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2023-05-16
Chronic and non-healing wounds are those that do not progress through the healing process in a timely or predicted manner. They are a global problem and are becoming harder to treat. Medicare estimates that over 8 million Americans have chronic wounds that cost the national health care system between $18.1 and $96.8 billion dollars annually.1
Most wound care protocols recommend standard wound care treatments, including debridement when indicated, the application of dressings, and periodic reassessment. However, non-healing wounds often require advanced treatment to enable these wounds to progress through the stages of healing.
During normal wound-healing, a balance of healthy proteins and enzymes promotes healing in the wound bed. Disruption to this balance can cause the wound to become chronic. Such disruption can take many forms, although a common type of disruption is elevated protease activity, which contributes to chronic inflammation. In addition, intrinsic factors, such as age and comorbidities, and extrinsic factors, such as lifestyle and polypharmacy, can impact the delicate chemical balance in the wound bed.2
The first step for moving a chronic wound to an acute status is adequate wound bed preparation, which can be achieved with various strategies, including debridement, maintaining a proper moisture balance, and reducing the bacterial bioburden and inflammation.3 For non-healing diabetic foot and pressure injuries, offloading is also a crucial strategy. For venous ulcers, compression can be beneficial.2
The road to healing for many wounds starts with management of the wound bed. Moreover, the effectiveness of many advanced therapies relies on proper wound bed preparation that promotes healing.2 Even with the introduction of advanced wound therapies, including dressings, negative pressure wound therapy (NPWT), and cellular and/or tissue-based products, less than half of wounds heal after 12 weeks of treatment. However, the combination of proper wound bed preparation and advanced therapy can lead to greater success in helping these wounds achieve healing.3
Cellular and Tissue-Based Therapies
This type of advanced therapy consists of several therapies based on cells, including3:
Stem cells derived from a variety of sources induce immunomodulation in the wound bed and facilitate healing by resolving inflammation, thus making them attractive cell therapeutic agents to treat chronic wounds.4
Negative Pressure Wound Therapy
NPWT has been described as an effective treatment for wounds of many etiologies, including complex non-healing wounds.5 With NPWT, subatmospheric pressure is applied to the surface of a wound sealed off by a film dressing and connected to a suction pump and drainage collection system with a tube. The use of NPWT is becoming increasingly popular because it can reduce the number of dressing changes required. It can be readily applied at the bedside,6 and it can result in improved healing and better patient outcomes.7
Antimicrobial Dressings
There are numerous innovative wound care dressings specifically developed to treat chronic wounds. These dressings contain a variety of antimicrobial agents, such as silver,2 polyhexamethylene biguanide, medical-grade honey, povidone-iodine, dialkylcarbamoyl chloride, and chlorhexidine gluconate.8 These dressings can work to manage bioburden levels in the wound and inhibit protease activity.2
Chronic wounds remain a significant challenge in clinical practice and can have a detrimental impact on patients’ quality of life. Understanding the biological processes occurring in the wound bed can help clinicians optimize these conditions and select compatible advanced therapies to overcome the challenges that delay healing of complex and chronic wounds.
References
1.Nussbaum SR, Carter MJ, Fife CE, et al. (2018). An economic evaluation of the impact, cost, and Medicare policy implications of chronic on-healing wounds. Value Health. 2018;21:27-32.
2.Chamanga ET. Clinical management of non-healing wounds. Nurs Stand. 2017;32(29):48-62.
3.Armstrong DG, Bauer K, Bohn G, et al. Principles of best diagnostic practice in tissue repair and wound healing; an expert consensus. Diagnostics (Basel). 2020;11(1):50. https://doi.org/10.3390/diagnostics11010050. Accessed February 15, 2021.
4.Nuschke A. Activity of mesenchymal stem cells in therapies for chronic skin wound healing. Organogenesis.2014;10(1):29-37.
5.Apelqvist J, Willy C, Fagerdahl A, et al. EWMA document: negative pressure wound therapy. J Wound Care.2017;26(Suppl 3):S1-S154.
6.Robert N. Negative pressure wound therapy in orthopaedic surgery. Orthop Traumatol Surg Res. 2017;103(1 Suppl):S99-S104.
7.El-Sabbagh AH. Negative pressure wound therapy: an update. Chin J Traumatol. 2017;20(2):103-107.
8.Mana TSC, Donskey C, Carty N, Perry L, Leaper D, Edmiston CD Jr. Preliminary analysis of the antimicrobial activity of a postoperative wound dressing containing chlorhexidine gluconate against methicillin-resistant Staphylococcus aureus in an in vivo porcine incision wound model. Am J Infect Control. 2019;47:1048-1052.
Dermlin series are developed by Jiangsu Yenssen Biotech Co., Ltd. as the advanced functional dressing in the world, containing inorganic formula with nano pores granule which has significant effects of neutralizing acidic exudation of the wound, preventing secondary infection, accelerating a proliferation of the human epithelial cells, resulting in fast healing and less scar formation.
Contact us for more details: [email protected].
2023-05-16
Wound healing can stall for a number of reasons. Wounds that have not healed or significantly reduced in size after four to six weeks are considered chronic. They are characterized by a multitude of impeding factors including biofilm, excess matrix metalloproteinases (MMPs) and extracellular matrix degradation, inflammation, fibrosis, unresponsive keratinocytes and fibroblasts, and atypical growth factor signaling.
The vast majority of chronic wounds contain biofilm, which delays or stalls progression in the inflammatory phase of wound healing.1 Molecular and cellular abnormalities in chronic and hard-to-heal wounds lock in chronic inflammation, which plays a major role in suspending the normal healing process. The ultimate aim is to transform chronic wounds back into acute wounds to enable them to heal.2,3
Monitoring healing progress by checking wound status every two to four weeks can help determine what the stalling factors are, as can knowing what signs to look for within the wound — specifically, biofilm, granulation tissue and wound pain.
If the wound is not smaller after four to six weeks, biofilm may be present in the wound, signaling that the clinician should review the treatment plan. Identifying biofilms early on and adjusting the plan of care as necessary are both essential in optimizing wound healing outcomes.4
Clinicians should know how to effectively identify devitalized wound tissue types and the signs of bacterial imbalance. Devitalized tissue (slough, eschar) impairs wound healing and should be removed as appropriate. Biofilm formation triggers a chronic inflammatory response in the wound that results in a high number of neutrophils and macrophages, which in turn leads to higher levels of reactive oxygen species and proteases ([MMPs] and elastase) that will then damage normal healing tissues, proteins and immune cells.
Biofilm formation follows a common pattern of bacterial cell attachment, microcolony formation, maturation and dispersion. During the initial attachment, biofilm is reversible; if not reversed, the attachment becomes stronger, and cells begin to multiply rapidly. They also begin to mutate so that they can compete in this now intensely crowded environment. At this point, the bacteria begin using quorum sensing, a communication process that enables the bacteria to regulate what genes they express as the cell population density increases.4-6
There is no fix-all solution or gold standard test for identifying or treating biofilm in a wound.5Evidence suggests that physical removal (debridement) and continuous, vigorous cleansing are the best ways to reduce biofilm colonies.6 These strategies not only help prevent and manage biofilm, but also reduce antibiotic usage, thereby supporting antimicrobial stewardship.
Using a combination of debridement methods is one way to battle biofilm in chronic wounds and accelerate healing.7 Sharp debridement is the most aggressive approach. The clinician uses a scalpel, forceps, scissors and other surgical instruments to remove biofilm and devitalized tissue, stimulating platelets to release growth factors key to tissue repair and move chronic wounds into an acute state.
Wound cleansers and solutions used in chronic wounds help decontaminate the wound, disrupt biofilm and promote healing. Cleansing the wound bed surface, periwound and surrounding skin with non-cytotoxic solutions is essential. Various delivery methods make them user-friendly for both the patient and clinician.
Advanced wound care dressings can be used in chronic wounds to prevent and manage biofilm. The wide array of impregnated dressing technologies includes antimicrobial formats in collagens, alginates, foams, hydrogels, gauzes and topical agents. Antimicrobial or bacteriostatic dressings may be impregnated with silver, cadexomer iodine, copper, methylene blue, gentian violet, polyhexamethylene biguanide (PHMB), etc. Used appropriately, these dressings and products have been found to be effective in chronic wound management.
Once biofilm and infection have been resolved, clinicians should look for methods of encouraging wound closure. Cellular and/or tissue-based products (CTP) can be one method of encouraging closure. CTPs come in a variety of formats, and may include collagens or antimicrobials such as silver or PHMB. They encourage wound closure by providing elements such as extracellular matrices, collagen, and other vital components that act as a scaffold for the healing wound. Encouraging rapid wound closure can ensure better outcomes for the patient, such as reduced costs, reduced pain, and better quality of life. CTPs that contain an antimicrobial component can provide a barrier against bioburden.
Irregular or unhealthy granulation tissue indicates poor healing and/or infection and requires a wound culture and appropriate treatment based on the culture results. Absent infection, chemical cauterization with silver nitrate or a topical steroid can be used to facilitate healing.8
Numerous factors can cause wound pain, including underlying pathology/etiology, skin damage, nerve damage, blood vessel injury, infection and ischemia. Psychological and emotional factors can also trigger wound pain. Clinicians need to listen to their patients to help identify the type of pain, its cause(s) and the best treatment options. Because chronic pain impacts patients’ quality of life, appropriately managing the pain is paramount to achieving the best possible outcomes for patients.9
Practical knowledge of prognostic indicators and risk factors in chronic and hard-to-heal wounds — including biofilm, granulation tissue and wound pain — is essential to early identification, treatment and successful healing outcomes.
References
1. Murphy C, Atkin L, Swanson T, et al. International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care. 2020;29(Suppl 3b):S1-S28.
2. Hayes, Skin Substitutes for Chronic Foot Ulcers in Adults with Diabetes Mellitus: A Review of Reviews, November 2018; Nicholas et al., 2016.
3. Liu Y, Panayi AC, Bayer LR, Orgill DP. Current Available Cellular and Tissue-Based Products for Treatment of Skin Defects. Adv Skin Wound Care. 2019 Jan;32(1):19-25.
4. Vowden P. Hard-to-Heal Wounds Made Easy. Wounds International. 2011;2(4):1-6. Available from: www.woundsinternational.com
5. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. J Wound Care. 2009;18(2):54-56.
6. World Union of Wound Healing Societies (WUWHS), Florence Congress, Position Document. Management of Biofilm. London: Wounds International 2016.
7. Ayello EA, Cuddigan JE. Debridement: controlling the necrotic/cellular burden. Adv Skin Wound Care. 2004;17(2):66-75.
8. Alhajj M, Bansal P, Goyal A. Physiology, Granulation Tissue. [Updated 2020 Nov 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: www.ncbi.nlm.nih.gov/books/NBK554402/
9. Frescos N. What causes wound pain?. J Foot Ankle Res. 2011;4(Suppl 1):22.
10. Wolcott RD, Kennedy JP, Dowd SE. Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. J Wound Care. 2009;18(2):54-56.
11. World Union of Wound Healing Societies (WUWHS), Florence Congress, Position Document. Management of Biofilm. London: Wounds International 2016.
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Dermlin series are developed by Jiangsu Yenssen Biotech Co., Ltd. as the advanced functional dressing in the world, containing inorganic formula with nano pores granule which has significant effects of neutralizing acidic exudation of the wound, preventing secondary infection, accelerating a proliferation of the human epithelial cells, resulting in fast healing and less scar formation.
Contact us for more details: [email protected].
2023-05-16
Refractory wounds comprise a significant worldwide health problem. Wounds that fail to heal not only impact quality of life but also impose a significant physical, psychosocial, and financial burden. Additionally, individuals with refractory wounds often experience significant morbidity and sometimes mortality. Wound infections and amputations are common in this population, and chronic conditions often exist as well.
By definition, refractory wounds are chronic wounds that do not respond normally to treatment. A wound is considered refractory if there is no improvement within two to four weeks of implementing an evidence-based plan of care. Wound size and duration are predicative factors for wound healing. Ninety percent of all non-healing wounds have been identified as diabetic or neuropathic wounds, pressure injuries, or wounds of venous etiology, and they are often multifactorial.
Identifying Wound Etiology and Causative Factors
We’ve all seen and cared for wounds that just won’t heal. When developing an evidence-based plan of care for wound management, it is important first to determine wound etiology. We cannot effectively heal something if we don’t know the cause. Wound etiology guides treatment, and determining the cause of a wound is an important first step in putting together an evidence-based plan of care for treatment and prevention of wound recurrence.
Once wound etiology is determined, we must try to correct the identified causative factor. If it cannot be fully corrected, the plan of care will need to be adjusted. Supportive, evidence-based topical treatment with an individualized plan of care is key to successful wound management. An inability to correct etiologic factors will lead to impaired healing. A bedbound patient with an inconsistent turning schedule and a diabetic patient with inconsistent offloading of the plantar surface are examples of patients in whom healing would be impaired and the etiologic factor is not fully corrected. It is important to remember that a biopsy should be considered whenever a wound is non-healing and the reason for failure to heal is unclear.
Systemic factors affecting repair are commonly categorized into four parts: intrinsic, extrinsic, iatrogenic, and adherence. In this blog, we will focus on intrinsic factors affecting repair and thereby contributing to a refractory wound.
Intrinsic factors are those belonging to the patient, and they include both modifiable and non-modifiable factors. The patient’s comorbidities and physical and physiologic conditions that impact wound healing are classified as intrinsic factors. Some examples include age, the presence of chronic illness, tissue perfusion and oxygenation (also related to chronic disease), immunosuppression (autoimmune diseases and medications that can suppress the immune system), and neurologic impairment (spinal cord injuries are common here).
As discussed in prior blogs, older adults are at risk for a multitude of skin issues, skin breakdown, and impaired healing related to aging changes both internally and specifically within the different layers of the skin (thinning epidermis, dermal atrophy, dryness, and reduced elasticity). Additionally, the increased prevalence of chronic illness among older adults contributes to recognizing age as an intrinsic factor affecting wound healing.
Chronic illnesses also contribute to refractory wounds as an intrinsic factor. Diabetes, heart disease, cancer, vascular disease, and neuropathic diseases are all examples of chronic illnesses that may cause a delay in healing for a multitude of reasons. Blood flow and tissue perfusion, sensory perception, and adequate oxygenation are all important factors to consider when looking at the healing process.
Perfusion and oxygenation are significant factors in the healing process as well; inadequacies in either will likely result in a failure to heal or delay in the healing process. Chronic illnesses can often lead to impairments in perfusion and oxygenation.
Immunosuppressive conditions (cancer, diabetes) and treatments (chemotherapy, whether for cancer or autoimmune reasons, and corticosteroid therapy leading to immunosuppression) cause impairment of the initial inflammatory response required for healing to occur and therefore usually result in delayed wound healing.
Finally, neurologic conditions often result in refractory wounds as well. Spinal cord injury (SCI) patients are known to have delayed healing below the level of injury for many reasons: persistent inflammation, edema, and changes in perfusion and oxygenation.1 Additionally, SCI patients are at a high risk for pressure injury development given their impaired sensory perception, impaired mobility, and often altered weight-bearing status. SCI patients are often identified as at risk for pressure injuries according to the Braden Scale.
It is important to piece together all of the systemic factors impacting healing when looking at reasons that a wound is not improving within two to four weeks of evidenced-based topical therapy and a comprehensive plan of care. Additionally, it is always important to remember to treat the WHOLE patient, not just the HOLE in the patient—a common theme among many of my prior blogs.
In future blogs, we will be exploring and defining the remaining three common factors affecting tissue repair: extrinsic factors, iatrogenic factors, and adherence.
Dermlin series are developed by Jiangsu Yenssen Biotech Co., Ltd. as the advanced functional dressing in the world, containing inorganic formula with nano pores granule which has significant effects of neutralizing acidic exudation of the wound, preventing secondary infection, accelerating a proliferation of the human epithelial cells, resulting in fast healing and less scar formation.
Contact us for more details: [email protected].
2023-05-16
2023-05-16
2023-05-16
Solutions
Dermlin series are developed by Jiangsu Yenssen Biotech Co., Ltd. as the advanced functional dressing in the world, containing inorganic formula with nano pores granule which has significant effects of neutralizing acidic exudation of the wound, preventing secondary infection, accelerating a proliferation of the human epithelial cells, resulting in fast healing and less scar formation.
See a clinical care solving chronic wounds by Dermlin on Youtube: https://youtu.be/RrQsktcYmlk
Contact us for more details: [email protected].
2023-05-16
When cooking, sometimes oil inside accidentally into the water, will be splashed out of oil scald, believe that women in the early stage of cooking and I will have the same experience, was very painful after oil scald, generally I will use their own method to deal with, to prevent the scar hot.
1. Immediately get rid of the heat source and wash the wound with running water for half an hour to reduce the temperature of the affected area and prevent further damage;
2. If there are blisters in the scald, do not remove the blister skin to avoid infection;
3. Mild scald can be applied in the affected area scald cream, serious scald should be timely diagnosis and treatment to the hospital.For specific medication, please combine it with clinical practice and follow the doctor’s guidance.
empyrosis
2023-05-16
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