Basic wound care management is an area that requires significant resources in any medical facility. The injury for every surgery and every treatment, and any circumstances that cause injury, will depend on the ability to provide effective wound care. There are many ways to manage basic wound care and reduce follow-up for infections and long hospital stays, both of which require the resources of medical institutions. By further understanding basic wound care management, we can have a domino effect on the efficiency of other areas of any facility. Basic wound care management has several goals that are achieved through a variety of means.

The purpose of wound care

If a wound does require specialized treatment based on its cause and condition, there are some basic steps that can be followed in all wound care.
1. Remove damaged tissue that can't be repaired.
2. Clean and disinfect the area.
3. Measures to prevent further damage.
4. Identify the source of the wound and determine the extent of care (acute or chronic) required.
5. Create conditions that allow healing without complications.
6. Ensure ideal healing conditions for wound dressings.
Having staff trained in the latest techniques for treating and dressing wounds can save patients time to heal and prevent slow healing wounds from having an unnecessary negative impact on patients' lives. When it comes to chronic wound care management, hyperbaric oxygen therapy should be considered if the type of wound is known to respond to it.

Overview of basic wound care management

Because basic wound care management is an important aspect of follow-up care, there is a lot of research on how to improve healing speed and prevent anything that further slows healing or causes complications. It is therefore vital that all staff concerned are kept informed of any and all new information. This is easier to do by building relationships and partnerships with institutions that specialize in wound care.
There is a degree of assumption that wound care management and risk involves extensive treatment or the use of additional methods. New information and methodologies should therefore be implemented with supervision and caution.

Assess the cause of injury and damage control

This step is critical to the long-term effects of the wound. The less attention that is given here, the more tedious or erratic the treatment becomes. Only in an emergency would you neglect the care and attention to remove the damaged tissue, and at the same time pay attention to the nerves and observe the extent of the damage. In some cases, the cause is not immediately obvious, so it takes time to establish information through diagnosis and evaluation.
Debridement
An important factor in slow wound healing is the thin film that forms on the surface of the wound, which allows microbes to grow, making any wound detrauma important. Sometimes this step is not included because the damaged tissue is not always obvious.
swelling
It is also necessary to examine the cause of swelling. Edema can be a potential problem that requires urgent attention. A normal swelling of the wound may require treatment before the wound closes and further treatment can be carried out, but the cause of the swelling should be identified.
Cleaning and disinfection
Materials used to clean the wound and bring the area around the wound into a state that can be properly treated have an impact on healing rates. Depending on the cause of the wound, the material can moderate or cause combustion. The latest information on wound care may mean that for some wounds, this step can help kick-start the healing process. One example is the topical foam treatment of certain ulcers. At the very least, knowing the cause and your patient information can prevent an unmanageable emergency.
This procedure is repeated each time a dressing change is required, which is also a way to monitor the condition of the wound. Continuing treatment with the right materials will increase healing time -- when the patient is under your care, all efforts should be made to ensure that the patient or the patient's caregivers are adequately equipped and trained to perform this step.
Trauma outpatient treatment
The area usually needs to be anaesthetized at least initially -- your doctor may prescribe pain medication or local anesthesia for this procedure. Antibiotics can also be prescribed by a doctor if there are any signs of infection, or as a preventive measure when certain conditions are effective. Oxygen therapy and hyperbaric oxygen therapy have been shown to be effective in wound healing. Increasing the amount of oxygen in the blood helps healing to occur from an internal channel, rather than just through local application.
The wound closed
There are several ways to suture the skin around a wound. Treatment will depend on the condition of the wound and sometimes on what is available. For example, adhesives can be used as a temporary method if suitable stitching materials are not available. Patients may want to know which methods heal with the least amount of scar, and new methods need to be studied. There are some exciting discoveries in this area.
Wound dressing
Wound dressings themselves are a big topic, and there are many ways to improve them. It has this effect on wound care. Almost all healing can be delayed or interrupted by improper bandaging.
Dermlin Wound Healing Dressings are a good choice.
Dress appropriately
Every little detail matters when dressing a wound, and tightening (affecting blood flow to the wound) and drying (conditions around the wound need to change at each stage of healing) are details that both patients and caregivers will benefit from. With staff on site, their first priority is to take the time to "upskill" patients and their care providers with all the right methods and information, which is the kind of care that patients will thank their healthcare providers for.
There is a method for layering wound dressings with different materials depending on the nature of the wound, how wet or dry it is kept, and how topical it is treated.
1. Usually, you need a first layer that won't stick to the wound or absorb any topical ointment.
2. Special care should be taken in bandaging wounds around joints and skin, as there is movement in these areas during the day.
3. Patients need to be informed of signs of infection, especially if a wound needs to be dressed.

Topic overview

Most scrapes heal well with home remedies without scarring. Minor abrasions can be uncomfortable, but usually heal within 3 to 7 days. The larger and deeper the abrasion, the longer it will take to heal. Large, deep abrasions may take 1 to 2 weeks or more to heal.
It is common for a small amount of fluid to flow or ooze when you scratch. This exudate usually disappears gradually and stops within 4 days. Drainage is not a problem as long as there are no signs of infection.

Recovery process

How an abrasion heals depends on the depth, size, and location of the abrasion. Whether the scratch heals or scabs does not affect the healing time or the amount of scarring.
When scraping removes the outer layer of skin, new skin forms at the bottom of the wound and the wound heals from the bottom up. This scratch looks pink and raw at first. As it heals, the new skin sometimes turns yellow and can be confused with pus.
When scraping removes all layers of skin, new skin forms around the edges of the wound, and the wound heals from edge to middle. This type of abrasion looks white at first, and fat cells may be seen. This type of abrasion takes longer to heal.

Scab

During the healing process, some scrapes will form a scab. A well-formed scab protects the abrasion from further damage and infection. Once a scab forms, the scratched area usually remains dry and does not ooze fluid.
A scab that forms on an active area, such as a joint, may rupture and a few drops of clear, yellowish to pink fluid may ooze from the wound. A cracked scab can be uncomfortable, and infection can develop under the scab.
The scab usually shrinks and falls off as new skin forms under the scab.
During the healing process, the scab may accidentally rub off, causing the wound to start bleeding again. Treat the wound and protect the area so the healing process can resume.

No scab

Some scrapes heal without a scab.
As it heals, the abrasion may remain moist and pink and ooze fluid or a small amount of blood. Over time, the area will turn pink and shiny as new skin forms. This usually occurs when the abrasion is covered with a bandage and washed regularly with soap and water to remove the scabbed tissue.
If the scrape is likely to be dirty or infected, or doesn't have a scab, it's best to wrap the scrape with a bandage and let it heal without a scab. This healing process requires more treatment, such as washing the scabbed tissue and dressing the abrasions regularly.

Wound care professionals often use a variety of wound treatment strategies to speed tissue recovery and optimize wound healing. A key strategy to achieve these goals is the use of wound dressings. While there are many benefits to using wound coverings during injury resolution, material selection is key to obtaining the desired clinical response.

What is a wound dressing?

Wound dressings are biological, chemical and physical materials applied to the wound site to aid in the healing process. Wound dressings can be used to limit tissue inflammation, prevent microbial overgrowth, prevent tissue infection, and control exudates at the wound site. In addition, some dressings contain materials that stimulate the reepithelialization phase of wound healing, allowing patients treated to recover more quickly.
Depending on the duration of the injury, the nature of the injury, the extent of tissue loss, and the presence of complex factors, wound care professionals will have to consider the best wound coverings for each individual case. Patients respond differently to wound dressings due to unique physiology, making it necessary for their care providers to perform wound care independently.

Wound dressing is essential for wound care

Wound dressings play a vital role in the management of wounds from acute to chronic. First, these materials act as a physical barrier between the external environment and the wound, preventing foreign body contamination or infection. In addition, some wound dressings contain antibiotics and antifungals that help prevent harmful infections at the site of injury.
In addition, wound dressings help regulate another key determinant of injury resolution: the level of wound exudate/moisture. Too little or too much exudate on the wound surface has been shown to slow wound healing while damaging the surrounding unaffected tissue (around the wound). The use of the most appropriate wound dressing can reduce the risk of moisture associated wound injury (MASD) in susceptible patients.

Type of wound dressing

Wound dressings can be classified according to their physical, chemical and biological properties. The most effective wound dressing materials are summarized below.

• Gauze/cloth dressing
• Transparent dressings
• Collagen dressing
• Foam dressings
• Hydrogel dressing
• Hydrocolloid dressing
• Alginate dressing

Gauze/cloth dressing

This is probably the most common and readily available type of wound dressing material. This dressing material can be applied to almost any wound site to cover different tissue injuries, such as cuts, abrasions and bruises. The dressing material can also be used to apply firm pressure to the wound area and to absorb excess wound fluid.
Advantages:
cheap
Easy to use dressing
It can be used by anyone with little or no training in wound care
Disadvantages:
If not replaced regularly, it can become a source of infection
If dressings are changed too frequently, loss of granulation tissue may result
May cause periwound damage when used by inexperienced caregivers

Transparent dressings

The clear wound dressing consists of a polyurethane material that allows oxygen to flow freely around the wound site and also allows moisture/exudate from the site to evaporate. This helps maintain the right amount of moisture needed for optimal healing. Transparent wound dressings can effectively cover donor sites in tissue transplant patients as well as in patients with mild burns and early pressure ulcers.
Advantages:
Reduce friction around the wound area
It is helpful for autolysis debridement
Minimize bacterial contamination at the wound site
disadvantages
Do not apply to excessive exudate laceration wound
May adhere to the wound causing loss of healthy tissue and damage around the wound during removal

Collagen dressing

Collagen dressings are particularly beneficial for patients with chronic, slow-healing wounds because they provide an organic scaffold for wound tissue repair. Collagen dressings contain biomaterials that promote the recruitment and proliferation of new cells at the wound site.
Advantages:
Promotes rapid tissue repair by helping cell proliferation, new blood vessel growth, and removal of necrotic tissue
Disadvantages:
Expensive wound dressing options
Need expert application and follow up

Foam dressings

In patients with damaged wounds, foam dressings can eliminate cavities or pockets that may have formed as tissue destruction. They also provide non-occlusive wound care for patients with burns, chronic venous ulcers and skin grafts. Foam dressings can also be used to reduce painful wound odors and improve patients' quality of life.
Advantages:
Optimize patient comfort
Not sticky dressings
Can handle a lot of wound exudate
Disadvantages:
Additional dressings are often required to hold in place
If left too long, the wound may macerate
Does not apply to infected wounds

Hydrogel dressing

Hydrogel dressings can be used to cover painful, necrotic wounds with minimal exudation. They can also form effective wound coverings in patients with burns or infected wound sites.
Advantages:
Effectively treats soft wounds and provides soothing relief
Prevent wound site infection; Optimize wound healing
Disadvantages:
Do not apply to weeping wounds

Hydrocolloid dressing

These highly absorbable forms of wound dressings can be used to achieve exudate control and optimize wound healing in patients with necrotizing injuries and chronic ulcers. Hydrocolloidal dressings are made from organic materials (such as pectin or methylcellulose) that expand and absorb large amounts of water.
Advantages:
High absorbent dressing type
It is helpful for autolysis debridement
Minimize bacterial contamination at the wound site
Disadvantages:
Does not apply to infected wounds
May cause more severe tissue damage in areas of the body prone to more friction

Alginate dressing

Alginate represents dressings made from a particular form of brown seaweed. In the presence of wound moisture, these dressings form a hydrophilic gel that allows rapid absorption.
Advantages:
Very absorbent dressings
Autolytic wound debridement is encouraged
Don't depend on
Disadvantages:
Additional wound dressings are required to hold in place
Excessive moisture absorption may cause the wound to dry out

The food you eat plays an important role in how your body functions on a daily basis. However, many people don't consider how the food they eat affects their body's wound healing process. Eating balanced healing foods can help your body heal faster and more efficiently.
Which food necessities are good for wound healing?
A healthy diet is an essential part of healing wounds and maintaining overall health and well-being. This means you should eat a balanced diet and include all dietary essentials, especially:

• Protein;
• Micronutrients (vitamins and minerals);
• Healthy fats;
• Carbohydrates .

The role of proteins in wound healing

Protein is arguably one of the most important aspects of any diet, as it is used for nearly every function of your body. In wound healing, proteins are used to repair tissue, help transport oxygen throughout the body and help fight infection.
Therapeutic Foods Containing Protein
Many foods are good sources of protein that can aid in healing. These include:

• 3 ounces chicken breast = 21 grams of protein
• 8 ounces of yogurt = 11 grams of protein
• 1 cup of milk = 8 grams of protein
• 1 cup of dry beans = 16 grams of protein

Protein needed for wound healing

The amount of protein needed per day depends on the individual, but in general, the average inactive man needs 56 grams per day. Inactive women need to eat an average of 46 grams of protein per day. People with wounds and other medical conditions need to eat more protein each day to help wounds heal. You may consider seeing a wound care professional to help determine the optimal amount you need to heal.

Amino Acids and Wound Healing

Amino acids help build proteins and are used in every cell of our body. Many amino acids play a role in building and repairing tissue, which is important for wound healing.

Therapeutic Foods Containing Amino Acids

Arginine is an amino acid that helps increase blood flow and oxygen to wounds. This increases collagen formation and reduces inflammation. Foods high in arginine include pumpkin seeds, milk, yogurt, and cheese.
Another important amino acid in therapy is glutamine, which stimulates collagen production, regulates nitrogen metabolism, and supports the immune system. Healing foods high in glutamine include chicken, fish, cabbage, spinach, dairy, tofu, lentils, and beans.
Wound care clinics can prescribe wound care supplements that contain these amino acids to ensure you are getting enough.

Micronutrients and Wound Healing

Micronutrients required for a healthy diet include vitamins and minerals. While your body needs a variety of micronutrients, research shows that zinc and vitamins A and C are essential for wound healing. Each of these micronutrients is essential to the body's innate healing process, and when you're not getting enough, you may notice that you start to feel more tired than usual. They also aid in the body's inflammatory response and help produce collagen.
Other notable micronutrients important for wound healing include magnesium, iron, copper, vitamin E and B vitamins.

Therapeutic Foods Containing Micronutrients

While it's best to eat a variety of foods to ensure you're getting all the nutrients your wound needs to heal, some good options include:

• Foods rich in minerals: oysters, spinach, nuts such as cashews, beans such as peanuts, dairy products, black and lentils, bananas, and fish.
• Foods rich in vitamins: citrus fruits, bell peppers, whole grains, eggs, dark leafy greens, fish, lean meats, leafy greens, soybeans, almonds, sweet potatoes, and milk.

Carbohydrates and Wound Healing

When some people hear the word "carbs," they automatically think of how carbohydrates are broken down into sugars, such as glucose. However, this glucose comes into play when part of a healthy, balanced diet. Glucose is converted to adenosine triphosphate (ATP), a form of cellular energy used in the healing process.

Fat is also important for wound healing

Healthy fats such as fatty acids, lipids, phospholipids, linoleic acid, and arachidonic acid play an important role in maintaining the body and promoting normal wound healing. Research shows that these healthy fats are essential for tissue regeneration and cell metabolism, and contribute to inflammation.

Healing Foods Containing Healthy Fats

Fatty foods that help wounds heal include oily fish, avocados, nuts, seeds, and eggs.

What if healing foods are not enough to heal wounds?

When it comes to nutrition, it's important to understand that everything you eat affects your body and how it functions. Eating a balanced diet ensures that your body is functioning properly and is constantly creating the necessary cells to help carry oxygen throughout the body. If you need help with a balanced diet, especially with wound healing, you may want to consult a registered dietitian or dietitian.
Unfortunately, sometimes individuals must undergo severe dietary restrictions,  which can significantly impact their ability to heal wounds. Underlying health conditions, such as diabetes, can also affect the body's ability to heal. If this is your case, you can seek out a wound clinic to help you plan your recovery.

Hyperbaric wound care and healing foods can help heal wounds

Some people may have trouble balancing essential nutrients to help get oxygen where it's needed. Hyperbaric Wound Care Therapy  delivers oxygen to the body through inhalation and absorption. This ensures your body gets the oxygen it needs to help improve your body's ability to heal wounds. When used in conjunction with a nutritional plan, they can ensure you receive optimal health benefits and help your body heal.

 

Mouth ulcers, also known as oral ulcers, aphthous ulcers, or canker sores, are breaks in the tissue lining of your mouth, often along the base of the gums or inside the cheeks or lips, but can form in the floor of the mouth or on the tongue. (Very rarely a mouth ulcer may be the early sign of a cancer.)
They can be painful, annoying, and sometimes embarrassing, interfering with eating, drinking, brushing, and even talking. They are also very common. The pain from a mouth ulcer is caused because the nerves just below the surface of the lining of the mouth become exposed. Luckily most mouth ulcers are easy to treat.
Mouth ulcers are usually temporary, healing on their own within one to two weeks, and harmless (except for pain and inconvenience). If you get mouth ulcers that last longer than three weeks, or they recur regularly, you should seek medical attention as it may be a sign of a more serious problem.

Causes

The exact cause of oral ulcers is not known, but there are several factors that are suspected of contributing to their appearance.²

• Trauma or tissue damage:Damage to the mouth lining is common. Damage from vigorous brushing, orthodontic braces, ill-fitting dentures or biting the inside of your mouth can cause a mouth ulcer to form.
• Infections:Bacterial, viral or fungal infections may cause mouth ulcers.
• Stress-related mouth ulcers, aphthous ulcers:Most common in teens, stress-related mouth ulcers will heal within a couple of weeks. Prevention is by resolving stress-related problems or using stress-busting relaxation strategies. Hormonal changes and allergic reactions may also cause mouth ulcers.
• Foods and drinks:Mouth ulcers may be triggered by acids in certain foods, including oranges, lemons, pineapples, strawberries, tomatoes, and others.
• Toothpaste or oral rinses:Pastes or rinses that contain sodium lauryl sulfate may contribute to the appearance of mouth ulcers.
• Vitamin deficiencies:A deficiency of vitamins such as B-12, iron, folate or zinc could also be a cause of mouth ulcers.

Disease-Related Mouth Ulcers

There are some serious causes of mouth ulcers. Mouth ulcers can be symptoms of herpes infection, sex-related infection, inflammatory bowel disease, leukoplakia, gingivostomatitis, oral cancer, oral thrush, celiac disease, and immune disorders.
If mouth ulcers are a symptom of a disease they are usually accompanied by other symptoms in the body, but not always.² Most mouth ulcers last between one to two weeks. If mouth ulcers do not heal it could be a sign of disease that needs medical attention.

When to See a Healthcare Provider

If mouth ulcers do not heal within two to three weeks it could be a sign of disease that you need medical attention and treatment for. If mouth ulcers recur frequently, are large in size, continue to develop or are painless, see your healthcare provider for advice and a health check-up.

Treatment

Some treatments will require the removal of the source of the mouth ulcer, such as the treatment of those caused by the disease.
For most mouth ulcers treatment is somewhat effective.¹

• Pain relief creams or ointments such as Orajel or Anbesol
• Rinsing the mouth with salt water and baking soda
• Cooling mouth rinses with cold water or applying ice to the ulcer
• Cool chamomile tea—swish it in your mouth and then swallow

Tips for Prevention

To prevent getting mouth ulcers, use these tactics:

• Practice good oral hygiene.
• Eat a healthy diet.
• Employ gentle brushing for your teeth and gums
• Get a good intake of vitamin B, C, and zinc
• Avoid very hot drinks and food
• Reduce stress

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.

Management of the Wound Bed

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

Advanced Therapies for Non-Healing Wounds

Cellular and Tissue-Based Therapies

This type of advanced therapy consists of several therapies based on cells, including3:

• Stem cells, including bone marrow stem cells, keratinocytes, and fibroblasts

• Scaffolds, including carrier systems

• Skin substitutes

• Tissue-based therapies, including autologous blood derivatives for wound care and advanced cell therapy

• Epidermal substitutes, dermal substitutes, and dermoepidermal substitutes

• Melanocytes, vessels, and genetic manipulation

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

Conclusion

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.

Recommended for You

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].

 

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.

Biofilm in Chronic Wounds

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.

Granulation Tissue in Chronic Wounds

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

Wound Pain

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.
Recommended for You

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].

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.

Definition of Refractory Wounds

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 in Wound Healing

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.

Conclusion

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.

Recommended for You

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].