How does proper wound care prevent infection and speed up healing. What are the key components of effective wound management. Why is wound care essential for minimizing scarring and complications. How has wound care evolved throughout history to modern medical practices.

The Evolution of Wound Care: From Ancient Civilizations to Modern Medicine

Wound care has a rich history dating back to the earliest human civilizations. The ancient Greeks were among the first to recognize and emphasize the importance of wound healing. Over millennia, this crucial aspect of medical treatment has evolved significantly, incorporating new technologies and scientific understanding.

Today, wound care remains a critical component of the recovery process, with modern techniques and practices designed to promote faster healing, prevent complications, and minimize scarring. Understanding the purpose and importance of proper wound care is essential for both healthcare professionals and patients alike.

Understanding the Basics of Wound Healing

Wounds heal through two primary mechanisms: regeneration and scar formation. Each process plays a unique role in the body’s recovery from injury.

Regeneration: Restoring Original Tissue

In regeneration, damaged tissue is replaced by new tissue of the same type. This process preserves the proper function of the injured area, allowing for a more complete recovery. Regeneration is often ideal, as it maintains the original properties and capabilities of the affected body part.

Scar Formation: Nature’s Backup Plan

When regeneration is not possible, the body resorts to scar formation. In this process, damaged tissue is replaced by fibrous scar tissue. While scar tissue helps close the wound and protect the body, it lacks the same properties as the original tissue, potentially affecting function and appearance.

The Vital Role of Wound Care in Preventing Infection

One of the primary purposes of wound care is to prevent infection, a potentially serious complication that can significantly impede the healing process.

• Regular monitoring and changing of wound dressings
• Observing the wound for signs of progress or complications
• Checking for abnormal bleeding, temperature changes, discharge, or odors
• Daily cleaning with appropriate disinfectants, clean water, or saline solution
• Applying clean dressings to maintain a sterile environment

By implementing these practices, healthcare professionals can dramatically reduce the risk of infection and other complications, ensuring a smoother recovery process for patients.

Accelerating the Healing Process Through Proper Wound Management

Contrary to popular belief, leaving wounds uncovered does not promote faster healing. In fact, proper wound care techniques can significantly accelerate the healing process.

The Benefits of Covered Wounds

Keeping a wound covered throughout the healing process offers several advantages:

1. Maintains a moist environment conducive to healing
2. Protects the wound from external contaminants
3. Reduces the risk of infection
4. Promotes faster cell regeneration and tissue repair

By providing additional protection and creating an optimal healing environment, proper bandaging techniques play a crucial role in speeding up recovery times.

Minimizing Scarring: The Long-Term Benefits of Effective Wound Care

While some degree of scarring is often inevitable in the wound healing process, proper wound care can significantly reduce its severity and appearance.

Techniques for Minimizing Scar Formation

• Keeping the wound soft and pliable throughout the healing process
• Preventing the formation of hard scabs
• Applying antibiotic ointments in the early stages of healing
• Using vitamin E oil, aloe vera gel, or petroleum jelly once the risk of infection has passed
• Gently massaging the healed area to prevent stiffness in scar tissue

By implementing these strategies, patients can achieve better cosmetic outcomes and potentially preserve more function in the affected area.

The Complexities of Wound Healing: Factors Affecting Recovery

The wound healing process is intricate and delicate, with numerous factors that can influence its success. Understanding these variables is crucial for healthcare providers and patients alike.

Common Factors That Can Impede Wound Healing

• Diabetes
• Arterial or venous disease
• Infections
• Metabolic deficiencies associated with advanced age
• Nutritional status
• Smoking and alcohol consumption
• Stress levels
• Certain medications

When these factors are present, they can lead to the development of non-healing chronic wounds, which require specialized care and attention.

Specialized Wound Care Techniques for Different Types of Injuries

While the principles of wound care remain consistent, different types of wounds may require specialized treatment approaches.

Pressure Ulcers (Bed Sores)

Pressure ulcers, also known as decubitus ulcers or bed sores, commonly develop at pressure points on the body when an immobilized individual’s weight rests continuously on a hard surface. The primary focus of care for these wounds is pressure relief and proper positioning.

Diabetic Foot Ulcers

Diabetic foot ulcers require careful management due to the compromised healing abilities of many diabetic patients. Treatment often involves strict glucose control, offloading pressure, and addressing any underlying vascular issues.

Traumatic Ulcers

Wounds caused by acute injuries may require initial debridement and careful cleaning before standard wound care practices can be applied. The focus is often on preventing infection and promoting optimal healing conditions.

Arterial and Venous Ulcers

These ulcers, caused by circulatory issues, often require a combination of wound care and treatment of the underlying vascular condition. Compression therapy is commonly used for venous ulcers, while improving blood flow is crucial for arterial ulcers.

Burns

Burn wounds require specialized care depending on their severity. Treatment may range from topical antibiotics and dressings for minor burns to skin grafts and intensive care for severe cases.

The Dual Purpose of Modern Wound Care Practices

Contemporary wound care serves two primary purposes, each equally important in the recovery process:

1. Pressure Relief: A critical aspect of wound care involves relieving pressure on weight-bearing parts of the body, such as bony prominences (e.g., hands, arms, knees, heels, hips, or buttocks) that rest against beds, wheelchairs, or other hard surfaces. This pressure relief is essential in preventing the development of new pressure ulcers and allowing existing ones to heal.
2. Wound Treatment: The second purpose focuses on treating the ulcerated wound itself, particularly when the skin has become weakened, inflamed, or potentially infected. This involves cleaning, dressing, and monitoring the wound to promote healing and prevent complications.

By addressing both these aspects, modern wound care practices aim to create an optimal environment for healing while preventing further tissue damage.

Identifying At-Risk Patients: Preventing Wounds Before They Occur

Proactive wound care often begins with identifying patients who are at higher risk of developing pressure ulcers and other types of wounds. Several factors can contribute to increased risk:

• Immobility due to acute or chronic illness
• Advanced age
• Reduced mental functioning
• Heavy sedation or unconsciousness
• Paralysis or limited range of motion
• Prolonged positioning in beds, chairs, or wheelchairs
• Use of traction or supportive devices

For these at-risk individuals, preventive measures such as regular repositioning, use of pressure-relieving surfaces, and vigilant skin monitoring can significantly reduce the likelihood of wound development.

Early Signs of Tissue Damage

Recognizing the early signs of potential wound development is crucial for timely intervention. Healthcare providers and caregivers should be alert to:

• Tender or inflamed areas over weight-bearing body parts
• Changes in skin color or temperature
• Unusual sensations reported by the patient, such as tingling or burning
• Any breaks in the skin, no matter how small

Early detection and intervention can prevent minor skin irritations from progressing to more serious wounds, significantly improving patient outcomes and reducing the need for extensive wound care treatments.

The Impact of Proper Wound Care on Patient Outcomes and Healthcare Costs

Effective wound care practices not only benefit individual patients but also have far-reaching implications for healthcare systems and society as a whole.

Improved Patient Quality of Life

Proper wound care can significantly enhance a patient’s quality of life by:

• Reducing pain and discomfort associated with wounds
• Speeding up recovery times, allowing for quicker return to normal activities
• Minimizing scarring and potential disfigurement
• Lowering the risk of complications that could lead to prolonged illness or disability

Reduced Healthcare Costs

Investing in effective wound care practices can lead to substantial cost savings for healthcare systems:

• Shorter hospital stays due to faster healing times
• Fewer resources required for treating complications
• Reduced need for additional surgeries or interventions
• Lower likelihood of readmissions related to wound complications

By prioritizing proper wound care, healthcare providers can improve patient outcomes while simultaneously reducing the overall financial burden on the healthcare system.

The Future of Wound Care: Emerging Technologies and Techniques

As medical science continues to advance, new technologies and techniques are emerging that promise to revolutionize the field of wound care.

Innovative Wound Care Technologies

• Smart Bandages: These advanced dressings can monitor wound healing progress and detect early signs of infection, allowing for more timely interventions.
• Negative Pressure Wound Therapy: This technique uses controlled suction to remove excess fluids and promote faster healing in certain types of wounds.
• Bioengineered Skin Substitutes: These products can provide temporary or permanent coverage for wounds, promoting faster healing and reducing the need for skin grafts.
• Growth Factor Therapies: The application of specific growth factors can stimulate cell growth and accelerate the wound healing process.
• 3D-Printed Wound Dressings: Customized dressings created using 3D printing technology can be tailored to fit complex wound shapes and sizes.

Personalized Wound Care Approaches

The future of wound care is likely to involve more personalized treatment plans based on individual patient factors such as:

• Genetic predisposition to certain wound healing complications
• Specific underlying health conditions
• Unique tissue characteristics
• Environmental and lifestyle factors

By tailoring wound care strategies to each patient’s unique needs, healthcare providers can optimize healing outcomes and minimize complications.

The Role of Patient Education in Successful Wound Care

While professional medical care is crucial in wound management, patient education and involvement play a significant role in achieving optimal outcomes.

Key Areas of Patient Education

• Proper wound cleaning and dressing techniques
• Recognition of signs of infection or other complications
• Understanding the importance of adherence to treatment plans
• Awareness of lifestyle factors that can impact wound healing
• Knowledge of when to seek additional medical attention

By empowering patients with the knowledge and skills to participate in their own wound care, healthcare providers can improve compliance with treatment plans and enhance overall healing outcomes.

The Importance of a Collaborative Approach

Effective wound care often requires a collaborative effort between healthcare providers, patients, and caregivers. This team-based approach ensures that all aspects of wound management are addressed, from professional medical interventions to day-to-day care and lifestyle modifications.

By fostering open communication and shared decision-making, healthcare providers can create a supportive environment that promotes optimal wound healing and patient well-being.

Why Wound Care is a Critical Part of Recovery

To say wound care has been around a long time is an understatement. It can, in fact, be traced back to the earliest civilizations, and the ancient Greeks were among the first to stress the importance of wound healing.

Wound care has obviously come a long way since then, and it’s importance in the role of recovery cannot be stressed enough. Here’s a look at why would care plays such a vital role in the recovery process:

Wound Care: The Basics

There are two ways that wounds heal: regeneration or scar formation. During regeneration, tissue that has been damaged is replaced by tissue of the same type. This preserves the proper function of the area of the body that has been injured. In scar formation, the damaged tissue is replaced by fibrous scar tissue which doesn’t have the same properties as the original tissue.

The Importance of Wound Care in Recovery

Proper wound care prevents infection and other complications, and also helps speed up the healing process with less scarring.

• Preventing Infection
  By keeping continual attention on the wound dressings and bandages the risk for infection and other complications is greatly decreased. A health professional can make medically-important decisions through changing the dressings, noting the wound’s progress, as well as by making observations of bleeding, temperature, discharge and smell. In general, wounds should be cleaned once a day with disinfectant specific to wound care, clean water or saline, as well as applying clean dressings.

• Speeds Healing
  A potentially dangerous myth is that wounds heal faster if left uncovered, which simply isn’t true. Covering the wound throughout the healing process actually hastens the healing process. Moreover, properly maintained bandaging provides additional protection against infection.

• Minimizes Scarring
  Keeping the wound soft through the healing process helps to minimize scars while not allowing hard scabs to form. Antibiotic ointments – and other treatment options recommended by your physician – applied during the early stages of healing will keep the skin around the wound soft and pliable.
  

Once the wound has healed enough that there’s no risk of infection, antibiotic ointment can be replaced with vitamin E oil, aloe vera gel, or petroleum jelly. Massaging the area while working with the thicker scar tissue to keep it from becoming stiff is also important. Softer skin will heal with a less noticeable scar.

It’s important to note that the wound healing process is complex and fragile. Interruption or failure can lead to non-healing chronic wounds involving factors such as diabetes, arterial or venous disease, infection, and the metabolic deficiencies of old age.

Wound Care | Encyclopedia.com

Definition

Wound care refers to specific types of treatment for pressure sores , skin ulcers and other wounds that break the skin. Pressure ulcers, also called “bed sores” and referred to medically as decubitus ulcers, are wounds that commonly develop at pressure points on the body when the weight of an immobilized individual rests continuously on a hard surface such as a mattress or wheel chair. Uninterrupted pressure is the cause of pressure sores and relieving pressure is the mainstay of wound care. Other wounds that may benefit from specialized wound care techniques are diabetic foot ulcers, traumatic ulcers caused by injury, arterial and vein ulcers caused by lack of circulation, and burns.

Purpose

The purpose of wound care is twofold: 1) to relieve pressure on a weight-bearing part of the body such as a boney prominence (hand, arm, knee, heel, hip or buttocks) that rests on a bed, wheelchair, another body part, a splint or other hard object, and 2) to treat the ulcerated wound itself when skin has become weakened, inflamed and possibly infected. Although the current discussion of wound care relates primarily to pressure ulcers, other skin ulcers and burn wounds may benefit from similar treatment principles and practices.

Pressure sores develop in immobilized individuals who are constantly positioned the same way in a bed, chair or wheelchair or who may be in traction or paralyzed with limited range of motion. Older individuals who are compromised through acute or chronic illness, under heavy sedation or unconscious, or who have reduced mental functioning, typically do not receive normal nerve signals to move as mobile individuals do. Tissue damage may begin as tender inflamed areas over weight-bearing parts of the body that are in contact with a supporting surface such as a bed or wheelchair, or with another body part or a supportive device. Constant contact at these points exerts pressure on the skin and soft tissue, cutting off the normal flow of blood, oxygen and nutrients to tissue (ischemia ), resulting in death of tissue cells

(anoxia ) and formation of pressure sores. The presence of sores is complicated by rubbing (shear) or friction between the supportive surface and skin over boney prominences. In compromised, immobilized individuals, skin breakdown can happen quickly within hours or days. Regular movement or turning of the individual is needed to relieve pressure, and clinical treatment of pressure sores is required to prevent infection and further breakdown.

Precautions

Physicians orders are required for wound care designed to prevent and treat pressure sores. Alertness to skin condition in immobilized patients is critical among caretakers and medical personal. Individuals at risk for pressure sores may only be aware of discomfort at the points of pressure and may not be aware of the presence of sores or the risk of infection. Caretakers should be informed of pressure sore risk and instructed about typical signs and preventive measures to protect the skin of at-risk individuals in their care.

Steps of recovery

Wound care is usually ordered for any immobilized or bedridden individual with compromised skin integrity in order to prevent pressure sores from developing or to keep red, tender areas from deepening into serious wounds. Care is typically provided by specialized registered nurses called “enterostomal therapists” who are trained in skin and wound care as well as incontinence care and retraining, and care of individuals with surgically diverted urinary or fecal elimination (ostomy). A thorough risk assessment is conducted first and therapy is designed accordingly, employing specific wound care principles and practices shown to be effective for various levels of tissue injury.

Risk Assessment

Enterostomal therapists will note any conditions such as underlying disease, incontinence, or mental confusion that could impede pressure sore recovery. Nutritional status will be evaluated and a specific dietary plan may be designed to provide nutrition to benefit skin healing, including dietary supplements , intravenous (parenteral) feeding, restoring nitrogen balance and normal protein levels. Weight loss may be recommended for obese individuals. Pressure sores will be classified in one of four stages based on wound depth and skin condition: Stage I has intact skin with redness (erythema) and warmth; Stage II has loss of normal skin thickness, possible abrasion, swelling and blistering or peeling of skin; Stage III has full loss of normal skin thickness, an open wound (crater), and possible exposure of deeper layers of skin; Stage IV has full loss of normal skin thickness and erosion of underlying tissue extending into muscle, bone, tendon or joint, along with possible bone destruction, dislocation or pathologic fractures. Therapists will note if wounds are draining, if foul odors are present, or if any debris such as pieces of dead skin are in the wound. Presence of urine or feces from incontinence will be noted as well and regular care personnel will be advised about need for increased hygienic measures.

Pressure Relief

Reducing or eliminating pressure is the first task of wound care and requires the cooperation of the nursing center or family member responsible for onsite care. Recommendations will be made for shifting or turning the patient every two hours or other regular intervals. Some patients may benefit from lying flat on their backs; others may need the head of the bed lowered. Shear can be minimized by placing the patient on a special surface that alternates pressure points. A low-level of pressure relief can be obtained by using egg-crate mattresses or chair cushions. Egg-crate surfaces are constructed of sculpted foam with deep gullies between raised points of cushioning, which alternates pressure on vulnerable areas. Other types of air, foam and gel pressure-relieving surfaces are available. Wheel chair patients may need to be trained to shift their weight or lean side to side to relieve pressure. For deep wounds, burns, or pressure sore prevention, special “low air-loss” or “air-fluidized” beds are available that relieve pressure by constantly-moving air within specially designed pillows or within an entire bed surface filled with millions of tiny silicone-coated beads. Many institutions use beds that employ these principles to help heal wounds of all types and to prevent pressure sores from developing in at risk individuals.

Wound Cleansing and Dressing

For more superficial Stage I and II pressure sores, treatment will involve keeping the wound clean and moist, and the area around the sore clean and dry. Saline washes may be used and placement of sterile medicated non-stick gauze dressings that absorb wound drainage and fight infection-causing bacteria. Other bio-protective cleaning solutions include acetic acid, povidone iodine, and sodium hypochlorite. Harsh antiseptics, soaps and regular skin cleansers are not used because they can damage newly developing tissue. However, drying agents, lotions or ointments may be applied in a thin film over the wound three or four times daily. Massage of any at-risk area should be avoided because it encourages skin breakdown.

Whirlpool Treatment

Warm-water whirlpool treatments are sometimes used to treat pressure ulcers on arms, hands, feet or legs. This technique removes destroyed tissue fragments (necrotic tissue) by the force of irrigation followed by application of wet-to-dry non-stick dressings. After a wet dressing has been applied to the wound and allowed to dry, its removal picks up necrotic debris and a new dressing of sterile, medicated non-stick gauze or semi-permeable transparent adhesive dressings is applied to keep the area dry and prevent destruction of healthy skin near the wound, reducing risk of infection. Adhesive dressings are not recommended for draining wounds.

Hyperbaric Oxygen Therapy

Treatment of Stage III and IV decubitus ulcers, and other types of skin ulcers or burn wounds, may benefit from treatment that saturates the body with oxygen. The individual rests in a pressurized hyperbaric oxygen chamber, breathing 100% oxygen for 90 to 120 minutes. As the oxygen is absorbed by the blood, extra oxygen is provided to all cells and tissues, increasing healing capability and clearing of bacterial infection. Hyperbaric chambers are available in larger hospitals and medical centers.

Antimicrobial or Antibiotic Therapy

Antimicrobial topical therapy or oral antibiotic therapy may be recommended by the individual’s physician to prevent possible bacterial infection or to address existing infection. Silver sulfadiazine is applied topically with good results. Antibiotics taken orally include penicillins, cephalospoins, aminoglycosides , sulfonamides, metronidazol and trimethoprim. Selection is based on specific bacteria causing infection or on obtaining the broadest possible coverage. Tissue biopsy may be performed to identify the causative bacteria.

Debridement and Debriding Agents

Surgical treatment is often needed for wounds showing poor response to standard wound care. Debridement is a surgical procedure that uses either a scalpel or chemicals to remove dead tissue (necrotic debris) from Stage III and IV wounds. Enzymatic debridement uses proteolytic enzymes that destroy collagen and necrotic wound debris without damaging new tissue. Mechanical debridement or “sharp debridement” perfomed with a scalpel loosens the necrotic tissue and removes it to encourage growth of new tissue. Debridement is accompanied by blood loss and may not be possible in individuals who are anemic or cannot afford to lose blood.

Urinary or Fecal Diversion

Incontinent individuals may require a surgical procedure (urinary or fecal diversion) to redirect the flow of urinary or fecal material to keep the wound clean, reducing likelihood of infection and encouraging positive response to medical treatment.

Reconstructive Surgery

Stage III and IV wounds may require consultation with a plastic surgeon to evaluate benefits of reconstructive surgery. Reconstructive surgery involves completely removing the ulcerated area and surrounding tissue (excision), debriding the bone, flushing the area with saline (lavage) to remove excess bacteria, and placing a drain in the wound for several days until risk of infection is gone and evidence of healing becomes apparent. Smaller wounds may then be sutured closed. Plastic surgery may follow surgical excision of a larger wound area, placing a flap of skin from another part of the body over the area to provide a new tissue surface. Skin grafts and other types of flaps may also be used for surgical closure (secondary closure) of excised wounds.

Challenges

Healing existing pressure sores and preventing recurrence is a long, arduous task for wound care professionals and caretakers, requiring patience and constant care. Impaired mobility is the critical factor in developing pressure sores, but risk in immobilized or bedridden individuals is increased by acute or chronic illnesses or conditions that might weaken muscles or soft tissue or that reduce blood circulation, which robs tissues of needed oxygen and causes skin to be thinner and more likely to break down and become infected. Conditions in immobilized older adults that may compromise skin integrity, increase risk of pressure sore development, or impede healing of pressure sores, include:

• atheroslerosis or peripheral vascular disease
• heart disease
• diabetes
• cancer
• anemia
• incontinence, inability to control urination or bowel movements
• malnutrition
• obesity
• stroke, paralysis (paraplegia) or spinal cord injury
• sensory loss (as in paralysis) with diminished sense of pain
• chronic infection
• smoking tobacco, which compromises skin healing

When therapists are providing regular care for individuals with existing pressure ulcers or at risk for pressure sores, progress may be challenged if caretakers are not able to identify warning signs of skin breakdown on regular inspection, are not providing regular bathing or care for incontinence, or are not consistent in moving patients as needed to support ongoing treatment. Adequate instruction must be provided to caretakers by therapists and consistent care given to the individual in order to achieve good results.

Risks

Risk is high for recurrence of pressure sores and deepening of existing sores into serious infection, especially in individuals compromised by poor nutritional status, chronic disease, or reduced immune system function. Complications can occur after pressure sore surgery, including bleeding under the skin (hematoma), bacterial infection, and wound recurrence. Amputation may be required if wounds will not heal or reconstructive surgery is not an option due to poor overall health status. Infection in deep wounds can spread to the blood and the entire body, becoming life threatening. Individuals at high risk for pressure ulcers are also at higher risk for chronic infection and death.

KEY TERMS

Anoxia —Reduced or almost entire absence of oxygen in the blood, cells and tissues of the body resulting in tissue death.

Debridement —Cutting away or “excising” dead tissue from a wound.

Erythema —Redness and warmth of the skin caused by dilation of small blood vessels (capillaries) under the skin.

Excision —Removal of tissue, organ, limb or other body part by cutting.

Friction —A force exerted when two surfaces move across each other such as moving patients across a bed or other support surface.

Hematoma —An area of blood that has gathered and remains confined under the skin or within an organ or body tissue.

Ischemia —Localized anemia stemming from reduced flow of blood and oxygen to organs and tissue, including skin.

Pathologic fracture —A fracture that occurs spontaneously at a weakened area of bone.

Shear —Mechanical stress experienced at the plane of the affected area such as pressure sores on the lower back or hip.

Ulcer —An inflammed sore or “lesion” that occurs on a surface such as skin or the mucus membrane of an organ, typically breaking the skin or membrane and resulting in loss of tissue.

Results

When consistent care is provided including removal or reduction of pressure source, attention to the patient’s general health and underlying condition, and treatment of existing wounds, pressure sores typically heal between two and four weeks after starting treatment. For successful surgical results, infection and complications must be avoided. Preventing recurrence of pressure sores requires regular surveillance and avoidance of pressure on vulnerable areas.

Resources

BOOKS

“Wound Healing.” Disease Prevention and Treatment. Expanded 4th ed. M. Segala, Ed. Ft. Lauderdale, FL: Life Extension Foundation; 2003, 1581-1592.

Haggerty M, Culvert LL. “Bedsores.” Gale Encyclopedia of Surgery. Farmington Hills, MI: Gale/Thomson; 2000.

WEBSITES

Salcido R, Popescu A. “Pressure Ulcers and Wound Care.” eMedicine Specialties. The Medscape Journal. Available at www.emedicine.com/pmr/topic179.htm. Updated Aug. 10, 2006. Accessed March 17, 2008.

Revis DR. “Decubitus Ulcers.” eMedicine Continuing Education, Available at emedicine.com. Updated August 2003. Accessed March 17, 2008.

ORGANIZATIONS

National Pressure Ulcer Advisory Panel, 12100 Sunset Hills Road, Suite 130, Reston, VA, 20190, 703-464-4849, 703-435-4390, [email protected], International Association of Enterostomal Therapists, 27241 La Paz Road, Suite 121, Laguna Niguel, CA, 714-476-0268.

L. Lee Culvert

Skin Wound Healing: An Update on the Current Knowledge and Concepts – FullText – European Surgical Research 2017, Vol. 58, No. 1-2

Abstract

Background: The integrity of healthy skin plays a crucial role in maintaining physiological homeostasis of the human body. The skin is the largest organ system of the body. As such, it plays pivotal roles in the protection against mechanical forces and infections, fluid imbalance, and thermal dysregulation. At the same time, it allows for flexibility to enable joint function in some areas of the body and more rigid fixation to hinder shifting of the palm or foot sole. Many instances lead to inadequate wound healing which necessitates medical intervention. Chronic conditions such as diabetes mellitus or peripheral vascular disease can lead to impaired wound healing. Acute trauma such as degloving or large-scale thermal injuries are followed by a loss of skin organ function rendering the organism vulnerable to infections, thermal dysregulation, and fluid loss. Methods: For this update article, we have reviewed the actual literature on skin wound healing purposes focusing on the main phases of wound healing, i.e., inflammation, proliferation, epithelialization, angiogenesis, remodeling, and scarring. Results: The reader will get briefed on new insights and up-to-date concepts in skin wound healing. The macrophage as a key player in the inflammatory phase will be highlighted. During the epithelialization process, we will present the different concepts of how the wound will get closed, e.g., leapfrogging, lamellipodial crawling, shuffling, and the stem cell niche. The neovascularization represents an essential component in wound healing due to its fundamental impact from the very beginning after skin injury until the end of the wound remodeling. Here, the distinct pattern of the neovascularization process and the special new functions of the pericyte will be underscored. At the end, this update will present 3 topics of high interest in skin wound healing issues, dealing with scarring, tissue engineering, and plasma application. Conclusion: Although wound healing mechanisms and specific cell functions in wound repair have been delineated in part, many underlying pathophysiological processes are still unknown. The purpose of the following update on skin wound healing is to focus on the different phases and to brief the reader on the current knowledge and new insights. Skin wound healing is a complex process, which is dependent on many cell types and mediators interacting in a highly sophisticated temporal sequence. Although some interactions during the healing process are crucial, redundancy is high and other cells or mediators can adopt functions or signaling without major complications.

© 2016 S. Karger AG, Basel

Introduction

Skin wound healing is a fascinating mechanism and represents an evolutionary advantage not only for mammals. Due to its vital functions as a physical, chemical and bacterial barrier, skin wound healing is an important step for survival finalizing in wound closure. Despite a great body of literature with regard to wound healing mechanisms, there are still many questions. Physiological regulation of skin wound healing is a complex process, which is dependent on many cell types and mediators interacting in a highly sophisticated temporal sequence. Although some interactions during the healing process are crucial, redundancy is high and other cells or mediators can adopt functions or signaling without major complications. The purpose of the following update on skin wound healing is to focus on the different phases briefing the reader on actual knowledge and new insights. At the end, this update will briefly focus on 3 topics of high interest, i.e., scarring, tissue engineering in skin wound repair, and plasma application in skin wound healing.

From Inflammation to Proliferation

One of the main reasons for skin wound healing seems to be the restoration of the barrier function in order to prevent further damage or infection. This requires the distinct interplay and crosstalk of a multitude of cells and mediators from the very onset. However, prolonged wound healing phases or excessive responses of the organism to the injury impede normal wound healing and might be associated with scarring. In this context, the transition from the inflammatory to the proliferative stage of wound repair is a topic of intensive current research [1]. First of all, skin cells are exposed to acute phase signals such as damage-associated molecular patterns or pathogen-specific molecular patterns, which are recognized on their parts by toll-like receptors initiating and perpetuating inflammation [2,3]. Leukocytes, especially neutrophil granulocytes, transmigrate alongside an increasing gradient of chemokines until arrival at the site of injury [4,5]. In addition, neutrophils secrete many pro-inflammatory cytokines and thereby amplify the inflammatory response [6]. The influence of cytokines and chemokines in wound repair has been extensively reviewed elsewhere [7,8]. Activated regulatory T cells are part of the adaptive immune system. Aside from leukocytes, regulatory T cells are able to regulate tissue inflammation via the attenuation of the interferon-γ production and the accumulation of pro-inflammatory macrophages. It is assumed that this effect is mediated by the epidermal growth factor receptor pathway, which is coopted for the facilitation of skin wound repair [9].

One of the key players in the transition from inflammation to proliferation is, however, the macrophage [1,10]. Depletion studies showed that the absence of macrophages in the inflammatory or the proliferation phase of wound healing resulted in reduced tissue formation or hemorrhage. Furthermore, the progression into the next scheduled phase failed [11]. Skin-resident macrophages as well as those differentiated from infiltrating monocytes get activated by pathogen-specific molecular patterns and damage-associated molecular patterns [2]. In early stages of wound repair, this results in the differentiation into the M1 subset of macrophages. M1 macrophages are associated with phagocytic activity, scavenging as well as the production of pro-inflammatory mediators [10,12,13]. Later on, M1 transform into the M2 subset, revealing a reparative phenotype of macrophages. M2 macrophages are involved in the synthesis of anti-inflammatory mediators and the production of extracellular matrix (ECM), in the initiation of fibroblast proliferation as well as in angiogenic processes [10,14]. M2 macrophages constitute a kind of cleanup crew as they phagocytose neutrophils (i.e., efferocytosis), bacteria, and cell debris in order to prevent further damage to the wound site in later healing phases. This supports the current paradigm of the M1-M2 switch [1,15]. If the M1-M2 transition does not occur, nonhealing or chronic wounds such as venous ulcers and diabetic wounds are the result [16,17,18]. These observations underpin the intimate and important role of macrophages throughout the process of skin wound healing. In contrast to the above-mentioned, however, many cellular or cytokine actions might get adopted by other cells as Martin et al. [19] could demonstrate that even macrophage-deficient PU.1 null mice were able to repair skin wounds with a similar time course to wild-type mice. Furthermore, these PU.1 null mice showed almost scar-free healing, questioning the impact of the inflammatory response for the skin wound healing process [19].

Epithelialization in Skin Wound Healing

Cutaneous wounds close by epithelial resurfacing and wound contraction. Dependent on the species, one or the other process dominates the progress of wound repair. For example, rodents heal mainly by contraction, whereas in humans, reepithelialization accounts for up to 80% of wound closure [20]. Skin wound epithelialization is reliant on the wound specifics such as the location, the depth, the size, microbial contamination as well as patient-related health conditions, genetics and epigenetics.

Partial thickness wounds that involve the epidermis and partially the dermis usually heal by primary intention with intact skin appendages, i.e., hair, nails, and sebaceous and sweat glands. In contrast, full-thickness wounds are characterized by complete destruction of the epidermis and dermis as well as deeper structures. Repair of tissue loss is initiated by the formation of granulation tissue that replaces the defect before epithelial covering can occur. This form of wound repair is called healing by secondary intention.

Healing by third intention is related to complex cases, e.g., septic conditions when wounds are left intentionally but temporarily open in order to be closed after regression of the highly inflammatory and often life-threatening situation. When the patient is stable and wounds are well-conditioned, wound closure is accomplished by sutures or by plastic surgical reconstruction [21]. This comprehensible classification of wound healing gives an estimate on the duration and course of wound healing phases and, thus, a prediction of later outcomes, e.g., complete skin regeneration or defective tissue repair by scarring.

Superficial, small and clean wounds are usually associated with a short duration of hemostatic and inflammatory phase because blood clot formation is limited to seal the wound with clearing of minor amounts of cell debris. Deep, large and contaminated/infected wounds, however, will need more time to heal as the initial phases of wound healing include longer time for hemostasis and removal of cell debris and necrotic tissue before the start of granulation tissue formation. Reepithelialization already starts some hours after injury by conversion of cobblestone-shaped stationary keratinocytes into flat migratory keratinocytes [22]. In pigs, the epidermis regenerates from hair follicles, apocrine gland ducts, and the wound margin, while in humans, this process seems to originate from pilosebaceous units, eccrine sweat glands [22,23], and the outer root sheath of the hair follicle [24]. Interestingly, the anatomical positioning of skin adnexa seems to be specifically configured for the purpose of highly efficient wound repair. Rittié [22] described this phenomenon by the fact that “no outgrowth has to migrate farther than half the distance that separates two adnexal structures before meeting another outgrowth moving in the opposite direction.” With regard to human partial thickness wounds, cells have to cover approximately 500 µm of distance and complete epithelialization normally within 8-10 days [23]. The resurfacing of an epidermal wound by migrating keratinocytes was initially described by the term of leapfrogging cells that progressively fall over each other and onto the wound bed without certain migrational activity [25,26]. Other authors depicted leader cells or even entire cell rows that drag others with them to crawl over the wound [27,28,29,30]. Additionally, 3 other mechanisms might also be involved such as extension membrane or epidermal tongue, lamellipodial crawling and shuffling [31,32]. The epidermal tongue is formed by the front row of keratinocytes adjacent to the wound site. Activated keratinocytes reorganize their cytoskeleton. This is followed by a succeeding advance over the tongue to spread across the wound (leapfrog-like) [22]. The leading row of activated keratinocytes drags them out of blood clot-derived fibrin, fibronectin, and vitronectin (lamellipodial crawling) and forward over the wound matrix. Interestingly, the leading row cells do not migrate centripetally into the wound center but change their shape, loosen their cell-cell contacts, rearrange themselves and leave the front edge (shuffling) [31]. Arrived in the middle of the wound, contact inhibition stops the migratory process of keratinocytes and the wound covering is finished [33]. Firm cell-cell contacts are reestablished and keratinocytes acquire their quiescent cobblestone-shaped phenotype followed by epidermal stratification. Of note, this repair process is performed from top to bottom with the purpose of fast and sufficient wound closure and to prevent further fluid loss or infection. The prerequisite for effective epithelialization is an appropriate ECM that facilitates keratinocyte migration. While adipose tissue, even in thin layers, counteracts wound coverage, tissues such as dermis, fascia or muscle represent optimal wound beds. Except for dermis as underlying substrate, other connective tissues require the formation of granulation tissue for unimpaired epithelial migration. Granulation tissue is constituted of macrophages, fibroblasts, blood vessels and a loose matrix out of type I collagen, glycoprotein, fibronectin, and hyaluronic acid.

After skin injury, the reconstitution of the resulting cellular defect is usually achieved by invading adult stem cells. In the context of epidermal regeneration, stem cells deriving from the hair follicle bulge and the interfollicular epidermis niche replace missing cells [34,35,36]. A deregulation of the epidermal stem cell niche is present in chronic wounds, i.e., nonhealing ulcers [37], where the cell pool is limited caused by continuous inflammation due to infection, hypoxia, ischemia and/or excessive exudates [38]. The use of stem cells, however, is propagated to overcome the problem of nonhealing wounds with extensive on-going research. Stem cells play an important role in many wound healing phases enabling the resolution of inflammation, cell migration, proliferation and differentiation, although their intriguing role is not yet fully understood [38,39,40].

Angiogenesis in Skin Wound Healing

Neovascularization represents an essential component in uncompromised wound healing due to its fundamental impact from the very beginning after skin injury until the end of the wound remodeling [41,42]. The (micro)vasculature contributes to the initial hemostasis, reduces blood loss and establishes a provisional wound matrix. Blood clot-derived cytokines and growth factors drive the recruitment of pivotal cells that are crucial for the healing process. This provisional wound microenvironment depicts the starting point for new vessel formation and regeneration thereby ensuring the nutritive perfusion of the wound and the delivery of immune cells that remove the cell debris. At first sight, the neovascularization process seems very disordered as the healing wound generates a high density of functional as well as dysfunctional new capillaries. Nonfunctional vessels will regress by time via maturation or apoptotic processes. However, a distinct pattern of the neovascularization process (Fig. 1) can be described forming a circle with an inner ring of circularly organized vessels directly at the wound border followed by radially shaped vessels supplying the inner ones and connecting to the normal, uninjured skin [43]. Disruption in the neovascularization process consecutively leads to wound healing disturbances or chronic ulcers, typically seen in venous insufficiency, arteriosclerotic disease or diabetic foot sores. This pathophysiological phenomenon deserves further attention. Recent research projects focus on blood vessel neoformation and/or delivery to the injury site in order to restore the perfusion and support the healing process. A prerequisite for these approaches is a profound understanding and acknowledgement of the underlying pathophysiological processes that lead to disturbed wound repair.

Fig. 1

Schematic cartoon of newly formed microvascular networks of a regenerating skin wound. It depicts the typical arrangement of neovascularization as given by circular vessels (orange) around the wound margins, radial vascular networks (green) building the bridge between the physiological vascular network and the newly formed microvasculature, and the physiological microcirculation running like a net around the hair follicles (blue).

With regard to chronic, nonhealing wounds, a plethora of causes are present that fuel and feed the unfavorable microenvironment that impedes cutaneous repair. Amongst others, hyperglycemia, persistent inflammation, and growth factor and cytokine deficiencies lead to impaired stem cell recruitment for sufficient angiogenesis [41]. In this context, the beneficial impact of stem cells on skin wound healing is evident, especially for the regeneration of blood vessels [41]. Stem cells or progenitor cells seem to support this process by multiple paracrine effects especially by high levels of pro-angiogenic molecules (i.e., VEGF, HGF, bFGF, EGF, TGF-β, IGF-1) [44,45,46,47]. These effects could be demonstrated in rodent diabetic wounding models, further underscoring the significant activity of stem cells and their potential in repair-resistant chronic wounds [45,46,48,49].

Recently, the pericyte received more attention in wound healing issues [50]. First of all, the pericyte is well characterized for its function in vascular development and stabilization of the endothelium in newly formed blood vessels. The pericyte provides blood barriers and regulates capillary flow-through. Furthermore, it acts in a paracrine way and regulates immune responses as well as processes that are associated with scarring or fibrosis. Pericytes provide adhesive substrates, i.e., VCAM-1 and E-selectin but mainly ICAM-1, to initiate neutrophil crawling at the endothelium in search for gates to migrate into the extravascular tissue [5,51,52,53]. The anti-inflammatory effect of pericytes manifests in their ability to inhibit antigen-specific activation of chemokine-recruited T cells [54]. Interestingly, pericytes can exert pro-fibrotic activity in that they dedifferentiate into activated fibroblasts producing collagen [55]. Fibroproliferation during hypertrophic scarring might be due to the high sensitivity of pericytes or transdifferentiated myofibroblasts to hypoxic states, resulting in occluded or even partially occluded (micro)vessels [50,56].

In contrast to previous reports, mounting evidence points to the recognition that the physiological capillary burst after skin injury might be dispensable. Recent research demonstrated that skin wounds healed normally despite reduced angiogenesis [57,58]. This observation is further supported by the fact that wounds in fetal skin and the oral mucosa heal without scarring despite less angiogenesis compared with adult skin [57,59]. Less scar formation in fetal skin and oral mucosa might be related to an inferior inflammatory response and a much faster maturation of newly formed capillary networks [57]. New therapies for hypertrophic scars or even keloids have therefore been suggested using anti-angiogenic treatments, although the distinct underlying mechanism is still unclear [57,60,61]. DiPietro [57] concluded in her review article that at first, it might seem odd to diminish angiogenesis during skin wound repair. However, as long as nutritive perfusion is provided, a reduced number of capillaries might be sufficient to promote normal skin regeneration.

Remodeling in Skin Wound Healing and Scarring

Scar formation demarcates the end of the last wound healing phase, e.g., the remodeling phase. In contrast to fetal wound repair, normal adult wound healing ultimately results in wound closure and replacement of the original tissue with a collagenous scar. The miracle of perfect, scarless embryonic wound repair is currently poorly understood.

The early-gestation fetus can heal skin wounds with regenerative-type repair and without scar formation [62,63]. In scarless fetal wounds, the epidermis and dermis are restored to a normal architecture. The collagen dermal matrix pattern is reticular and unchanged from unwounded dermis. The wound hair follicle and sweat gland patterns are normal as well. Previous studies on fetal wound repair in sheep showed that wounds healed with complete skin restoration until the end of the second trimenon. In humans, however, scarring occurs earlier in fetal wound repair [64]. This might be due to the specific response of fetal fibroblasts to the pro-fibrotic mediator TGF-β [65].

Scar formation is the ultimate outcome of wound repair in children and adults. Cutaneous scars have no epidermal appendages (hair follicles and sebaceous glands) and a collagen pattern that is distinctly different from unwounded skin. New collagen fibers secreted by fibroblasts are present as early as 3 days after wounding. As the collagen matrix forms, densely packed fibers fill the wound site. The ultimate pattern of collagen in scar is one of densely packed fibers and not the reticular pattern found in unwounded dermis.

To understand the physiology of normal scarring and the pathophysiology of hypertrophic scarring (Fig. 2), one has to be familiar with the role of fibroblasts and myofibroblasts in skin wound healing. It has become accepted that myofibroblasts play a key role in wound contraction. After wounding, dermal fibroblasts at wound margins are activated by growth factors released into the wound. Stimulated by mechanical tension and platelet-derived growth factor (PDGF), they turn into stress fiber-expressing protomyofibroblasts. Protomyofibroblasts are found in early granulation tissue and in normal connective tissue with high mechanical load. Approximately 4 days after wounding, myofibroblasts appear in the wound [66]. Mechanical tension, activated TGF-β [67] and the splice variant EDA fibronectin trigger protofibroblast differentiation into α-smooth muscle actin-expressing myofibroblasts [68]. Myofibroblasts exert their contractile forces by focal adhesion contacts that link the intracellular cytoskeleton to the ECM. Wound contraction must be distinguished from contracture. Clinically, contracture is defined as tissue shortening or distortion that causes decreased joint mobility and function. Scar contracture commonly refers to decreased function in the area, whereas scar contraction refers to shortening of the scar length compared with the original wound (Fig. 2b). Wound scar remodeling occurs during months to years to form a mature scar. The early scar appearance is red due to its dense capillary network induced at the injury site. When closure is complete, capillaries regress until relatively few remain. As the scar redness dissipates during a period of months, the true scar pigmentation becomes evident. Scars are usually hypopigmented after full maturation. However, scars can become hyperpigmented in darker-pigmented patients and in those lighter-pigmented patients whose scars receive excessive sun exposure. For this reason, sun protection measures are recommended for patients with early scars on sun-exposed areas such as the scalp, face, and neck. During remodeling, wounds gradually become stronger with time.

Fig. 2

Examples for different scar types. a Linear hypertrophic scar after midline sternotomy. b Wide-spread hypertrophic scars after burn injury with scar contractures impairing movement of fingers and the hand. c Keloid scar after presternal folliculitis.

Growth factors are the focal regulatory points of the repair process. They are polypeptides that are released by a variety of activated cells at the wound site. In general, they stimulate cellular proliferation and chemoattract new cells to the wound. Myriad growth factors are present in wounds and many have overlapping biologic functions. PDGF is released from platelet α-granules immediately after injury. It attracts neutrophils, macrophages, and fibroblasts to the wound and serves as a powerful mitogen. Moreover, it stimulates fibroblasts to synthesize new ECM and strongly induces granulation tissue production. TGF-β₁ predominates in adult wound healing and is a pro-migratory and pro-fibrotic growth factor that directly stimulates collagen synthesis and decreases ECM degradation by fibroblasts. It is released from all cells at the wound site, including platelets, macrophages, fibroblasts, and keratinocytes. TGF-β accelerates wound repair when it is applied experimentally to wounds that have no deficiency in repair. However, the increase in the repair rate is at the expense of increased fibrosis, which could be a detriment during normal skin healing.

Normal wounds have “stop” signals that halt the repair process when the dermal defect is closed and epithelialization is complete. When these signals are absent or ineffective, the repair process may continue unabated and cause excessive scar. The underlying molecular mechanisms leading to excessive repair are still a topic of intensive research. Pro-fibrotic cytokine overexpression and reduction of collagenase activity were found in skin tissue of burn patients [69.] A lack of programmed cell death, i.e., apoptosis, at the conclusion of repair with the continued presence of activated fibroblasts secreting ECM components has also been implicated [70].

Notwithstanding the molecular regulation of excessive scar formation, there are clinical factors that affect it. To minimize a visible cutaneous scar, elective incisions are least noticeable when they are placed parallel to the natural lines of skin tension (Langer’s lines). This placement has 2 advantages: the scar is parallel or within a natural skin crease, which camouflages the scar, and this location places the least amount of tension on the wound. Wound tension widens the scar. Sharply defined and well-aligned wound edges that are approximated without tension heal with the least amount of scar. Infection or separation of the wound edges with subsequent secondary intention healing also results in more scar formation. Hyperpigmentation and hypopigmentation of the scar increase its contrast with the surrounding skin, making the scar more visible. Sun protection of all wounds is recommended to prevent scar hyperpigmentation.

Hypertrophic scars and keloids (Fig. 2a-c) are unique to humans and very rarely occur in animals, e.g., on horses’ legs or after severe burns [71]. Pathologic scar types are distinguished on the basis of their clinical characteristics. Hypertrophic scars are defined as scars that have not overgrown the original wound boundaries but are instead raised, reddish and itchy (Fig. 2a). They usually form secondary to excessive tensile forces across the wound and are most common in wounds across joint surfaces on the extremities but also commonly occur on the sternum and neck. Physical therapy with range-of-motion exercises is helpful in minimizing hypertrophic scar as well as joint contracture in the extremities. Hypertrophic scar is a self-limited type of overhealing that can regress with time. These scars generally fade as well as flatten to the surrounding skin level.

The first step toward treatment of excessive scarring is early recognition and institution of therapy after surgery or trauma. Meticulous tissue handling, suturing, and wound management with efforts to prevent infection are mandatory [72]. Sun protection to reduce scar hyperpigmentation is essential. Patients who are at increased risk of excessive scarring benefit from preventive techniques, which include silicone gel sheeting or ointments, hypoallergenic microporous tape, and concurrent intralesional steroid injection [72,73]. Silicone gel sheeting is widely used for hypertrophic scar treatment and the only remedy with high evidence [74]. Silicone gel sheeting has a 20-plus-year history with several randomized controlled trials that support its safe and effective use [73,75]. Proposed mechanisms of action for scar reduction include improved hydration and occlusion, increased temperature and change in scar mechanical tension.

A great deal of research is focused on the development of treatment strategies to reduce or prevent scarring. Prompted by fetal wound-healing observations, investigators initially analyzed the anti-scarring effect of anti-TGF-β strategies. The complexity of scar formation and remodeling is underpinned by the fact that simple addition of anti-fibrotic TGF-β₃ was insufficient to prevent scarring [76]. Clearly, more studies are needed, and because of the redundancy of action among growth factors, TGF-β is likely not to be the only growth factor targeted to reduce human scar formation and fibrosis. Lately, tissue mechanics, duration of wound closure and intensity of the inflammatory reaction have come more into focus to address excessive scarring.

Clinical phase II and III trials are currently performed using several novel drugs to tackle fibrotic diseases [77]. Amongst others, the effect of antibodies against TGF-β, the integrin αvβ6, interleukin-13, connective tissue growth factor CTGF/CCN2 and many more is investigated in lung or liver fibrosis or in keloids. Surprisingly, systemic treatment with leukotriene receptor antagonists, angiotensin-converting enzyme, calcium antagonists or statins for asthma, hypertension or hypercholesterinemia, respectively, coincided with reduced scarring [78]. These incidental effects could be, in part, reproduced in animal models [79]. Hopefully, on-going clinical studies will yield sufficient and convincing results for future treatment of excessive scarring.

Tissue Engineering and Cell-Based Therapy for Wound Healing

Currently, the surgical state of the art for the covering of wounds displays autologous skin grafting, which is, however, limited by the availability of autologous skin. Even though the plastic surgical armamentarium comprises a diverse spectrum for tissue transfer, the efforts do not resemble true tissue regeneration or replacements yet. Tissue engineering seeks to create replacement tissues to restore or maintain organ function and to repair tissue defects [40]. Recreating an environment that promotes fundamental homeostatic mechanisms is a significant challenge in tissue engineering [80]. Optimizing cell survival, proliferation, differentiation, apoptosis and angiogenesis and provide suitable stromal support and signaling clues are the key to successfully generating clinically useful tissue [81]. The increasing knowledge of molecular and cellular mechanisms and lessons learned through frustrated attempts enables us to better define future directions, taking into account the various underlying pathophysiological conditions and differing wound types and their specific requirements. Independent of the tissue engineering product, a meticulous wound bed preparation, minimizing bacterial burden, thorough debridement of nonviable tissue, control of edema, optimizing the vascular status to allow for optimal nutrient supply, prevent additional trauma and reduction of mechanical stress are fundamental prerequisites for successful wound healing. Various tissue engineering approaches ranging from temporary wound dressings to improve wound milieu to acellular scaffolds to cell transplants and dermal substitutes are being investigated focusing on many different growth factors, as already mentioned above. Yet the orchestra of growth factors is numerous and the timely interaction is not completely explored, hence further research is needed to provide the appropriate cell signaling clues to promote true wound regeneration.

Another widely studied aspect is the field of matrix materials and scaffolds to provide structural support and promote cell migration. A variety of different components for skin substitutes are being examined each with their unique physical (pore size, elasticity) and biological (cell adhesion, cell migration) characteristics, such as collagens, fibrin/fibronectin, chitosan, elastin, gelatin and glycosaminoglycans [82,83,84,85,86]. Furthermore, decellularization of allogenic or xenogenic skin, 3D printing and currently genetic modifications of the wound bed offer new perspectives [40,87]. In addition, cell transplantation either incorporated in the matrix material or implanted in the wound bed has gained recent interest. Stem and progenitor cells originally thought to replace organ-specific cells have recently been discovered to also deploy their potential for wound healing through chemotaxis of host cells and as a source for cell signaling molecules. However, none of the above-mentioned research work has found its way to standardized clinical application yet [40]. In summary, an optimal dermal substitute or skin replacement therapy has not been found yet by means of tissue engineering. With increasing knowledge about cellular interaction and cell signaling as well as the pathophysiological requirements of specific wound conditions, tissue engineering holds great perspectives for the future to enhance wound healing.

Plasma

Plasma is a well-known phenomenon in daily life. Almost 99% of all materials, based on the whole universe, consist of plasma. In physics, plasma is a particle mixture at the atomic-molecular level, the components of which are partially charged components, ions, and electrons. This means that plasma contains free charge carriers. In addition to the 3 classical aggregate states (solid, liquid, gaseous), plasma is considered a further state of matter. A characteristic of plasma, which is essential for its behavior, but also for technical use, is, therefore, its electrical conductivity. On earth, there are natural plasmas in the ionosphere and lightning. In the biosphere, there are no practically usable natural plasmas. Therefore, plasma must be generated in order to be able to apply it technically. This is usually done by gas discharge. Neon tubes, plasma TVs and nuclear fusion are examples of regular application of plasma technique. In medical engineering, plasma already has a wide spectrum of use, e.g., in surface treatments and meanwhile plasma application is used in cauterization and operative debridement. After years of technological progress, plasma is now ready for medical application. That means, electric currents and temperature are now tolerable for medical application in vivo (Fig. 3). The functional principle is the electric stimulation of argon gas that produces a plasma flame with tolerable temperatures and currencies (Fig. 3). Different studies gave evidence of the successful decontamination of multidrug-resistant, contaminated wounds through nonthermal plasma (NTP) or cold atmospheric plasma (CAP) [88,89,90]. A secondary beneficial feature of plasma derives from its genomic effects [91]. To examine wound healing activity of an atmospheric pressure plasma jet in vivo aside from decontamination effects, Schmidt et al. [92] examined the efficacy of CAP on dermal regeneration in a model of dermal full-thickness ear wounds in mice. Herein, the study could show significantly accelerated wound reepithelialization from day 3 to 9 compared to untreated controls. This was further underscored by in vitro studies, showing enhanced migratory behavior of keratinocytes and fibroblasts. Gap closure in wound scratch assays was significantly accelerated in CAP-treated cells [92]. Keratinocytes mainly regenerate the epidermis and play an important role in wound closure. Daily short plasma applications (up to 40 s) to murine superficial skin wounds showed significantly increased epidermal cell regeneration, granulation tissue hyperplasia, and collagen deposition [93]. This was also confirmed by plasma application on human skin biopsies where short CAP exposure (1-3 min) was already able to induce the proliferation of keratinocytes [94]. Concomitantly, longer exposures might lead to overdosing of the plasma application inducing apoptotic cell death with a further disturbed wound healing process [93,94]. Chernets et al. [95] examined appendage regeneration stimulated by NTP dependent on reactive oxidative species. Single treatment of in vitro organ culture systems with NTP was already able to enhance the survival, growth, and elongation of mouse limb autopods. Perceptible transformations comprised an improved development of the digit length as well as the definition of digit separation [95]. In our own group, we have treated cultivated fibrocytes with NTP for different periods [unpublished data]. Like the effects of plasma on keratinocytes, only short-term treatments with NTP showed expression of macrophage migration inhibitory factor. This cytokine plays an important role in wound healing processes by significantly influencing the expression of anti-microbial peptides from the β-defensin family, important actors for the cellular pathogen defense.

Fig. 3

a Argon plasma application to blood agar plates. b Treatment of burn wounds by 3 argon plasma applicators.

Conclusion

The integrity of healthy skin plays an important role in maintaining physiological homeostasis of the human body. Many instances are described which lead to insufficient healing necessitating further intervention. Although wound healing mechanisms and specific cell functions in wound repair have been delineated in part, many underlying pathophysiological processes are still unknown and we are only able to design new and effective wound healing therapies if we better understand this complex interplay. The here presented new perspectives further support the enormous importance of research in this field in order to reduce the incidence of nonhealing wounds and to facilitate the healing process in general.

Disclosure Statement

The authors declare no conflicts of interest.

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Author Contacts

Heiko Sorg, MD, PhD, MHBA

Department of Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery

Alfried Krupp Krankenhaus Essen, Hellweg 100

DE-45273 Essen (Germany)

E-Mail [email protected]

Article / Publication Details

First-Page Preview

Received: December 03, 2016
Accepted: December 05, 2016
Published online: December 15, 2016

Issue release date: February 2017

Number of Print Pages: 14

Number of Figures: 3

Number of Tables: 0

ISSN: 0014-312X (Print)
eISSN: 1421-9921 (Online)

For additional information: https://www.karger.com/ESR

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What is a Wound Vac?

If you are not familiar with the term wound vac, you are not alone. Many people are unaware of this technique for treating chronic and acute wounds. Another name for wound vac is Negative Pressure Wound Therapy (NPWT).  Basically, this type of treatment helps a wound heal by applying a vacuum through a special sealed dressing. The purpose of the vacuum is to draw the fluid out of the wound and increase blood flow to the area. It used to treat wounds that are difficult to heal on their own.

How Does It Work?

There are three different techniques available with wound vac treatment. Each one involves a different type of dressing. The type of dressing used is dependent upon the type of wound and the objective when treating it.

The first technique involves using a foam dressing. A foam dressing is cut to size to fill an open cavity wound. A film is draped over the foam to create a seal around the dressing. This is then connected to a vacuum pump with a drainage tube. Excess fluids are pumped out of the wound and a moist, healing environment is created.

Another technique involves the use of cotton gauze instead of foam. The cotton gauze is covered by a transparent film and draped over the wound. This creates a seal and the fluids are pumped out in a similar fashion as with the foam dressing.

Non-woven polyester along with a silicon elastomer create a honeycombed textile dressing that can also be used in this treatment.

Depending on the device used, type of dressing, and wound that needs treating, the pressure that is applied can be continuous or intermittent. The length of time for the treatment to be effective varies on the type of wound involved. However, most wounds are healed after anywhere from six weeks, to 16 to 20 weeks for larger chronic wounds.

Who is a Good Candidate for this Type of Wound Therapy?

Anyone who suffers from acute or chronic wounds, or has experienced second or third-degree burns is a potential candidate for negative pressure wound therapy. NPWT is often used to treat advanced bed sores. In patients with bed sores, the use of wound vacs has been proven to help them heal faster and reduce the number of infections.

Those suffering from diabetic ulcers are also potential candidates for wound vac therapy. Currently, diabetic ulcers are the leading cause of foot and leg amputations in the US. This is because of infections that often set in. Wound vac treatment can reduce the chances of these infections, and potentially save someone from having an amputation.

Pressure ulcers are often found in patients who are unconscious or paralyzed and unaware that they need repositioning. This type of chronic wound can also be treated with negative pressure wound therapy. Venous stasis ulcers that are the result of hypoxia can also be treated this way.

Advantages Over Other Possible Treatments

Most treatments for chronic wounds involve a lengthy stay in the hospital. This time can be reduced by using wound vac care because it helps to promote wound closure. If the wound heals quickly, the patient can return to normal activities sooner. Negative pressure wound therapy is also an option with less pain and discomfort for the patient than other possible treatments. And the wound vac success rate is very high.

Wound vac treatment also reduces the risk of an infection versus other forms of treatment. Because wound vac dressing change is only needed every 48 hours, there is less risk of exposure. Other treatments may need to be changed out as much as twice daily.

Schedule an Appointment

Bed sores, second and third-degree burns, ulcers, and other chronic sores can be extremely dangerous if not treated properly. Infections can set in creating a more serious situation than before. People who have these types of wounds should seek medical care and treatment immediately.

At the DFW Wound Care Center, Dr. Reza Mobarak and his team provide advanced solutions and cutting-edge medical techniques for treating chronic and acute wounds. With locations in Irving, Lewisville, and Plano, the team at DFW Wound Care delivers top-notch orthopedic services. Call us today at (972) 665-6292 or visit any of our offices for a free consultation.

Understanding Wound Care in the Hospice and Palliative Setting

In the hospice and palliative care setting, the comfort and care preferences of patients are always the primary foci of care providers. Throughout the span of a patient care, and as terminal illness progress, bodily wounds may occur. Wounds, if left untreated or improperly cared for, impact patients not only physically, but psychosocially as well, and can erode the quality of life that patients enjoy.

Proper wound care provides healing for not only the body, but for the whole person.

By understanding the goals of wound care, the causes of the wounds and their respective treatments, and the effects of effectively treating wounds on a patient’s whole person, we can better understand how the healing practice of wound care serves such a vital role in a non-curative setting.

The Goals of Wound Care in Hospice

Wounds are a common occurrence in patients with terminal illnesses. Of the over 1.6 million patients who receive care from hospice programs across the United States, nearly 1 out of every 3 patients suffer from some form of wound as they near the end of life.

Percentage of Hospice Patients with and without Wounds

With comfort and adherence to patients’ care preferences being the highest priorities, wound care in the hospice and palliative settings is based upon 4 key tenets:

1. Patient-driven Care

The care of a patient’s wounds must be in alignment with the patient’s wishes for their end-of-life care.

2. Management of Wound Symptoms

Though the total healing of the wound may not be possible given a patient’s terminal illness, proper management of wound symptoms — managing the bleeding, malodor, pain, exudate, and progression of wounds, and preventing future wounds — is critical to providing quality wound care.

3. Improvement of Psychosocial Wellness

Wounds not only affect the physical, but the social and emotional well-being of patients, as well. Hospice and palliative care practices must also seek to reinforce a positive body image and guide towards improved psychosocial wellness.

4. Multidisciplinary Team Care

Wounds, and the end-of-life process as a whole, affect the patient’s whole person, as well as the lives of family, friends, and caregivers. Hospice and palliative care organizations must employ a multidisciplinary team of care professionals and various care practices to improve the physical, social, and spiritual well-being of all who are on the end-of-life journey.

In seeking to provide patients with the highest quality of life, wound care in hospice is an evolving practice — one that takes a multidisciplinary, holistic approach for the care of the wound and the relief of patient and family suffering, regardless of whether or not that wound is healable.

Most Common End-of-Life Wounds

Percentage of Common End-of-Life Wounds

The wounds experienced in the hospice and palliative care setting typically fall into a few common categories, each with their own unique characteristics.

Pressure Wounds

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Stages of Pressure Wound – Hide

Pressure wounds, the most common type of wounds found in the palliative care setting, comprise over 50% of the wounds encountered at the end-of-life. Pressure wounds are seen most often in elderly and terminally ill patients as a result skin failure — a naturally occurring process commonly associated with terminal illness wherein the skin begins to break down and die.

Pressure wounds, if left untreated, can advance through 4 stages:

4 stages of pressure wounds and their characteristics:

Stage I: Redness and painful — often darkly pigmented — skin that differs in temperature and texture from the surrounding skin.

Stage II: Partial loss of outer skin, often with a shallow, open wound with a red wound bed.

Stage III: Full thickness outer skin loss. Subcutaneous fat may be visible, but no muscle, bone, or tendon is exposed.

Stage IV: Wound extends deeply, often into muscles or tendons.

Skin Tears

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Arm Skin Tear – Hide

Skin tears are very traumatic wounds that usually occur on the arms and legs of older patients. These wounds are often the result of extreme friction that separates the outer layers of skin from one another, or in more extreme cases, full separation of the layers of skin from the underlying skin structures.

Characteristics of Skin Tears

Deep Tissue Injuries

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Deep Tissue Injury – Hide

If the underlying soft tissues in a patient’s body are damaged by constant friction, shear, or continued pressure, deep tissue injuries can begin to form. If left unmanaged, deep tissue injuries can progress quickly, causing the surrounding skin to deteriorate rapidly, forming a more advanced wound.

Characteristics of Deep Tissue Injuries

• Purple or maroon in color

• Dissimilar feeling to the skin surrounding the wound — squishy or quite firm to the touch

• Dissimilar in temperature to the skin surrounding the wound — warmer or cooler to the touch

Venous Ulcers

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Venous Ulcer – Hide

Venous ulcers are ulcers that most often occur on the legs of those who have been diagnosed with some form of venous disease.

Characteristics of Venous Ulcers

• Develop in irregular shapes

• Shallow

• Most often form on the lower legs and ankles

• Usually accompanied by painful swelling

Malignant Wounds

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Malignant Wound – Hide

Malignant wounds form when cancer, growing under the skin, penetrates through the skin and forms a wound. As these wounds and the cancer within them progress, the cancer blocks the oxygen supply to the tiny vessels around the skin, starving the skin in that area of the oxygen it needs.

Characteristics of Malignant Wounds

• Strong malodor

• Heavy exudate that crusts

• Purple or maroon in color

• Dissimilar in feel to the skin surrounding the wound — squishy or quite firm to the touch

• Dissimilar in temperature to the skin surrounding the wound — warmer or cooler to the touch

Psychosocial Effects of Wounds

Though wounds affect hospice and palliative care patients on a physical level, with mobility-limiting pain, odor, and exudate, so too do wounds have a negative psychosocial impact on patients.

Social Isolation

Wounds, especially those with exudate and malodor, cause patients to feel ashamed of their body, and feel cut off from friends and family. This feeling of shame typically results in patients isolating themselves from others out of fear of rejection and potentially sensing disgust from others.

Negative Body Image

The presence of wounds, being potentially malodorous or leaky, erodes positivity that a patient may have regarding their body image. Over time, patients can begin to feel and believe that their body is unacceptable to others.

Depression

Often as a result of the negative body image and social isolation, patients with wounds can begin sinking into depression. No longer feeling acceptable in the presence of friends or family, feelings of shame, embarrassment, and self-disgust take root, leading to potentially severe depression.

Common Causes of Wounds

Wounds can form for a variety of reasons. While some wounds may be the result of a patient’s specific terminal illness, there are common factors in the development of wounds at the end of life.

Lack of Movement

Hospice and palliative care patients often, over time, become less mobile as their terminal illness progresses. This increased lack of physical motion causes pressure to build on the patient’s body where the body is making contact with a weight-bearing surface, resulting in the development of a pressure wound.

Friction and Shear

A patient rubbing their heels against the bed linens, sliding their body across the bed to sit up, or any number of frequent, repeated movements against a surface are examples of friction and shear. Both friction and shear cause the skin to be damaged externally and internally.

Inadequate Nutrition

When a patient is still able to receive food and drink, but is not receiving the nutrients they need, the body enters into a state of stress, creating a hypermetabolic state wherein the body’s natural tissue repair mechanisms begin to slow.

In this state, sudden, severe weight loss can occur, reducing the body’s fat. Without a healthy amount of fat, the body’s natural padding for the skin is reduced, giving way to resultant pressure ulcers.

Old Age

As people age, the skin’s natural process of cell restoration slows and the skin naturally begins to become more fragile, thin, dry, and more easily injured. This increased vulnerability to cuts and bruising greatly increases the risk of pressure ulcers forming.

Moisture

Moisture, be it from sweat, waste, or other sources, creates an environment of bacterial growth and increases the permeability of the outer layer of skin, reducing its ability to guard against injury from friction. With a greater chance for injury, paired with increased bacterial growth, the skin is much more easily infected when the presence of constant moisture is a factor.

Treating and Reducing the Risk of Wounds

When treating the wounds of patients who suffer from terminal illness, complete healing of the wound might not always be possible. While pressure wounds might not be able to be completely healed, there are steps taken to help reduce the chance of wound progression and future wound formation.

Repositioning

The patient, in accordance with their wishes and in the best interest of their overall comfort, is repositioned periodically for optimal comfort. Repositioning is often done on a schedule to ensure that pressure isn’t allowed to build for too long of a period on any one portion of the patient’s body.

Protecting pressure-prone areas

While frequent repositioning works well at staving off pressure wounds, improved support and protection on high-friction or high-pressure areas helps reduce the risk of wound formation.

Foam supports or specialty pillows can help position the body in a manner that promotes reduced pressure. Elbow and heel protectors also help cut down on friction against the bedding surface.

Skin care

By maintaining proper skin cleanliness and health, the risk of pressure wounds developing is greatly reduced. Using emollients (non-cosmetic moisturisers) on the skin promotes increase elasticity and prevents dryness — a common occurrence in elderly or terminally ill skin.

Proper management of incontinence

Incontinence, the involuntary loss of urine or feces, if left improperly managed, can lead to excess moisture and bacterial infection. The presence of additional moisture and bacteria can lead to significant weakening of the skin and exacerbation of existing wounds.

By assisting patients with their toileting needs and by providing assistance in cleansing after toileting, the risk of future wound formation is greatly reduced.

Wound Care at the End of Life

In the hospice and palliative care settings, it is often difficult to achieve full healing and closure of wounds as patients begin to draw closer to death. While the complete healing of a wound may not be possible, properly treating wounds and managing wound symptoms provides patients with comfort, a positive body image, and improved psychosocial wellness. Proper wound care provides healing for not only the body, but for the whole person.

Home wound care do’s and don’ts | UCI Health

Cut, scrape or puncture the skin and our bodies immediately begin to heal the wound.

When it comes to animal bites, cuts deeper than a quarter inch or those that bleed excessively, people should see a doctor, says UCI Health family medicine specialist Sara Etemad, MD.

But many minor injuries can be treated at home by observing a few rules to prevent infection and ensure complete healing.

First, it’s helpful to understand the stages of the body’s natural healing process, says Etemad, who sees patients at UCI Health — Tustin.

Stages of wound healing

• Blood begins to clot and a scab begins to form.
• White blood cells help to ward off infection and begin to repair the damaged tissue and any broken blood vessels.
• Red blood cells create collagen to form a base for new tissue to grow in the wound.
• New skin forms over this tissue, and as the edges pull inward, the wound gets smaller.
• A scar forms, strengthening the area over the wound.

To boost this natural healing process, cleansing the wound is the first priority. Etemad offers the following advice:

Do this to promote healing

• Immediately irrigate the wound with water by holding it under the tap and wash the area with gentle soap then pat dry.
• Small cuts and scrapes can be left uncovered, but moisture is usually needed to help speed up the healing process.
• Apply petroleum jelly (Vaseline) and cover with an adhesive bandage any exposed wounds that might become dirty on the hands, feet, arms or legs. For people who are sensitive to adhesive, a gauze pad can be secured with paper tape.
• Cleanse the wound daily with soap and water, and apply fresh petroleum jelly and a bandage.
• Once the wound has healed, apply sunscreen with an SPF of at least 30 to control scarring.

Don’t do this to your wounds

• Don’t apply a topical antibiotic. Studies show that petroleum jelly is just as effective as an antibiotic ointment for non-infected wounds.
• Don’t douse a minor wound with antiseptics like iodine or hydrogen peroxide. They’re actually harmful to the skin and can delay healing.

Most minor cuts and scrapes will heal in a matter of days. But some wounds are at a higher risk of infection and may need a topical antibiotic. If you are unsure about your wound, it’s a good idea to seek medical attention.

Etemad says it’s also important to know when to get medical treatment.

When to see your doctor

• Animal bites
• Cuts or punctures from a rusty or dirty object, because you may need a tetanus shot 
• Wounds deeper than a quarter inch, that won’t stop bleeding after keeping direct pressure on the injury for over 5 minutes
• Wounds with jagged or far apart edges that can’t be brought together easily and may require stitches or skin glue
• Wounds on the face that may need special attention for cosmetic reasons
• Signs of serious infection, such as when the wound is red, warm or painful to touch, draining pus or is surrounded by red streaks

Remember to cleanse your wound daily with gentle soap and water, apply petroleum jelly and cover it with an adhesive bandage for faster healing, Etemad says, adding, “And if you have any questions or are unsure about your wound, come visit us at our Tustin office.”

Related stories

Cut, scrape or puncture the skin and our bodies immediately begin to heal the wound.

When it comes to animal bites, cuts deeper than a quarter inch or those that bleed excessively, people should see a doctor, says UCI Health family medicine specialist Sara Etemad, MD.

But many minor injuries can be treated at home by observing a few rules to prevent infection and ensure complete healing.

First, it’s helpful to understand the stages of the body’s natural healing process, says Etemad, who sees patients at UCI Health — Tustin.

Stages of wound healing

• Blood begins to clot and a scab begins to form.
• Beneath the skin, blood vessels carry oxygen and nutrients essential to healing to the area.
• White blood cells help to ward off infection and begin to repair the damaged tissue and any broken blood vessels.
• Red blood cells create collagen to form a base for new tissue to grow in the wound.
• New skin forms over this tissue, and as the edges pull inward, the wound gets smaller.
• A scar forms, strengthening the area over the wound.

To boost this natural healing process, cleansing the wound is the first priority. Etemad offers the following advice:

Do this to promote healing

• Immediately irrigate the wound with water by holding it under the tap and wash the area with gentle soap then pat dry.
• Small cuts and scrapes can be left uncovered, but moisture is usually needed to help speed up the healing process.
• Apply petroleum jelly (Vaseline) and cover with an adhesive bandage any exposed wounds that might become dirty on the hands, feet, arms or legs. For people who are sensitive to adhesive, a gauze pad can be secured with paper tape.
• Cleanse the wound daily with soap and water, and apply fresh petroleum jelly and a bandage.
• Once the wound has healed, apply sunscreen with an SPF of at least 30 to control scarring.

Don’t do this to your wounds

• Don’t apply a topical antibiotic. Studies show that petroleum jelly is just as effective as an antibiotic ointment for non-infected wounds.
• Don’t douse a minor wound with antiseptics like iodine or hydrogen peroxide. They’re actually harmful to the skin and can delay wound healing.

Most minor cuts and scrapes will heal in a matter of days. But some wounds are at a higher risk of infection and may need a topical antibiotic. If you are unsure about your wound, it’s a good idea to seek medical attention.

Etemad says it’s also important to know when to get medical treatment.

When to see your doctor

• Animal bites
• Cuts or punctures from a rusty or dirty object, because you may need a tetanus shot 
• Wounds deeper than a quarter inch, that won’t stop bleeding after keeping direct pressure on the injury for over 5 minutes
• Wounds with jagged or far apart edges that can’t be brought together easily and may require stitches or skin glue
• Wounds on the face that may need special attention for cosmetic reasons
• Signs of serious infection, such as when the wound is red, warm or painful to touch, draining pus or is surrounded by red streaks

Remember to cleanse your wound daily with gentle soap and water, apply petroleum jelly and cover it with an adhesive bandage for faster healing. And if you have any questions or are unsure about your wound, come visit us at our Tustin office.

Related stories

Cut, scrape or puncture the skin and our bodies immediately begin to heal the wound.

When it comes to animal bites, cuts deeper than a quarter inch or those that bleed excessively, people should see a doctor, says UCI Health family medicine specialist Sara Etemad, MD.

But many minor injuries can be treated at home by observing a few rules to prevent infection and ensure complete healing.

First, it’s helpful to understand the stages of the body’s natural healing process, says Etemad, who sees patients at UCI Health — Tustin.

Stages of wound healing

• Blood begins to clot and a scab begins to form.
• Beneath the skin, blood vessels carry oxygen and nutrients essential to healing to the area.
• White blood cells help to ward off infection and begin to repair the damaged tissue and any broken blood vessels.
• Red blood cells create collagen to form a base for new tissue to grow in the wound.
• New skin forms over this tissue, and as the edges pull inward, the wound gets smaller.
• A scar forms, strengthening the area over the wound.

To boost this natural healing process, cleansing the wound is the first priority. Etemad offers the following advice:

Do this to promote healing

• Immediately irrigate the wound with water by holding it under the tap and wash the area with gentle soap then pat dry.
• Small cuts and scrapes can be left uncovered, but moisture is usually needed to help speed up the healing process.
• Apply petroleum jelly (Vaseline) and cover with an adhesive bandage any exposed wounds that might become dirty on the hands, feet, arms or legs. For people who are sensitive to adhesive, a gauze pad can be secured with paper tape.
• Cleanse the wound daily with soap and water, and apply fresh petroleum jelly and a bandage.
• Once the wound has healed, apply sunscreen with an SPF of at least 30 to control scarring.

Don’t do this to your wounds

• Don’t apply a topical antibiotic. Studies show that petroleum jelly is just as effective as an antibiotic ointment for non-infected wounds.
• Don’t douse a minor wound with antiseptics like iodine or hydrogen peroxide. They’re actually harmful to the skin and can delay wound healing.

Most minor cuts and scrapes will heal in a matter of days. But some wounds are at a higher risk of infection and may need a topical antibiotic. If you are unsure about your wound, it’s a good idea to seek medical attention.

Etemad says it’s also important to know when to get medical treatment.

When to see your doctor

• Animal bites
• Cuts or punctures from a rusty or dirty object, because you may need a tetanus shot 
• Wounds deeper than a quarter inch, that won’t stop bleeding after keeping direct pressure on the injury for over 5 minutes
• Wounds with jagged or far apart edges that can’t be brought together easily and may require stitches or skin glue
• Wounds on the face that may need special attention for cosmetic reasons
• Signs of serious infection, such as when the wound is red, warm or painful to touch, draining pus or is surrounded by red streaks

Remember to cleanse your wound daily with gentle soap and water, apply petroleum jelly and cover it with an adhesive bandage for faster healing. And if you have any questions or are unsure about your wound, come visit us at our Tustin office.

Related stories

Cut, scrape or puncture the skin and our bodies immediately begin to heal the wound.

When it comes to animal bites, cuts deeper than a quarter inch or those that bleed excessively, people should see a doctor, says UCI Health family medicine specialist Sara Etemad, MD.

But many minor injuries can be treated at home by observing a few rules to prevent infection and ensure complete healing.

First, it’s helpful to understand the stages of the body’s natural healing process, says Etemad, who sees patients at UCI Health — Tustin.

Stages of wound healing

• Blood begins to clot and a scab begins to form.
• Beneath the skin, blood vessels carry oxygen and nutrients essential to healing to the area.
• White blood cells help to ward off infection and begin to repair the damaged tissue and any broken blood vessels.
• Red blood cells create collagen to form a base for new tissue to grow in the wound.
• New skin forms over this tissue, and as the edges pull inward, the wound gets smaller.
• A scar forms, strengthening the area over the wound.

To boost this natural healing process, cleansing the wound is the first priority. Etemad offers the following advice:

Do this to promote healing

• Immediately irrigate the wound with water by holding it under the tap and wash the area with gentle soap then pat dry.
• Small cuts and scrapes can be left uncovered, but moisture is usually needed to help speed up the healing process.
• Apply petroleum jelly (Vaseline) and cover with an adhesive bandage any exposed wounds that might become dirty on the hands, feet, arms or legs. For people who are sensitive to adhesive, a gauze pad can be secured with paper tape.
• Cleanse the wound daily with soap and water, and apply fresh petroleum jelly and a bandage.
• Once the wound has healed, apply sunscreen with an SPF of at least 30 to control scarring.

Don’t do this to your wounds

• Don’t apply a topical antibiotic. Studies show that petroleum jelly is just as effective as an antibiotic ointment for non-infected wounds.
• Don’t douse a minor wound with antiseptics like iodine or hydrogen peroxide. They’re actually harmful to the skin and can delay wound healing.

Most minor cuts and scrapes will heal in a matter of days. But some wounds are at a higher risk of infection and may need a topical antibiotic. If you are unsure about your wound, it’s a good idea to seek medical attention.

Etemad says it’s also important to know when to get medical treatment.

When to see your doctor

• Animal bites
• Cuts or punctures from a rusty or dirty object, because you may need a tetanus shot 
• Wounds deeper than a quarter inch, that won’t stop bleeding after keeping direct pressure on the injury for over 5 minutes
• Wounds with jagged or far apart edges that can’t be brought together easily and may require stitches or skin glue
• Wounds on the face that may need special attention for cosmetic reasons
• Signs of serious infection, such as when the wound is red, warm or painful to touch, draining pus or is surrounded by red streaks

Remember to cleanse your wound daily with gentle soap and water, apply petroleum jelly and cover it with an adhesive bandage for faster healing. And if you have any questions or are unsure about your wound, come visit us at our Tustin office.

Related stories

Trends in wound management-The role of autologous wound care products

3C Patch^® is a concentrated growth factor construct, so I don’t necessarily have to use the patch to act as a scaffold; I just put it on as a stimulant. You can put it on as it comes from the device, fenestrate it and stretch it, or divide it into sections and spread it out onto different places on the wound. It seems to work each time because I am not disrupting the tissue’s purpose, and we can manipulate it in many ways. Furthermore, it can be used in conjunction with almost all types of secondary dressings. It means that you are free to select a dressing of your choice that can handle the volume of exudate.

Helpfully, 3C Patch^® is classified as a procedure – draw the blood, make the patch, put it on the wound – and when it comes to reimbursement, procedures are always preferable to non-procedures. They tend to get approved and paid better and more easily.

Our clinic is an outpatient chronic wound referral centre and most of the wounds we see are at least four weeks old and tend to be covered with biofilm, which complicates the healing process further. Even so, in our patient population, 3C Patch^® has been seen to help move the wound from a “stalled” phase back to active healing.

Our patients are most 50-60 years plus, with poorly controlled diabetes (HBA1c ≥7) and associated complications and comorbidities including kidney disease, connective tissue disorders, nutritional challenges, etc. They are often not the best at following directions around dressing changes at home, coming on time, wearing their offloading devices, etc. All this means that having a point of care, regenerative treatment that can stimulate wound healing in this patient population is advantageous.

Can you tell us about implementing 3C Patch

^® into the clinic’s workflow?

We have implemented it in our clinic by optimizing the process as much as possible. The nurse takes the patient’s blood on arrival, puts the sample in the centrifuge, and starts the automated process to produce the 3C Patch^®. While this is happening, on the first visit I do a thorough debridement and if it’s a follow-up visit and debridement is not necessary, I use this time to see other patients.

After the centrifugation process is finished, I come back and apply the 3C Patch^® and the patient is ready to go home. With 3C Patch^®, I’ve noticed that in most cases, when the patient comes back for the next appointment, the wound shows signs of improvement.

Change of dressings

Change of dressing

The quality of dressing is one of the factors that significantly affect the entire course of wound healing. Taking into account the contact route of transmission of wound infection, dressing always uses the principle of continuous asepsis and non-touch technique, in which the wound or dressing is not allowed to be touched without gloves. To reduce the risk of transmission, dressing of infected wounds should be done by two people.Moreover, all materials that come into contact with the wound or serve as aseptic process must be sterile.

The practical implementation of changing the dressing includes mandatory preliminary protective measures in accordance with the instructions for hygiene and patient preparation. When changing dressings in patients with HIV, AIDS, viral hepatitis, in patients with multi-resistant or anaerobic microflora in the wound, the dressing person must take special measures to protect himself from infection: latex gloves, goggles and a mask that covers the nose and mouth are required.The patient is informed about the upcoming dressing and the nature of the wound treatment. Before dressing, give an anesthetic 30 minutes before changing the dressing.

Stages of dressing

1. Removal of previously applied dressing – performed in non-sterile gloves with the obligatory wet separation of the dried textile dressing from the wound, followed by replacement of gloves with sterile ones;
2. Examination of the wound – a visual examination is carried out for the purpose of a comprehensive clinical assessment of the condition of the wound and the course of the wound process, possible complications are identified;
3. Cleaning of the wound and surrounding tissues – removal of residual exudate, antiseptic treatment of the skin surrounding the wound, if necessary, instrumental removal of dry crusts, necrosis, fibrinous plaque, foreign bodies within non-viable tissues, final treatment of the wound with antiseptics;
4. Application of a new dressing – carried out with sterile gloves ensuring the most complete contact of the dressing corresponding to the current local status without excessive mechanical impact on the wound and the obligatory use of a sterile instrument;
5. Fixation of the dressing – is performed using fixing plasters (for small wounds) or bandaging according to the rules of desmurgy with an even distribution of pressure on the wound area.Gidrokoll and Gidrosorb comfort – self-fixing dressings;
6. After dressing, the used materials are prepared according to the hygienic regime for final disposal or reuse;
7. Finally, a hygienic hand disinfection (Sterillium) is carried out.

Dressing change frequency

The dressing change frequency depends on the condition of the wound and the specific properties of the dressing itself. The wound should be kept as quiet as possible.However, the dressing should be removed immediately if: the patient complains of pain, develops a fever, the dressing becomes dirty or has exhausted its absorbency, or its fixation is impaired. In an aseptic wound that heals by primary intention, the dressing may be left on until the stitches are removed. In the first phase of the wound process with abundant exudation, one should focus on the degree of absorption of the wound discharge by the bandage. This may require 1-2 or more dressings per day. With normal development of granulation tissue in the wound, the frequency of dressings decreases.With epithelialization, the physiological secretion of the wound decreases, and therefore the intervals between dressings can be further increased. So, in the 2nd and 3rd phase of the wound process when using the hydroactive dressings “Hydrocoll” and “Gidrosorb”, the dressing intervals can be increased up to 7 days.

Pharm Line Group – Wound Protection

The main goal of wound care is to provide conditions for a smooth healing process to prevent complications.

The site of the wound, after its formation, becomes defenseless against various microbes and viruses that can cause infection, edema or such serious complications as the formation of keloid scars.

Maximum Wound Protection – Minimum Scarring

Bacteria can migrate deeper into the wound and cause severe infection.

Bacteria can easily enter the body through an open, unprotected wound and cause infection. Inflammation slows down the healing process and can spread to healthy tissue, causing uncontrolled cell proliferation and replacement of normal fibers with connective fibers to form keloid scars.

Water is also a threat to wound healing.The water can be contaminated or contain harmful elements such as chlorine, which greatly increase the risk of complications. In addition, water promotes swelling of skin cells, as a result of which the wound narrows and its edges close. In this case, bacteria and microbes, remaining inside, create a focus of inflammation.

Proper wound protection is key to wound healing.

The optimal solution for wound protection is an adhesive plaster, which should be selected depending on the type of wound, size and location.

After you have picked up the patch, follow these guidelines:

STEP 1

Always wash your hands thoroughly with soap and water before treating any wound.
The most important thing for a wound is peace. Friction should be avoided in the area of ​​abrasions and deeper damage to the skin.

STEP 2

Now you need to clean and disinfect the wound directly. Do not try to remove foreign objects from the wound (such as glass shards) yourself.This should be done by a qualified healthcare professional. Before applying the patch, it is necessary to stop the bleeding, if any.

STEP 3

Apply the patch to clean, dry skin. Make sure the patch is applied without wrinkling or stretching. The patch provides an optimal environment for wound healing.

A word to the expert:

The head expert Pharm Line Group – Doctor Morton
Research & Development
Interview with a leading expert Pharm Line Group,
Research and Development Department

“The main task in the process of wound healing is to provide optimal conditions for quick and correct healing, without further complications under the influence of external factors.Infection is the number one threat!

Is it possible to protect the wound in contact with water?

Water and moisture accumulated under the patch create swelling of the skin. Because of this, a wound site that is at risk of attack by bacteria and germs is prone to an increased risk of infection. In case of contact with water and when taking water procedures, we recommend using a special waterproof series of Pharm Line Group plasters.

Waterproof adhesive plasters provide optimal protection against bacteria while allowing the skin to breathe.

How does the patch help protect the wound?

Adhesive plaster provides protection from the moment of injury until the end of the wound healing process. They protect skin tissues from external influences such as pressure and friction, water ingress, pollution and infection.

How long can the patch be worn?

From the very beginning until the wound is completely healed. The patch should be changed daily to check the healing process and control inflammation and / or other abnormalities, as well as to maintain hygiene standards. “

How to speed up the wound healing process and prevent the appearance of scars?

• It is very important that the wound is protected at all times. Only in this case the risk of infection and the occurrence of complications will be minimized.
• Another important factor is wound rest. Do not touch abrasions and wounds with your hands. Friction and pressure from clothing or other external factors must be avoided.
• UV and sunlight should be avoided at all stages of wound healing.Exposure to the sun can lead to redness, scarring and discoloration of the skin.

Prevention

• When cleaning, use rubber gloves to protect against cuts.
• Be careful when shaving – do not overuse disposable razors. After a short use, the blade becomes less sharp, you automatically apply more pressure, which increases the risk of skin cuts.
• When working with sharp objects such as knives, scissors, saws, be calm and attentive.Stress or being overworked increases the risk of injury.

! We recommend that you see a doctor in the following cases:

• if the wound is deep and accompanied by severe bleeding
• if there are signs of infection such as redness, pain, swelling and fever
• if foreign objects get into the wound
• in case of an animal bite
• if the wound is in the face
• if you have diabetes

If you have diabetes, proper wound care is of particular importance.We strongly recommend that you see a doctor! Even small wounds and cracks in the skin, especially the legs, if not properly treated, can have the most adverse consequences.

Please note that none of the above tips or advice is a substitute for medical advice.

Carefully read the instructions for use on the packaging of our products.

The information provided on this site is not a substitute for the professional assistance of a physician.

For more information on Pharm Line Group products, please contact us by e-mail at [email protected]

90,000 Chronic Wound – Kolan British Hospital

What is Chronic Wound?

A chronic wound is called a long, difficult or generally incurable wound. Unlike acute wounds, chronic wounds have a specific environment. Features of the environment are ischemia, hypoxia, or infection. If the wound does not heal within three months, it can be called chronic.Chronic wounds include wounds of diabetic feet, bedsores, trophic ulcers, ischemic ulcers, ulcers due to various vasculitis. The causes may also be soft tissue necrosis as a result of radiation therapy or extravasation of drugs (leakage of fluid from a vein into the tissue).

The main factors in the appearance of chronic wounds are obesity, smoking, eating disorders, old age, lack of vitamins and microelements, malignant tumors, chemotherapy and radiotherapy, immunosuppressants, corticosteroids and anticoagulants.However, chronic wounds can occur for no reason at all. In this case, more local causes are considered. Insufficient blood supply to the skin, excessive stress, inadequate closure of the surgical wound, insufficient venous drainage, foreign bodies, and the presence of infection in the wound area can impede wound healing.

Types of chronic wounds

Chronic wounds

Wounds that do not heal within a certain time and recur again are called chronic.These wounds can be symptomatic evidence of tissue pressure, poor circulation, poor nutrition. Pressure ulcers, venous ulcers, and diabetic foot are examples of chronic wounds. For successful wound healing, a complete examination of the person is necessary. In addition, careful wound care, monitoring of wound healing, knowledge of modern dressings, and regulation and control of the underlying cause are required.

Diabetic wounds (diabetic wounds)

Diabetes is a chronic disease that over time damages blood vessels and nerve tissues.Disorders of blood circulation in the veins, especially in the area of ​​the fingers, leads to scarring. Unfortunately, wounds are not immediately noticed, which complicates further healing. During treatment, it is important to control blood sugar levels, keep the leg at heart level, and provide appropriate treatment and care depending on the wound. The treatment is lengthy and requires patience. Applying proper wound care accelerates the wound healing process.

Wounds due to circulatory disorders

Diseases such as Buerger’s disease, which develops as a result of smoking, hardening of the arteries due to blockage contributes to the blockage of blood vessels.The blockage of blood vessels, in turn, leads to wounds on the legs, with the subsequent possible amputation. The wounds arising from such diseases are deep and require a long treatment.

Varicose wounds

The cause of wounds, mainly occurring on the ankle and the front of the legs, is varicose veins, which interferes with blood circulation. Treatment of varicose wounds is difficult and requires specialist intervention. These wounds must be monitored by doctors. Treatment includes medical supervision, appropriate dressing and, if necessary, surgery.

Pressure ulcers

Wounds resulting from bedridden / paralyzed patients forced to lie in the same position for a long time or use a wheelchair, constant contact with a bed or chair. As a result of pressure, redness occurs and if left untreated, wounds can grow.

Wounds associated with physical trauma

Injuries occur when tissue or nerves are damaged due to a fall, collision, etc.e. Immediately after the patient is injured, urgent delivery to an ambulance doctor is required, who will determine the severity and severity of the injury and, if necessary, referring to other doctors, surgical treatment is performed. Postoperative treatment or wound dressing is carried out under the supervision of a physician.

Yanık Yaraları

For 1st and 2nd degree burns, dressing is carried out depending on the condition of the burns, dressings are usually carried out after 2-3 days. Wound healing depends on the age of the patient and the condition of the wound.

Wounds that do not heal after surgery

Basically, if after surgery, proper care and dressing are provided, the wound heals on average within 3-6 weeks. Depending on the condition of the wound, it is necessary to treat the wounds daily or every other day.

Chronic Wound Care Unit

Various methods have been developed to treat, shorten the healing time and prevent losses in chronic wounds due to patient noncompliance. One of these methods is hyperbaric oxygenation

Hyperbaric oxygenation (HBO):

Hyperbaric oxygenation; 100% oxygen supply, is a treatment carried out at sea level, with oxygen 2-3 times the atmospheric pressure (usually 2.5-2.6 times).In other words, in order to provide hemoglobin with vital oxygen for tissues, oxygen treatment in an enclosed space under a pressure of 2.5 ATA is carried out.

In the course of research, it was found that with 100% inhalation of oxygen under high pressure, the oxygen content in arterial blood flowing into the tissue increases 20 times. Due to the increase in oxygen pressure in the tissues;

• Supports cells that cannot perform their functions due to lack of oxygen,
• Provides the growth of new vessels and the production of wound healing substances.
• Prevents the growth of anaerobic bacteria and reduces the effect of their toxins.
• Prevents the growth of anaerobic bacteria and reduces the effect of their toxins.
• Has a decongestant effect.
• Reduces poisoning at the cellular level with carbon dioxide poisoning.

Recommendations for wound healing

The cause of the wound must be determined, prevented or healed.

Complications of wounds. Basic principles of treatment

Wounds can be accompanied by a variety of complications, both immediately after the infliction of wounds, and in the long term.Complications of wounds include:

· The development of traumatic or hemorrhagic shock is the earliest and most formidable complication. In the absence of immediate assistance, it becomes the cause of an unfavorable outcome.

· Seromas – accumulations of wound exudate in wound cavities, dangerous with the possibility of suppuration. With the development of seroma, it is necessary to ensure the evacuation of fluid from the wound.

· Wound hematomas – are formed due to incomplete stop of bleeding.Hematomas are potential foci of infection, in addition, squeezing the surrounding tissues, lead to their ischemia. They must be removed by puncture or by revision of the wound.

· Necrosis of surrounding tissues – develops when the blood supply in the corresponding area is disturbed during tissue trauma during surgery or improper suture. Wet necrosis of the skin must be removed due to the risk of deep accumulations of pus. Superficial dry skin necrosis is not removed, since they perform a protective function.

Wound infection – its development is facilitated by a high level of contamination and high virulence of microflora trapped in the wound, the presence of foreign bodies in the wound, necrosis, accumulations of fluid or blood, damage from injury to bones, nerves, blood vessels, chronic disturbance of local blood supply, as well as late surgical treatment and general factors affecting the course of the wound process. In experimental and clinical studies, it has been established that in most cases, for the development of an infectious process in a wound, it is necessary that its contamination exceeds the critical level of 105-106 microorganisms per gram of tissue.Among the general factors contributing to the development of wound infection, an important role is played by significant blood loss, the development of traumatic shock, previous fasting, vitamin deficiencies, overwork, the presence of diabetes mellitus and some other chronic diseases.

The development of pyogenic infection is caused by staphylococcus, Pseudomonas aeruginosa, Escherichia coli and other pyogenic bacteria, anaerobic infection – clostridia and non-clostridial anaerobic microflora, erysipelas – streptococci.With the generalization of a wound infection, sepsis develops. Most often, the development of pyogenic wound infection occurs 3-5 days after injury, less often at a later date – 13-15 days. Anaerobic infection can develop very quickly, with fulminant forms, it is diagnosed several hours after injury.

In case of contact with a wound with soil, dust, foreign bodies Cl. Tetani may develop tetanus. In the absence of specific prophylaxis, the likelihood of tetanus disease in the presence of contaminated wounds reaches 0.8%.The rabies virus can enter the body through bitten wounds.

· Divergence of the edges of wounds – occurs when there are local or general factors that impede healing, as well as when the stitches are removed too early. With laparotomy, the divergence of the edges of the wound can be complete – with eventration, that is, with the outward movement of the internal organs, incomplete – with preservation of the integrity of the peritoneum, and hidden, when the integrity of the skin is preserved. The divergence of the edges of the wound is eliminated by surgery.

Complications of scars – the formation of hypertrophied scars and keloids. Hypertrophic scars develop when there is a tendency to excessive scar tissue formation and most often when the wound is located perpendicular to the Langer’s line. Keloids, in contrast to hypertrophied scars, have a special structure and spread beyond the boundaries of the wound. Scar complications lead to not only cosmetic but also functional defects, such as impaired walking or function of the upper limb due to limited range of motion in the joints.Surgical correction is indicated for hypertrophied scars with impaired function, however, with keloids, it often leads to a deterioration in the result of treatment.

· Long-term chronic wounds can be complicated by the development of malignancy. The diagnosis is confirmed by a biopsy of the wound tissue. Surgical treatment – radical excision is required within healthy tissues.

Basic principles of wound care

Treatment for injuries usually takes place in two stages – the first aid stage and the skilled aid stage.

¨ First aid stage

When providing first aid at the site of injury, two main tasks are solved: stopping bleeding and preventing further microbial contamination. First aid includes the use of available methods to temporarily stop bleeding, pain relief, the imposition of a protective dressing and transport immobilization. At this stage, you should not rinse the wound and remove foreign bodies from it.

¨ Skilled assistance stage

At the stage of hospital care, the following tasks are solved:

· prevention and treatment of wound complications;

· acceleration of the healing process;

· restoration of functions of damaged organs and tissues.

Basic principles of wound care:

· strict adherence to asepsis at all stages of treatment;

compulsory surgical treatment;

active drainage;

· the earliest possible closure of wounds with primary or secondary sutures or with the help of autodermoplasty;

· targeted antibacterial and immunotherapy, correction of systemic disorders.

To choose an adequate tactics for treating wounds, a thorough assessment of its condition is necessary, while the following are estimated:

Localization, size, depth of the wound, damage to underlying structures such as fascia, muscles, tendons, bones.

· Condition of the edges, walls and bottom of the wound, as well as the surrounding tissues, the presence and characteristics of necrotic tissues.

· The quantity and quality of exudate – serous, hemorrhagic, purulent.

Level of microbial contamination. The critical level is the value of 105 – 106 microbial bodies per 1 g of tissue, at which the development of wound infection is predicted.

Time elapsed since the injury.

¨ Treatment of contaminated wounds

The risk of developing wound complications in the presence of contaminated wounds is much higher than in aseptic wounds. Treatment of contaminated wounds consists of the following steps:

In case of possible contact of the wound with the ground (all injuries with violation of the integrity of the integuments of the body, frostbite, burns, gangrene and tissue necrosis, community-acquired delivery and abortion, animal bites), measures are required to prevent specific infection – tetanus, and in case of bites animals – and rabies.

In order to prevent tetanus, vaccinated patients are injected with 0.5 ml of adsorbed tetanus toxoid, unvaccinated patients – 1 ml of toxoid and 3000 IU of tetanus toxoid. Due to the danger of developing anaphylactic reactions to protein, tetanus toxoid is administered according to Frequently: first, 0.1 ml of diluted serum is injected intradermally, if the papule size is less than 10 mm, 0.1 ml of undiluted serum is injected subcutaneously after 20 minutes, and only if there is no reaction to subcutaneous administration 30 minutes later, the entire dose is administered subcutaneously.

In case of bites of animals (dogs, foxes, wolves, etc.) suspicious of rabies, or if their saliva gets on damaged tissues, it is impossible to perform primary surgical treatment of the wound. The wound is only washed and treated with an antiseptic. No seams are applied. A course of subcutaneous rabies vaccine is required, which is performed at specialized rabies points, and tetanus prophylaxis. In the presence of superficial injuries (abrasions, scratches) of any localization other than the head, neck, hands, toes and genitals, caused by pets, cultured purified concentrated rabies vaccine (COCAV) is injected in 1 ml immediately, as well as 3, 7, 14, 30 and 90 days.But if, when observing an animal, it remains healthy for 10 days, then the treatment is stopped after 3 injections.

If saliva of animals gets on the mucous membranes, with localization of bites in the head, neck, hands, toes and genitals, as well as with deep and multiple bites and any bites of wild animals, in addition to the introduction of COCAV, immediate administration of antirabic immune globulin (RIG) is required … Heterologic AIH is prescribed at a dose of 40 IU per kg of body weight, homologous – at a dose of 20 IU per kg of body weight.Most of the dose should be infiltrated into the tissue surrounding the wound, with the remainder injected intramuscularly. If it is possible to observe the animal, and it remains healthy for 10 days, then the administration of COCAVs is stopped after 3 injections.

In all cases of contaminated wounds, except for small superficial injuries and cases when there are cosmetic and functional contraindications, it is mandatory to carry out primary surgical treatment (PHO) with wound dissection, revision of the wound canal, excision of the edges, walls and bottom of the wound.The goal of the PHO is to completely remove non-viable and contaminated tissues. The later the PHO is performed, the lower the likelihood of preventing infectious wound complications.

PHO is not carried out when localizing wounds on the face, as it leads to an increase in the cosmetic defect, and a good blood supply to this area ensures a low risk of suppuration and active wound healing. In case of extensive wounds of the scalp, the implementation of PST in full can lead to the impossibility of matching the edges and closing the wound.Non-penetrating puncture wounds without damage to large vessels and bite wounds are also not subject to PSH if the possibility of rabies virus penetration is suspected. PHO can end with the imposition of primary sutures – with suturing tightly or, in the presence of risk factors for wound suppuration, with leaving drainages.

Preferably flow-lavage drainage of sutured wounds followed by dialysis with effective antiseptics. Flow-flush drainage is carried out by installing counter perforated drains, through one of which the drug is injected, and on the other, outflow is carried out.The introduction of drugs can be jet and drip, fractional or continuous. In this case, the outflow can be carried out in a passive and active way – by means of evacuation.

This method protects wounds from secondary seeding, promotes more complete removal of the discharge, creates a controlled abacterial environment and favorable conditions for wound healing. There are a few general principles to follow when draining. Drainage is installed in sloping places of the wound cavity, where the accumulation of fluid is maximal.The removal of the drainage tube through a counteropening is preferable than through the wound, since drainage, being a foreign body, interferes with the normal healing of the wound and contributes to its suppuration.

At a high risk of developing wound suppuration, for example, in the presence of sharp changes in the surrounding tissues, the imposition of delayed primary sutures, including provisional sutures, is indicated. Like the primary ones, these sutures are applied to the wound before the development of granulation tissue, usually 1-5 days after the PST when the inflammatory process subsides.The healing of such wounds proceeds according to the type of primary tension. Sutures are not applied only after the treatment of gunshot wounds and if it is impossible to match the edges of the wound without tension, in the latter cases, the earliest possible closure of the wound defect using reconstructive surgery is shown.

· Antibiotic prophylaxis is carried out according to the same scheme as in “dirty” surgical interventions. A 5-7 day course of antibiotics is required.

Antiseptic prophylaxis involves the use of effective antiseptics at all stages of the operation and during wound care.When treating wounds, chlorhexidine, sodium hypochlorite, dioxidine, lavasept, hydrogen peroxide, potassium permanganate and other antiseptics can be used. Such drugs as furacilin, rivanol, chloramine are not currently recommended for use in surgical departments, since the hospital microflora is resistant to them almost everywhere.

· Wound management after PHO with suturing is similar to the management of surgical wounds. Aseptic dressings are regularly changed and drains are maintained.Treatment of open wounds after PCO is carried out, as well as treatment of purulent wounds, in accordance with the phases of the course of the wound process.

¨ Treatment of purulent wounds

Treatment of purulent wounds is complex – operative and conservative.

· In all cases of infected wounds, when there are no special functional contraindications, secondary surgical treatment is performed (VHO). It consists in opening a purulent focus and leaks, evacuation of pus, excision of non-viable tissues and the mandatory provision of adequate drainage of the wound.If after conducting VHO the wound was not sutured, in the future it is possible to apply secondary sutures. In some cases, with radical excision of the abscess with VHO, primary sutures can be imposed with mandatory drainage of the wound. Flow-through drainage is preferred. If there are contraindications to conducting WMO, they are limited to measures to ensure adequate evacuation of exudate.

· Further local treatment of purulent wounds depends on the phase of the wound process.

In the phase of inflammation, the main tasks of treatment are the fight against infection, adequate drainage, acceleration of the wound cleansing process, and reduction of systemic manifestations of the inflammatory response. The basis is the treatment with bandages. For all wounds that heal by secondary intention, wet dressing is considered the standard treatment. Dry dressing with the imposition of dry sterile wipes on the wound is used only for temporary coverage of wounds and treatment of wounds that heal by primary intention.

Wet dressing uses dressings to create a moist wound environment.Osmotically active substances, antiseptics, water-soluble ointments are used. Fat-soluble ointments are contraindicated, as they interfere with the outflow of secretions. It is possible to use modern atraumatic dressings with high absorption capacity, maintaining a certain level of moisture and helping to remove exudate from the wound and keep it firmly in the bandage. Modern combined preparations for local treatment of wounds contain immobilized enzymes – gentatsikol, lysosorb, dalcex-trypsin.

Dressings should be changed with adequate pain relief. The frequency of dressing changes depends on the condition of the wound. Usually 1-2 changes of dressings are required per day, hydroactive dressings such as “Hydrosorb” can remain on the wound for several days, the need to change the dressing immediately occurs in the following cases: the patient complains of pain, developed a fever, the dressing is wet or dirty, its fixation is broken. At each dressing, the wound is cleaned of pus and sequesters, necrosis is excised and washed with antiseptics.Chlorhexidine, sodium hypochlorite, dioxidine, lavasept, hydrogen peroxide, ozonized solutions can be used to wash the wound. To accelerate necrolysis, proteolytic enzymes, ultrasound cavitation, vacuum wound treatment, and pulsating jet treatment are used. From physiotherapeutic procedures, ultraviolet irradiation of wounds, electro- and phonophoresis with antibacterial and analgesic substances are shown.

In the regeneration phase, the main tasks of treatment are to continue the fight against infection, protect the granulation tissue and stimulate the repair processes.There is no longer any need for drainage. Dressings applied during the regeneration phase should protect the wound from trauma and infection, do not stick to the wound and regulate the humidity of the environment in the wound, preventing both drying and excess moisture. Apply dressings with fat-soluble antibacterial ointments, stimulating substances, modern atraumatic dressings.

After complete cleansing of the wound, the imposition of secondary sutures or adhesive tape comparison is shown, with large defects – autodermoplasty.Unlike primary sutures, secondary sutures are applied to granulating wounds after elimination of the inflammatory process. The aim is to reduce the volume of the wound defect and the gateway for infection. After 21 days, secondary sutures are applied only after excision of the formed scar tissue. In cases where it is impossible to match the edges to close the defect, autodermoplasty is performed as early as possible – immediately after the inflammatory process subsides.

In the phase of scar reorganization, the main task of treatment is to accelerate epithelialization and protect the wound from trauma.Since during drying, a crust forms, which slows down epithelialization, and epithelial cells die with excess moisture, the dressings should still keep the wound in a moderately moist state and protect against trauma. Bandages are applied with indifferent and stimulating ointments. Sometimes physiotherapy is used – UFO, laser, pulsating magnetic field.

· General treatment of purulent wounds includes antibacterial therapy, detoxification, immunotherapy, symptomatic treatment.

Antibacterial therapy is used in phases 1-2 of the wound process. The drug must be prescribed taking into account the sensitivity of the wound microflora. Systemic administration of antibiotics is indicated, topical administration is not currently recommended. The primary empirical choice of antibiotic therapy, pending sensitivity results, should be directed against typical pathogens, which are staphylococci, streptococci, and gram-negative aerobic bacteria.

Amoxiclav, levofloxacin are used, cefuroxime, ciprofloxacin, ofloxacin are used as a reserve, and doxycycline is used for bites. Treatment of staphylococcal wound infections with resistance of the pathogen requires the appointment of vancomycin or linezolid. With erysipelas, penicillins, azithromycin, lincosomides are indicated. If the infection is caused by Pseudomonas aeruginosa, drugs of choice are carbenicillin, tazocin, tymentin, as well as 3rd generation cephalosporins and fluoroquinolones. In addition to antibiotics, bacteriophages are used in the treatment of purulent wounds.

Detoxification is used in the presence of systemic manifestations of the inflammatory process. Used infusion of saline solutions, detoxifying solutions, forced diuresis, in severe cases – extracorporeal detoxification.

Immunocorrective therapy can be specific (vaccines, sera, toxoids) and non-specific. Tetanus toxoid, anti-tetanus and anti-gangrenous serum, anti-tetanus and anti-staphylococcal gamma globulin are often used.Of the means of nonspecific immunotherapy in patients with purulent wounds, only immunomodulators are used, and only in the presence of immune disorders and necessarily in combination with an antimicrobial drug, since they exacerbate the course of the infection. Synthetic immunomodulators, such as diocephone, polyoxidonium, are the most promising. Polyoxidonium has properties not only to restore the impaired immune response, but also to adsorb toxins, and is also an antioxidant and membrane stabilizer.Usually 6 mg is prescribed 2 times a week, a full course of 5-10 injections.

Symptomatic therapy includes relief of pain syndrome, correction of organ and system disorders, correction of homeostasis disorders. For pain relief, non-narcotic analgesics are usually used, however, narcotic drugs can be used in the early postoperative period, as well as in case of extensive injuries. When the temperature rises above 39 ° C or fever against the background of severe diseases of the cardiovascular and respiratory system, antipyretic drugs are required.

¨ Prevention of infectious complications of surgical wounds

Surgical wounds are applied under conditions that minimize the risk of wound complications. In addition, before the wound is inflicted, it is possible to carry out the prevention of wound complications. Prevention of complications of surgical wounds includes:

Preparing for surgery

Before the planned operation, a thorough examination of the patient is carried out, during which the existing risk factors for wound complications are identified.When assessing the degree of risk, the age, nutritional status, immune status of the patient, concomitant diseases, disorders of homeostasis, previous drug treatment, tissue condition in the area of ​​the proposed incision, type and duration of the forthcoming surgery are taken into account. Correction of existing violations and direct preparation of the patient for surgery is performed, taking into account the requirements of asepsis.

Selective bowel decontamination is carried out to prevent infectious complications during operations on the large intestine, as well as during extensive surgical interventions in extremely serious patients.Selective intestinal decontamination reduces the risk of enterogenic infection resulting from translocation of intestinal microorganisms. Usually a combination of an aminoglycoside or fluoroquinolone with polymyxin and amphotericin B or fluconazole is used.

With each day of stay in the hospital, the contamination of the patient with pathogens of hospital infections increases, so the stage of inpatient preoperative preparation should not be delayed unnecessarily.

Careful adherence to operational techniques

When performing surgical intervention, careful handling of tissues, careful hemostasis, maintenance of blood supply to tissues in the wound area, obliteration of the resulting “dead” space, matching the edges of the wound and their stitching without tension are required.The sutures should not be ischemic, but should ensure complete closure of the wound edges. Whenever possible, the suture left in the wound should be absorbable and monofilament. In addition, the duration of the operation plays an important role. With its increase, the degree of contamination of the wound and the susceptibility of tissues to causative agents of wound infection increase due to drying of tissues, impaired blood supply, and reactive edema.

Antibiotic prophylaxis

Antibiotic prophylaxis of infectious wound complications depends on the type of surgical aid.In clean operations, it is indicated only in the presence of factors that adversely affect the course of the wound process, such as immunodeficiency states, diabetes mellitus, and the use of immunosuppressants. In most clean and conditionally clean operations, as well as in contaminated interventions in the upper gastrointestinal tract, cephalosporins of the 1st and 2nd generation, such as cefazolin or cefuroxime, can be used for antibiotic priming. In contaminated operations on the colon, biliary system and internal genital organs, the use of protected aminopenicillins or 1-2 generation cephalosporins in combination with metronidazole is indicated.

Medium therapeutic doses of antibiotics are used for perioperative prophylaxis. The first dose of the drug is administered intravenously 30-60 minutes before the skin incision, usually during induction of anesthesia. If the operation lasts more than 2-3 hours, repeated administration of the antibiotic is required to maintain its therapeutic concentration in the tissues during the entire operation. In most cases, the duration of antibiotic administration does not exceed 24 hours, however, the presence of additional risk factors necessitates prolongation of prophylaxis up to 3 days.With “dirty” interventions, a full course of antibiotic therapy is indicated, which should be started even in the preoperative period.

Antiseptic prophylaxis

Antiseptic prophylaxis involves the use of effective antiseptics at all stages of the operation, including for treating the skin, washing cavities, subcutaneous tissue. General requirements for the antiseptics used: wide spectrum of action, high bactericidal action, toxicological safety.For the treatment of the skin, iodophores, chlorhexidine, surfactants are usually used, for washing cavities – chlorhexidine, sodium hypochlorite, dioxidine.

Drainage of surgical wounds

Drainage of operating wounds is carried out according to certain indications. It is necessary when it is impossible to obliterate the “dead space” formed after the operation, with a large area of ​​the wound surface of the subcutaneous fat, when using artificial materials for plasty of the aponeurosis and in some other cases, creating prerequisites for the formation of seromas.Drainage is also necessary for radical excision of abscesses with suturing of a postoperative wound. Preferably aspiration or flow-lavage drainage, while proper care of the drainage system in the postoperative period is mandatory.

Correct wound management in the postoperative period

A local cold is prescribed immediately after the operation, adequate anesthesia, aseptic dressings are regularly changed and drains are taken care of, if indicated, dialysis and wound evacuation, physiotherapy and other measures.

¨ Control of wound treatment

The effectiveness of wound treatment is assessed by the dynamics of general and local signs of inflammation. They are guided by the subsiding of fever, leukocytosis, pain in the area of ​​the wound, and the normalization of the general well-being of the patient. During dressings, visually assess the condition of the seams, the presence and prevalence of hyperemia and edema in the circumference of the wound, necrosis of the edges of the wound, the type of wound discharge and granulation. To control the course of the wound process in the treatment of drained wounds, instrumental research methods can be used.

Endoscopic examination of the wound with simultaneous biopsy of subcutaneous fat for bacteriological examination is used. At the same time, during the dressing through the drainage of the postoperative wound, the optical tube of the endoscope with end optics with a diameter of 3-6 mm is inserted, the presence of wound exudate, areas of necrosis, fibrin is assessed, then a biopsy is taken. The degree of contamination of the wound tissue is determined using express methods, for example, by the method of phase contrast microscopy.After taking a biopsy, the wound canal is filled with saline to assess the correct location of the drains and the direction of fluid flow during its jet injection.

Favorable endoscopic signs of the course of the wound process and an indication for stopping drainage are: the presence of bright pink granulations, the absence of pus, necrosis, a significant amount of fibrin, tissue contamination below critical. Flaccid granulation, the presence of a large amount of exudate and fibrin in the wound, as well as high bacterial contamination, require continuation of the dialysis of the wound with antiseptic solutions.

After removal of the drainage systems, an ultrasound scan is indicated to assess the condition of the wound canal and surrounding tissues. Favorable ultrasound signs of the course of the wound process are:

· narrowing of the wound canal on the next day after removal of the drainage tubes, visualization of it in the form of a heterogeneous echo-negative strip by 3-5 days, no dilatation and disappearance of the canal by 6-7 days;

· uniform echogenicity of the surrounding tissues, the absence of additional formations in them.

Adverse ultrasound signs of the course of the wound process are the dilation of the drainage canal and an increase in the echogenicity of the surrounding tissues with the appearance of additional formations in them. These symptoms indicate the development of purulent-inflammatory wound complications even before the appearance of their clinical signs.

When treating a purulent wound, daily monitoring of the course of the wound process is necessary. With continued exudation and flaccid granulation, correction of treatment is required.In addition to visual assessment of the condition of the wound and assessment of the severity of general clinical and laboratory symptoms, various methods are used to control the dynamics of the microbial landscape, the level of contamination and regenerative processes in tissues: bacteriological, cytological, modern high-precision – gas-liquid chromatography, tests using enzyme systems, and others.

Added May 25, 2016

Trophic ulcers (venous ulcers)

When wounds do not heal

Poorly healing or not healing wounds on the lower leg, as a rule, are trophic ulcers of varicose origin.

Most often they are located near the medial ankle. They usually affect the elderly with a number of concomitant diseases. The development of leg ulcers may be due to the presence of diabetes mellitus or heart failure. Varicose ulcers are more common in women than in men. The main reason for their development is usually long-term venous insufficiency. In such cases, they speak of a trophic ulcer of varicose origin.

How does a varicose ulcer develop

Due to dysfunction (medical term: chronic venous insufficiency), the veins are no longer able to quickly transport blood from the legs to the heart.Stagnation of blood develops, which leads to varicose veins. This stasis, called stasis, ultimately damages the smallest blood vessels, the capillaries, which supply oxygen and nutrients to cells and remove metabolic products from tissues. Damaged capillaries cannot perform their functions satisfactorily. In the beginning, the skin in the affected areas becomes sensitive, loses its elasticity and thickens. Further, skin necrosis begins, and any barely noticeable injury turns into an open wound.

Open wounds are very painful. Microorganisms that multiply in the wound and on the surrounding skin can cause an unpleasant odor. Often because of this, patients do not leave the house and avoid contact with other people. Due to severe pain, patients practically do not move the affected limb. The lack of movement, in turn, turns off the pumping mechanism that helps transport blood towards the heart, which triggers a vicious circle.

Forecast

Although a patient may have suffered from varicose ulcers for many years, the prospects for recovery for such a patient are positive: about 90% of all varicose ulcers can be cured using the treatments available today.

Prerequisites for wound healing

Effective treatment of chronic wounds is based on two fundamental principles: wound debridement and treatment of the underlying disease. These principles describe two main points of medi’s wound management concept. Medi also offers universal solutions for relapse prevention. In addition to the tried and tested mediven ulcer kit, two types of compression golf, medi also offers medical wipes for wound debridement and a completely new approach to compression treatment of venous ulcers: RNCB circaid juxtacures.

Effective treatment of venous ulcers includes:

• Wound treatment and debridement and wound care: cleaning the wound and caring for the surrounding skin.
• Compression therapy is an essential element in the treatment of chronic wounds. However, many believe that wound care is limited to cleaning and treating the surrounding skin.
• Treatment of the underlying disease: In the case of venous ulcers, this means that the disease of the veins must be treated. Medical compression hosiery is used for symptom-modifying therapy of venous diseases.

In addition to pain relief and compression therapy, wound care, which must be carried out by qualified specialists, plays an important role in the treatment of venous ulcers. Do not try to treat venous ulcers yourself with ointments and bandages. The ulcer should be cleared, non-viable tissue removed. Special medicated coatings promote the healing process.

Healing and Healing Phases

Phase 1: Wound Debridement
As a result of chronic venous insufficiency, varicose ulcers are usually surrounded by hardened connective tissue that must be removed.Alternatively, ointments can be used that soften tissue detritus, break down biofilms, and cleanse the wound. The non-woven material of the dressing absorbs exudate. Silver dressings are used to heal infected wounds.

Phase 2: proliferation
In the second phase, the body replenishes the missing tissue. To support the growth of connective tissue, wound dressings (hydrocolloid and hydropolymer dressings) are used to stimulate the growth of connective tissue and keep the wound moist.

Phase 3: epithelialization
In the third phase, the wound shrinks and the epithelium grows inward from the edges of the wound. Because phases 1 and 2 are severely impaired in the presence of chronic venous insufficiency, most venous ulcers do not reach phase three without supportive treatment. In this last step, the wound should also have a balanced moisture level and the dressing should not stick to new skin.For this purpose, thin dressings (hydrocolloid or hydropolymer) are usually used. To shorten this phase, the wound can be closed with a skin graft taken from the patient. For this, there are a number of surgical techniques in which small areas of skin are transplanted, or a mesh skin graft is applied to the wound.

Medi adjustable non-extensible compression bandages

Debridement of trophic ulcers on the legs

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