non-healing ulcer treatment kerala

Non-healing ulcers – chronic wounds that refuse to heal – are a serious medical concern. They often indicate underlying problems such as diabetes, poor circulation or immobility. In Kerala, patients seeking non-healing ulcer treatment turn to TRIVES Hospital in Thrissur, a specialized vascular and endovascular care center. TRIVES combines advanced wound care and vascular surgery to heal stubborn wounds. This article explains what causes chronic ulcers, how they are diagnosed and treated, and why timely care at a dedicated wound healing center like TRIVES is so important.

What Are Non-Healing Ulcers?

A non-healing ulcer (or chronic wound) is one that fails to progress through normal stages of healing in an expected time – typically beyond 4–6 weeks or if it does not restore normal skin and function after 3 months. Unlike simple cuts that heal in days to weeks, chronic ulcers linger and worsen without proper care. They can become deep and infected, leading to pain, disability or even amputation. In fact, chronic diabetic foot ulcers precede about 85% of lower-limb amputations, and carry a five-year mortality around 40%.

Key points about non-healing ulcers:

• They do not move through the normal repair process, causing persistent open sores.

• Chronic ulcers are often a symptom of other diseases (circulatory problems, diabetes, nerve damage, etc.), not a standalone disease.

• “TIME” principles guide general care: Tissue debridement, Infection control, Moisture balance, and Edge advancement.

• Expert vascular evaluation is essential. All persistent leg ulcers need a circulation assessment (pulses, Doppler/ABI testing).

TRIVES Hospital treats chronic ulcers by first identifying and addressing underlying causes. As TRIVES notes, chronic non-healing ulcers are often a sign of vascular issues, so they “focus on improving circulation, infection control, and advanced wound care for faster healing”.

Causes and Risk Factors

Several factors can cause or delay healing of ulcers. Common causes include:

• Diabetes and neuropathy: High blood sugar over time damages nerves (diabetic neuropathy) and blood vessels. Patients may injure their feet without feeling it, and poor circulation makes even minor sores slow to heal.

• Peripheral arterial disease (PAD): Blocked or narrowed arteries (due to atherosclerosis) reduce blood flow to the legs and feet. Without enough oxygen-rich blood, wounds stall or worsen. Arterial disease often underlies ischemic ulcers.

• Chronic venous insufficiency: Weakened vein valves or leg vein blockages cause blood pooling (venous stasis). This leads to swelling, skin breakdown and shallow ulcers, often around the ankles.

• Immobility and pressure: Patients who are bedridden or wheelchair-bound can develop pressure ulcers (bedsores) over bony areas (heels, hips, sacrum) due to unrelieved pressure.

• Infection and poor nutrition: Uncontrolled infection in a wound or poor nutrition (e.g. low protein, vitamin deficiencies) can impede healing. Smoking and advancing age also increase risk of chronic ulcers.

Risk factors include obesity, high cholesterol, smoking, and a history of deep vein thrombosis or varicose veins. Older age and inactivity contribute to all types of chronic wounds. For example, research shows that nearly half of diabetic foot ulcer patients have PAD, which greatly raises the chance of amputation.

Signs of diabetes and vascular disease often accompany non-healing ulcers. For instance, diabetic nerve damage may also change foot shape, leading to unnoticed pressure points. Chronic venous disease causes varicose veins, leg swelling and skin changes (itching, color changes) that herald venous ulcers. Recognizing these risk factors early can prompt preventive care.

Symptoms and Warning Signs

Non-healing ulcers have telltale symptoms beyond a stubborn wound. Look for:

• Persistent open wound: A sore that does not shrink or fill in over weeks, even with basic care.

• Pain: Pain is common in arterial ulcers, often severe and worse when the leg is elevated. Diabetic foot ulcers can be surprisingly painless because of neuropathy. Venous ulcers may cause a dull ache or heaviness in the leg that improves on elevation.

• Wound appearance: Arterial ulcers often appear “punched-out” with smooth, even edges and minimal drainage. Venous ulcers typically have irregular borders, are shallow, and can ooze fluid or blood. Pressure ulcers may start as a red, hot spot and progress to deeper tissue breakdown.

• Skin changes: The surrounding skin provides clues. Dusky, cold or hairless skin suggests poor arterial flow. Swollen ankles, varicose veins, brownish discoloration or hardened skin suggest venous stasis. Redness, warmth or pus indicate infection.

• Systemic signs: Fever, chills, or spreading redness (cellulitis) mean infection is present. Unexplained fatigue may accompany chronic, infected wounds.

When to seek help: Any foot or leg wound that does not show clear improvement after 2–4 weeks should prompt medical attention. If the ulcer grows, deepens, or is accompanied by pain or infection (pus, bad odor), it requires urgent evaluation. Early consultation with a vascular specialist or wound care center (such as TRIVES Hospital) can prevent complications.

Types of Non-Healing Ulcers

Chronic ulcers are classified by their underlying cause. The four main types are diabetic foot ulcers, venous leg ulcers, arterial (ischemic) ulcers, and pressure (bed) ulcers. Each type has distinct causes, features, and treatments.

Diabetic Foot Ulcers

Figure: Diabetic foot ulcers often form on the plantar (bottom) surface of the foot, where nerve damage and pressure cause sores.

Diabetic foot ulcers occur in people with diabetes, especially those with long-standing disease. High blood glucose leads to neuropathy (nerve damage) and often peripheral artery disease. Neuropathy means loss of feeling, so minor injuries (stepping on a stone, wearing tight shoes) can go unnoticed. Poor circulation means the body’s healing response is sluggish. The result: even small cuts can turn into chronic ulcers on the foot, especially on pressure points like the heel or ball of the foot.

Risk factors: Poorly controlled diabetes (high HbA1c), loss of protective sensation, foot deformities (like hammer toes), and previous ulcers. Smoking, high cholesterol and kidney disease further impair healing.

Symptoms: Ulcers usually appear on the sole or toes and may be surrounded by callus. They often lack pain (due to neuropathy) but can become deep. Signs of infection (redness, warmth, drainage) are common if not treated.

Complications: Diabetic foot ulcers are the leading cause of non-traumatic amputations. Without proper care, an ulcer can extend to bone (osteomyelitis) or spread infection systemically.

TRIVES’s approach: At TRIVES Hospital, diabetic foot ulcers are managed by a multidisciplinary team (vascular surgeons, podiatrists, endocrinologists). Care includes:

• Foot offloading: Reducing pressure on the ulcer is critical. TRIVES uses total contact casting or special shoes to redistribute weight away from the sore. (Meta-analysis shows a total contact cast is optimal for healing diabetic foot ulcers.)

• Debridement: Removing dead tissue from the wound bed (sharp or surgical debridement) promotes healing.

• Infection control: Wound cultures guide antibiotic therapy. Infected ulcers may require long-term antibiotics or minor surgeries.

• Vascular interventions: Since poor blood flow often coexists, TRIVES performs angioplasty, stenting or bypass surgery to restore circulation. Studies show that after revascularization, about 60% or more of diabetic foot ulcers heal by one year.

• Advanced wound care: Hyperbaric oxygen, growth factors or skin substitutes may be used for stubborn ulcers. Offloading, infection control and optimized blood sugar are still the foundation.

By combining these strategies, TRIVES Hospital significantly improves healing rates. As the TRIVES website notes, “diabetic foot complications… are common” and they provide “vascular interventions to improve blood flow, infection control, and wound healing”. Early referral to a vascular specialist can save limbs for many diabetic patients.

Venous Leg Ulcers

Venous ulcers (also called stasis ulcers) arise from chronic venous insufficiency. When vein valves in the legs fail, blood pools under pressure and stretches the skin. Over time, this causes edema, inflammation and tissue breakdown – most often just above the ankle on the inner side of the leg.

Risk factors: Varicose veins, history of deep vein thrombosis, obesity, multiple pregnancies, and jobs involving long standing. A family history of venous disease, older age (over 55), and inactivity also contribute.

Symptoms: These ulcers are usually shallow with irregular, sloping borders. The area around the ulcer often shows swelling, skin darkening or redness, and sometimes varicose veins or white scar-like patches called atrophie blanche. Leg aching or heaviness is common, and patients often feel better when the leg is elevated. Unlike arterial ulcers, venous ulcers typically produce more drainage.

TRIVES’s approach: Treatment focuses on correcting the underlying venous problem and supporting wound healing:

• Compression therapy: This is the cornerstone. Medical-grade compression stockings or bandages push fluid back toward the heart. Clinical guidelines note that “compression therapy has been proven beneficial for venous ulcer treatment and is the standard of care”. TRIVES fits patients with graduated compression garments and teaches how to use elastic wraps properly.

• Elevation and exercise: Keeping the leg elevated when sitting or lying down reduces swelling. Supervised calf exercises and walking programs encourage venous return.

• Endovenous ablation or surgery: For ulcers caused by large varicose veins or reflux, TRIVES offers treatments like radiofrequency ablation or sclerotherapy. These procedures close off malfunctioning veins and have been shown to speed ulcer healing and reduce recurrence.

• Advanced dressings: Moist wound dressings and skin grafts may be applied to promote healing. Bacteriological control is maintained to prevent infection.

With these measures, many venous ulcers will heal. The key is persistence: even when healed, patients should continue wearing compression and walking daily to prevent new ulcers.

Arterial (Ischemic) Ulcers

Arterial ulcers result from insufficient blood supply due to peripheral arterial disease (PAD). Atherosclerotic plaques narrow arteries, starving tissues of oxygen. These ulcers are often very painful, especially when the leg is elevated or at rest, and are considered a vascular emergency.

Risk factors: Smoking, diabetes, high cholesterol, hypertension, and any condition that causes atherosclerosis. PAD is more common in older adults and diabetics.

Symptoms: Arterial ulcers typically occur on the toes, feet, heels or outer ankle. They have a “punched-out” appearance with sharply defined edges and a pale or gray base. Surrounding skin may be cool, thin, shiny and hairless, reflecting poor circulation. Pain is a prominent symptom and often worsens with leg elevation (gravity does not help push the blood).

TRIVES’s approach: Because arterial ulcers reflect severe circulation problems, restoring blood flow is priority:

• Vascular assessment: TRIVES performs Doppler ultrasound, ankle-brachial and toe-brachial index tests to confirm PAD. Advanced imaging (CT angiogram or MR angiogram) may be used to pinpoint blockages.

• Revascularization: Interventions like angioplasty (balloon dilation), stenting, or bypass surgery are done by TRIVES’s vascular surgeons to open blocked arteries. Studies show these procedures heal ulcers and greatly improve limb salvage rates. For instance, over 60% of ulcerated diabetic feet healed after revascularization.

• Pain management and wound care: Pain relief is provided (medication or nerve blocks), and the ulcer is kept clean and moist. Sharp debridement is done only if safe (avoiding excessive bleeding). In some cases, specialized grafts or regenerative therapies support healing.

• Risk factor modification: Aggressive control of blood pressure, cholesterol and smoking cessation are emphasized to improve overall circulation.

Referring to vascular specialists early is crucial. TRIVES notes that “patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention”. With rapid diagnosis and revascularization, even severe ischemic ulcers can often heal.

Pressure (Bed) Ulcers

Pressure ulcers, also known as bedsores or decubitus ulcers, occur from prolonged pressure on the skin – typically over bony areas (heels, hips, tailbone). They are common in patients who are bedridden, immobilized or have sensory impairments.

Risk factors: Immobility (from injury, illness or sedation), elderly age (fragile skin), poor nutrition, incontinence (moisture), and any condition that prevents normal repositioning.

Symptoms: Early pressure injury appears as a non-blanching red patch on the skin. If unrelieved, the tissue breaks down to form a sore that can extend into muscle and bone. Debilitated patients may have multiple ulcers of different severity.

TRIVES’s approach: Treatment and prevention are intertwined:

• Pressure relief: Special mattresses, cushions or heel protectors (like the air-filled cushion shown below) redistribute weight. Regular repositioning (every 2 hours) is instituted, and nurses are trained to avoid pressure on bony prominences. Clinical guidelines confirm that pressure-reducing surfaces significantly cut the incidence of ulcers.

• Wound care: Ulcers are kept clean; necrotic tissue is debrided as needed. Appropriate dressings maintain a moist environment to promote healing. If infection is present, topical or systemic antibiotics are used.

• Nutrition and skin care: Adequate protein and calories are provided to support repair. Special creams protect the surrounding skin from moisture and friction.

Even though TRIVES is a specialized vascular center, they collaborate with wound care nurses and rehabilitation to manage pressure ulcers. In Kerala’s humid climate, preventing skin moisture (which can macerate skin) is especially important.