Myths surround wound healing
I am writing today to quash another myth, to stamp out another old wives’ tale. A noble quest this is, the eradication of ignorance, bringing enlightenment to the world.
I realize this sounds rather grandiose, and I admit to some theatricality here, but the concept is accurate. This particular myth is held not only by old people, and not just by wives, nor simply by the general public. To be more specific, people who should know better, specifically, those in health care also fall victim to this falsehood.
A patient presented to my office recently, with a challenging condition. He had diabetes, and recently developed a wound that was not healing in a timely fashion. As appropriate, the individual in question had presented to his family doctor.
Because this population requires specialized care, this fellow was referred to a local specialist. I mention this since the individual related to me the care recommended for his wound, as per the specialty physician’s instructions.
This article, although not about diabetes, is written with great concern and some dismay. As I have stated previously, wound care is a unique specialty. There are some definitive standards in wound care.
Certain principles are accepted without question world-wide. In the following pages, I will list some of these universally acknowledged guidelines.
The diabetic gentleman came into my office because of a failure of his wound to heal. This is a common complication of diabetes, due to a variety of physical and biochemical changes. These complications may include vascular disease, problems with nerve function, and immunopathy.
This latter condition, which is not well publicized, means the afflicted individual can’t fight infection well. Thus, diabetic infections can progress quickly, and often do so without pain. (But I wasn’t going to talk about diabetes!)
The individual had sought care promptly upon observing the wound. But this is where the story gets upsetting. He had been told by the specialist that he should cover the ulcer with gauze … and nothing else
“Let it dry” he was told, which is the mantra repeated by many people. (And this is where I start pulling my hair out. Oh, wait … I don’t have any!) It has been the standard of care, a proven fact, held without question for the last 50 years, wounds heal better if kept moist.
Yes, you read that correctly. Like the TV show says, the truth is out there: moist wound healing is the standard. There is no controversy; it is not theoretical. This fact is recognized by all the experts in the field of wound care: moist occlusive environments allow the growth of new skin, at twice the rate when compared to a dry environment.
For your wound to form new skin tissue, new cells need to form. Cell growth though, thrives on moist conditions. The principle aim of moist wound therapy is to create and maintain optimal moist conditions for your skin to renew itself.
A wound kept sufficiently moist allows cells to grow, divide and migrate at an increased rate. According to many studies, healing may be up to 50 percent faster. Although this is not to say the optimal environment for healing is a wet wound. Moist is different than wet and a wound allowed to stay wet will provide a better situation for bacterial growth.
I achieved board certification in wound care more than ten years ago. To do this, I had to study this topic extensively, and I learned that certain axioms are accepted without controversy in the modern era. For one, we know that wounds which have much too much non-viable (not alive) tissue will heal slower, if at all. The removal of this dead material through debridement, the selective removal of dead tissue, with a scalpel or some other surgical instrument, is required for optimal healing.
These dead tissues provide food for bacteria, as well as clogging the wound, blocking the ingrowth of new tissue. Any patient receiving wound care that has not had regular debridement is receiving inadequate care, below the standards of the day. The only exception to this is one in which the patient’s blood supply to the wound is so poor, they will not be able to grow new tissue. Other than this singular scenario, debridement is essential for timely closure of a chronic ulcer.
A predictable tenet in the science of wound care is the eradication of infection. Here again, inadequate education in this field leads many physicians to prescribe an antibiotic simply because a patient has a non-healing wound.
Quite often, there is no infectious agent, but merely insufficient vascular supply, inadequate numbers and types of nutrients, or problems with the functioning of various cells that are part of the healing process. More likely, bacteria are living on the surface, changing the environment where cell growth is supposed to occur. Antibiotics taken by mouth, or via an IV, will have no effect on these superficial organisms.
Many exciting and effective new methods and techniques are available now for optimizing this repair process. It seems nearly every day, a new product comes on the market. A special spongy material, placed on top of an ulcer, then hooked up to a vacuum device, leads to an explosive growth of new, living tissue. A unique form of electrical stimulation triggers the growth of new tiny blood vessels around a sore that isn’t healing, often jump-starting the healing process.
We have cultured, artificial skin, grown in the lab, which, when applied to an ulcer, provides many substances the body needs to close the wound. Adipose tissue, taken from other parts of the body, provides growth factors which, as expected, lead to the growth of new tissue. One particular cell type, obtained from the patient’s own blood, is another source of growth factors.
Treating wounds that aren’t healing appropriately is a challenging endeavor, especially given the obstacles to healing that many have. Diabetes, insufficient blood flow, cigarette smoking, problems with blood chemistry, these and other conditions are known to interfere with this process.
Overcoming these hurdles requires a thorough knowledge of wound care, and the many treatment options now readily obtainable. Certainly, some amazing, advanced modalities and methods can be used. But too often, the basics of wound care are not performed, leading to an avoidable delay in closure. Chronic wounds are debilitating, and aren’t simply an inconvenient.
There is a social stigma in living with a chronic wound, along with the pain associated, and the possibility of more severe complications. In those who suffer from a chronic wound, there is usually some medical condition responsible for the delay. A wound care expert will determine the reason you are not going through the proper steps and stages to healing. This determination is followed by the institution of the basics, the standards of wound care.
Chronic wounds are not just an inconvenience: the longer they are open, the greater the chance of developing a deep infection, which can be the precursor to an even worse consequence, amputation. To put it another way, these are not just quality of life issues; chronic wounds can be a matter of life and death. I’m sure you’ll agree, that’s a serious issue.
Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at firstname.lastname@example.org.