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Volume1: Number 1 – January - April 2001
An Approach to Chronic Wounds: Why You Shouldn't Listen to Your Mom
by Brian Kunimoto, Md, Editor, Exploration
Can you remember when you were a kid and fell off
your bike creating a nasty bit of “road rash”? Wound care was
simple. All you had to do was let the blood dry and leave the crust alone.
You might even be considered to be a sissy if you put on a Band-Aid TM
(Johnson & Johnson). Who would ever argue with Mom? The fact is that acute
wounds practically all heal despite all the weird things we might apply
such as peroxide, iodine (ouch), mercurichrome, and countless other antiseptics
that would otherwise be a pain in the eye. No matter what, that nasty
bit of road rash usually healed uneventfully in about 10 days becoming
very itchy in the process. Scarring would be minimal and besides, who
would care anyway? You were a kid.
Chronic wounds are another matter, however. The
chronic wound might be considered to be like an acute wound that has,
somehow, lost its way. For some reason, the wound becomes stuck in neutral.
It is as if the string section of the symphony doesn't know when to stop
and the concerto goes on and on. There are usually logical reasons why
this should be so. The majority of leg ulcers are caused by an underlying
disease. Similarly, there may be other easily identifiable factors, some
relating to the local condition of the wound, and others that involve
the patient as a whole, that conspire to prevent wound healing. With these
potential etiologic, systemic, and local factors in mind, the approach
to chronic wound healing is actually quite simple.
There are three, and only three, critical steps
in treatment of the chronic wound:
1. Treat the underlying disease
2. Optimize the patient
3. Optimize the wound
1. Treating the underlying disease
This part is easy; yet, unbelievably, it is so often forgotten. Without
managing the underlying disease, no chronic wound will heal. There is
no substitute. For example, diabetic neuropathic foot ulcers will not
heal if one does not provide proper pressure off-loading. Venous leg ulcers
will not heal if one does not manage venous hypertension. Pressure ulcers
will continue to worsen if the original cause is not rectified. The vasculitis
that underlies vasculitic ulcers must be managed. Arterial ulcers respond
to revascularization. The list is, of course, a lot longer but you get
the point.
2. Optimize the patient
Patients come in all shapes and sizes and may suffer from other diseases
that may impact on healing. Nutritional factors are very important to
manage, particularly if there is protein malnutrition present. Similarly,
vitamin and trace metal deficiencies may be important occasionally. Systemic
medications such as prednisone (considered to be significant if the dose
exceeds 10 mg per day) could halt the wound healing process. There is
weaker evidence that suggests drugs such as immunosuppressants and cancer
chemotherapy drugs play roles. If the ulcer is located on the leg, the
arterial supply is of critical importance. Since many patients who suffer
from chronic wounds are elderly, concomitant arterial disease is not uncommon.
If it is present and severe, it must be managed before healing can be
expected.
Social and psychological factors are often ignored,
yet are often very important. Try to respect the social network surrounding
the patient. Realize the spouse and extended family may be capable of
providing supportive care and are indeed part of the wound care team.
Occasionally, elderly patients may become dependent on the “team.”
This dependence is not unusual given the often long-standing nature of
these chronic ulcers. This fact should not be ignored as it is a significant
factor in ulcer recurrence.
3. Optimize the wound
There are three aspects to optimizing the wound bed:
1) Moist Occlusion
There is a great deal of evidence to show that a moist environment is
the best for healing of chronic wounds. Remember Mom‘s advice about
treating your scraped knee? If an acute traumatic wound is left open to
the air, there is usually no adverse effect. The acute healthy wound will
heal no matter what is done. The chronic wound, on the other hand, needs
all the help it can get. Moist occlusion maintains the integrity of the
cells and growth factors involved in the wound healing process. These
cells would, otherwise, die at an air/wound interface. Moist occlusion
also reduces the formation of crust, which inhibits the migration of skin
cells across granulation tissue. Moist occlusion is actually associated
with reduced infection rates, contrary to initial fears. Moist occlusive
dressings are contraindicated in the presence of clinically significant
infection.
2) Debride when necessary
The presence of yellow slough and dry eschar is detrimental to healing.
These are made up of dead and dying cells and act like foreign bodies.
They also provide a haven for bacteria, safe from the host immune system.
They need to be removed to optimize the wound bed. Debridement can be
accomplished by means of sharp dissection with the help of local
anesthesia. Mechanical debridement can involve the use of hydrotherapy.
Dextranomer beads are not used much anymore. Wet-to-dry dressings tend
to remove both live and dead tissue and have little indication. Chemical
debridement involves the use of enzymes such as Collagenase, Fibrinolysins,
Papain, and Trypsin. Autolytic debridement is what is employed
by the use of moist occlusive dressings. Here, the moist environment allows
for natural cellular and enzymatic breakdown of necrotic tissue. This
means of debridement is the slowest but does not require the caregiver
to acquire any special skills other than knowledge of the dressings used.
Debridement is contraindicated in the presence
of significant arterial ischemia.
3) Treat infection when necessary
Bacteria, in the wound, are sometimes present in sufficient numbers and
virulence that host defenses are overwhelmed. When this occurs, significant
infection exists and healing is compromised. In this situation, several
things need to be done. Debridement reduces bacterial numbers, and improves
host defenses by removing the ”bacterial hotel.” Making sure
the patient is not protein deficient, and has diabetes under control can
further enhance host defenses. Eventually, one must make the decision
to start antibiotics. The choice of drug depends on the clinical severity
of the infection and the suspected pathogen. Surprisingly, bacterial swabs
are not generally helpful in this situation. Usually there are several
bacteria identified, many of which are potential pathogens. The final
choice of antibiotic may depend more on clinical experience and judgment
than on objective data.
It is often mentioned to me when I am teaching
that the healing of chronic wounds must be a frustrating experience. They
complain the patients are elderly and heal very slowly. They usually have
that look about them after leaving a room reeking like a garbage dump
in the middle of summer. Who knows, they may have once had exudate spilled
on their good clothes. Trust me, when that happens you think about it
all day until you can get home to change.
After a decade of running the clinic, I can only
say that chronic wound healing is the most rewarding part of my practice.
Yes, patients are elderly. They do heal slowly but not as slowly as neophyte
caregivers think. There is nothing more satisfying than seeing dramatic
results following the application of the simple principles outlined above.
The look on the faces of your patients when the bandages are taken off
tells the whole story. Remember many of them are afraid of losing their
legs. For them to see healing is often nothing short of miraculous.
Get out there and start creating miracles. It's
easier than you think.
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