ABSTRACT

When treating chronic wounds, therapeutic success has traditionally been focused on complete wound closure. However, it is well known that this goal is not easy to achieve and, in many cases, impractical, especially for complex cases, such as older people, people with multiple morbidities, and those living in socially or economically disadvantaged environments. When closure is considered the most critical isolated outcome, patient-related outcomes that significantly affect patients' overall health, such as pain, functional limitations, and quality of life, are often overlooked. Recently, it has been shown that novel methods, such as topical oxygen therapy, offer advantages beyond epithelialization, helping relieve pain, improve mobility, and increase satisfaction with the therapeutic approach. From a practical perspective and in terms of equitable access to healthcare opportunities, limiting access to these treatments due to economic costs complicates the most complex clinical and human challenges associated with chronic non-healing wounds, such as frequent hospitalizations, prolonged use of antibiotics, disabilities, and ongoing pain. In primary health care, health outcomes such as pain control, maintaining independence, and the ability to perform activities of daily living are directly meaningful to patients and essential for the sustainability of health care models. Therefore, we affirm that therapeutic efficacy in the treatment of chronic wounds should be considered not only in terms of wound closure but also in relation to outcomes such as dignity, functional capacity, and quality of life.

Keywords: Wounds and injuries, pain management, patient outcome assessment, quality of life, primary health care.

INTRODUCTION

Chronic wounds are a common and complex health condition around the world, mainly related to cardiometabolic diseases, but also to the pathological aging of the population [1]. Although it has traditionally been believed that the most important clinical aspect of managing this type of wound is complete closure, there are actually additional outcomes that are overlooked and that go far beyond delayed healing, as they affect patients' physical health, mobility, emotional health, and social participation (outcomes that are particularly relevant in nursing, gerontology, and geriatrics). At the same time, chronic wounds generate a significant economic and disease burden, which, due to the routine frequency of these wounds, often goes unnoticed by health systems, especially when treatment is prolonged, and healing is difficult or impossible to achieve [1-3].

Although complete healing is clearly an essential biological goal, this limited perspective is a form of clinical reductionism that overlooks outcomes many patients consider most important, given their clinical, social, and human contexts [4]. For people with complex health conditions or limited access to advanced treatments, complete wound closure is an unrealistic expectation rather than a feasible goal. In these cases, relieving pain, maintaining functionality, and preserving the best possible quality of life represent opportunities for better health outcomes than the closure of chronic wounds [2-4].

The purpose of this commentary is to discuss the need to consider redefining therapeutic success in the treatment of chronic wounds. We suggest that patient-centered outcomes be more clearly incorporated into clinical practice and research, ensuring that care continues to respond to patients' real experiences and is consistent with the realities of primary care. By not considering wound closure alone as the primary goal, healthcare providers can take a broader, more compassionate, and fairer approach to evaluating the overall success of chronic wound treatment.

LIMITATIONS OF THE CHRONIC WOUND HEALING PARADIGM FOCUSED ON COMPLETE CLOSURE

Following recommendations from various authors over the years, complete wound closure has been the primary criterion for evaluating treatment effectiveness in the management of chronic wounds [3, 4]. In routine clinical practice, this goal is often unattainable. Older people, polymorbid patients, and people living in areas with restricted access to specialized treatment usually face biological and systemic obstacles that make complete recovery unlikely. When this approach predominates, essential elements of the patient's experience, such as ongoing pain, worsening functional impairment, and reduced quality of life, are likely to be overlooked during clinical assessments. Depending on the context, these elements may even have greater predictive value for recovery and/or overall prognosis [3, 4].

The current reliance on traditional economic methods, such as simple dressings and antiseptic agents, reveals the limitations of a closure-focused approach [4]. Although these strategies are still frequently used, they tend to offer minimal benefits in hard-to-heal wounds and do not directly influence pain or functional limitations. In contrast, newer treatments, such as continuous topical oxygen therapy, have demonstrated benefits beyond faster healing, including improved pain control, infection prevention, and increased functional independence [5-7]. Taken together, these findings call into question the adequacy of closure as the sole indicator of success and highlight the need for broader assessment frameworks that better reflect the multifaceted effects of chronic wounds on patients' lives.

PATIENT-ORIENTED OUTCOMES: PAIN, FUNCTIONALITY, AND QUALITY OF LIFE

According to the essential pillars of evidence-based medicine, a clinical outcome is only considered significant if it addresses patient priorities and guides decisions that affect both individuals and communities [8]. From this perspective, it is feasible to assert that pain intensity, functional independence, and quality of life should not be considered secondary or minor factors in the treatment of chronic wounds. On the contrary, these outcomes represent key therapeutic objectives, underscoring the importance of clinical interventions in routine practice [5-7]. Neglecting them carries the risk of continuing with treatments that treat wounds as biological entities, without taking into account that chronic wounds behave like a syndrome.

Despite the above, a significant proportion of clinical studies on the treatment of chronic wounds continue to emphasize complete closure as the primary outcome, relegating patient-centered outcomes to secondary analyses or exploratory assessments (Table 1) [5-7]. This approach warrants reevaluation. A patient who can walk without pain, return to daily activities, or maintain functional independence can be considered to have achieved treatment success, even if complete wound closure has not occurred.

Pain and loss of functional capacity are not just clinical parameters; they are experiences that influence how people perceive their bodies, relate to others, and participate in society [9]. When pain is reduced or functional capacity is restored, the benefits go beyond simple physical improvement and encompass dignity, self-esteem, and a revitalized sense of control. We propose to defend that medicine and nursing achieve one of their fundamental objectives when they aim not only to repair tissue, but also to alleviate suffering in all its manifestations.