stage 1 pressure injury — but it is a warning sign and a trigger to act.

NPUAP Pressure Injury Stages, 2016 (npiap.com).

• Non-blanchable erythema "may appear differently in darkly pigmented skin". The classic red patch may be absent entirely. Stage 1 and DTPI are both explicitly noted as difficult to detect in individuals with dark skin tones.
• Use temperature. Assess the temperature of skin and soft tissue — the area may be warmer or cooler than adjacent tissue. Skin temperature assessment is named as an important adjunct strategy in darkly pigmented skin.
• Use induration and tissue consistency. Assess oedema and change in tissue consistency in relation to surrounding tissues — firm, boggy or mushy against the adjacent norm.
• Use pain. Pain and temperature change often precede skin colour changes in DTPI. Localised pain over a bony prominence is a finding, not a complaint.
• Sub-epidermal moisture (SEM) devices are named alongside temperature as an important adjunct in darkly pigmented skin, and may be considered as an adjunct to routine clinical skin assessment generally.
• Compare, don't judge in isolation. The area's colour may simply differ from the surrounding area. Assess in good natural light, and against the patient's own baseline.

NPIAP/EPUAP/PPPIA International Guideline 3rd ed, 2019 — Recs 2.3 (B1, ↑↑), 2.4 (B1, ↑), 2.5 (GPS), 2.6 (B2, ↔), 2.7 (B2, ↑), 2.8 (B2, ↔). NPUAP Pressure Injury Stages, 2016. The 4th edition Classification chapter is in development and will address "reliability and validity of pressure injury classification across the continuum of skin tones"; the guideline already publishes separate classification tools for dark and light skin tones (June 2026).

Braden Scale — six subscales. Sensory perception, moisture, activity, mobility and nutrition score 1–4; friction and shear scores 1–3. Total range 6–23. Lower score = higher risk.

← swipe table →

• Act on the subscale, not just the total. A patient with an adequate total but a 1 on moisture needs an incontinence plan; a 1 on mobility needs a repositioning and surface plan. The 4th edition explicitly names risk-based planning "driven by risk assessment tool items, subscales or specific individual risk factors".
• Braden QD — paediatrics. Developed and tested to predict both immobility-related and device-related pressure injury in paediatric patients. Multicentre prospective cohort, 625 patients preterm to 21 years on bedrest ≥24h with medical devices in place. AUC 0.78 (95% CI 0.73–0.84). At a cut-off score of 13: sensitivity 0.86, specificity 0.59, negative predictive value 0.98 — i.e. it is good at ruling risk out, weak at ruling it in.

Braden subscales and risk bands: StatPearls/NCBI Bookshelf, Pressure Injury (NBK553107). Braden QD: Curley MAQ, Hasbani NR, Quigley SM, et al. Predicting Pressure Injury Risk in Pediatric Patients: The Braden QD Scale. J Pediatr 2018;192:189-195.e2 (PMID 29246340). Subscale-driven planning: International Guideline 4th ed QRG (Prevention), 25 Feb 2026 — RISK3.

• Two-hourly or three-hourly is the current suggestion — for most at-risk individuals, provided they are also on an appropriate pressure redistribution full body support surface. Conditional recommendation, very low certainty.
• Do not routinely extend to 4, 5 or 6 hourly. Conditional recommendation, very low certainty. Progressive extension may be appropriate only where risk is decreasing, self-repositioning capacity is increasing, and skin and tissue status is normal.
• No support surface entirely replaces repositioning. The interval may be adjusted for the surface's capability and the individual's response — but the turning does not stop.
• Individualise on: level of activity and mobility, ability to independently reposition, skin and tissue tolerance, clinical condition, comfort, sleep patterns, goals of care, and the support surface in use.
• Critically ill / shock states: may need more frequent, incremental repositioning, supplemented with assisted small shifts in position. For those too unstable to tolerate a full turn, initiate frequent small incremental shifts (micromovements).
• Palliative and end-of-life: offer the frequency best suited to goals of care and comfort — documented, with the patient's full knowledge of the pressure injury risk incurred.
• Use slide sheets and handling equipment designed to reduce friction and shear. Drag = shear = deep tissue damage.
• Reassess early skin changes as a trigger for more frequent repositioning or preferential positioning off the damaged area.

NPIAP/EPUAP/PPPIA International Guideline 4th ed, Quick Reference Guide (Prevention), 25 February 2026 — R1–R9.

← swipe table →

• Bottom line: there is no evidence that alternating (active) beats reactive foam. Reactive foam is the graded default; escalation is a clinical judgement, not a guideline mandate.
• Fit the surface to the person — weight, height, size and body mass distribution.
• Selection factors: overall risk, skin/tissue response, independence and mobility needs, posture and sleeping position, need for microclimate management and shear reduction features, and patient preference and care goals.
• Check for bottoming out and reassess the surface if the injury fails to heal, deteriorates, the patient is at high risk of further injury, has had a flap or graft, or is uncomfortable.

International Guideline 4th ed QRG (Prevention), 25 Feb 2026 — SS1–SS10. Bottoming-out / reassessment triggers and air-fluidized microclimate effect: International Guideline 3rd ed, 2019 — Recs 7.9, 7.10 (B1, ↑).

• Sacrum and heels: "We suggest using a multilayered soft silicone foam dressing on sacrum and heels for individuals assessed as having a high risk of pressure injuries, where resources permit." Conditional recommendation, very low certainty.
• Under medical devices: suggest a preventive dressing underneath devices when it will not interfere with the position or functionality of the device. Conditional recommendation.
• Heels specifically: a preventive dressing may be used as an adjunct to heel elevation and regular repositioning — not instead of it. If used, select a soft silicone adhesive multilayered foam dressing.
• Low-friction fabrics may be considered for those unable to reposition independently. Conditional, very low certainty.
• No recommendation on routine leave-on topical skin products for prevention — extremely low confidence in effect estimates and unclear mechanism of action.
• The Cochrane 2024 reality check. "The evidence for all interventions is uncertain or very uncertain; thus, it is unclear whether any of the dressings or topical agents studied make any difference to pressure ulcer development." Silicone foam vs no dressing gave RR 0.50 (95% CI 0.33–0.77) — but all low or very low certainty. Treat prophylactic dressings as a plausible adjunct, never as a reason to relax turning, offloading or skin inspection.
• Practical: the dressing must allow the skin underneath to be inspected. Lift or replace per manufacturer instruction and inspect the skin — a dressing that hides a developing injury is worse than no dressing.

International Guideline 4th ed QRG (Prevention), 25 Feb 2026 — SK2, SK3, SK4, H4, H5, device-related dressing recommendation. Patton D, Moore ZE, Boland F, Chaboyer WP, Latimer SL, Walker RM, Avsar P. Dressings and topical agents for preventing pressure ulcers. Cochrane Database Syst Rev 2024, published 3 December 2024 (PMID 39625073).

• Elevate the heels so they are not in contact with the support surface. Good practice statement. This is the intervention — everything else is adjunct.
• Use a heel offloading device appropriate to the individual's mobility and activity level. Conditional recommendation, very low certainty.
• If no device is available or appropriate, use standard pillows or cushions with sufficient height to ensure the heels are not touching. Support the length of the calf, avoid pressure on the Achilles tendon, and keep the knee in slight flexion.
• Heel-specific risk factors: anything reducing perfusion or increasing friction/shear at the heel — peripheral arterial disease, systemic perfusion problems (shock states), vasopressors, diabetes mellitus.
• No recommendation on leave-on topical products for heel prevention.

International Guideline 4th ed QRG (Prevention), 25 Feb 2026 — H1, H2, H3, H6, RISK6.5.

• Skin care regimen: keep skin clean and appropriately hydrated; cleanse promptly after episodes of incontinence; avoid alkaline soaps and cleansers. (2019: B2, ↑↑)
• Microclimate = heat + moisture at the skin/surface interface. It is one of the named selection factors when choosing a support surface in the 4th edition, and the 2019 guideline recognises reduction of skin temperature and excess hydration as a mechanism (assessed for air-fluidized beds in Stage 3/4 injuries, B1 ↑).
• Sheepskin caution: only medical-grade. Non-medical-grade sheepskins do not have the same microclimate management properties and may increase pressure injury risk.
• Don't defeat your own mattress. Layers of linen, incontinence pads and overlays reduce immersion and trap heat and moisture. Fewest layers possible.
• SSKIN bundle — Skin, Surface, Keep moving, Incontinence/moisture, Nutrition/hydration. A five-step care bundle widely implemented for pressure ulcer prevention. The aSSKIN variant prefixes assess risk, making risk assessment the explicit first step.
• Bundles are a delivery mechanism, not new evidence. The 4th edition lists care bundles as one of three prevention-planning strategies alongside risk-based intervention and clinical algorithms — all as good practice, not graded recommendations.

SSKIN expansion: Kennedy E. An Evidence-Based Approach to Protecting Our Biggest Organ: Implementation of a Skin, Surface, Keep Moving, Incontinence/Moisture, and Nutrition/Hydration (SSKIN) Care Bundle. J Dr Nurs Pract 2023;16(1):62-80. See also Whitlock J, Br J Community Nurs 2013 Suppl:S32-39. Skin care regimen: International Guideline 3rd ed, 2019 — Rec 3.1 (B2, ↑↑); microclimate/air-fluidized Rec 7.10 (B1, ↑). Bundles and sheepskin: 4th ed QRG (Prevention), 25 Feb 2026 — RISK3, SS4, SS8.2.

← swipe table →

• Cleanse the pressure injury (B1, ↑) and the surrounding skin (B2, ↑). Use antimicrobial cleansing solutions where infection is suspected or confirmed (GPS).
• Suspect local infection if: delayed healing, no signs of healing in the preceding two weeks despite appropriate treatment, increasing size or depth, wound breakdown/dehiscence, or necrotic tissue.
• Where advanced dressings are not an option: moist gauze to maintain a moist environment (B1, ↔), transparent film as a secondary dressing (B1, ↔).
• None of this works without offloading. Continued pressure on the wound overrides every dressing decision.
• Consider NPWT as an early adjunct for deep Stage 3 and Stage 4 injuries after conservative debridement.

NPIAP/EPUAP/PPPIA International Guideline 3rd ed, 2019 — Recs 12.1–12.3, 13.1, 14.3–14.11, 17.4. Note: treatment chapters of the 4th edition are still under development, so the 2019 3rd edition remains the operative source for treatment.

• Debride devitalised tissue and suspected or confirmed biofilm, and perform maintenance debridement until the wound bed is free of devitalised tissue and covered with granulation tissue. (B2, ↑↑)
• Maintenance debridement is the point most nurses miss — one debridement is not a treatment. Biofilm reforms; the wound needs repeated preparation alongside topical antimicrobials.
• Debride first, then stage. An Unstageable injury cannot be accurately staged until the base is exposed.
• Assess perfusion before sharp debridement of any lower limb wound. Palpate pulses, check ABPI/toe pressures, refer to vascular if arterial disease is suspected.
• Do not debride intact-skin DTPI. There is no devitalised tissue to remove and the skin is the only barrier present.

NPIAP/EPUAP/PPPIA International Guideline 3rd ed, 2019 — Recs 12.4, 12.5.

• The consensus position: "most pressure ulcers are avoidable; not all pressure ulcers are avoidable." Unanimous NPUAP consensus conference finding.
• Named unavoidable circumstances include haemodynamic instability that is worsened with physical movement, and inability to maintain nutrition and hydration status. The panel also concluded that even if enough pressure were removed from the external body, the skin cannot always survive.
• Kennedy Terminal Ulcer (KTU) — a pear-, butterfly- or horseshoe-shaped lesion, typically on the sacrum/coccyx, of sudden onset with red/yellow/black discolouration and rapid deterioration, occurring in the dying patient.
• SCALE — Skin Changes At Life's End. The framework holding that the skin, as the largest organ, can fail like any other organ at end of life, and that some end-of-life skin changes are not preventable by standard prevention.
• Skin failure — the concept applied to end-of-life skin injury; the terminology remains contested and was formally re-examined in a 2019 professional consensus survey. Use the term carefully and define it in your documentation.
• "Unavoidable" is a documentation finding, not a clinical excuse. It is only defensible if the record shows you did everything and it still happened.

Black J, Edsberg LE, Baharestani MM, Langemo D, Goldberg M, McNichol L, Cuddigan J. Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer Advisory Panel Consensus Conference. Ostomy Wound Manage 2011;57(2):24-37. Ayello EA, Levine JM, Langemo D, Kennedy-Evans KL, Brennan MR, Sibbald RG. Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries. Adv Skin Wound Care 2019;32(3):109-121. Sibbald RG, Ayello EA. Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries: Results of the 2019 Terminology Survey. Adv Skin Wound Care 2020;33(3):137-145.

• Risk assessed on admission and reassessed — with dates, scores and the changes in condition that triggered each reassessment.
• A prevention plan that matches the assessed risk — and evidence it was revised as risk changed.
• Repositioning actually delivered — times, positions, and specifically why any interval was extended or a turn was not done (haemodynamic instability with movement, patient refusal, comfort-focused goals of care).
• Refusals and their handling — capacity, the risk explained, alternatives offered, who was informed. A documented, informed refusal is a defence; an undocumented one is not.
• Support surface in use — named product, date provided, and any escalation, with the rationale.
• Heel offloading — device or pillows, and confirmation the heels were clear of the surface.
• Nutrition and hydration — screening, dietitian referral, intake, and the clinical reason nutrition could not be optimised if that is the case.
• Serial skin assessments — including temperature, induration, tissue consistency and pain, not just colour. Photograph with consent, per local policy, with a measurement scale.
• The clinical instability itself — vasopressor doses, perfusion, shock state, oxygenation. This is what makes the injury unavoidable; if it is not in the record it did not happen.
• Goals of care conversations — who was present, what was decided, and that pressure injury risk was explicitly discussed when comfort was prioritised over repositioning.
• Multidisciplinary input — tissue viability, dietetics, vascular, palliative care referrals with dates.

Documentation elements derived from the NPUAP consensus criteria for unavoidable pressure ulcers (Black et al., Ostomy Wound Manage 2011) and the good practice statements on documentation and individualised repositioning in the International Guideline 4th ed QRG (Prevention), 25 Feb 2026 — RISK5, R5, R7.3.

• The 4th edition is being released as rolling online chapters, not a single book. The guideline site states the document "is a document in development and new sections will be uploaded as they are completed."
• Prevention chapters are published. The abridged Quick Reference Guide (Prevention Recommendations), 4th edition, is dated 25 February 2026 and is free to download from internationalguideline.com.
• Treatment chapters are NOT yet published. Listed as "Topics and Clinical Questions Under Development": nutrition to support healing, support surfaces for healing (bed and chair), repositioning to facilitate healing, principles of chronic wound management (wound assessment, wound bed preparation including debridement and cleansing, infection, dressings and topical agents, wound-related pain), biophysical agents (electrical stimulation, NPWT, low- and high-frequency ultrasound), and surgical treatment (grafts, flaps).
• So the 2019 3rd edition remains the operative source for treatment until those chapters publish. It is still hosted and freely downloadable on the same site.
• Skin and Tissue Assessment and Classifying Pressure Injuries are also still under development — stakeholder comments were being considered before finalisation, with a stakeholder review round open until 23 July 2026. Classification definitions "will be updated as needed", so NPIAP 2016 staging remains current.
• The online interactive guideline is in beta and content is updated regularly — check the date stamp on anything you cite, and note the download date.
• Citation: NPIAP, EPUAP and PPPIA. Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide. The International Guideline: Fourth Edition. Emily Haesler (Ed.). 2026.

Verified at internationalguideline.com, August 2026 — 4th edition QRG (Prevention) dated 25 Feb 2026; "Topics and Clinical Questions Under Development" list; news announcement that prevention sections launched first; 2019 3rd edition CPG and QRG still hosted.

← swipe table →

Sociedade Brasileira de Dermatologia, Consensus on the diagnosis and management of chronic leg ulcers, An Bras Dermatol 2020;95(Suppl 1):1–18. IWGDF Practical Guidelines, International Working Group on the Diabetic Foot, 2023.

This is not a technicality. Two current, authoritative guidelines calculate the ankle-brachial index from different numbers, and the same leg can come back normal under one and PAD under the other.

← swipe table →

Below-knee disease — the pattern that dominates in diabetes — frequently affects only one tibial artery. Taking the higher of the two pressures can read straight past it. Switching from the higher to the lower convention raises measured PAD prevalence by roughly 2.7 to 4 times in diabetic cohorts.

Gornik HL, et al. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease. J Am Coll Cardiol 2024;83:2497–2604. IWGDF/ESVS/SVS Intersocietal PAD Guideline, in IWGDF Guidelines 2023.

← swipe table →

IWGDF frames the same test for diabetic feet as a rule-out rather than a rule-in: PAD is less likely with an ABI of 0.9–1.3, a TBI ≥ 0.70, and triphasic or biphasic pedal Doppler waveforms. No single bedside test is good enough alone — IWGDF recommends running ABI, TBI and continuous-wave Doppler waveforms together.

Gornik HL, et al. J Am Coll Cardiol 2024;83:2497–2604 (ABI bands; Class 1 recommendation for TBI when ABI > 1.40). IWGDF Practical Guidelines and Intersocietal PAD Guideline, 2023.

An ABI is a ratio, and a ratio discards the information that determines whether a bandage is safe.

Absolute perfusion thresholds already carry the urgent arterial decisions in the diabetic foot as well — ankle pressure < 50 mmHg, toe pressure < 30 mmHg and TcPO₂ < 25 mmHg all trigger urgent vascular assessment regardless of what the index says.

O'Donnell TF Jr, Passman MA, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2014;60(2 Suppl):3S–59S. IWGDF/ESVS/SVS Intersocietal PAD Guideline, 2023 (absolute pressure triggers).

There is no single agreed ABPI at which compression becomes unsafe. Published thresholds for "do not compress" span 0.5 to 0.8 — a roughly two-fold spread. Anyone who quotes you one number as settled fact is quoting their local policy, not the literature.

← swipe table →

The dogma has formally reversed. German AWMF S2k guideline 037-009 v4.1 (January 2024) states that the blanket rule against compression in peripheral arterial disease "should no longer apply in everyday clinical practice," and permits an attempt at inelastic compression at an ankle pressure of 50–60 mmHg under close monitoring. Inelastic material is the point: it exerts low resting pressure while the patient is still, and high working pressure only during calf muscle contraction.

What this means on the ward: in the contested 0.5–0.8 band, the decision is a specialist one, it is made on absolute ankle perfusion pressure and not the ratio alone, it uses inelastic material at reduced pressure, and it comes with a monitoring plan — not a bandage and a four-week review.

Rabe E, Partsch H, Morrison N, et al. Risks and contraindications of medical compression treatment — a critical reappraisal. An international consensus statement. Phlebology 2020;35(7):447–460. Ratliff CR, Yates S, McNichol L, Gray M. J Wound Ostomy Continence Nurs 2016;43(4):347–364. Thresholds by organisation as tabulated in a scoping review of ABPI reporting and compression recommendations in global VLU guidelines, Int Wound J 2019. AWMF S2k Leitlinie 037-009, Medizinische Kompressionstherapie, v4.1, January 2024. IWGDF makes no compression recommendation — do not attribute one to it.

Pathophysiology. Incompetent valves in the superficial, deep or perforating veins, or venous outflow obstruction, produce sustained ambulatory venous hypertension. That drives capillary leak, fibrin cuffing, leucocyte trapping and chronic inflammation in the gaiter skin — hence the haemosiderin staining, lipodermatosclerosis and atrophie blanche that precede the ulcer. Compression works because it opposes the hypertension. A dressing alone treats nothing.

Compression is the treatment. Against no compression, it probably increases complete healing (RR 1.77, 95% CI 1.41–2.21, moderate certainty) and probably shortens time to healing (HR 2.17, 95% CI 1.52–3.10, moderate certainty).

← swipe table →

Early endovenous ablation — refer now, do not wait for healing. EVRA randomised 450 patients with a venous leg ulcer and superficial reflux to ablation within 2 weeks versus deferral until healing or 6 months. Median time to healing 56 days early vs 82 days deferred (HR for healing 1.38, 95% CI 1.13–1.68, p = 0.001). Healing at 24 weeks 85.6% vs 76.3%. Median ulcer-free time in year one 306 vs 278 days (p = 0.002). At extended follow-up, recurrence ran at 0.11 vs 0.16 per person-year (IRR 0.658, 95% CI 0.480–0.898, p = 0.003), and early intervention was highly likely to be cost-effective over 3 years. Practical consequence: an open venous ulcer earns a duplex scan and a vascular referral today, not after it heals.

Recurrence prevention. Compression continues after healing — recurrence is the default without it. EU class 3 stockings may reduce reulceration versus no compression at 6 months (RR 0.46, 95% CI 0.27–0.76; single study, 153 participants; low certainty). Higher-compression hosiery is favoured over medium where the patient tolerates it and arterial status permits. Concordance is the binding constraint: fit, application aids, and review matter more than the class printed on the packet.

Pentoxifylline. An effective adjunct, not a substitute. Versus placebo for complete healing or significant improvement RR 1.70 (95% CI 1.30–2.24); with compression RR 1.56 (95% CI 1.14–2.13); in the absence of compression RR 2.25 (95% CI 1.49–3.39). Adverse effects are more frequent (RR 1.56, 95% CI 1.10–2.22) and 72% of them are gastrointestinal. Prescribing is off-label in some jurisdictions — check locally.

Shi C, Dumville JC, Cullum N, et al. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane 2021, CD013397. O'Meara S, Cullum N, Nelson EA, Dumville JC. Cochrane 2012, CD000265. Arundel C, et al. VenUS 6. PLOS Med 2026;23(7):e1005154. Gohel MS, et al. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med 2018;378:2105–2114; long-term outcomes JAMA Surg 2020;155:1113–1121. de Moraes Silva MA, et al. Cochrane 2024, CD002303. Jull AB, Arroll B, Parag V, Waters J. Cochrane 2012, CD001733. De Maeseneer MG, et al. ESVS 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022;63:184–267. Note: the current SVS/AVF venous leg ulcer guideline remains O'Donnell & Passman, J Vasc Surg 2014;60(2 Suppl):3S–59S — the 2022–2024 SVS/AVF/AVLS documents cover varicose veins, not venous leg ulcers.

The wound is a perfusion problem. Dressings, debridement and compression are all downstream of restoring blood flow.

← swipe table →

WIfI ischaemia grading — the ischaemia axis of the SVS Wound, Ischaemia and foot Infection system, as reproduced in the IWGDF 2023 Classification guideline. Grade on whichever perfusion measure you have.

← swipe table →

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 3rd edition, 2019 — Recommendation 12.4. Heel Pressure Injuries: Consensus-Based Recommendations for Assessment and Management, Adv Wound Care 2020 (perfusion thresholds for avoiding occlusive dressings). IWGDF Practical Guidelines and Classification Guideline, 2023 (perfusion triggers; WIfI, after Mills et al., SVS 2014). Wound Healing Society 2023 update on guidelines for arterial ulcers, Wound Repair Regen 2024;32:619–629.

Offloading is the intervention that heals the ulcer. IWGDF describes offloading as arguably the most important of all interventions in neuropathic DFU. The hierarchy is explicit.

← swipe table →

Why the gold standard is underused. Only 1.7% of 895 US foot-ulcer centres surveyed used total contact casting, while 41.2% relied on shoe modifications — under 2% using what the authors call "the gold standard." IWGDF names the reasons plainly: a TCC takes about 13 minutes longer to apply and 4.8 minutes longer to remove than a non-removable walker, is likely less cost-effective over the treatment course (mean difference €564.79 higher), needs a trained technician and ongoing materials, and scores slightly lower on patient satisfaction.

The point for practice: the evidence-based requirement is non-removability, not plaster. A removable walker the patient takes off at the front door delivers almost nothing. Rendering a walker non-removable achieves the same healing as a TCC and is within reach of far more services — which makes "we don't have a casting technician" an argument for a rendered-non-removable walker, not for a removable boot.

Offloading when infection or ischaemia is present — the hierarchy changes.

← swipe table →

SINBAD — the classification IWGDF recommends for communication between professionals and for audit. No equipment needed beyond clinical examination. Each item scores 0 or 1; total 0–6.

← swipe table →

Use WIfI where perfusion measurement and vascular expertise are available — it stratifies 1-year amputation risk and likely benefit from revascularisation. IWGDF is explicit that no current classification should be used to give an individual patient a prognosis (Strong; Low).

IWGDF/IDSA infection grading. Infection is present when at least two of the following are found: local swelling or induration; erythema > 0.5 cm and ≤ 2 cm around the ulcer; local tenderness or pain; local warmth; purulent discharge.

← swipe table →

Probe-to-bone for osteomyelitis. A sterile blunt metal probe gently inserted into the wound; positive when you feel a hard, gritty structure. Pooled sensitivity 0.87, specificity 0.83. It rules bone infection in when positive in a high-risk patient and helps rule it out when negative in a low-risk patient. Interobserver agreement is only moderate — if you are not trained in the technique, do not act on your own result. IWGDF recommends combining probe-to-bone with plain X-ray and ESR, CRP or procalcitonin as the initial workup (Conditional; Low). Osteomyelitis is likely when probe-to-bone is positive and the plain X-ray is abnormal. Suspect it under any wound that is long-standing, wide, deep, over a bony prominence, showing visible bone, or presenting as a swollen erythematous "sausage toe." MRI when in doubt.

Neuropathy screening — 10 g (5.07) Semmes-Weinstein monofilament, exact IWGDF technique:

• First apply it to the patient's hand, elbow or forehead so they know what they are feeling for.
• Test three different sites on both feet, selected from the sites in the IWGDF site diagram — IWGDF publishes these as a figure, not a list, so use your service's copy of it rather than improvising locations.
• Ensure the patient cannot see whether or where you apply it.
• Apply perpendicular to the skin, with enough force to make the filament bend or buckle.
• Total approach → skin contact → removal takes approximately 2 seconds.
• Never apply over an ulcer, callus, scar or necrotic tissue.
• Do not let the filament slide across the skin or make repetitive contact at the same spot.
• Ask two questions each time: do you feel it (yes/no), and where.
• Apply twice at the same site, alternating with at least one "mock" application where no filament touches — three questions per site.
• Protective sensation present = 2 out of 3 correct. Absent = 2 out of 3 incorrect.
• Filaments fatigue: rest the monofilament 24 hours after 10–15 patients, and replace it after 70–90 patients.

A 128 Hz tuning fork tests vibration and is IWGDF's alternative when no monofilament is available.

IWGDF Guidelines 2023 — Practical, Offloading, Classification, IWGDF/IDSA Infection and Charcot guidelines. International Working Group on the Diabetic Foot, 2023. Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care 2008;31:2118–2119.

A mixed arterial-venous ulcer is generally defined as superficial venous reflux on duplex together with an ABPI below 0.9. The venous component says compress; the arterial component says do not. The arterial component governs until perfusion has been assessed and, where indicated, corrected.

← swipe table →

Practical rules for the modified-compression band. Inelastic over elastic — low resting pressure, high working pressure. Never leave a first application on overnight unmonitored. At every visit check pedal skin colour, temperature, capillary refill and pain, and re-measure perfusion on a schedule rather than assuming last quarter's number still holds. New or worsening rest pain, night pain, numbness, coolness or colour change after applying compression means remove it now and escalate the same day.

Diabetes and ESRD change the calculus. Do not settle a mixed-ulcer compression decision on ABPI alone in these patients — calcified vessels can place a genuinely ischaemic limb inside the "safe to compress" band. Get the toe-brachial index and the absolute ankle pressure.

Review of Mixed Arterial Venous Leg Ulcers (MAVLU) Disease in Contemporary Practice, Vasc Endovascular Surg 2024. Ratliff CR, et al. J Wound Ostomy Continence Nurs 2016;43(4):347–364. Rabe E, et al. Phlebology 2020;35(7):447–460. AWMF S2k Leitlinie 037-009, v4.1, January 2024.

Between 2.0% and 2.8% of chronic leg ulcers prove malignant in retrospective series, and 4% to 10.4% in prospective ones; one tertiary cohort found 3.9%. Of those malignancies: basal cell carcinoma 44%, squamous cell carcinoma 30%, melanoma 26%. A malignancy under a compression bandage is being treated as a venous ulcer for months at a time.

← swipe table →

Biopsy technique matters. For suspected Martorell hypertensive ischaemic ulcer a surgical biopsy extending to the fascia should always be performed; punch biopsy can give an incorrect diagnosis and should be avoided. In general: sample the ulcer edge including adjacent intact skin, take more than one specimen from different quadrants of a large ulcer, and send tissue for histology. A swab answers a different question and cannot exclude malignancy.

Malignant Tumours Presenting as Chronic Leg or Foot Ulcers, J Clin Med 2021 (prevalence, tumour types, biopsy indications, German S3 six-week rule). Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 2003;26:1879–1882. Sociedade Brasileira de Dermatologia, An Bras Dermatol 2020;95(Suppl 1):1–18 (Martorell biopsy technique).

← swipe table →

EPUAP differentiation criteria (Defloor et al., 2005) — still the reference standard. Colour alone is the weakest discriminator; never decide on colour.

Why skin breaks down: (1) Overhydration — corneocytes swell, the brick-and-mortar structure disrupts, barrier fails. (2) pH elevation — urea → ammonia raises pH, disrupting the acid mantle and activating faecal lipases and proteases that digest the stratum corneum directly.

Risk hierarchy: urine alone → formed faeces ± urine → liquid faeces ± urine (highest).

IAD occurs in continent patients too — anyone with prolonged skin exposure. Risk assessment must go beyond continence status.

CLEANSE → PROTECT → RESTORE, at least daily and after each episode:

• Cleanse: pH-balanced, non-perfumed, no-rinse cleanser with a disposable cloth. Pat dry. Not soap and water — soap raises pH and strips lipids.
• Protect: a barrier to stop direct contact with irritants. Avoid thick occlusive products that block the absorbent product's fluid uptake.
• Restore: only when the epidermis is intact. Where it's breached, use an advanced elastomeric (cyanoacrylate) protectant.

Expect improvement in 1–2 days and resolution in 1–2 weeks. If not, reassess and change the barrier product.

Definition (2025): a traumatic wound from mechanical forces including adhesive removal and handling, the depth of which may vary but does not extend through the subcutaneous layer. That depth boundary is what separates a skin tear from a laceration.

ISTAP classification: Type 1 — no skin loss, flap can be repositioned to cover the bed. Type 2 — partial flap loss, cannot cover the bed. Type 3 — total flap loss, entire bed exposed.

Prevention that works: twice-daily moisturising reduces skin tear incidence by ~50%. Soap-free pH-neutral cleansers, tepid water, pat dry, protective clothing, safe handling, never grab with fingertips, routinely use adhesive removers and skin sealants.

⭐ The arrow: mark the dressing with an arrow showing the direction of removal, and note it in the chart. Remove toward the flap's attached base — never against it, which lifts and destroys the flap. Write it on the dressing with the date: ← remove with arrow · 2026/08/07 · JE

Assess flap viability (pink/dusky/pale/purple/black) — often more useful than measurement. Measure only the visible open bed.

Definition: erythema or other skin abnormality persisting ≥30 minutes after adhesive removal. That threshold is what separates MARSI from benign transient redness.

Types: mechanical (epidermal stripping, tension blister, skin tear) · dermatitis (irritant, allergic) · other (maceration, folliculitis).

Removal is the highest-yield intervention:

• Support the skin with one hand while removing with the other
• Remove low and slow, parallel to the skin — peel back over itself, never up at 90°
• Remove in the direction of hair growth; use a medical adhesive remover
• Never rip. Speed is the enemy.

Application: apply without tension or stretch — tension injury is almost entirely a technique problem. Clip hair, don't shave. Let skin prep dry fully. Don't put creams under adhesive.

Excluding superficial burns from TBSA is the single most common error — including them inflates TBSA, distorts fluid resuscitation and misdirects referral.

Counterintuitive but critical: deeper burns hurt less. Reduced pain and absent pin-prick sensation mean a deeper injury, not a milder one.

Palmar method: the patient's entire palmar surface — palm plus fingers — is ~1% TBSA. Lund–Browder is the most accurate method and the standard for paediatrics and definitive documentation; Rule of Nines is for the rapid initial estimate only.

Immediate consultation with consideration for transfer:

• Full thickness burns · partial thickness ≥10% TBSA
• Any deep partial or full thickness burn of the face, hands, genitalia, feet, perineum, or over any joint
• Burns with other comorbidities · concomitant traumatic injuries · poorly controlled pain
• All suspected inhalation injury · all chemical injuries · all high-voltage (≥1,000 V) electrical and lightning injuries
• All paediatric burns (≤14 years or <30 kg) may benefit — including for non-accidental trauma screening

American Burn Association, Guidelines for Burn Patient Referral, © 2022. This two-column format supersedes the older flat 10-criterion list still printed in many nursing textbooks.

• Cool with cool running water for 20 minutes — the only proven method, effective up to ~3 hours post-injury. Cool the wound, warm the patient (hypothermia risk, especially children).
• Remove clothing and all jewellery before swelling. Cover with cling film laid on in sheets, never wrapped circumferentially (it becomes a tourniquet as oedema develops).
• Do not delay transfer for definitive wound care. Cover and go.

← swipe table →

Recommended for prevention: photobiomodulation (breast cancer) · Mepitel film (breast cancer) · Hydrofilm · mometasone · betamethasone · olive oil. For management: Mepilex Lite dressings.

Gentle washing with lukewarm water and a mild cleanser is permitted — the old "don't wash the treatment field" advice is obsolete. Avoid friction, tight clothing, adhesive tape in the field, and blade shaving. Sun protection of the field is lifelong.

Behroozian et al., MASCC/ISOO clinical practice guidelines, April 2023 — systematic review of 235 studies including 149 RCTs.

← swipe table →

• Surgical and conservative sharp debridement are within scope for physicians, NPs, PAs and podiatrists in all US states.
• RN conservative sharp debridement is permitted in some but not all US states — positions range from explicitly permitted, to permitted with conditions, to silent, to prohibited, and they change.
• Where permitted, boards typically require all four: didactic education, supervised practice with documented competency, written facility policy, and a prescriber's order.
• Facility policy may be more restrictive than the board — and it governs your employment. It may never be less restrictive.
• Certification does not expand legal scope. A credential evidences competence; the board defines what you may do.

Before performing CSWD, confirm in writing: your board's current position, your employer's policy, your documented competency, and that an order exists.

Also stop and think: wounds over exposed vessels, nerves, tendon, bone, graft, mesh or hardware · calciphylaxis · uncorrected coagulopathy · wounds of unclear aetiology · patient declines or lacks capacity.

• Removes healthy granulation and epithelium along with necrotic tissue — non-selective by design
• Painful at every change; cools the wound bed, impairing cellular activity
• Prolongs the inflammatory phase; increases infection risk including bacterial aerosolisation on removal
• Labour-intensive and frequently performed incorrectly

Its only historical indication was mechanical debridement — and every other method does that better. If you inherit a wet-to-dry order, seek an order change, don't perfect the technique.

← swipe table →

Every cell assumes the underlying aetiology is being treated — compression for venous, offloading for pressure and diabetic foot, perfusion assessment for arterial. No dressing compensates for missing aetiological therapy.

• Cavity / undermining / tunnelling: conformable filler (gelling fibre or alginate rope). Pack loosely. Count and document every piece in and out. Never pack a tunnel whose end you can't see. Never use bordered foam as filler.
• Local infection: add a topical antimicrobial matched to exudate and start the two-week clock. Avoid occlusive hydrocolloid and film.
• Biofilm suspected (stalled >4 weeks despite correct care): Wound Hygiene at every change.
• Fragile periwound / skin tear: silicone-faced foam or silicone contact layer; barrier film; low-and-slow removal parallel to skin.
• Periwound maceration: step up absorption (gelling fibre → superabsorbent), increase change frequency, acrylate terpolymer barrier film, and fix the exudate source.
• Bleeding after debridement: alginate — calcium-mediated haemostasis is its specific advantage over gelling fibre.
• Painful changes: contact layer or silicone-faced dressing; extend wear time; pre-emptive analgesia; never alginate on a dry bed.
• Patient self-managing at home: prioritise longest safe wear time and simplest application. A theoretically optimal dressing applied wrongly is worse than a good-enough one applied correctly. This is TIMERS' "S".

• Hydrocolloid: the yellow-brown gel and odour on removal are normal, not pus — a routine source of false infection reports. Avoid in infection, heavy exudate, tunnelling, fragile periwound.
• Alginate vs gelling fibre: alginate is haemostatic; gelling fibre absorbs vertically with minimal lateral wicking — the better choice when maceration is the problem.
• Superabsorbents are the single most under-used answer to "the foam keeps leaking."
• Collagen needs a clean bed — it is not a debriding agent. Note IWGDF 2023 recommends against collagen or alginate for the purpose of healing in diabetic foot ulcers; both facts are true, the guideline just applies a stricter evidence bar.
• NPWT is not a debridement method. Necrotic tissue with eschar is an explicit FDA contraindication.

ARE indicated:

• Spreading or systemic infection — advancing erythema/cellulitis, lymphangitis, crepitus, fever, malaise, sepsis
• Osteomyelitis (probe-to-bone positive, imaging, bone culture)
• Deep-space infection, abscess, necrotising soft tissue infection (plus urgent surgery)
• Moderate-to-severe diabetic foot infection per IWGDF/IDSA

NOT indicated:

• Chronic wounds with no clinical signs of infection. All chronic wounds are colonised; colonisation is not infection.
• A positive swab in an asymptomatic wound. Don't treat the swab, treat the patient. Swabs of undebrided, uncleansed wounds sample surface colonisers — cleanse and debride first, then sample deep tissue (Levine technique or biopsy).
• Malodour or exudate alone · "prophylaxis" for a chronic ulcer

IWII 2022: antibiotics in non-healing wounds are "frequently prescribed without clinical justification, without addressing the underlying aetiological causes, and often without significant clinical benefit."

IWII Practice Point: use a topical antiseptic for at least 2 weeks before judging efficacy. Biofilm-based step-up/step-down care may need up to 4 weeks.

• Improved and infection signs resolved → stop, step down to a non-antimicrobial dressing
• Improved but signs persist → continue with a defined review point
• No improvement → stop. Reconsider the diagnosis, aetiology, systemic factors, deep infection/osteomyelitis, or malignancy

Document start date, indication and review date every time. Rotating antiseptics on a fixed cycle is popular but not evidence-supported.

• AMR induction — topicals deliver sub-therapeutic doses to a large bacterial population: near-ideal conditions for selecting resistance
• Sensitisation — neomycin is a top-5 contact allergen; bacitracin is a leading cause of allergic contact dermatitis and a documented cause of anaphylaxis on open wounds. Both are used OTC by patients constantly
• Marginal efficacy — prophylactic topical antibiotics for uncomplicated wounds show minimal absolute risk reduction vs placebo and no significant difference vs antiseptics

The canonical legitimate exception: topical metronidazole for malodour in fungating wounds.

• It is not reliably visible. Slough is suggestive, not diagnostic. Do not claim to "see biofilm."
• It shields organisms from antibiotics, antiseptics and immune defences — the reason systemic antibiotics so often fail in chronic wounds
• It re-forms within hours to days. This is the operationally important fact

Wound Hygiene (2020), four steps, at EVERY dressing change:

1. Cleanse — wound bed and periwound skin out to 10–20 cm, with mechanical action, not a passive rinse
2. Debride — whatever method is available and appropriate, every time
3. Refashion the wound edge — remove epibole and callus. The most frequently skipped step. The edge is a biofilm reservoir and a barrier to epithelial migration
4. Dress — antimicrobial/antibiofilm dressing applied immediately, before biofilm re-establishes

Evidence honesty: much of the Wound Hygiene literature is industry-developed or sponsored, and supporting case series often use that manufacturer's products. The biological rationale follows from established biofilm science; the outcome data are not independent randomised evidence.

• Routine non-infected wound: potable tap water or normal saline. Cochrane found no significant difference in infection rates; certainty is low, so the honest statement is "no evidence of harm, plausible practical advantages" — not "proven equivalent." Tap water enables showering, which helps adherence.
• Sterile saline instead for: immunocompromised patients, exposed bone/joint/tendon, deep cavities, the operating field.
• Pressure: 4–15 psi (AHCPR 1994). Below ~4 psi is inadequate; above 15 psi risks trauma and driving bacteria deeper. A 35 mL syringe with a 19 G angiocatheter delivers ~8 psi. Treat this as a sound safety envelope, not a precisely validated therapeutic window — it rests largely on 1994-era lab and animal work.
• Mechanical action is what disrupts biofilm. Irrigation removes what has been loosened; it does not do the loosening. Gentle swabbing with gauze or a monofilament pad is often superior to irrigation alone.
• Warm the solution. Cleanse periwound first. Observe antiseptic dwell times. Direct flow away from clean tissue. Contain runoff and wear PPE — cleansing aerosolises. Reassess the bed after cleansing, not before.

• Terminology: "skin substitutes" → CAMPs (Cellular, Acellular and Matrix-like Products). You'll see CTP too.
• The driver: Medicare Part B spend on these products went from ~$252 million (2019) to over $10 billion (2024).
• CY2026 Physician Fee Schedule (CMS-1832-F), effective 1 Jan 2026: most CAMPs reclassified from biologicals to "incident-to supplies", paid at a single flat national rate of $127.14/cm², site-neutral across office, HOPD and ASC.
• Only the applied area is paid. No payment for wasted product; JW/JZ wastage modifiers don't apply.
• LCD whiplash: the restrictive DFU/VLU LCDs due 1 Jan 2026 were withdrawn 24 Dec 2025. Coverage now varies by MAC — verify your jurisdiction.

What this changes for you at the bedside: document measurements meticulously (applied cm², not product size), record the 4-week standard-of-care trial before application, and stop assuming a given brand is on formulary.

Early clinical fallout is being reported (a 2026 Journal of Wound Care survey claims service-line closures and access harms) — but it had a ~3% response rate, was self-selected and industry-adjacent, with no control group. Read it as a signal of disruption, not proof of harm.

← swipe table →

Bottom line: there was no verifiable new FDA approval of a systemic or topical drug specifically for chronic DFU / VLU / pressure injury healing in 2024–2026. The genuinely new US approvals in wound healing are the epidermolysis bullosa gene and cell therapies. If a rep claims otherwise, ask for the FDA approval letter.

• Typical settings: −125 mmHg continuous; −75 to −80 mmHg for fragile tissue, grafts, pain or ischaemia.
• FDA contraindications (memorise): malignancy in the wound bed · untreated osteomyelitis · non-enteric and unexplored fistulas · necrotic tissue with eschar present · exposed vasculature, anastomoses, nerves or organs.
• FDA has issued alerts on deaths from bleeding. Foam must never contact exposed vessels or anastomoses.
• The distinction routinely ignored (IWGDF 2023): consider NPWT for post-surgical diabetic foot wounds — but do NOT use it for non-surgical diabetic foot ulcers (strong recommendation against).
• Instillation (NPWTi-d): consensus shifted to normal saline as the default; dwell 10–20 min, then 2–4 h at −125 mmHg. Extra contraindication: never in an unexplored wound.
• Closed-incision NPWT: NICE MTG43 (reconfirmed Sept 2024) supports it for closed surgical incisions in high-risk patients — high BMI, diabetes, renal insufficiency, smoking. Not for routine closure.

Hyperbaric oxygen: defensible for ischaemic/neuro-ischaemic Wagner ≥3 DFU after documented failure of optimal care, plus radiation tissue injury and refractory osteomyelitis. Medicare NCD 20.29 requires all three: diabetes with a lower-extremity wound, Wagner grade III or higher, and ≥30 days of failed standard therapy with no measurable healing. Evidence weak — nearly all positive meta-analyses rest on small unblinded trials, and a 2023/24 HBOT-for-DFU meta-analysis was retracted in 2025 over compromised peer review. Check for retraction notices before citing.

Topical oxygen: IWGDF 2023 moved to "consider as an adjunct where standard care has failed" — the conditional grade was driven by cost, not absence of signal. A US DME LCD was proposed 23 July 2026 and is not final. Promising

Fluorescence imaging (MolecuLight and similar): detects bacterial loads >10⁴ CFU/g. It does not speciate and does not diagnose infection — its real value is targeting sampling and debridement. CPT 0598T/0599T are Category III, so payment is at payer discretion. Useful

Photobiomodulation / low-level laser: a 2026 meta-analysis of 11 RCTs found no significant benefit in venous leg ulcers. IWGDF sweeps physical therapies into a strong "do not use" for DFU. Do not offer as evidence-based

Smart dressings / biosensors: of ~179 studies reviewed, most are preclinical. No sensor-enabled dressing has shown improved patient outcomes in an adequately powered RCT. Hype for 2026 — expect vendor pitches; ask for the RCT.

AI wound apps: genuinely useful for reproducible measurement and auto-documentation (and now for defensible applied-cm² CAMP billing). But Breakthrough Device Designation is not clearance or approval, and Class I registration is not a diagnostic clearance. Neither authorises autonomous clinical decisions.

← swipe table →

Arginine/glutamine reality check: a 2025 systematic review of 15 studies found reported wound-size reductions of 18.6% to 98.2% — that range is not a treatment effect, it describes how wildly inconsistent the studies are. Heterogeneity was so great that only narrative synthesis was possible. HMB is not named in the guideline at all — don't present it as guideline-supported.

Vitamin C: correct deficiency where it exists. No good evidence that supra-physiologic dosing accelerates healing in replete patients — the widely quoted 1–2 g/day mega-doses are not guideline-supported.

Zinc: the American College of Physicians states the evidence is insufficient to determine effectiveness for pressure ulcers. Correct documented deficiency only.

The strongest nutrition interventions are the unglamorous ones: screen everyone (MST, MUST, MNA-SF, NRS-2002), assess those who screen positive, involve a dietitian, and get adequate calories and protein into malnourished patients.

Background pain is present at rest and needs scheduled analgesia plus treatment of the cause. Procedural pain is provoked by the dressing change and needs pre-emptive, time-targeted intervention — standing analgesia alone does not cover it. Score both, every time.

The single highest-yield intervention is dressing selection. Per WUWHS, gauze is the dressing most likely to cause pain.

• Soft silicone / atraumatic contact layers as the default in any painful wound
• Maintain a moist wound bed — dry beds adhere
• Moisten with warm saline before removal; use adhesive removers
• Warm the cleansing solution — cold irrigation hurts and impairs cellular activity
• Irrigate rather than swab. Never scrub the wound bed

Pharmacologic: pre-emptive systemic analgesia timed to peak at the procedure (~30–60 min for oral) · EMLA under occlusion 30–60 min (best evidence in venous leg ulcer debridement) · ibuprofen-impregnated foam · topical morphine gel in palliative care (limited evidence — case series, be explicit about that).

Non-pharmacologic — the most effective is giving the patient control: agree a "time-out" signal they can use at any moment, and honour it immediately. Explain each step before doing it. Let them remove their own dressing if they wish — they control the rate.

Order: pain → odour → exudate and leakage → bleeding → dignity → carer burden.

• Reduce dressing change frequency to the minimum needed — every change is a pain and bleeding event
• Atraumatic silicone contact layers universally. Never gauze directly on a palliative wound
• Larger, more absorbent, longer-wear dressings; accept a "non-ideal" wound bed over painful debridement
• Debridement is usually contraindicated unless it directly relieves a symptom
• Consider whether the wound's odour and appearance let the patient be in the room with their family. That is a clinical outcome

Odour — often the symptom patients rate as most distressing; it drives social isolation. Topical metronidazole 0.75–0.8% gel is the most-used agent (evidence is tentative and it has not been shown to improve overall quality of life). Activated charcoal dressings must be kept dry to work. Medical-grade honey deodorises and desloughs but increases exudate and can sting. Environmental measures help; avoid applying scents to the wound or patient — masking can worsen the association.

Bleeding — prevention first: never let a dressing adhere; moisten before removal; irrigate rather than swab; review anticoagulants with the team.

Escalating ladder: direct pressure 10–15 min → alginate / oxidised regenerated cellulose → topical tranexamic acid or adrenaline 1:1000 on gauze → systemic tranexamic acid → sucralfate paste → palliative radiotherapy (highly effective — refer early) → embolisation.

As the body transitions toward death, perfusion is prioritised to vital organs and the skin — the largest organ — becomes hypoperfused. Tissue ischaemia occurs despite consistently implemented, evidence-based prevention. The SCALE panel (2008/09) agreed these are unavoidable.

Document the prevention that was in place, the clinical decline, and the rapidity of onset — that's what distinguishes an unavoidable end-of-life skin change from a preventable facility-acquired injury.

Honest caveat: KTU has no universally validated diagnostic criteria and the terminology is inconsistently applied. Do not use "Kennedy ulcer" as a shield for inadequate prevention.

• Deep tissue injury is not always reportable. NWCSP says do not report DTI as a pressure ulcer unless the skin breaks or it fails to resolve with palpable deep damage — the skin change must still be documented. NPIAP classifies DTPI as a reportable stage. Dual-reporting organisations should expect discrepancies. (NWCSP Pressure Ulcer Recommendations, 2023/2024; NPIAP staging system.)
• "Category" and "pressure ulcer", not "stage" and "pressure injury." UK uses NPUAP-EPUAP Categories 1–4; unstageable is recorded initially as Category 3 and re-categorised to 4 if debridement reveals bone/tendon/muscle. (NWCSP, 2023.)
• Don't swab a leg ulcer at first presentation — even if you think it's infected. NICE NG152 recommendation 1.1.2. Sample only if worsening or not improving as expected, after cleaning. (NICE NG152, 2020.)
• Preop wash is plain soap. NICE says shower or bathe with soap the day before or day of surgery — not routine antiseptic wash. (NICE NG125, 2019/2020.)
• Advanced dressings on closed surgical incisions are recommended against. WHO pooled 10 RCTs: OR 0.80 (95% CI 0.52–1.23), low quality; hydrocolloid, silver, hydroactive and PHMB each failed to beat plain dressings. (WHO Global Guidelines for the Prevention of Surgical Site Infection, 2nd ed., 2018.)
• Compression class numbers don't cross the Atlantic — or even the Channel. British Standard Class 2 = 18–24 mmHg; European/RAL Class 2 = 23–32 mmHg. US conventions (15–20, 20–30, 30–40) are a third system. Always specify standard and mmHg. (Wounds UK, Primary and Secondary Prevention in Lower Leg Wounds, 2024.)
• Europe wants antiseptic stewardship, not just antibiotic stewardship. EWMA cites efflux pumps (qacA, mexAB-oprM) conferring cross-resistance to antiseptics, antibiotics and heavy metals, and concludes it is important to "monitor and even restrict the use of antiseptics." This is more restrictive than most US/UK sponsored consensus. (EWMA, Antimicrobials and Non-healing Wounds: An Update, 2022.)
• Scotland and Wales are not "the UK" for guidance purposes. NWCSP was an NHS England programme only; Scotland uses SIGN and the Scottish Medicines Consortium, and NICE guidance does not automatically apply there. (NICE / SIGN jurisdictional position, verified Aug 2026.)

Composite: NICE NG125 (2019/2020), NG152 (2020); NWCSP Pressure Ulcer Recommendations (2023/2024); WHO SSI Guidelines 2nd ed. (2018); EWMA (2022); Wounds UK (2024).

• CG179 — Pressure ulcers (2014, reviewed 2018). Reposition at-risk adults at least 6-hourly, high-risk at least 4-hourly. High-specification foam mattress for anyone admitted to secondary care or at high risk in the community. Autolytic debridement first line. Do not: massage skin, give supplements or fluids where intake is adequate, use gauze, routinely use NPWT (only exception: reducing dressing-change frequency in a heavily exuding wound), offer electrotherapy or hyperbaric oxygen, or give systemic antibiotics on a positive swab without clinical infection.
• QS89 — Pressure ulcers quality standard (2015). Risk assessment within 6 hours of admission to hospital or a care home with nursing; at the first face-to-face visit in the community.
• NG19 — Diabetic foot (2015, updated 2019). Inpatient foot problem → MDT foot service within 24 hours. Active problem in the community → refer within 1 working day, triage within 1 further working day. Classify with SINBAD or University of Texas — do not use Wagner. Offer non-removable casting for plantar neuropathic, non-ischaemic, uninfected forefoot/midfoot ulcers. Do not offer hyperbaric oxygen, PRP gel, growth factors or regenerative matrices outside a trial.
• NG152 — Leg ulcer infection (2020). Antibiotics only with signs of infection spreading beyond the ulcer. First choice: flucloxacillin 500 mg–1 g QDS for 7 days. Review any IV by 48 hours. Tell the patient to seek help if not improving in 2–3 days.
• NG125 — Surgical site infection (2019, updated 2020). Never razors — clippers with a single-use head on the day of surgery, if hair must go at all. Alcohol-based chlorhexidine skin prep first choice. Sterile saline for cleansing up to 48 hours, tap water after. Showering safe at 48 hours. Do not use topical antimicrobials on wounds healing by primary intention.
• CG168 — Varicose veins (2013). Source of the rule that a break in the skin below the knee not healed within 2 weeks goes to a vascular service.
• CG147 — Peripheral arterial disease (2012, reviewed 2026). Contains no numeric ABPI cut-off in its recommendations. Prefers manual Doppler over automated systems. Do not exclude PAD in diabetes on a normal or raised ABPI alone.
• MTG43 is now HTG509. NICE merged its device programmes into HealthTech (HTG) in 2025–26 and renumbered: MTG42→HTG502 (UrgoStart), MTG43→HTG509 (PICO), MTG17→HTG334 (Debrisoft), DG52→HTG677 (automated ABPI). NICE states the guidance itself has not changed — only the reference number.
• Only three wound devices are positively recommended by NICE: UrgoStart (HTG502, DFU + VLU), PICO for closed surgical incisions in high-SSI-risk patients (HTG509), and Debrisoft for community debridement (HTG334). SEM Scanner, Mepilex Border Heel/Sacrum, Parafricta, Prontosan and VAC Veraflo are all "research only." A NICE Medtech Innovation Briefing is not guidance and not a recommendation at all.
• HTG751 (2025) — topical antimicrobial dressings for locally infected leg ulcers. Not enough evidence to say whether price variation between agents is justified: NICE cannot separate silver, iodine, honey, PHMB or DACC on outcomes. If more than one is appropriate, choose the least expensive.
• HTG758 (2025) — compression products for VLU. A price premium for hosiery over bandaging is justified; a premium for wraps is not, unless a wrap is the only suitable option. Providers must still give access to wraps.

NICE: CG179 (2014, rev. 2018); QS89 (2015); NG19 (2015, upd. 2019); NG152 (2020); NG125 (2019, upd. 2020); CG168 (2013); CG147 (2012, rev. 2026); HTG502/509/334/677/751/758 (2019–2025).

• Leg ulcer = on or above the malleolus, below the knee, not healed within 2 weeks. Below the malleolus is a foot ulcer on a different pathway. (NWCSP Leg Ulcer Recommendations, 2023.)
• Comprehensive assessment within 14 days of presentation, including ABPI and/or toe pressure index.
• Mild compression first, while you wait. If no red flags and low risk of pressure damage over bony prominences, apply ≤20 mmHg at the ankle before full assessment. NWCSP states plainly that this is based on clinical expert consensus, not trial evidence.
• Then ≥40 mmHg at the ankle once venous aetiology and adequate arterial supply are confirmed — hosiery first line where possible; bandaging preferred for chronic oedema not reduced by elevation, abnormal limb shape, copious exudate or very fragile skin.
• ABPI triggers. <0.5 → urgent vascular referral on the CLTI pathway. >0.5 → vascular referral, continue mild ≤20 mmHg if oedematous with no limb-threatening ischaemia. >0.8 with uncertain aetiology → consider strong compression pending specialist opinion. Toe pressure ≥60 mmHg indicates adequate perfusion to heal.
• Measure ankle circumference at every visit — it drives the compression regime and tracks oedema reduction.
• 4-weekly review; 12-week comprehensive reassessment. No significant progress at 4 weeks → escalate. Benchmark: ≥75% of uncomplicated VLUs heal within 24 weeks. This 4/12-week rhythm applies to leg, foot and pressure ulcers alike.
• Foot ulcer clocks (2024 document). Diabetic foot ulcer found on admission → refer within 24 h, assess within 24 h of referral. Diabetic foot ulcer elsewhere → refer within 1 working day, assess within 2 working days. Non-diabetic foot ulcer → refer within 1 working day, assess within 7 working days. The whole point of the 2024 split from leg ulcers was to give non-diabetic foot ulcers a rapid pathway they never had.
• Surgical wound complications (2024). Usually reported around days 7–9 post-surgery, range day 1 to day 20 or later after implant surgery. Refer to the surgical team within 24 h for local infection, implant-related dehiscence or exposed implant; within 72 h for dehiscence exposing fascia, suspected sinus/fistula, draining seroma or peri-stoma dehiscence. Perianal abscesses: after intraoperative packing is removed in the first 24 h, do not repack. Scar aftercare: emollient up to 4× daily and factor 50 for a minimum of 12 months, ideally 24.
• Pressure ulcers. PURPOSE-T is the named screening tool. Screening combines skin temperature, skin texture, patient-reported pain and visual assessment — "particularly important when considering skin of dark colour and tone." Care bundle is aSSKINg. All Category 3 and 4 ulcers should be considered for surgical revision against five explicit criteria. Red flag: a fall with a "long lie" of more than 1 hour on the floor.
• Practical caveat: the NWCSP closed in March 2025 and nationalwoundcarestrategy.net was returning HTTP 503 in August 2026. The documents survive only on NHS trust and professional-society mirrors — if your policy links to the original site, download and host the PDFs locally.
• Reality check on the 14-day target: NWCSP's own implementation evaluation reported only 45% of patients assessed within 14 days at first-tranche sites — the ones specifically resourced to hit it. (NWCSP implementation evaluation, 14 Aug 2024.)

NWCSP / NHS England: Leg Ulcer Recommendations (2023); Foot Ulcer Recommendations (15 July 2024); Pressure Ulcer Recommendations and Clinical Pathway (Oct 2023, updated May 2024); Surgical Wound Complications Recommendations (2 May 2024); implementation evaluation (Aug 2024).

• The strong recommendations are a short list. Mupirocin 2% intranasal ± chlorhexidine body wash for known nasal S. aureus carriers in cardiothoracic/orthopaedic surgery; no mechanical bowel prep alone in elective colorectal surgery; never shave (clippers only if hair must be removed); prophylaxis before incision and within 120 minutes of it; surgical hand preparation; alcohol-based chlorhexidine skin prep; and prophylaxis must not be prolonged after the operation ends — not for drains, not "until the drain comes out."
• Conditional and against: advanced dressings on primarily closed incisions, antibiotic incisional irrigation, plastic adhesive incise drapes, antimicrobial sealants, laminar airflow for arthroplasty. Conditional and for: prophylactic NPWT on high-risk closed incisions, triclosan-coated sutures, wound protector devices, aqueous povidone-iodine incisional irrigation before closure, intraoperative warming, glucose control in diabetic and non-diabetic adults.
• Most WHO SSI recommendations are conditional and rest on low or very low quality evidence — that is WHO's own grading, not editorialising.
• WHO's own wound infection protocol (2013) is short and blunt: never close an infected wound; do not close contaminated wounds or clean wounds more than 6 hours old — leave open and close at 48 hours (delayed primary closure); debride within 8 hours if possible; antibiotics are "necessary but not sufficient" because they do not reach the wound bed; topical antibiotics and antibiotic wound irrigation are not recommended.
• Tetanus-prone wound = treated >6 h after injury, or at any interval with puncture wound, significant devitalised tissue, sepsis, soil/manure contamination, burns, frostbite or high-velocity missile injury. TIG 250 units IM, raised to 500 units if the wound is over 12 hours old, heavily contaminated, or the patient weighs >90 kg. (WHO, 2013.)
• Rabies-risk bites: wash for at least 15 minutes with soap and copious water before anything else. Antiseptic afterwards is an additional precaution, not a substitute. (WHO Rabies fact sheet, 5 Jun 2024.)
• Irrigate with the whole litre. WHO/ICRC frontline teaching: flush with at least 1 litre of clean water under pressure — improvise with a syringe and 14 G needle, or a hole poked in a squeezed bottle. Check capillary refill and sensation beyond the wound before and after dressing. (WHO/ICRC Basic Emergency Care, 2018.)
• Burns: start fluids at ≥15% TBSA in adults, ≥10% in children; Parkland 4 mL × kg × %TBSA, first half in the first 8 hours from the time of the burn, not from arrival; superficial burn area is not counted. Do not use ice; do not apply paste, oil or turmeric. WHO states "cool running water" with no duration — the familiar "20 minutes" comes from burn-specialty bodies, not WHO. (WHO/ICRC BEC 2018; WHO Burns fact sheet, 13 Oct 2023.)
• The burden numbers: SSI is the most frequent healthcare-associated infection in LMIC hospitals — 5.9 per 100 operations, and 11.7% after caesarean section versus 2.9% in Europe. 15 per 100 patients acquire an HAI in LMIC acute care versus 7 per 100 in high-income countries. (WHO Global Report on Infection Prevention and Control, 2024.)
• Potable water is a defensible cleansing fluid when saline is unavailable — but Cochrane rates all the evidence low or very low certainty. That is "no signal of harm in weak evidence," not proven equivalence. (Cochrane CD003861, 2022.)
• Two things WHO does not have: any pressure injury guideline, and any diabetic foot ulcer guideline. Do not cite "WHO" for pressure ulcer staging or repositioning — that is EPUAP/NPIAP/PPPIA territory, and IWGDF for the diabetic foot.
• Hypochlorous acid was rejected for the Essential Medicines List for topical antisepsis and wound care — twice (2021 and 2025) on inconclusive evidence. It was added in 2025 only as an environmental disinfectant. If a rep says WHO endorses HOCl for wounds, that is false. (WHO Expert Committee on Essential Medicines, 2025.)

WHO: Global Guidelines for the Prevention of SSI, 2nd ed. (Dec 2018); Prevention and Management of Wound Infection (2013); WHO/ICRC Basic Emergency Care (2018); Rabies fact sheet (2024); Burns fact sheet (2023); Global Report on IPC (2024); Model List of Essential Medicines, 24th list (2025). Cochrane CD003861 (2022).

• The 2 cm rule is the decision point. Erythema and inflammation confined to the wound plus <2 cm of periwound = local infection, manage topically. ≥2 cm from the wound edge = spreading infection, systemic antibiotics. This aligns exactly with IWGDF/IDSA diabetic foot grading — a rare piece of cross-framework consistency.
• "Critical colonisation" is dead. Retired in 2016 and still retired: the idea of a threshold moment at >10⁵ CFU/g "was not representative of the science." If a local policy still uses the term, that policy predates 2016 thinking.
• Covert (subtle) local infection replaced it — and it is the WOCN-level catch: hypergranulation, bleeding or friable granulation, epithelial bridging and pocketing, increasing exudate, and healing delayed beyond expectations. Overt signs are the classic five plus new or increasing pain and increasing malodour.
• Suspect infection on multiple signs, not one. IWII states clinical signs "have been reported to be inaccurate and unreliable" — CSSC individual signs run sensitivity 0.18–0.81, specificity 0.56–1.00. Overt signs may be masked by immunosuppression or poor perfusion.
• The IWII-WIC has not itself been psychometrically validated. IWII says so. It is a conceptual model and teaching tool containing signs validated in other instruments — say that out loud when someone calls it "validated."
• Swab only when there are spreading or systemic signs; the wound has failed to respond to appropriate antimicrobial treatment; a local surveillance protocol requires it; or a species would negate surgery (e.g. beta-haemolytic streptococci before grafting). Immunocompromised patients: also consider sampling local infection or delayed healing.
• Levine technique, and two swabs. Cleanse with warm sterile saline → debride → re-cleanse → moisten the swab → pick the cleanest area of the wound bed → press firmly and rotate over 1 cm² to express fluid from the tissue. First swab for Gram stain (result in hours), second into transport medium (culture 24–48 h). Levine beat the Z-technique in Gardner 2006 (accuracy 0.80) and Angel 2011. Tissue biopsy or curettage remains preferred.
• Biofilm cannot be seen. IWII is explicit that shiny or slimy surface material does not identify biofilm and that there is no gold-standard sampling method. Infer it from behaviour: antimicrobial failure, recurrence on stopping treatment, delayed healing despite optimal care, increased exudate, low-level chronic inflammation, friable hypergranulation.
• Biofilm-based wound care sequence: debride → refashion the wound edge → re-cleanse → apply a topical antimicrobial → repeat. Step down as it improves, step up when it stalls.
• The 2-week challenge: use a topical antiseptic for at least 2 weeks before evaluating its efficacy; full response in many chronic wounds takes 4 weeks or longer. Rotating antiseptics on a 2- or 4-week cycle is "popular" — IWII says further research is required to support it.
• Stop using in open wounds: hydrogen peroxide, traditional sodium hypochlorite (EUSOL, Dakin's) and chlorhexidine, "due to the risk of tissue damage." Sole exception is under-resourced settings with nothing else available.
• In-vitro biofilm kill claims do not translate. Lab contact time is often 24 hours or more; clinical contact during cleansing is 10–15 minutes. IWII Table 14 reports clinical biofilm outcomes for exactly two agents.
• Irrigation numbers (IWII 2025, the newer figures): 8–15 PSI — a 35 mL syringe with a 19-gauge angiocatheter, explicitly safer than a needle; 50–100 mL per centimetre of wound length; warm to body temperature; never microwave the solution. Cleanse surrounding skin and periwound first, then the wound bed from most vulnerable to least vulnerable region — which reverses what many nurses were taught.

International Wound Infection Institute, Wound Infection in Clinical Practice: Principles of Best Practice, 3rd ed. / International Consensus Update (Wounds International, 2022); IWII, Therapeutic Wound and Skin Cleansing: Clinical Evidence and Recommendations (Wounds International, 26 Mar 2025); Haesler et al., J Wound Care 2022;31(Sup12):S48–59.

• Wound Hygiene is four steps at every dressing change: cleanse (bed and periwound), debride, refashion the wound edges to pinpoint bleeding, dress. The one hard number: when cleansing periwound skin, cover the area 10–20 cm from the wound edge, or whatever the dressing covers, whichever is larger. Statement 2: assume all hard-to-heal wounds contain biofilm. Statement 17: antimicrobial dressings alone are not sufficient to disrupt and remove biofilm.
• The two-week antimicrobial challenge, operationalised. Use an antimicrobial dressing for a minimum of 2 weeks, then: discontinue if signs resolved; continue if progressing but signs remain; consider an alternative and refer to a wound care specialist if there is no improvement. (Wounds UK AMS BPS, 2nd ed., 4 Nov 2025.)
• Antimicrobials should not be used precautionarily on a clinically uninfected wound. Stated exceptions: suspected infection in a diabetic foot ulcer, and suspected SSI with cellulitis. Routine swabbing without clinical indicators "is neither helpful nor cost-effective."
• Bilateral "red legs" are almost never cellulitis. "Bilateral leg cellulitis is extremely rare." Bilateral red legs are usually varicose or gravitational eczema, contact dermatitis or tinea pedis — they will not respond to antibiotics, and the treatment is usually compression. This is the highest-yield teaching point in the UK lower limb literature.
• The Atkin & Tickle lower limb pathway: within 24 hours of presentation, cleanse and apply <20 mmHg compression; within 14 days, full holistic assessment with ABPI. Then act on ABPI — <0.5 urgent vascular referral and stop compression; 0.5–0.8 mixed disease, refer, continue <20 mmHg; 0.8–1.3 requires at least 40 mmHg; >1.3 consider calcification and check waveform. No reduction in ulcer size or limb volume at 4 weeks → refer. Unhealed at 12 weeks → refer.
• Under-compression is the commonest failure mode. "Mild compression may only be suitable for less than 10% of a caseload and can be used inappropriately, especially when full compression is clinically indicated." First-aid compression up to 20 mmHg is a holding position for a maximum of 2 weeks.
• Compression terminology: mild <20 mmHg, moderate 20–40, strong 40–60, very strong >60 mmHg at the ankle. All compression hosiery kits are designed to deliver 40 mmHg at the ankle. Re-measure and replace usually every 3–6 months.
• Wraps lost. VenUS 6 (637 patients, 33 UK sites, PLOS Medicine 2026): 12-month cumulative healing 79.4% four-layer/hosiery, 80.1% two-layer bandage, 76.2% wraps. Wraps vs evidence-based compression HR 0.78 (0.61–1.00, p=0.046) — they heal slower. Two-layer bandage was confirmed non-inferior. Wraps remain defensible on self-care and concordance grounds, not on time-to-healing.
• Skin tears (ISTAP 2nd ed., 2025): Type 1 no skin loss, Type 2 partial flap loss, Type 3 total flap loss. Twice-daily moisturiser reduces skin tear incidence by 50%. Expect healing in 14–21 days, or before 4 weeks. Remove dressings in the direction the flap lies. Routine or preventative topical or systemic antimicrobials are not indicated. If the wound extends past subcutaneous tissue it is no longer a skin tear.
• MASD (Wounds UK, 2025): normal skin surface pH is 4.5–5.5; urease-producing bacteria convert urinary urea to ammonia and push it alkaline — hence pH-balanced no-rinse cleansers, not soap. Categorise IAD with GLOBIAD (1A/1B/2A/2B, the B categories denoting infection signs). Pat dry, do not rub. ICD-11 recognises MASD under EK02.2 for the first time — but the UK and US still code in ICD-10, so it is not yet usable.
• Dark skin tones: compare affected with adjacent skin; palpate for warmth, swelling and raised areas; look for subtle darkening, texture change or loss of normal skin markings rather than erythema; ask about itch, burning and tingling. Erythema may present purple, maroon or dark red. (Wounds UK, Addressing Skin Tone Bias in Wound Care, 2021; Wounds International, Wound Care and Skin Tone, 2023.)

Murphy C, Atkin L, Swanson T et al., Wound Hygiene international consensus, J Wound Care 2020;29(Sup3b); Wounds UK, Antimicrobial Stewardship Strategies for Wound Management, 2nd ed. (2025); Wounds UK, Holistic Management of Venous Leg Ulceration, 2nd ed. (2022) and Effectively Assessing ABPI (2024); Kerr, Mosti & Vowden, Demystifying Mild, Moderate and High Compression Systems (Wounds International, 2020); ISTAP, Skin Tears in Aged Skin, 2nd ed. (2025); Wounds UK, MASD (2025); Arundel C et al., VenUS 6, PLOS Medicine 2026;23(7):e1005154.

• EWMA's treat/don't-treat rule: if the wound is not clinically infected and there is no clinical or epidemiological reason to culture, do not culture and give no antimicrobial. If infected, take a tissue specimen where possible, start empirical therapy by severity, then narrow. Duration: shortest necessary — 1–2 weeks for most, longer only for bone, foreign body, or deep/extensive infection.
• Antiseptics for mild infection; never topical antibiotics. EWMA cites recommendations that topical antibiotics are contraindicated for treating non-healing wounds, and notes higher consumption tracks higher resistance.
• Antimicrobial efficacy is "almost exclusively evaluated in vitro in planktonic bacteria." Standardised wound-biofilm test methods exist but are not used in patient care. That is EWMA's own sentence, and it is the cleanest available rebuttal to dressing packaging claims. (EWMA 2022; Maillard, Kampf & Cooper, JAC-AMR 2021.)
• EWMA's debridement pathway says when not to debride: non-healing wounds with inadequate perfusion or an uncorrected underlying cause; suspected atypical wounds (pyoderma gangrenosum, vasculitis, malignancy — involve a dermatologist); dry eschar on foot, fingers or calcaneus even in well-perfused limbs; older patients, palliative situations and very young children. If a wound is clean and progressing, stop debriding. If it is not progressing after debridement, review the diagnosis before changing technique.
• NPWT numbers: standard negative pressure 75–125 mmHg (up to 200 mmHg only as a single-indication exception); foam pore size ~400 microns; dressing changes "only necessary every two to three days." Instilling antibiotics is for "extremely selected indications and should not be used as routine practice." (EWMA NPWT update, 2024.)
• Closed-incision NPWT is one of the only high-certainty findings in wound care: 57 RCTs, 13,744 patients, RR 0.67 (95% CI 0.59–0.76), GRADE high certainty, with trial sequential analysis indicating further trials are unlikely to change the estimate. (Reported in EWMA NPWT, 2024.)
• Community NPWT is an organisational problem, not a technology one. Of 22 European countries responding, 97% use NPWT in primary care — but in 60% the hospital staff still perform it. EWMA's 2017 prediction that outpatient NPWT would expand did not happen, and the document says so.
• EWMA lower leg ulcer vascular thresholds (2023): normal ABI 0.9–1.4; refer to vascular for a wound with ABI <0.6 or TBI <50 mmHg ("mandatory for limb salvage"); TBI <30 mmHg is incompatible with healing without revascularisation; ABI >0.8 permits full compression; ABI 0.6–0.8 means modified compression under close supervision. EWMA itself flags that guidelines disagree at the 0.5 vs 0.6 mark. Skin temperature <27 °C impairs perfusion readings, and 5–10% of people have alternative pedal artery anatomy.
• The pressure injury guideline citation trap. The EPUAP/NPIAP/PPPIA 4th edition launched free online on 27 February 2025 — but as of August 2026 only the prevention chapters are published. For treatment, classification, wound bed preparation, debridement, infection management and dressings, the 2019 3rd edition is still the current international reference. Cite 2019 for treatment, 2026 for prevention, and say which.
• What changed in prevention (4th ed., 2026): either 2-hourly or 3-hourly repositioning may be used for most at-risk individuals if they are on an appropriate pressure-redistribution surface — conditional, very low certainty. Do not routinely extend to 4, 5 or 6-hourly. 30° lateral tilt, but 40° may be needed at higher BMI, and in pre-adolescent children a 30° turn is equivalent to a full body turn. Head of bed ≤30°.
• Only two strong recommendations in the whole prevention set: use a reactive foam full-body support surface, and do not tube-feed for the specific purpose of preventing pressure injuries. The second is the one most likely to contradict local practice.
• Read the signal in what is coming: debridement, cleansing, infection management and dressings will be handled in the 4th edition as Good Practice Statements, not GRADE recommendations — an explicit admission that the evidence does not support graded recommendations there.

EWMA: Antimicrobials and Non-healing Wounds: An Update, J Wound Manag 2022;23(3 Sup1); Lower Leg Ulcer Diagnosis & Principles of Treatment 2023;24(2 Sup1); Negative Pressure Wound Therapy: An Update 2024;25(2 Sup1); Wound Debridement Pathway (12 Sep 2025); Local Wound Infection Fact Sheets (2025). EPUAP/NPIAP/PPPIA, Prevention and Treatment of Pressure Ulcers/Injuries: The International Guideline, 3rd ed. (2019) and 4th ed. prevention QRG (Haesler E, ed., 2026).

IWII wound infection continuum (2022)

← swipe table →

Compression classes — the three systems do not match

← swipe table →

A British Standard Class 2 is roughly a European Class 1. Always specify the standard and the mmHg on the prescription.

Cross-guideline timings cheat sheet

← swipe table →

Composite of the sources cited in the cards above.

• Almost nothing in wound care carries high-certainty evidence. The exceptions surfaced across all these bodies are closed-incision NPWT for reducing SSI (GRADE high), honey for partial-thickness burns (Cochrane high, ~4–5 days faster than conventional dressings), and the EPUAP/NPIAP strong recommendation against tube feeding for pressure injury prevention.
• "Strong recommendation" ≠ "high certainty." The 4th-edition strong recommendation for reactive foam support surfaces rests on low certainty evidence. Read both columns.
• No dressing type has demonstrated superiority for standard care of chronic wounds. NICE ESMPB2 (2016), NWCSP (2023) and NICE HTG751 (2025) reach that conclusion independently. Simple low-adherent with sufficient absorbency is the defensible default. NICE ESMPB2 adds: silver dressings only when there are clinical signs or symptoms of infection.
• No bedside biofilm test exists. Every "biofilm indicator" in current guidance is an inference from treatment failure. Prevalence figures across current consensus documents are mutually inconsistent — 60% chronic vs 6% acute; "almost 80%"; "up to 10% acute and 60% chronic." Do not quote a precise number.
• The NWCSP mild-compression-first rule is self-declared expert consensus, and the 20 mmHg figure is a WUWHS definition of "mild graduated compression" intended to illustrate rather than specify. A reasonable risk trade-off, not a trial finding.
• Cost-of-wounds figures should be handled with tongs. NICE itself quotes a range from £102 million to £3.2 billion per year for the same condition (leg ulcers). A 30-fold spread is a warning about the literature, not a fact about the disease.
• Two claims flagged unverified in the underlying research and carried forward as such: that NICE set a PAD upper ABPI diagnostic threshold of 1.4 in 2025 (asserted in a 2026 Wounds UK article; no NICE document supports it, and CG147 contains no numeric ABPI thresholds at all); and the "≥3 °F versus the mirror-image limb" temperature cut-off attached to the T in STONEES (no primary source found — do not put a number on it).

NICE ESMPB2 (2016), HTG751 (2025); NWCSP (2023); IWII (2022); EWMA (2022); EPUAP/NPIAP/PPPIA 4th ed. (2026); Jull AB et al., Cochrane CD005083 (2015); WHO SSI 2nd ed. (2018).

• Wounds Canada BPR 2025 replaced "Foundations." Best Practice Recommendations for Skin Health and Wound Management 2025 (13 chapters, published 10 Feb 2025) supersedes the 2017–2021 Foundations series still sitting on hospital intranets. New chapters: lymphedema, and skin anatomy/physiology. It carries no evidence grading at all — no GRADE, no strength labels. It is a practice framework, not an evidence synthesis. Cite it as expert consensus.
• Healability is the single most exportable Canadian idea. Every wound is classed healable (capacity to heal, cause correctable, adequate perfusion → moisture balance and active debridement), non-healing/maintenance (capacity exists but patient or system factors block it), or non-healable (inadequate perfusion or uncorrectable cause → palliative goals: pain, odour, exudate, bacterial reduction, moisture reduction, not moisture balance). Sibbald's 2025 estimates: roughly two-thirds healable, a quarter maintenance, 5–10% non-healable — expert orientation, not registry data.
• The audible handheld Doppler as a compression gate. WBP 2021's headline change: a multiphasic (bi/triphasic) audible waveform over dorsalis pedis or posterior tibial lets you start compression today — no cuff, no ABPI. Validation against a certified vascular lab (379 legs): specificity for excluding disease 98.6% PT / 97.8% DP, but sensitivity for diagnosing it only 37.5% / 30.2%. Read it correctly — rule-out only. Monophasic or absent means formal studies, not a diagnosis. Value: it is unaffected by calcification, and up to 80% of people with diabetes have falsely elevated, useless ABPIs.
• NERDS and STONEES, mapped onto IWII. ≥3 NERDS (Non-healing, Exudate, Red friable granulation, Debris, Smell) = superficial/covert infection → topical antimicrobial. ≥3 STONEES (Size increasing, Temperature +3°F vs the mirror-image site on the other limb, Os/probe-to-bone, New satellite breakdown, Exudate, Erythema/Edema, Smell) = deep and surrounding/overt → systemic. Four of the seven STONEES criteria describe the surrounding tissue. Cellulitis is not always present and erythema is unreliable in skin of colour and in oedema — do not require it.
• Release vs non-release antimicrobials — a distinction product literature blurs. Non-release dressings (PHMB gauze/foam) act above the wound surface and cannot reach the superficial compartment. Treating that compartment needs an agent that releases onto the surface (silver, iodine). Topical antimicrobials penetrate only a few millimetres — which is exactly why STONEES triggers systemic therapy.
• The 2025 therapeutic index addition. Hypochlorous acid had the highest therapeutic index (kill vs host-cell toxicity) against Pseudomonas, S. aureus and E. coli; PHMB highest against MRSA. Nuance the marketing drops: early on you may deliberately pick a lower-index agent with a better bactericidal concentration against the likely pathogen, then step down to saline or potable water once bioburden is controlled. This is a laboratory index with no clinical outcome evidence attached.
• Stall triggers. WBP Statement 8: a wound not at least 20–40% smaller by week 4 is unlikely to heal by week 12. Canadian VLU consensus 2025: no size reduction in 2–4 weeks, or <30% at 4 weeks → re-verify the diagnosis first, then check whether the protocol was actually implemented.
• Honest evidence reading. RNAO's Pressure Injury Management 4th ed. (Nov 2024) is Canada's only GRADE-rated wound guideline — and every single graded recommendation is conditional, with low or very low certainty. Repositioning (Rec 2.0, every 2–4 hours) rests on evidence that cannot distinguish 2- from 4-hourly. RNAO explicitly made no recommendation on powered support surfaces. Prophylactic silicone foam works (RR 0.25) but caused 33 adverse device events in 28 patients in one RCT, including skin tears and two falls from heel dressings contacting the floor.

Wounds Canada, Best Practice Recommendations for Skin Health and Wound Management 2025. Sibbald RG et al., Wound Bed Preparation 2021, Adv Skin Wound Care 2021;34(4):183–195; WBP 2024 Delphi (resource-limited settings), Adv Skin Wound Care 2024;37(4):180–196; Sibbald & Gregory, Practice Points, Adv Skin Wound Care 2025;38(1):53–55; Geng/Sibbald/Slomovic therapeutic index systematic review, same issue. RNAO, Pressure Injury Management 4th ed., 2024. Stacey MC et al., Canadian Consensus Statement for the Management of Venous Leg Ulcers, Int Wound J 2025;22(4):e70415.

• What it is. Australian Standards for Wound Prevention and Management, 4th edition, 2023 (Haesler & Carville, eds.; Cambridge Media for AHRA, Wounds Australia and WAHTN; ISBN 978-0-6487313-5-1). Free download. The 2016 third edition had 6 standards; the 4th has 8, with 60 criteria. The genuinely new material is Standard 8.
• The eight standards. 1 Scope of practice · 2 Collaborative practice · 3 Wound assessment · 4 Wound prevention · 5 Wound treatment · 6 Documentation · 7 Knowledge, education and research · 8 Digital platforms and technologies (telehealth, wound photography, social media) — no other national wound standard in the world has a dedicated digital standard.
• Two streams per standard, and this is the useful part. Every criterion is labelled WP (the individual wound practitioner) or WSP (the wound service provider/organisation). You are audited as a clinician against WP criteria; your employer is audited against WSP criteria. Criteria counts:

← swipe table →

• The Standards deliberately contain no numbers. No ABI cut-offs, no repositioning intervals, no dressing-change frequencies. They are consensus-level practice architecture with source-type codes (EBG/C/P) rather than GRADE ratings. If a vendor tells you "the Australian Standards require ABI >0.8 before compression," that is false — the number lives in the VLU guideline, not here.
• Where the numbers do live. Pressure injury: the international NPIAP/EPUAP/PPPIA guideline — PPPIA is the ANZ co-custodian, so there is no separate current ANZ pressure injury CPG. The 4th edition's 2025 Repositioning chapter now says 2-hourly or 3-hourly are both acceptable on an appropriate support surface, and suggests not routinely extending to 4, 5 or 6 hourly — both conditional. VLU: the Pan Pacific Clinical Practice Guideline for Venous Leg Ulcers: Assessment, 2nd ed. 2025 (Australia + NZ + Hong Kong + Singapore), which is 14 good practice statements and zero graded recommendations, and covers assessment only — the prevention and treatment instalments are not yet published.
• The Australian diabetic-foot table worth stealing. The 2021 Australian DFD wound-healing guideline is unusually blunt: sharp debridement Strong; "dressings should be selected principally on exudate control, comfort and cost" Strong; and "do not use dressings containing surface antimicrobial agents with the sole aim of accelerating healing" — Strong. It recommends against growth factors, bioengineered skin, ozone, topical oxygen, topical CO₂, nitric oxide, electricity, magnetism, ultrasound, shockwave, and NPWT for non-surgical DFU.
• The funding change with real clinical effect. Australia's Chronic Wound Consumables Scheme launched June 2025 (~A$50M): full cost of dressings and bandages, delivered free to the home, for people with diabetes plus a chronic wound aged 65+ (50+ for First Nations people). It removes the cost constraint from "choose on exudate, comfort and cost." New Zealand has no verified national equivalent.

Wounds Australia / AHRA / WAHTN, Australian Standards for Wound Prevention and Management, 4th ed., 2023. NPIAP/EPUAP/PPPIA International Guideline 4th ed. (Repositioning chapter v. 25 Feb 2025). VLU Guideline Committee, Clinical Practice Guideline for Venous Leg Ulcers: Assessment, 2nd ed., 2025. Chen P, Carville K, Swanson T et al., Australian guideline on wound healing interventions, J Foot Ankle Res 2022. Australian Dept of Health, Chronic Wound Consumables Scheme, 2025.

• Why it matters. DESIGN-R® has been mandated in Japan's national fee schedule since 2013 as the assessment tool for every inpatient with a pressure ulcer. It is the only widely used PU instrument that is simultaneously a severity classifier and a validated healing predictor with published cut-offs. Created by the Japanese Society of Pressure Ulcers (JSPU) in 2002; "R" was added in 2008 and stands for Rating — the items were evidence-weighted so scores are comparable between patients, not just within one.
• How it actually scores. Seven items spell the name. Lowercase = milder, UPPERCASE = severe. Depth is recorded but never added to the total. Total range 0–66; higher is worse.

← swipe table →

• How it is written in the chart. Hyphen after depth, then the six scored items, then a colon and the total. JSPU's own worked examples: D3-e1s6i0g3n3p0 : 13 · DDTI-e0S15i1g0n0p0 : 16 · D3-E6s6I3CG6n0p0 : 21. Site is recorded separately (sacrum / ischium / greater trochanter / calcaneus / other).
• The prediction numbers — this is why it is more than paperwork. Pooled analysis of two multicentre cohorts, n = 3,196: adjusted hazard ratio for healing 0.90 (0.89–0.92) per point of total score, independent of patient characteristics, setting, depth and location. AUROC 0.81 for healing within 30 days, 0.74 for 30–90 days. Cut-off for healing within 30 days: total 9 (PPV 78.8%, NPV 74.1%). For 30–90 days: total 18 (PPV 63.9%, NPV 81.1%).
• Weekly change predicts healing better than any single score. Multicentre cohort: per 1-point improvement, HR for healing in the next 30 days 1.16–1.33 (superficial) and 1.21–1.27 (deep). Optimal thresholds: superficial ulcers — any improvement at all; deep ulcers — improvement of ≥2 points per week. Bedside translation: score weekly; a deep ulcer that has not gained 2 points in a week is your escalation trigger, not a reason to wait a fortnight.
• What changed in 2020, and the deliberate design choice. Exactly two additions: DDTI (suspected deep tissue injury, judged on inspection, palpation and supporting data — history, bloods, imaging) and 3C (suspected critical colonisation: slimy wound surface, copious exudate, oedematous friable granulation if any). Both were added without changing any point weights — DDTI contributes 0, and 3C scores exactly the same 3 points as overt infection — so totals stay comparable with two decades of prior DESIGN-R data. JSPU states outright that the evidence for both phenomena is thin and re-weighting is future work.
• Two things that will surprise a US nurse. First, DESIGN-R deliberately re-scores depth downward as a wound improves — the opposite of the NPIAP "never back-stage" rule, because Depth is a description, not the score. Second, scoring 3C means you manage the wound as infected, pre-emptively, on biofilm reasoning — JSPU admits clinicians currently diagnose critical colonisation retrospectively (a wound stalled ≥2 weeks with no visible infection that then responds to antiseptics).
• JSPU's DTI red flag. A mud-like floating sensation, pus collection or crepitus over a pressure ulcer should prompt serious consideration of necrotising soft-tissue infection. Adjuncts JSPU recommends for suspected DTI: point-of-care ultrasound with a linear probe ≥8 MHz; thermography (a DTI-suspicious dark-purple area is typically cooler than surrounding skin); serum CK as a marker of muscle involvement; and daily serial physical assessment, because true depth only declares itself over time.

JSPU, DESIGN-R®2020 褥瘡経過評価用 (official form) and 改定DESIGN-R®2020 コンセンサス・ドキュメント, Shorinsha, Dec 2020, ISBN 978-4-7965-2524-4. Sanada H, Iizaka S, Matsui Y et al., Wound Repair Regen 2011;19(5):559–67. Iizaka S et al., Wound Repair Regen 2012;20(4):473–81.

• Japan treats pressure ulcers with prescription ointments, not dressings. There is a licensed "skin ulcer treatment drug" (皮膚潰瘍治療薬) class. Agents in routine Japanese use that you cannot obtain in the US: trafermin (recombinant human bFGF spray, MHLW-approved April 2001), bucladesine sodium (dibutyryl cAMP, favoured for oedematous/high-exudate beds), alprostadil alfadex (PGE₁ ointment), and povidone-iodine sugar paste (U-Pasta). Cadexomer iodine and silver sulfadiazine are the two that travel.
• The structural cause is reimbursement, and it is instructive. Japanese dressings are regulated by wound depth (dermis / subcutaneous / muscle-bone categories) and claimable for 2 weeks standard, 3 weeks with written justification. Ointments are dispensed as drugs with no equivalent ceiling. A Japanese ward simply cannot run a foam dressing for six weeks the way a US ward does — so the algorithms became ointment-centric, with the ointment base (oleaginous vs emulsion vs water-absorbing) doing the moisture management that a dressing does in Western practice.
• The reimbursement levers are a case study in changing national practice. 2002: a deduction from the inpatient basic fee for facilities with no pressure ulcer programme. 2006: a high-risk pressure ulcer care add-on requiring a designated full-time pressure ulcer manager — in practice the Japanese WOC nurse — which made a specialist wound nurse financially self-justifying. 2013: DESIGN-R® mandated. National point-prevalence fell across four surveys (662,419 patients, 2,631 facilities): 2.67% (2006) → 2.61% (2010) → 1.99% (2013) → 1.79% (2016).
• A second Japanese scale worth knowing: IAD-set. From JWOCM. "set" = Skin, Excrement, Tool. Eight sites inspected in the order you actually examine a bottom (perianal, natal cleft, L buttock, R buttock, genitals, lower abdomen/pubis, L groin, R groin), each scored for skin damage (0 none / 1 erythema / 2 erosion / 3 ulcer) plus suspected candidiasis (0/1); then stool (none/formed/soft/watery, 0–3) and urine (none/normal/suspected infection, 0–2) scored once. Total = sites + excreta. Honest reliability: JWOCM's own study of 307 raters found mean agreement of only 71.4% on the skin-damage item (84.1% on candidiasis) — trust serial scores by the same assessor far more than cross-assessor comparisons.
• The Japanese evidence appraisal that travels even when the drugs don't. The Japanese Dermatological Association's Wound, Pressure Ulcer and Burn Guidelines (2023), published in English in J Dermatol 2025, used GRADE properly. All four questions carrying meta-analyses — debridement, topical medication, dressings and NPWT — produced weak recommendations. That is the most current and most honest appraisal of pressure ulcer treatment evidence coming out of the region.
• Also genuinely Japanese: "wrap therapy" (ラップ療法). Covering wounds with non-sterile commercial food wrap, mostly in home care where reimbursable dressings can't be sustained. JSPU rated it C1 — may be considered only where approved dressings are unavailable, only under a knowledgeable physician's supervision, and only with informed patient and family consent. Evidence: one RCT (no significant difference) and two non-randomised trials.

JSPU, Guidelines for the Prevention and Management of Pressure Ulcers, 3rd ed. (English), 2014; 5th ed., Shorinsha, 2022. Fujiwara H, Irisawa R, Otsuka M et al., Wound, Pressure Ulcer and Burn Guidelines (2023)-2, J Dermatol 2025;52(9):e744–e794. JWOCM, IAD ベストプラクティス (IAD-set), 2016/2017. Konya C et al., J Wound Care 2022;31(Sup12):S40–S47. MHLW specified insurance medical materials rules; DSJP drug-supply database record for Olcenon, 28 Jan 2026.

• The most rigorous and most sceptical wound guideline in Europe. AWMF S3 091/001, Lokaltherapie schwerheilender und/oder chronischer Wunden, v2.2, 31 Oct 2023, led by the DGfW with 22 further societies. Method: GRADE, admitting only RCTs as efficacy evidence for local interventions. Grades: A = soll (strong), B = sollte, 0 = kann, EK = expert consensus.
• The table that should be printed and pinned up. The guideline group searched for RCT evidence and then deliberately issued no recommendation whatsoever for: keratin dressings · protease-modulating products (hyaluronic acid, collagen) · haemoglobin spray · growth factors · naturopathic methods including medical honey · PRP · silver dressings · polihexanide-, octenidine- and antibiotic-containing dressings or gels · cryotherapy — and, among physical measures: electrical stimulation, phototherapy, magnetic field therapy, ultrasound, cold atmospheric plasma, ozone, shockwave and topical continuous oxygen. In German guideline practice "no recommendation" is not neutrality; it is a signal not to assume benefit.
• What Germany positively recommends instead. E29 (Grade B): for wounds without clinical infection signs, use plain, active-substance-free dressings. E30 (B): do not use cadexomer iodine or PVP-iodine products in wounds without infection signs — toxicity, allergenic potency and iodine load. The only Grade A recommendation in the entire guideline is E41: avoid damage to the wound edge and periwound skin from maceration, drying or pressure. Everything B or above is about process, assessment or skin protection — not about which dressing you pick.
• Silver, with the numbers Germany used. DFU, silver vs non-medicated: Cochrane RR 1.49 (0.97–2.47), low certainty; adding one 31-patient RCT tips it to RR 1.58 (1.04–2.41) at very low certainty — and the guideline says plainly the borderline result depends entirely on that one tiny trial. Infection incidence RR 0.34 (0.04–3.10), not significant. For polihexanide-, octenidine-, chloramine- or antibiotic-containing dressings, no RCTs met the inclusion criteria at all. Germany also cites resistance development and environmental burden among its reasons.
• Three German positions that will look wrong to a US-trained nurse. E20: dry avital necrosis shall NOT be rehydrated — stated across all three wound types in scope, not just the ischaemic foot, which is broader than the international position. E7: routine microbiological swabbing is not required, including before using antiseptics — culture only when systemic antibiotics are being considered. E16: use sterile, active-substance-free solutions, because non-sterile drinking water risks introducing pathogens.
• Germany's own two guidelines contradict each other on antiseptics. The S3 gives antiseptics only a kann (E17, weakest possible) on suspicion of infection. The German venous leg ulcer guideline (S2k 037/009, v4.1, Jan 2024) says you should use octenidine- or polihexanide-based antiseptics (Rec. 58), with contact times of 1–2 minutes for octenidine and 10–20 minutes for polihexanide, and requires the indication to be critically re-questioned after at most 14 days. In practice German nurses follow the wound-type-specific S2k for VLU and the S3 elsewhere — but note S2k has no systematic evidence grading; its 100%-consensus arrows are not the same thing as evidence.
• Two German scoring tools worth knowing. TILI (Therapeutischer Index Lokaler Infektionen), validated and now the standard German trigger for local antimicrobial therapy: six non-specific criteria (periwound erythema; increased warmth; oedema/induration/swelling; spontaneous or pressure pain; stagnating healing; increase or change in exudate colour/odour) — ≥5 of 6 triggers, OR any single direct-indication criterion (pathogenic organisms detected, surgical septic wound, free pus). W.A.R. (Wounds At Risk): antimicrobial therapy at ≥3 points, with 1 point each for e.g. diabetes, age ≥80, wound >1 year, wound ≥10 cm², depth >1.5 cm.
• The nursing document that actually binds in Germany. DNQP Expertenstandard Pflege von Menschen mit chronischen Wunden, 2nd update, published June 2025: structure/process/outcome criteria S1–S5, wound assessment at every dressing change, and evaluate effectiveness at the latest after 4 weeks. Terminology change to note: Ulcus cruris arterio-venosum now replaces Ulcus cruris mixtum — if your documentation still says mixtum, it is out of date in Germany from mid-2025. The DNQP's own honest admission: the update produced few new findings and largely confirmed existing ones.

DGfW/AWMF, S3-Leitlinie 091/001 Lokaltherapie schwerheilender und/oder chronischer Wunden, v2.2, 31.10.2023 (with Evidenzbericht v1.6, 15.08.2023). DGPL/AWMF, S2k-Leitlinie 037/009 Diagnostik und Therapie des Ulcus cruris venosum, v4.1, 30.01.2024. DNQP, Expertenstandard Pflege von Menschen mit chronischen Wunden, 2. Aktualisierung, Stand April 2025, published June 2025. No living-guideline update to 091/001 after v2.2 was found.

• "May I compress this mixed arterio-venous ulcer?" is the sharpest example. Every one of these is a current national document, and they do not agree:

← swipe table →

• Germany explicitly killed the old dogma. The S2k states: "Das Dogma 'keine Kompressionstherapie bei PAVK' sollte im klinischen Alltag nicht mehr gelten." Evidence cited: in 25 patients with ABI 0.5–0.8, inelastic bandages at interface pressures up to 40 mmHg did not impair perfusion — peri-ulcer and plantar TcPO₂ and arterial flow actually improved.
• A "class II stocking" is not the same object in two countries. Sweden: class I 15–21, II 23–32, III 34–46, IV >49 mmHg. Spain (CONUEI): class I 15–20, II 21–29, III 30–40, IV >40 mmHg. Finland recommends class 2 (≈30 mmHg), with class 1 acceptable in the elderly and in mixed ulcers to protect adherence. Check the banding before comparing across borders or reading a foreign paper.
• Italy's 88 recommendations are NICE's recommendations. SNLG LG C0030 (ISS, published 10 Jan 2025, AIUC-led) is a formal adolopment of NICE CG179 — each recommendation labelled adottata or adattata. Legitimate and transparent, but Italy's 2025 national guideline therefore rests on a 2014-with-2018-update evidence base. Notable Italian positions: reposition at-risk adults at least every 4 hours (strong — tighter than NICE for at-risk, looser for high-risk); do not routinely use topical antiseptics or antimicrobials on pressure ulcers (strong); do not routinely use NPWT, electrical stimulation or HBOT; do not use gauze; do not use standard foam mattresses in adults with a pressure ulcer. The Italian panel also prefers finger pressure over transparent discs for blanch testing, because discs are often unavailable or an infection risk.
• Spain reframed the whole category. GNEAUPP's lesiones cutáneas relacionadas con la dependencia (LRD) framework, DT nº II 3rd ed., Nov 2021, classifies pressure/shear injuries, LESCAH (moisture-associated damage), friction injuries and mixed lesions as one family, with skin tears since folded in. In Spain, calling a perineal moisture lesion a "category II pressure ulcer" is a classification error, not a nuance — aetiology must be named first, and only pressure/shear lesions are staged. GNEAUPP also has DT nº XVI (2024) on skin lesions in severe end-of-life physiological compromise, with no equivalent in the international guideline.
• The Netherlands never abandoned red/yellow/black — and made it work. The WCS Classificatiemodel is the operational Dutch bedside standard, used within TIME rather than instead of it, with an explicit "worst colour wins" rule (black+yellow+red = black wound; yellow+red = yellow wound). Two things it does that English-language algorithms don't: it lists gauze soaked in tap water as a base product for black and yellow wet wounds — a documented direct conflict with Germany's sterile-solutions position — and it recommends no antimicrobial dressing at all, routing infection to a prescriber instead.
• France is running a large modern health system on very old wound guidance. The national pressure ulcer reference is still the ANAES/PERSE consensus conference of 15–16 November 2001 (repositioning every 2–3 hours, grade B; massage, friction, ice and hot air interdits), and the national dressing reference is a HAS fiche published 2010 and last updated 2013. The 2001 conference names its industry sponsors in the document itself — Convatec, J&J, Smith & Nephew, Coloplast, B. Braun, Urgo, Mölnlycke and others — so read its support-surface and dressing sections accordingly. What did change French practice was regulatory: an arrêté effective 1 April 2025 limits the first pharmacy dispensing after a new prescription to 7 days of dressings, with a real risk of pack size, not wound need, driving the regimen.
• Sweden has the one thing nobody else does. RiksSår, a national quality registry for hard-to-heal leg, foot and pressure ulcers, national since 2009, capturing healing time, antibiotic treatment, ulcer duration and size. No other European country in this review has an equivalent — and registry data beats guideline consensus for outcomes questions.

ISS/SNLG LG C0030 (AIUC), Prevenzione e trattamento delle lesioni da pressione, 10.01.2025 — adolopment of NICE CG179. GNEAUPP, Documento Técnico nº II, 3ª ed., Nov 2021; DT nº XVI, 2024. CONUEI, Documento de Consenso, 2018. Nationellt vårdprogram för svårläkta sår (NPO hud- och könssjukdomar), 2023-01-31. Käypä hoito, Krooninen alaraajahaava, 09.04.2021. WCS Kenniscentrum Wondzorg, Classificatiemodel (WCS Wondenboek, © 2018). NHG-Standaard Ulcus cruris venosum, June 2026. ANAES/PERSE consensus conference, 15–16 Nov 2001; HAS fiche BUTS Les pansements, 2010, updated 11.01.2013; Arrêté of 13 March 2025 (JO 19.03.2025).

• Resource scarcity does not change the physiology. A neuropathic plantar ulcer that is not offloaded will not heal, whatever dressing sits on it. The single biggest quality gain available in a resource-limited clinic is getting the causal interventions right, not upgrading the dressing.
• The WHO five principles. From the WHO South-East Asia Region handbook (New Delhi, 2026, ISBN 978-92-9280-002-4), Chapter 4 — the best free current low-resource wound protocol in existence, and it is only five items. 1 Wash with clean water or saline; if water cleanliness is doubtful, boil it and cool it — clean water means fit for drinking. "Avoid hydrogen peroxide, alcohol or iodine products — these may damage the newly growing cells." 2 Keep moist: petroleum jelly is named as one of the best and cheapest options; honey, turmeric and aloe vera named as community alternatives. 3 Change dressings timely: clean gauze or cloth, generally once daily or whenever wet or dirty; more often if periwound maceration; a few times a week may suffice for a clean healing wound. 4 Remove dead tissue and foreign bodies — but "do not debride dry and intact black eschars with no evidence of infection," and exposed or palpable bone means possible osteomyelitis → refer. 5 Diagnose and treat infection early: fever, lymphangitis or tender regional nodes → systemic antibiotics; fever and chills → suspect sepsis and refer immediately.
• Spend scarce effort in this order. 1 Offload/relieve pressure (a non-removable knee-high device is the only Level A offloading recommendation in the Brazilian vascular guideline) → 2 assess and restore perfusion → 3 debride → 4 diagnose and treat infection correctly → 5 correct the systemic cause (glycaemia, TB, leprosy, sickle cell, HIV, nutrition, smoking) → 6 manage oedema (elevation and compression cost almost nothing) → 7 keep the person moving → 8 choose a dressing — genuinely the least evidence-differentiated step in the list.
• India's "Recommended Care" vs "Limited Care" is the cleanest template anywhere. RSSDI-ESI writes every chapter twice. Note carefully what does not get downgraded in the Limited Care tier: risk stratification, review intervals, offloading, infection classification, and the safeguards that must be satisfied before amputation. What gets downgraded is technology — sensory testing falls back to monofilament or 128 Hz tuning fork alone, and vascular assessment to palpation of pedal pulses alone. That is the correct hierarchy.

← swipe table →

• Stop-doing list, each with a named source. Prophylactic antibiotics for clinically uninfected ulcers (SBD 2025 R12, Class III) · topical antimicrobials for diabetic foot infection, even mild (R10, Class III) · quantitative culture thresholds (≥10⁵ CFU/g) to define infection (R4, Class III) · skin temperature to diagnose infection, as distinct from its recommended preventive use (R4 vs R5) · hyperbaric or topical oxygen to treat infection (R14) · growth factors for infected DFU (R15) · debriding dry intact non-infected eschar (WHO 2026) · massaging bony prominences or erythematous skin, and alkaline soaps (ANVISA NT 05/2023) · chemical corn removers and patient self-paring of callus (RSSDI-ESI 2020).
• Skin tone assessment is a patient-safety issue, not a cosmetic one. ANVISA requires specific assessment for darkly pigmented skin because Stage 1 erythema may simply not be visible; where visual erythema is unreliable, assess changes in sensation, temperature and tissue consistency (induration) and compare against the contralateral site rather than relying on blanch testing. Brazil classifies Stage 3 and 4 pressure injuries as never events — missing Stage 1 in dark skin is a direct route to Stage 3.
• The escalation number to memorise. WHO: if a wound has not improved in size within 4–6 weeks, refer to a specialised facility; refer immediately if it worsens at any point; photograph or measure at every review, follow-up every 1–2 weeks. WHO's complicated-ulcer criteria (any one → refer): purulent discharge, bad smell, hot red swollen surrounding skin, pain, fever/chills, deep wound, suspected internal cause.
• Brazil rewrote the nurse's scope in 2025. COFEN Resolution 787/2025 (21 Aug 2025) revokes 567/2018 and explicitly authorises the registered nurse to order tests, perform conservative sharp/instrumental debridement, perform and interpret ABPI to prescribe compression, take biopsy and culture, and prescribe medicines, compounded formulations, dressings and adjuvant therapies. The gate is documented competence, not job title — institutions need training records, not just protocols. Any Brazilian protocol still citing 567/2018 is out of date.
• The honest verdict on the adjuncts people ask about. Honey: genuinely good for partial-thickness burns (heals ~4.7 days faster than conventional dressings, high quality) and infected post-operative wounds (RR 1.69); everything else low or very low. Prophylactic silicone foam: RR 0.50 (0.33–0.77) but Cochrane 2024 rates all 51 trials low or very low certainty and concludes it is unclear whether any dressing or topical agent studied makes a difference. Larval therapy: reasonable adjunct for slough when conventional debridement is unsuitable — IWGDF 2023 could not recommend it because no RCTs met its criteria. Brazil's ubiquitous AGE (essential fatty acids): no effect vs placebo (RR 0.86, 0.54–1.36); the positive signal exists only against the weakest comparator, at very low certainty. Treat it as cheap, probably harmless skin care — not a prevention intervention.

WHO Regional Office for South-East Asia, Integrated approach to management of skin-related neglected tropical diseases and common skin conditions: a practical handbook for health-care workers, New Delhi, 2026, Ch. 4. RSSDI-ESI Clinical Practice Recommendations for the Management of Type 2 Diabetes Mellitus 2020, Indian J Endocrinol Metab. SBD (Sociedade Brasileira de Diabetes) Diretriz, ed. 2025 — prevention and infection chapters. SBACV, Jornal Vascular Brasileiro 2023. ANVISA Nota Técnica GVIMS/GGTES nº 05/2023. COFEN Resolução nº 787/2025. COREN-BA manual, 2025. Cochrane 2024 (dressings and topical agents for preventing pressure ulcers, 51 trials, 13,303 participants); Cochrane 2015 (honey, 26 trials; growth factors, 28 RCTs).

• The differential when a "chronic ulcer" doesn't behave. WHO's 2026 handbook lists internal causes a nurse must exclude before settling on a venous or pressure diagnosis: severe bacterial infection, leprosy, tuberculosis and other mycobacterial disease, lymphatic filariasis, diabetic foot, venous, arterial, and cutaneous tumour. Add by region: Buruli ulcer, cutaneous leishmaniasis, mycetoma, chromoblastomycosis, sporotrichosis, sickle cell leg ulcer and podoconiosis.
• Buruli ulcer (Mycobacterium ulcerans). Reported in 33 countries; over 80% of global cases in the WHO African Region. WHO stages by lesion category: I single lesion ≤5 cm · II single lesion 5–15 cm · III lesion >15 cm, or multiple lesions, or lesions at critical sites (eye, breast, genitalia), or osteomyelitis. Category III is used as a proxy indicator of late detection and rose about 30% between 2019 and 2023 against a target of <10% by 2030. Diagnosis: PCR for IS2404 is the method of choice — biopsy, store carefully, send to a WHO Skin NTD Laboratory Network facility.
• The Buruli practice gap to check for. Treatment is now an all-oral eight-week course, typically rifampicin + clarithromycin. The phase 3 non-inferiority trial (n = 297): healing at 52 weeks 96% with oral rifampicin + clarithromycin vs 95% with rifampicin + intramuscular streptomycin, difference −0.5% (−5.2 to 4.2), non-inferiority margin 12% — met. Treatment-related adverse events 7% vs 13%, including one serious ototoxicity requiring discontinuation in the streptomycin arm. If a service is still giving IM streptomycin for limited Buruli, that is a practice gap. Beyond antibiotics: hygienic wound care, surgery for severe cases, lymphoedema management with compression and elevation, physiotherapy and long-term rehabilitation.
• Cutaneous leishmaniasis — simple vs complex decides whether you manage or refer. Complex = any one of: >4 lesions each >1 cm · a single lesion >5 cm · lesions on face, fingers, toes or genitalia · mucosal involvement · enlarged regional nodes · immunocompromised host. Simple CL: WHO explicitly endorses "wait and watch" with wound care only — keep clean and dry, teach simple wound care, follow up; many lesions heal spontaneously, though facial scarring can be permanent and disfiguring. Complex CL: refer. Diagnosis by slit smear or biopsy with microscopy for amastigotes; PCR for species where available. WHO's differentials: leprosy, cutaneous TB, sarcoidosis, lupus erythematosus and skin cancer.
• Mycetoma is two entirely different diseases sharing one name. Eumycetoma is fungal, actinomycetoma is bacterial — antifungals vs antibacterials, so getting the identification wrong means treating with the wrong drug class entirely. Clinical triad: painless firm subcutaneous swelling → multiple sinuses → grains discharged in the pus. WHO diagnostic tip that needs no equipment: a saline dressing applied overnight, or aspiration from an unopened sinus, improves grain yield without a biopsy. Sobering trial result (Sudan, n = 104, all with surgery, 12 months of therapy): complete cure at one year was 75% with daily itraconazole vs 65% and 50% for two fosravuconazole doses — neither was superior, and the trial stopped early for futility. Even the best arm cures only about three in four at a year.
• Chromoblastomycosis. Pigmented soil and plant fungi; classic occupational disease of farmers and forestry workers. Usually starts on foot or leg; slow-growing crusted, verrucous ("warty") or ulcerated lesions with satellite lesions; intensely itchy, and scratching auto-inoculates. Diagnostic pearl: sample the black dots ("cayenne pepper" appearance) — and where no dermatoscope exists, the photo-enlargement function on a smartphone substitutes. Chronic lesions can develop squamous cell carcinoma: biopsy any long-standing lesion that changes. Sporotrichosis presents as nodules in a linear distribution following lymphatics.
• Lymphoedema, filariasis and podoconiosis — the whole intervention is five things. WHO's MMDP basic package: hygiene; skin and wound care; elevation; exercises; suitable shoes. It works by preventing acute attacks (acute dermatolymphangioadenitis: sudden swelling, warmth, redness and pain ± fever and chills), which are triggered by entry lesions — interdigital cracks, fungal infection, minor wounds. Finding and treating those is the core preventive act. WHO surveys programme staff on whether they can actually demonstrate correct limb washing — the skill, not the knowledge, is the deliverable. Your highest-value acts here are teaching daily washing and thorough drying between the toes, treating tinea and cracks, elevating, moving, and getting shoes on the patient. Not dressings.
• Leprosy plantar ulcer is the diabetic foot, historically speaking. The pathology is identical — loss of protective sensation plus repetitive pressure — and Paul Brand's leprosy work is the direct ancestor of modern diabetic foot offloading. Management is the same hierarchy: offloading, protective footwear, self-inspection, callus care.
• Sickle cell leg ulcer — a Brazil / Africa / India shared burden, not a curiosity. Leg ulcers are the most common cutaneous manifestation of sickle cell disease, affecting around 20% of people with the disease in Brazil, typically from about age 20, with severe continuous pain, high recurrence and slow healing. Mechanism: vaso-occlusion causing hypoxia and necrosis around the ankle, plus intravascular haemolysis scavenging nitric oxide. Ankle venous filling times are shortened, implicating venous valve insufficiency — so compression is often appropriate, but check ABPI and respect that the pain is a disease symptom disproportionate to ulcer size.

WHO SEARO, Integrated approach to management of skin-related neglected tropical diseases and common skin conditions, New Delhi, 2026. WHO Regional Office for Africa, Buruli ulcer in Africa: 20 years of progress, 2025. Phillips RO et al., Lancet 2020 (RC8 vs RS8 phase 3 non-inferiority trial). Lancet Infect Dis 2024 (fosravuconazole vs itraconazole in eumycetoma, Sudan, n = 104). PAHO/WHO, Guideline for the Treatment of Leishmaniasis in the Region of the Americas, evidence synthesis Rev Panam Salud Publica 2023. WHO, Lymphatic filariasis: managing morbidity and preventing disability, 2nd ed., 2021. COREN-BA manual 2025, Ch. 11 (sickle cell leg ulcers).