Expectation Versus Reality in Chronic Wound Care

At the recent 2026 South Beach Symposium, Ayman Grada, MD, delivered a concise but thought-provoking overview of chronic wound care, framing the discussion around a theme many clinicians know well: “expectation versus reality.” Grada set the tone for a clinically grounded session aimed at reassessing dermatology’s role in this high-burden field.¹

Who Is Managing Chronic Wounds?

Drawing on data from the National Ambulatory Medical Care Survey, managed by the Centers for Disease Control and Prevention, Grada highlighted a striking statistic: only 7.4% of chronic wound visits in the United States are managed by dermatologists. Most are handled by primary care physicians and surgical specialists.²

For a specialty centered on skin biology and pathology, this represents, in his view, a significant care gap. The reasons are likely multifactorial—training exposure during residency, time constraints in clinic, and the resource-intensive nature of wound visits. As he noted, individual wound encounters can take 20 to 30 minutes. Yet the low percentage suggests an opportunity for dermatologists to expand their presence in multidisciplinary wound care.

Defining Chronicity and Understanding Burden

Clinically, a wound that fails to heal within 4 to 6 weeks is considered chronic. This definition has practical implications: the Centers for Medicare & Medicaid Services typically require 4 weeks of standard therapy before approving advanced treatments such as bioengineered skin substitutes.

The epidemiologic burden is substantial. Lifetime prevalence of chronic wounds in the US is estimated at 1–2%, encompassing diabetic foot ulcers, venous leg ulcers, pressure injuries, and less common etiologies such as connective tissue disease. Venous ulcers may require 6 to 12 months to heal, and recurrence rates approach 70% within 5 years. The financial strain on the health care system mirrors this chronicity.

Obesity as an Upstream Driver

A particularly compelling segment of the lecture focused on obesity. Referencing a 2024 analysis published in The Lancet, Grada emphasized that approximately 172 million US adults had overweight or obesity in 2021, with projections suggesting an additional 40 million by 2050. If trends persist, 2 out of 3 US adults may meet criteria for obesity within the next 25 years.³

Obesity functions as a unifying upstream risk factor. It contributes to venous hypertension, impaired perfusion, systemic inflammation, mechanical pressure, and metabolic dysregulation. In this framework, chronic wounds are not isolated dermatologic events but cutaneous manifestations of systemic disease.

Diagnostic Foundations

Grada underscored the importance of comprehensive clinical evaluation. Noninvasive vascular assessment—particularly the ankle-brachial index (ABI)—is essential before initiating compression therapy. An ABI between 0.9 and 1.3 generally indicates adequate perfusion for compression.

Biopsy should be considered for wounds persisting beyond 6 weeks with atypical features, especially when pyoderma gangrenosum or malignancy is suspected. The guiding principle is not reflexive testing, but thoughtful case-by-case assessment.

Clinical Patterns: Recognizing the Major Ulcers

For clinicians, pattern recognition remains central.

Venous ulcers typically present in the gaiter region, most often near the medial malleolus. They are shallow, irregularly bordered, and associated with edema, hemosiderin deposition, and lipodermatosclerosis—the latter characterized by indurated, woody skin. Pain is usually mild and relieved by elevation. Peripheral pulses are intact.

Pathophysiologically, venous hypertension drives capillary leakage and inflammatory mediator release, including tumor necrosis factor-alpha and interleukins, leading to tissue breakdown. Treatment rests on a familiar triad: compression, compression, compression. Modalities such as Unna boots and multilayer wraps provide graduated support. Adjunctive therapies, including pentoxifylline and bioengineered constructs, may be considered in nonhealing cases.

Diabetic foot ulcers often arise in the context of neuropathy. In patients with diabetes, callus formation over pressure points should prompt suspicion. Neuropathic ulcers are typically less painful than arterial lesions.

Arterial ulcers, in contrast, are sharply demarcated, “punched-out,” and frequently covered by eschar. They are painful, and distal pulses are diminished or absent. These findings mandate vascular evaluation.

Pressure injuries occur in areas of sustained mechanical load, especially in older or immobilized patients. Offloading and pressure redistribution are foundational; dressings alone are insufficient without mechanical correction.

Universal Principles

The 2022 wound care guidelines emphasize a standardized approach: vascular assessment, debridement when appropriate, infection control, moisture balance, and offloading or compression tailored to etiology. Advanced therapies should follow, not replace, optimized foundational care.

In a brief but dense session, Grada distilled chronic wound management into a clear message: dermatologists possess the diagnostic acumen and pathophysiologic insight to play a larger role. The gap between expectation and reality remains—but so does the opportunity.

References

1. Grada A. Ulcers. Presented at: South Beach Symposium 2026; February 5-7, 2026; Miami Beach, FL.
2. Grada A, Chandy RJ, Park J, Feldman SR. Outpatient cutaneous wound care in the United States: specialty distribution and antimicrobial prescribing patterns. Antibiotics. 2026; 15(2):142. doi:10.3390/antibiotics15020142
3. GBD 2021 US Obesity Forecasting Collaborators. National-level and state-level prevalence of overweight and obesity among children, adolescents, and adults in the USA, 1990-2021, and forecasts up to 2050. Lancet. 2024;404(10469):2278-2298. doi:10.1016/S0140-6736(24)01548-4