Therapy Achievements provides help with wound healing for patients with lymphedema, burns, radiation/chemotherapy and more.
Wounds come in all shapes and sizes. Some are due to burns or injury while others may be due to pressure or venous insufficiency. Some can heal fast and some can take a very long time to heal. It is helpful to know the basics about how to heal a wound when deciding if you need help.
What Is a Wound?
A wound is an opening in the skin that causes a loss of the protective function of the skin. It can result from a multitude of reasons and range from minor to severe. Likewise, wound healing treatment can be quick and easy or prolonged and difficult.
Who Gets a Wound?
Wounds can occur for numerous reasons:
Trauma – as a result of a blow, a cut, or a surgical incision
Burns – caused by hot liquid spills, steam,electrical current, fire, chemical exposure, or frostbite
Pressure / Sheering – when there is friction, shear force, or prolonged pressure
Neuropathic ulcers – because of disease, such as diabetes or carcinomas
How Does a Wound Occur?
Each wound is different and identifying how a wound occurred is important because treatment may be different depending on the cause. However, not all wounds have a clear-cut cause and the etiology may involve a number of factors.
But before we jump in to talk about how wounds heal, let’s talk a little bit about the anatomy of the skin. The skin has three layers:
Epidermis: The top layer of the skin – the epidermis – is avascular. It provides protection and a waterproof barrier for the tissues below. It contains cells that produce Melanin which is the primary determinant of skin color.
Dermis: The next layer – the dermis – is the thickest layer of the skin. Made up of collagen and elastin, it contains tough connective tissue, hair follicles, and sweat glands. It is highly vascularized and houses nerves and sensory organs such as touch, pain, vibration, temperature, and pressure.
Hypodermis: The deepest layer – the hypodermis or subcutaneous tissue – consists of fat and connective tissue.
How Does a Wound Heal?
So now that we know a little bit about the skin structure and the importance of determining the cause, let’s dive into how wounds heal. Regardless of the cause, all wounds heal in a predictable pattern of events:
Inflammation: 1 – 10 days
Proliferation: 3-38 days
Maturation & Remodeling: 9 days – 2 years
Wound Healing Stage 1: Inflammation
The body’s first response to a wound is to prevent excessive loss of fluid and blood. Blood vessels constrict and form of blood clots. Once this life-saving stabilization has occurred, the process of healing can begin:
- Macrophages and other support cells rally to wound site to eat up bacteria and debris. Cellular fluid transports these cells to the site and the blood vessels transition from constriction to dilation to allow extra fluid (swelling and edema) to carry these cells quickly to their destination.
- Histamine releases to increase capillary permeability and allow a flood of proteins, white blood cells and other cells into area.
- Tissue temperature rises to further block bacteria’s ability to take hold because most bacteria and viruses can only survive in a narrow temperature range. This Increase in swelling and heat causes redness and pain.
- Inflammation continues for 1-7 days after the injury.
Wound Healing Stage 2: Proliferation
Once the wound site has been cleared of debris and bacteria, the next step is to get key cells in place. These cells are the building blocks for a foundation for new skin to stand on. And they start the process of closing open areas with scar or granulated tissue. They do their job within 3 – 21 days after the injury and include:
- Fibroblasts – produce proteins needed to make a collagen matrix that replaces the original clot or fibrin mesh.
- Endothelial Cells – begin the process of forming new blood vessels to meet increased oxygen demands of the intensified support cells (support cells require 3-5 times more oxygen when at work than when at rest). This gives the bright red appearance of granular tissue.
- Myofibroblasts –draw the would edges together.
Wound Healing Stage 3: Maturation & Remodeling
The next stage of wound healing is maturation – the resurfacing of the wound.
- Epithelial cells begin to migrate in a single layer across a granulated wound surface towards the middle and begin to proliferate. If there is insufficient granular tissue to cross, the edges of the wound may become rolled or curled, and the resurfacing process is arrested.
- Contact inhibition is what stops the process when complete
Once a wound has matured, it begins the remodeling phase – the process of re-establishing the tensile strength of tissue
- Fibroblasts disappear, Collagen reorganizes and scar matures
- Collagenase regulates the balance between the synthesis and lysis of collagen (fibroplasia)
Even after a scar has matured and remodeled, a scar will never have the same tensile strength as normal skin tissue. A year after closure, it is only about 15% as strong as normal skin. After two years, it is still only 70-80% as strong. In addition to having less strength, other problems with scars are:
Keloid Scars: A keloid is a thick, raised scar and it forms in the maturation phase of wound healing. Somehow, the tissues don’t get the signal to slow down production of collagen resulting in excessive growth. Anyone can get keloids but they are more common in people with dark skin.
Contractures: The purpose of a scar is to pull the edges of open the skin together. This often causes a decrease in the size of the skin and tightness. This, in turn, can then affect the muscles, joints, and tendons, causing a decrease in movement.
Adhesions: Adhesions are scar tissues that join two normally separate surfaces together. For example, adhesions can make skin “stick” to the muscle or tendon below and limit the normal glide between the tissues. Or they can “glue” normally separate internal organs together.
Fortunately, even if a scar has matured, there are things that you can do to flatten your scars and increase the tissue flexibility.
Why Won’t My Wound Heal?
Although healing follows a predictable pattern, the rate of healing varies depending upon several influences. Factors that affect how quickly a wound heals include:
- Amount of surface area involved
- Jagged or defined wound edges
- Depth of the wound
- Wet or dry wound
If a wound it fails to progress in a timely manner through the normal phases of healing, it becomes chronic and may require intervention. Factors that contribute to chronic wounds include:
Age Related Factors – as we age, it is typical for our skin to change in ways that make it harder to heal:
- Decrease in dermal vascularity
- Decrease in collagen density
- Fragmentation of elastin
- Flattening of the basement membrane
- Decrease in the number of mast cells
Absence of inflammation – inflammation is necessary for healing but can be blocked by:
- Taking excessive anti-inflammatory meds, chemotherapy or steroids
- Disorders such as malnutrition, immune disorders, or leukemia
Chronic Inflammation – when inflammation is excessive, wound healing won’t progress to the next stage. Things that contribute to chronic inflammation include:
- Foreign bodies in the wound bed – this can happen if gauze fibers from dressings get stuck in the wound
- Repeated trauma – this can happen when new tissue is pulled off during dressing changes
- Use of cytotoxic agents – this can happen with excessive use of peroxide or betadine
- Excessive use of anti-bacterial agents kill healthy cells as well as bacteria
Rehabilitation: How Do You Treat a Wound?
If your wound is not healing, you may need help from a wound care specialist. A wound specialist is a professional who has specialized in the care and treatment of acute, chronic and non-healing wounds. The primary goal of the wound care specialist is to optimize the wound environment. By making sure the key elements are present and removing distracting or detrimental elements, you set the stage for wound healing.
Manage Comorbid Conditions:
Managing other medical conditions helps the body focus on wound healing and reduces then need to divert resources to other issues:
Clean and Remove Dead Tissue (Debridement)
Creating a good environment for wounds healing includes keeping it clean and removing dead tissues caused by trauma and loss of oxygen. This not only promotes healing and reduces infection but reduces odor as well. It is important to change the dressings as often as indicated and clean the wound with each dressing change.
Debridement is the process for removing dead tissues and is important for several reasons. First, if dead tissue is present, it gives bacteria a place to grow, and this can lead to infection. Second, dead tissue slows the growth of healthy tissue. Debridement be as simple as using water or saline to wash dead tissues away. Sometimes topical enzymes or bio-surgical methods to “eat up” dead tissues are necessary. And sometimes using blades and tweezers are necessary to remove dead tissues.
Prevent and Manage Infection
Excessive bacteria in the wound bed can result in failure to heal, poor quality tissue, increased fragility and increased drainage. If a wound is not healing, a culture can identify whether there is a bacterial imbalance. If there is, it can identify which antibiotics are most effective for that type of bacteria.
Protect and Maintain Moisture Balance
For an ideal healing environment, you need to control the moisture level of a wound bed. It can’t be too wet or too dry. It needs to be just right. Selecting the right wound care dressings and products is the key to moisture control:
- Dressings with a high moisture vapor transmission rate will allow moisture to escape and evaporate in minimally exudative wounds
- Absorptive dressings are necessary for wounds with moderate to heavily drainage
- Use barrier products to protect from adhesives and moisture
- Change dressings at appropriate intervals to avoid pooling of exudates
Adequate Nutrition & Hydration
The final key element to wound healing is good nutrition and hydration. Diets with high protein and calorie-dense foods and fluids provide the building blocks needed to repair damaged tissues and re-construct open areas for successful wound closure. These building blocks include:
Protein: Protein is essential to healing. It is a critical component of fibroblast formation, collagen synthesis, the formation of antibodies and leukocytes needed to prevent infection, wound contraction and scar formation. It is the “framing structure” just like wood is the framing structure for a house. Chemotherapy interferes with protein absorption and so patient on chemo therapy will need to take extra measures to ensure adequate levels of protein.
Carbohydrates and Fats: Carbohydrates and fats provide energy and therefore, are very important. They support the energy requirements for protein to do it’s job. Glucose is the simplest form of carbohydrates and is the primary fuel for all cellular metabolism. If enough glucose is not available to cells, they will catabolize protein and fat. But, a diet with too many carbs & fats and not enough protein is like a house with bricks overlaying a straw foundation.
Vitamin C: Vitamin C is necessary for fibroblasts to synthesize collagen. It enhances immune function and is necessary for granulation tissue.
Vitamin A: Vitamin A is essential for the inflammatory response. It is depleted with autoimmune disease or chronic steroid use. Boost vitamin A intake as high as 25,000 IU per day or use topical applications of 200,000 to the wound three times per day.
Zinc: Zinc is important for collagen synthesis, iRNA formation and protein synthesis. Zinc is easily depleted by diarrhea, stress, open wounds, and chronic illness. If zinc is depleted this can be a MAJOR reason the wound is not healing.
Vitamin E: Vitamin E is Essential for cell wall stability and enhancing immune response. Be careful! Too much vitamin E will decrease collagen production (why do we put it on scars?) and decrease inflammatory response
Iron: Iron is necessary for collagen maturation as well as O2 transport
What To Do Now?
Now that you know the basics of wound healing, you can decide if your wound healing is on track or if you need help. If your wound is not healing, you may need the help of a specialist. At Therapy Achievements, our certified wound therapists possess in-depth knowledge of anatomy and tissue healing. Our specially trained physical and occupational therapists use the most current and advanced wound care protocols. In addition, they provide mobility training and positioning expertise. They partner with you and your doctor to identify what factors are interfering with wound healing and develop a plan to provide the most effective and efficient treatment for your wound. If you are concerned about how your wound is healing, let us partner with you. Give us a call today!