18: Indications for Adjuvant Therapies

• We recommend adjuvant wound therapy options for venous leg ulcers that fail to demonstrate improvement after a minimum of 4 to 6 weeks of standard wound therapy (Grade 1, Level B).

19: Split-thickness Skin Grafting

• We suggest against split-thickness skin grafting as primary therapy in treatment of venous leg ulcers (Grade 2, Level B).
• We suggest split-thickness skin grafting with continued compression for selected large venous leg ulcers that have failed to show signs of healing with standard care for 4 to 6 weeks (Grade 2, Level B).

20: Cellular Therapy

• We suggest the use of cultured allogeneic bilayer skin replacements (with both epidermal and dermal layers) to increase the chances for healing in patients with difficult to heal venous leg ulcers in addition to compression therapy in patients who have failed to show signs of healing after standard therapy for 4 to 6 weeks (Grade 2, Level A).

21: Preparation for Cellular Therapy

• We suggest a therapeutic trial of appropriate compression and wound bed moisture control before application of cellular therapy (Grade 2, Level C).
• We recommend that adequate wound bed preparation, including complete removal of slough, debris, and any necrotic tissue, be completed before the application of a bilayered cellular graft (Grade 1, Level C).
• We recommend additional evaluation and management of increased bioburden levels before the application of cellular therapy (Grade 1, Level C).

22: Frequency of Cellular Therapy Application

• We suggest reapplication of cellular therapy as long as the venous leg ulcer continues to respond on the basis of wound documentation (Grade 2, Level C).

23: Tissue Matrices, Human Tissues, or Other Skin Substitutes

• We suggest the use of a porcine small intestinal submucosa tissue construct in addition to compression therapy for the treatment of venous leg ulcers that have failed to show signs of healing after standard therapy for 4 to 6 weeks (Grade 2, Level B).

24: Negative Pressure Therapy

• We suggest against routine primary use of negative pressure wound therapy for venous leg ulcers (Grade 2, Level C).

25: Electrical Stimulation

• We suggest against electrical stimulation therapy for venous leg ulcers (Grade 2, Level C).

26: Ultrasound Therapy

• We suggest against routine ultrasound therapy for venous leg ulceration (Grade 2, Level B).