Volume 26 Number 2

Once again, it was a privilege to attend EWMA. It is always a pleasure to connect with so many dedicated individuals. This year, a record-breaking 6264 participants from 90 countries attended the conference, highlighting the growing urgency to address the needs of the millions affected by chronic wounds.

Over the three-day conference, more than 2300 sessions, workshops, and presentations were held, and around 150 industry exhibitors showcased the latest innovations in wound care.

One presentation in particular stood out – not only for its content, but for how it was received. It captured the current state of the field, shaped by decades of research, competing methodologies, and enduring uncertainty.

Dr José Contreras-Ruiz gave a memorable presentation titled Different Antimicrobial Stewardship Depending on Wound Etiology and Location? The talk included interactive elements: various infection scenarios were presented, and attendees were asked to vote by a show of hands on which of four treatment strategies they believed to be the most effective.

What was striking – and frankly, alarming – was the complete absence of consensus. The room, filled with raised hands pointing in different directions, became a metaphor for the collective confusion. If this audience – a mix of clinicians, nurses, researchers, and industry experts – reflected the field as a whole, the message was clear: when it comes to antibiotic use in wound management, we are navigating in the dark.

My disillusionment deepened in the exhibition area, where industry professionals showcased a wide range of current approaches to alleviate or combat chronic wounds. Once again, the diversity of strategies highlighted the same confusion – a variety that, ironically, underscored the futility of each individual approach. After all, if one truly worked, the rest would likely have been naturally phased out by clinical evolution.

Over the years, an impressive array of animal-derived materials has been explored and promoted in the field of wound treatment: snail mucin, honey from bees, larval therapy, sheep lanolin, collagen from pigs and cows, and most recently, fish skin. To this list, I propose we add one more animal – one we have ignored for far too long: it is time we confront the elephant in the room. When it comes to chronic wounds, we are collectively confused – and many of the measures we take are, at their core, still experimental.

I look forward to EWMA 2026 in Bremen, but if we want next year’s conference to leave us with a clearer direction and renewed optimism, we must begin investigating the as-yet unidentified parameters that might guide truly effective treatments.

Healing progresses through tightly regulated stages, each influenced by a complex interplay of known and unknown factors, making causation elusive. For example, while the presence of biofilms suggests potential involvement, it does not imply direct responsibility. Nevertheless, biofilms are often targeted by default, despite unclear causation.

We know that high pH levels reduce bacterial metabolism and alter antibiotic uptake, impairing treatment efficacy. The Bohr effect further limits oxygenation and immune function, while alkaline conditions can disrupt antibiotic stability, ionization and membrane permeability – ultimately lowering the bioavailability of antibiotics in the wound bed. Despite this, these aspects are rarely considered in antibiotic treatment strategies.

These examples illustrate the nature of our confusion: we do not understand how biofilms contribute to chronicity, yet we target them aggressively. Conversely, we understand how pH and several other aspects affect healing, yet these fields remain largely neglected in clinical practice.

These are just a couple among many areas where both unknown and well-understood mechanisms have yet to be incorporated meaningfully into clinical practice to improve both symptomatic care and long-term outcomes.

If we succeed in that endeavor, we will not just reduce the severity of chronic wounds – we will change the trajectory of how we manage them. Prevention, however, remains an even larger challenge. While pathogens undoubtedly play a role, it is not their mere presence that makes wounds chronic. It is the intricate interplay between microbes, the host, and the host’s underlying vulnerabilities that builds chronicity. Once we truly understand – and learn to modulate – that interaction, the problem EWMA aims to solve will disappear. In that sense, like all charitable organisations, EWMA is ultimately working toward its own obsolescence.

Unfortunately, that farewell party isn’t on our calendar anytime soon. Until then, we must stay focused on symptomatic treatments. Whether the most effective approach lies in biofilms, pH modulation, or yet another animal-derived material remains to be seen. As for animals, I suggest we start with the elephant.

See you in Bremen.

Thomas Bjarnsholt

Author(s)

Thomas Bjarnsholt^1,2
1Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Denmark
²Department of Clinical Microbiology, Copenhagen University Hospital, Denmark

Email tbjarnsholt@sund.ku.dk