Many roads to healing wounds
The statistics are overwhelming: diabetes is epidemic. The consequences to our health care system will become ever more devastating as this unspoken contagion rages, the consequences social, physical and financial. A large part of the costs are for care of the skin ulcers that many diabetics develop. Up to one-third of the half billion people with diabetes worldwide will develop a diabetic foot ulcer at some point during their lifetime. Over half of these wounds will become infected and 17% will require an amputation. These defects in our skin covering take a massive toll on the health and wealth of American society.
Diabetic wounds are a difficult, challenging problem, occurring far too often. Hospitalization is frequently required due to the development of infection (which dramatically increases expenditures). Because there are so many obstacles to healing in this population, from inadequate blood supply to a faulty immune system, these lesions sometimes require extraordinary measures to close them. As should be expected, these complex methods generally entail greater costs, but can result in reduced amputation rates. To calculate the savings provided by preventing amputation, one should include the fees involved in being fit with a prosthetic, the rehab, even the psychological effects. Many factors should be considered in determining the over-all consequences of limb loss, even the high rate of mortality which is associated.
The number of medications and techniques, new technologies and physical therapies, all for the evaluation and treatment of chronic wounds, is growing exponentially. It seems every day new products and devices become available. Still, some methods of treatment for diabetic foot wounds have withstood the test of time, having been developed and found effective for decades.
Some of these long-used techniques should be obvious. The removal of dead tissue, termed debridement, is essential since this dead material provides food for bacteria, as well as blocking skin growth. Creating a moist wound environment is part of the standard of care and has been for decades, beneficial since all of the tissues beneath the outer layer of skin are in a moist environment. If allowed to dry out, new skin cannot form, preventing wound closure.
Keeping the surface of the ulcer free of bacteria is desirable but nearly impossible. Still, finding some bugs hanging out on the surface is very different from infection, whereby the bacteria have moved into the tissues, rather than being on the surface. Too often, a variety of bacteria will form a cooperative colony, which produces a tough, fibrous layer, also altering the chemistry of wound. This structure, called a biofilm, is an extremely common finding and makes healing difficult. Several topical medications have been developed specifically to fight this barrier to healing.
One successful approach is the application of a common protein, termed collagen, to the surface of a wound. This is one of the primary proteins in skin and its addition provides building blocks for new tissue, and also improves the chemistry of the surface, critical to closing a chronic skin ulcer. Although somewhat pricey when compared to an over-the-counter product, it is a covered service by Medicare, and significantly more effective in moving the wound into a healing trajectory.
A very established technology is a wound vac, whereby a vacuum is created over an ulcer. This has unexpected effects besides the expected removal of excess fluids (which will create a wet wound, proven to be detrimental). This vacuum stimulates the formation of abundant new tissue. These newly formed tissues have an excellent blood supply, providing a good foundation for new skin.
Skin grafting isn’t new. The concept is quite simple: remove a patch of skin from somewhere on the body and plug it into a defect. Although technically demanding, this method of covering a skin deficit has been utilized for years. Typically, the section taken is not a full thickness piece of skin. This is called a split thickness skin graft. When a full thickness graft is obtained, problems with healing of the donor site are more common. An amazing new technology uses a small device to take tiny sections of partial-thickness skin, creating small, circular skin grafts. When grouped together, they can cover large areas.
Naturally, there are some drawbacks to skin grafts, specifically a second surgical site. But what if you didn’t need to remove the skin to create the “patch”? This is now achievable with the use of alternative skin grafts, sometimes referred to as Biological Alternative Tissues (BAT’s). These products have now been used for long enough to have withstood the test of time. They are proven commodities. These “alternative” tissues may be grown in a lab, obtained from a cadaver (don’t worry, there’s lots of “cleaning”), some are harvested from placental tissues (from a planned C-section), even fish skin. Yes, you heard that correctly: fish skin is being used to heal chronic ulcers, be they diabetic or from some other cause. Be not concerned, there are no living cells included. The material acts as a scaffold for the ingrowth of new skin cells.
Along with a huge variety of medicines for wounds, and the BAT’s (Biological Alternative Tissues), many techniques are used to improve the health of the tissues around the wound. This approach can result in greatly improved healing. One is the application of a specialized electrical stimulation, able to improve blood flow through the tiniest blood vessels. This is known as FREMS therapy. Better blood flow means better healing: it’s basically that simple. Even newer is the use of shock wave therapy, bursts of sound waves into tissues, which also function to improve blood flow and healing.
Determining why a wound is not healing is critical to successful treatment. Unfortunately, the reason a chronic ulcer isn’t healing is rarely obvious. Many tests are used to rule out certain limiting factors, but typically these provide only a hint of the problem. The expertise and experience of the treating physician is a vital factor in determining a plan of care, creating a road map to healing. The options for treating these common but debilitating conditions are numerous, and sometimes exorbitantly expensive. But the need to heal these in an expedient manner is without question. The lasting complications, one being amputation, are game changers. And that’s a game you don’t want to play.
Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at firstname.lastname@example.org.