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Fact sheet: Chronic wounds

Last Update: April 17, 2013.

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It is easy to get hurt in your day-to-day life, but most small wounds will heal on their own. Yet for larger wounds from surgery or bigger cuts, you might need more than just a small adhesive bandage. These wounds have to be closed with stitches or staples, and it may take a few weeks for them to fully heal. But some wounds, like foot or leg ulcers, pressure sores, or cancer treatment wounds, heal even more slowly, or do not heal at all. Wounds that do not heal normally are called chronic wounds. Treating chronic wounds usually takes a very long time and is often painful. These wounds can also be a heavy psychological burden for those who have them. In this fact sheet we describe the different options for helping chronic wounds to heal and relieving the pain they cause.

How do wounds normally heal?

Wound healing involves several steps. After an injury the body increases the blood flow to the area that has been wounded. This makes the wound become red and warm and allows white blood cells (leucocytes) and platelets (thrombocytes) to reach the wound. White blood cells help fight off infection of the wound. Platelets activate blood clotting (coagulation), preventing further bleeding. Scavenger cells (phagocytes), which remove damaged or dead cells and germs also travel in the bloodstream to the wound. The blood also brings many other substances needed for wound healing, such as oxygen and certain nutrients. After that, cells are produced that form new skin and underlying skin tissue, as well as new blood vessels. Connective tissue fibers (collagen) and small muscle cells are also produced. This stabilizes the wound, and it helps the edges join together so the wound can close. Depending on how deep the wound is, it heals with or without a scar.

Why do some wounds take so long to heal?

There are many reasons why a wound may heal poorly. Infection can slow down healing as germs enter the wound. Infected wounds often even get worse. Pressure sores (bed sores) may also heal poorly because of constant pressure on them in people who have to lie in bed. These areas of the body have to be relieved from pressure to help the wound heal. You can read about preventing pressure sores in our feature on pressure sores.

Poor blood flow to the wound can also prevent it from healing quickly. In people with a circulation problem, not enough blood flows to their legs and feet in particular. Therefore, wounds on these parts of the body heal especially poorly. Narrowing of the blood vessels that transport oxygen (arteries) or problems with the leg veins like venous valve insufficiency can cause leg or foot ulcers. These ulcers are extremely painful and heal very slowly. People with diabetes might not experience the pain from these ulcers if their diabetes has damaged their nerves (diabetic neuropathy). This is especially dangerous, as they might not realize that an open wound has developed or become worse.

Diabetes can slow healing, but so can other chronic diseases like cancer. Immune suppression can also cause wounds to heal poorly or become inflamed.

It is also harder for the skin to heal as people get older, or when they are not well-nourished. We do not know if a special type of diet or food supplements lead to faster wound healing, but a healthy diet and proper treatment of the underlying diseases are essential to wound healing.

What other things influence the development and healing of chronic wounds?

Underlying diseases, personal circumstances and other factors can all contribute to a wound developing or healing poorly. Some examples: It is important for wound healing in people with diabetes that blood sugar levels not be too high for too long. Wearing very tight shoes also affects the healing of wounds in people who have diabetes because they often do not feel the pressure on the wounds from the shoes, so it is important for them to wear shoes that fit a bit looser.

People with venous insufficiency are often treated for high blood pressure. An important part of the treatment of a leg ulcer is also wrapping the leg in elastic bandages or wearing compression stockings. These put external pressure on the tissue and relieve the pressure on the veins, allowing leg ulcers to heal better. Bandages with several layers are more effective than ones with only a single layer. There are also devices with inflatable chambers that are placed around the full length of the legs and then inflated and deflated in cycles from ankle to groin. This puts pressure on the legs to force the blood out of the deep veins – this is called “intermittent pneumatic compression”. It is not known whether this intervention has a greater benefit than just bandages or stockings or whether a combination of these measures is a good idea.

People who develop a pressure sore (decubitus ulcer) are usually physically weak or have diseases that limit their ability to move around. They often need help to move. When someone is able to move only hardly or not at all, regular repositioning is important. This is done to reduce pressure as much as possible on the parts of the body that have bed sores, and to make sure that no new bed sores develop.

Wounds can also become infected, making the healing process even slower. Depending on how severe the inflammation is, your doctor may also prescribe antibiotics.

How are chronic wounds treated?

Wound cleaning

More severe chronic wounds are often first cleaned thoroughly. A doctor or nurse first performs what is called debridement: they remove dead cells or inflamed tissue from the wound. This can be done by using a gel containing enzymes, forceps, a sharp curette or a scalpel, for example. Cleaning of the wound with a high-pressure water jet is called mechanical debridement. Yet another kind of debridement involves placing specially bred maggots (fly larvae) on the wound with or without a pouch. The maggots remove dead tissue and fluid from the wound. Debridement is often painful. A local anesthetic, in an ointment for example, can help ease the pain. Debridement of large wounds is often done under general anesthetic. Debridement can be repeated regularly.

A simple wound cleaning is frequently done when the bandage is changed. This means that the wound is rinsed with a saline or electrolyte solution. Tap water may also be used in some cases. Even though there are sometimes concerns that tap water might not be clean enough, there is no evidence that in Germany cleaning a wound with tap water increases the risk of infection. Overall, too little is known about the advantages and disadvantages of different cleaning solutions and the effect of cleaning on wound healing in general.

Wound dressings

After the wound is cleaned, a dressing is applied. There are many different types of dressings, such as moist compresses, foils, hydrogels, hydrocolloids, silver-containing wound dressings and foam bandages. These dressings aim to keep the wound moist, remove excess wound fluid, and protect the wound from infection. They usually remain on the wound for a few days and are then changed when they are soaked through with fluid from the wound or have become loose. There have not been enough trials investigating which type of dressing is best for which type of wound.

There are also wound dressings that have substances to help the healing process by promoting the growth of the body’s cells (growth factors). It is unclear whether they have a benefit, though. Applying specially prepared honey to a chronic wound before the dressing is put on probably does not have a benefit for venous leg ulcers. Supplementary treatment with honey has not been studied enough for other types of chronic wounds.

Technical aids

Some hospitals use technical devices to improve wound healing. These include hyperbaric oxygen therapy, vacuum-assisted closure therapy and therapeutic ultrasound. In hyperbaric oxygen therapy, the person with the wound enters a special chamber to breathe in oxygen under high pressure.

In vacuum-assisted closure therapy, the wound is covered with a sponge that is connected to a pump by a tube. The pump sucks fluid out of the wound and improves the flow of blood in the area around the wound. Large chronic wounds might heal better by using vacuum-assisted closure techniques. You can read more about research on vacuum-assisted closure therapy in the research summary "Chronic wounds: Do they heal better with vacuum therapy?".

In therapeutic ultrasound chronic wounds are treated with sound waves. This warms up the parts of the body around the wound and the tissue moves, as if it were being massaged. The goal of therapeutic ultrasound is to promote self-healing, but it has not been shown that this causes chronic wounds to heal better. The same is true of the electromagnetic therapy, which applies electromagnetic waves to the wound through different devices (for example pillows or mats).

Skin grafts

Some wounds are so large that they do not close on their own. In these cases a skin graft could be an option. Skin grafts involve a surgeon transplanting skin from another part of the body, usually the thigh, onto the wound so that it is closed. Grafts made from human cell products and synthetic materials can increase the chances of a poorly healing wound closing faster.

Some complex, poorly healing wounds require close cooperation on the part of the treatment team, and psychological as well as medical aspects have to be considered. It is important that pain is also treated properly in every wound treatment.

What are the pain relief options for chronic wounds?

The pain that chronic wounds cause is often underestimated by people who have not experienced it themselves. It can make daily life and sleeping difficult, and it can be depressing. Drugs like paracetamol can help ease the pain. If these are not enough, a doctor can prescribe stronger medication that will help more. Some wound dressings have the painkiller ibuprofen in them. But research done so far has not allowed a final answer to the question whether these dressings reduce wound pain.

It is especially important for people with chronic wounds who are often in pain to let others know if they are suffering pain, and to quickly find ways of relieving it. Friends and relatives can help a lot by providing care and support. Relatives can also make a major contribution by helping to organize quality care that will ensure regular and good treatment of the wound. Important contacts include the family doctor, specialists for wound treatment and outpatient nurses.

People with chronic wounds can feel very uncomfortable, are often embarrassed and are shy of social contact. Particularly because of this, it can be a big help if someone is there to support them. Maybe they also need someone to help keep them from losing their patience – also and especially if it takes a long time until the wound heals. Good personal and medical support is important to help someone along this path, and even makes it easier to reach the desired goal – it is also easier to cope with setbacks if you know that you are not alone. Support can be especially important if treatment is not successful and ways of dealing with the problem over the long term have to be found.

Published by the Institute for Quality and Efficiency in Health Care (IQWiG)

References

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