Wound healing

• A wound is a break in the outer layer of the skin, called the epidermis. Wounds are usually caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another, depending upon how they happened and how serious they are. Other wounds include puncture wounds, lacerations (cuts), pressure sores, anal fissures, extravasations (a drug accidentally going outside of a vein causing tissue damage), skin damage caused by incontinence (lack of bladder control), skin graft healing (split thickness), diabetic ulcers, and surgical skin flap ischemia (lack of blood flow to surgically attached skin).
• Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone, all tissues heal with some external scarring. The object of proper care is to minimize the possibility of infection and scarring.
• There are basically four phases to the healing process: the inflammatory phase, proliferative phase, remodeling phase, and epithelialization phase.
• The inflammatory phase begins with the injury itself. In the inflammatory phase, there is bleeding, immediate narrowing of the blood vessels, clot formation, and release of various chemical substances into the wound that will begin the healing process. Specialized cells (macrophages) clear the wound of debris over the course of several days.
• Next is the proliferative phase in which a matrix or latticework of cells forms. On this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and support the production of proteins (primarily collagen). The collagen acts as the framework upon which the new tissues build. Collagen is the dominant substance in the final scar.
• The remodeling phase begins after 2-3 weeks. The framework (collagen) becomes more organized making the tissue stronger. The blood vessel density becomes less, and the wound begins to lose its pinkish color. Over the course of six months, the area increases in strength, eventually reaching 70% of the strength of uninjured skin.
• Epithelialization is the process of laying down new skin, or epithelial, cells. The skin forms a protective barrier between the outer environment and the body. Its primary purpose is to protect against excessive water loss and bacteria. Reconstruction of this layer begins within a few hours of the injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take 7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring occurs when the injury extends beyond the deep layer of the skin (into the dermis, which is the second layer of skin).

Signs and Symptoms

• Skin wounds: All bites and any cut or laceration greater than 1/2-inch long in which fat or deeper tissues (muscle or bone) can be seen will require medical attention.
• Any redness extending from the wound after two days or yellow drainage from the area should warrant medical attention. Infection may cause redness, swelling, heat, pus, or watery discharge from a puncture wound that is not noticed or not treated properly.
• Puncture wounds usually cause pain and mild bleeding at the site of the puncture. It is usually fairly obvious if cut. However, small pieces of glass may cause puncture wounds that the individual may not notice at first.
• Most doctors will not stitch a cut or laceration that is more than eight to 12 hours old. This is because there is a greater chance of infection after that time. In fact, after three hours, the incidence of infection begins to increase. Therefore, do not wait to have the injury repaired. If in doubt, call a doctor or go to the nearest hospital's emergency department. An open wound takes longer to heal and leaves a bigger scar.
• Healthcare providers recommend that 911 be called if: the wound is obviously life-threatening; any laceration is greater than 1/2-inch long and is through all layers of the skin exposing the underlying fat; the bleeding cannot be stopped; if the blood continues to spurt from the wound. Apply pressure and go to the hospital's emergency department: if there may be something in the wound such as glass, wood, or rust; if the individual cannot move their fingers or toes in the area of the laceration or if they have lost sensation in the area beyond the laceration; and for any bite wound (human or animal).
• Pressure sores: Bedsores fall into one of four stages based on their severity. Pressure sores are categorized by severity, from Stage I (earliest signs) to Stage IV (worst). The National Pressure Ulcer Advisory Panel, a professional organization dedicated to the prevention and treatment of pressure sores, has defined each stage as follows:
• Stage I: Initially, a pressure sore appears as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In African Americans, Hispanics, and people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved.
• Stage II: In stage II, some skin loss has already occurred, either in the epidermis, the outermost layer of skin, in the dermis, the skin's deeper layer, or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. If treated promptly, stage II sores usually heal fairly quickly.
• Stage III: When a pressure ulcer reaches stage III, the damage has extended to the tissue below the skin, creating a deep, crater-like wound.
• Stage IV: Stage IV is the most serious and advanced stage. The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints. Stage IV wounds are extremely difficult to heal and can lead to lethal infections.
• If an individual uses a wheelchair, they are most likely to develop a pressure sore on: the tailbone or buttocks; the shoulder blades and spine; or the backs of the arms and legs where they rest against the chair. When an individual is bed-bound, pressure sores can occur on: the back or sides of the head; the rims of the ears; the shoulders or shoulder blades; the hipbones, lower back, or tailbone; or the backs or sides of the knees, heels, ankles, and toes.
• Anal fissure: The main signs and symptoms of an anal fissure include: pain or burning during bowel movements that eases until the next bowel movement; bright red blood on the outside of the stool or on toilet paper or wipes after a bowel movement; and itching or irritation around the anus.
• Extravasation: During extravasation, the individual will feel burning, stinging, or pain at the injection site. Redness or swelling may be observed at the site of injection. Also, there may be no blood return in the syringe when the healthcare worker tries to get blood.

• If a skin injury required medical attention, a doctor will want to know how the injury occurred, what home care was performed, if there is any pain, and when the last tetanus shot may have been.
• If a hand or finger is involved, the doctor will want to make sure the individual is able to move the extremity or finger through its full range of motion. Sensation and circulation to the area will be tested carefully as well. If there is some suspicion of a foreign body in the wound or an underlying bone break, an x-ray may be ordered.
• Pressure sores (bedsores) are usually unmistakable, even in the initial stages, but a doctor is likely to order blood tests to check the individual's nutritional status and overall health. Other tests may include: urine analysis and culture, stool culture, and a wound biopsy. A wound biopsy is a sample of tissue taken from wounds that do not heal or from chronic (long-term) pressure sores. The tissue may also be checked for cancer, which is a risk in individuals with chronic wounds.

• Complications from a lack of wound care can lead to other health problems.
• Cellulitis: Cellulitis is a potentially serious bacterial infection of the skin. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. Skin on the face or lower legs is most commonly affected by this infection, though cellulitis can occur on any part of the body. Cellulitis may only affect the surface of the skin. However, cellulitis may also affect the tissues underlying skin and can spread to lymph nodes and the bloodstream. Left untreated, the spreading bacterial infection may rapidly turn into a life-threatening condition.
• Bone and joint infections: Bone and joint infections develop when the infection from a bedsore burrows deep into the joints and bones. Joint infections (called septic or infectious arthritis) can damage cartilage and tissue within days, whereas bone infections (osteomyelitis) may develop over years if not treated. Eventually, bone infections can lead to bone death, reduced function of the joints and limbs, and amputation.
• Necrotizing fasciitis: Necrotizing fasciitis is a rapidly spreading infection that destroys the layers of tissue that surround the muscles. Initial signs and symptoms include fever, pain, and massive swelling. Without treatment, death can occur in as little as 12-24 hours.
• Gas gangrene (myonecrosis): Gas gangrene is a rare and severe form of gangrene. Gas gangrene develops suddenly and dramatically and spreads so rapidly that changes in tissue are noticeable within minutes. The bacteria responsible for gas gangrene (Clostridium sp.) produce toxins that completely destroy affected muscle tissue and cause potentially fatal systemic problems.
• Sepsis: Sepsis (a whole body response to an infection) can occur from a wound such as advanced pressure sores. Sepsis occurs when bacteria from a massive infection enter the bloodstream and spread throughout the body. Sepsis is a rapidly progressing, life-threatening condition that can cause shock and organ failure.
• Skin cancer: Cancer resulting from poor wound healing may occur. This type of cancer is usually an aggressive carcinoma affecting the skin's squamous cells.
• Fistulas: A fistula is an abnormal connection between an organ, vessel, or intestine and another structure. Fistulas are usually the result of a wound from an injury or surgery. They may also result from infection or inflammation.

 

• General Self-treatment :
• Minor cuts and scrapes usually do not require a trip to the emergency room, yet proper care is essential to avoid infection or other complications. Puncture wounds do not usually cause excessive bleeding. Puncture wounds resulting from human or animal bites, including those of domestic dogs and cats, may be especially prone to infection. Puncture wounds on the foot are also more vulnerable to infection.
• Guidelines developed by healthcare professionals can help individuals care for simple wounds at home. These guidelines include:
• Stopping the bleeding: Minor cuts and scrapes usually stop bleeding on their own. If they do not, apply gentle pressure with a clean cloth or bandage. Hold the pressure continuously for 20-30 minutes. Lifting the pressure to check on bleeding may damage or dislodge the fresh clot that has forming and cause bleeding to resume. If the blood spurts or continues to flow after continuous pressure, seek medical assistance.
• Cleaning the wound: Rinse out the wound with clear water in order to clean the wound. It is best to avoid getting soap into the wound itself, as soap can irritate the wound. If debris remains embedded in the wound after cleaning, see a doctor. Thorough wound cleaning reduces the risk of tetanus. Tetanus (also called lockjaw) is a preventable disease that affects the muscles and nerves, usually due to a contaminated puncture wound.
• To clean the area around the wound, use soap and a washcloth. Hydrogen peroxide, iodine, or an iodine-containing cleanser may irritate living cells. If they are used, do not apply them directly on the wound.
• Medicines: After cleaning the wound, apply a thin layer of an antibiotic cream or ointment such as Neosporin® or Polysporin® to help keep the surface moist. The products do not make the wound heal faster, but they can discourage infection and allow the body's healing process to close the wound more efficiently. Certain ingredients in some ointments can cause a mild rash in some individuals. If a rash appears, stop using the ointment.
• Over-the-counter (OTC) pain relievers such as acetaminophen (Tylenol®) or ibuprofen (Motrin®) are usually sufficient for any pain.
• Doctors recommend getting a tetanus shot every 10 years. If the wound is deep or dirty and the individual's last shot was more than five years ago, a doctor may recommend a tetanus shot booster within 48 hours of the injury.
• Bandaging the wound: Bandages can help keep the wound clean and keep harmful bacteria out. After the wound has healed (three to four days) enough to make infection unlikely, exposure to the air will speed wound healing.
• Dressing change: Change the dressing at least daily or whenever it becomes wet or dirty. If the individual is allergic to the adhesive used in most bandages, switch to adhesive-free dressings or sterile gauze held in place with paper tape, gauze roll, or a loosely applied elastic bandage. A local pharmacy will carry these supplies.
• Stitches: A wound that cuts deeply through the skin or is gaping or jagged-edged and has fat or muscle protruding usually requires stitches. A strip or two of surgical tape may hold a minor cut together, but if the individual cannot easily close the opening of the wound, see a doctor as soon as possible. Proper closure within a few hours minimizes the risk of infection.
• Signs of infection: It is recommended by healthcare professionals to see a doctor if the wound does not heal in a five to seven days or if there is redness, drainage, warmth, or swelling.
• Treatments for specific wounds :
• Animal bites :
• If an animal (especially a stray dog or a wild animal) inflicted the wound, the individual may have been exposed to rabies. A doctor may give antibiotics and suggest initiation of a rabies vaccination series. Report such incidents to county public health officials. If possible, the animal should be confined for ten days of observation by a veterinarian.
• Pressure sores :
• Once a pressure ulcer is identified, steps must be taken immediately to: relieve the pressure on that area. Use pillows, special foam cushions, and sheepskin to reduce the pressure; treat the sore based on the stage of the ulcer. A healthcare provider will give specific treatment and care instructions; avoid further trauma or friction. Powder the sheets lightly to decrease friction in bed; improve nutrition and other underlying problems that may affect the healing process; if the pressure ulcer is at Stage II or worse, a healthcare provider will give specific instructions on how to clean and care for open ulcers. It is very important to do this properly to prevent infection; keep the area clean and free of dead tissue. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers. Do not massage the area of the ulcer, as massage can damage tissue under the skin. Donut-shaped or ring-shaped cushions are not recommended. They interfere with blood-flow to that area and cause complications, such as pressure sores.
• Non-surgical treatment: Treating pressure sores is challenging. Open wounds are slow to close, and because skin and other tissues have already been damaged or destroyed, healing is never perfect. Although it may take some time, most stage I and stage II sores will heal with conservative measures. But stage III and stage IV wounds, which are less likely to resolve on their own, may require surgery.
• The first step in treating a sore at any stage is relieving the pressure that caused it. Pressure can be reduced by changing positions often. Carefully follow a schedule for turning and repositioning - approximately every 15 minutes if in a wheelchair and at least once every two hours when in bed. If the individual is unable to change position on their own, a family member or other caregiver must be able to help. Using sheepskin or other padding over the wound can help prevent friction when moving.
• Using support surfaces is important. These are special cushions, pads, mattresses, and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown. The most effective support depends on many factors, including the individual's level of mobility, their body build, and the severity of their wound. Healthcare professionals recommend avoiding using pillows and rubber rings, which actually cause compression.
• Mattresses should be low-air-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend the individual on an air-permeable mattress that contains millions of silicon-coated beads.
• Other non-surgical treatments of pressure sores include cleaning the wound to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Saline solution is available at a pharmacy, or can be made at home by boiling 1 teaspoon of salt in 1 quart of water for five minutes. Store the solution in a sterile container and cool before using. It is best to avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.
• Controlling incontinence as far as possible is crucial to helping sores heal. If the individual is experiencing bladder or bowel problems, they may be helped by lifestyle changes, behavioral programs, incontinence pads, or medications.
• To heal properly, wounds need to be free of damaged, dead, or infected tissue. One approach to removing dead tissue is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. A doctor may use one or more non-surgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing the body's own enzymes to break down dead tissue (autolytic debridement), or applying topical debriding enzymes, such as Granulex®.
• Dressings: A variety of dressings are used to help protect wounds and speed healing. The type of dressing used usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and the skin surrounding it dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids, or transparent semi-permeable dressings that retain moisture and encourage skin cell growth. Examples of hydrocolloid dressings include Tegasorb® and Relicare®. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream.
• Hydrotherapy: Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue. Whirlpool baths used for burn treatment are specialized, stainless steel baths used by trained healthcare professionals.
• Healthy diet: Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals, especially vitamins A, C, E, and zinc, has been reported to improve wound healing. A well nourished body can produce healthy skin, which guards against breakdown.
• Surgical repair: The goals of surgery include improving the hygiene and appearance of the sore, preventing or treating infection, reducing fluid loss through the wound, and lowering the risk of future cancer. The type of reconstruction that's best in any particular case depends mainly on the location of the wound and whether there's scar tissue from a previous operation. In general, though, most pressure wounds are repaired using a pad of muscle, skin, or other tissue that covers the wound and cushions the affected bone (flap reconstruction). The tissue is usually harvested from the individual's own body. In spite of every precaution, flap reconstruction has one of the highest complication rates of any surgery, and the recovery period is long and arduous. Individuals must have a strong social support system, optimal nutritional status, state-of-the-art resources such as a pressure-release bed, and the ability and motivation to participate in their own recovery to be a candidate for this operation.
• Other treatment options: Hyperbaric oxygen, electrotherapy, and the topical use of human growth factors are methods of wound healing that are being researched. Growth factors, proteins that stimulate cell growth, have been approved for the treatment of diabetic ulcers but not, as yet, for pressure sores.
• Anal fissures :
• Anal fissures are fairly common and usually heal without treatment or with non-surgical treatments. Signs and symptoms may go away within two weeks, but it may take up to eight weeks for the tear to heal. If the tear doesn't heal within six to eight weeks, however, the individual may need surgery.
• For infants, the only intervention necessary may be changing the diaper regularly and keeping the anal area clean. A pediatrician can help provide ways to avoid constipation and ensure regular bowel movements to prevent the baby from straining.
• Non-surgical treatments: Lifestyle and dietary changes include adding more fiber to the diet, drinking more water, getting regular exercise, and taking a stool softener, such as docusate sodium (Colace®). A doctor may recommend non-surgical treatments including medicated creams or suppositories. A doctor may prescribe a rectal corticosteroid (Anusol® or Anusol HC®) or recommend an over-the-counter (OTC) cream or ointment containing hydrocortisone (Preparation H®) to help reduce inflammation and ease discomfort.
• Some doctors recommend applying nitroglycerine ointment (Nitrol® ointment) to the anus, which widens blood vessels and increases blood flow to the tear, promoting healing. This fairly new therapy also helps reduce pressure in the anal sphincter, which eases the spasm and decreases pain, thereby promoting healing. The dose of nitroglycerine is small to avoid dangerous side effects. However, it may cause side effects such as headaches, low blood pressure, and dizziness. Men shouldn't use nitroglycerine within 24 hours of taking erectile dysfunction medications such as sildenafil (Viagra®), tadalafil (Cialis®), and vardenafil (Levitra®) because of the possibility of significantly lowered blood pressure.
• Another fairly new treatment involves injecting a small dose of botulinum toxin type A (Botox®) into the internal anal sphincter. Botox paralyzes the muscle for up to three months, causing the spasm to relax. A possible side effect is temporary, mild leakage of gas or stool (anal incontinence).
• Both topical nitroglycerine and Botox® have shown promise in relieving anal fissures in most studies. Researchers are testing these treatments alone and in combination with other drugs. Blood pressure medications nifedipine (Adalat®) and diltiazem (Cardizem®), taken orally or ground into a gel and applied to the tear, also have shown some promise.
• Surgery: If an individual has a chronic anal fissure that will not heal on its own, a doctor may recommend surgery. Surgery usually involves cutting a portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery may also include removal of the fissure and any scar tissue resulting from it.
• Adults usually have outpatient surgery. Children who have surgery may need to stay overnight in the hospital. Rarely, cutting the anal sphincter results in loss of ability to control bowel movements.

• In order to prevent wounds from occurring, healthcare providers recommend that individuals: take care when using sharp objects such as knives, scissors, saws, and trimmers; wear shoes or boots on the feet; use helmets when riding a bicycle; use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates or skateboards; and avoid picking up broken pieces of glass and handling razor blades.
• If bedridden or immobile with diabetes, circulation problems, incontinence, or mental disabilities, healthcare providers recommend that the individual be checked for pressure sores every day. Also, look for reddened areas that, when pressed, do not turn white. Also look for blisters, sores, or craters. In addition, take the following steps: change position at least every two hours to relieve pressure; use items that can help reduce pressure such as pillows, sheepskin, foam padding, and powders from medical supply stores; eat healthy, well-balanced meals; exercise daily, including range-of-motion exercises for immobile patients; and keep skin clean and dry. Incontinent people need to take extra steps to limit moisture.
• Individuals with diabetes should check their feet daily for blisters, sores, or other wounds in order to prevent serious infection and possibly amputation.