Patient-centered Wound Healing

The kinetic day-in-the-life of a dermatologist has us bouncing from a young, healthy patient post-chemical peel to a medically fragile patient with a complex distal-extremity surgical wound to a pediatric patient recovering from cantharidin treatment for molluscum. Every procedural appointment concludes with basic wound care guidance that relies on keeping the area clean and moist. This seems too simple when you consider the patient-to-patient variability of immunocompetence, wound type, wound depth, cultural inputs, and medical myths. However, the wound healing process is the same with varia. Consequently, my practice has one wound care handout that, with a few pen strokes, is tailored to the patient based on the pitfalls they are likely to encounter. We present here a practical approach to the most common high-risk populations and pearls to help you tailor wound care to the individual.

Understanding Challenging Wounds 

Understanding the various classifications of wounds and the challenges that certain types may present in healing is critical.

Vasculopathic patients and wounds on the lower extremities pose the greatest challenge, as the wounds tend to heal at a markedly slower rate. Venous stasis (VS) is an outflow problem typified by varicose veins and edema. The stagnation interferes with wound healing by impeding outflow of waste products, reducing inflow, and worsening oxidative stress. VS should be actively managed with compression.¹ If a dorsal pedal pulse is present, compression with over-the-counter or prescription 20-30 mm Hg is a highly effective adjunct to wound care. If the patient has claudication, a nonpalpable dorsal pedal pulse, or an arterial-brachial-index of less than one, assume peripheral arterial disease is present. Compression should be deferred to a vascular specialist as increased pressure will further decrease blood flow. The Unna boot (UB) is an excellent adjunctive therapy for lower extremities that keeps the wound moist and clean while supplying a modest amount of compression.² The UB can be used with innumerable topical medicaments to speed wound healing. Finally, don’t forget to encourage your patient to elevate the lower leg above their heart every 1 to 2 hours for 5 minutes. 

Diabetes is another special consideration. Whether diabetes is the cause of the ulcer or not, it can interfere and dramatically delay wound closure; it is estimated that impaired healing of diabetic wounds affects approximately 25% of all patients with diabetes mellitus.³ Hyperglycemia leads to blunted laminar blood and increased oxidative stress on the intima of blood vessels. 

Optimizing compression, encouraging elevation, and emphasizing glucose control are paramount to wound healing. In the age of continuous glucose monitoring, review the patients’ recent glucose levels or hemoglobin A1C tests and discuss the importance of glycemic control on wound healing. 

Educating Patients on Common Pitfalls

When approaching a chronic wound, it is imperative to patiently listen to the home wound care regimen. Elucidating a well-intentioned intervention that is prolonging the healing process is more cost-effective than a punch biopsy, tissue culture, and course of antibiotics. The most common pitfalls are failing to keep the wound moist, tearing off bandages, applying cytotoxic agents, or utilizing unnecessary topicals that lead to allergic contact dermatitis. The commercial, familial, and social media influences must be addressed directly and countered with simple instructions:

At the end of a shower, gently remove the bandage and allow warm water to run over the area for 15 to 30 seconds.

Pat-dry with a clean towel and immediately apply a thin layer of petrolatum.

Apply a fresh bandage.

Wet or Dry?

 As dermatologists, we know the chemical milieu of water-soluble signaling molecules and the movement of neutrophils and macrophages function optimally in a moist environment.⁴ Diligent application of plain petrolatum as needed is the key to maintaining a healthy wound bed. The notion that drying out a wound will help it heal faster is a myth propagated by social media influencers and by some health professionals. I suggest using a humorous metaphor: Explain to the patient that a dry wound is like taking down cell phone towers and that communication at the cellular level is dependent on their keeping the area moist.

Aggressive Bandage Changes

A common idiom in our culture is “ripping off the Band-Aid,” a false dichotomy that creates value in short-term pain in an effort over the longer duration of pain with a slow removal. Though this may be good for ending a tenuous relationship, it is terrible for wound care! The pain felt with the quick rip is the removal of healing fibrinous matrix that that has adhered to the bandage. When loosely bound epidermal cells and stratum corneum are removed, skin breakdown and medical adhesive-related skin injuries can follow.⁵ The traumatic removal sets the wound healing timeline back 12 to 18 hours, or roughly to the time the bandage was applied. Educate the patient on using water in the shower to assist in removal. Patients are often convinced the white fibrinous matrix of normal healing tissue is the purulence of infection. Start by giving regular in-services to staff as they are generally the front lines of wound care education. 

Irritant Contact Dermatitis

The worldwide phobia of infections has sent the developed world into an antimicrobial frenzy. Alcohol-based sanitizers are in every clinic, store, and mother’s purse! Applied to the stratum corneum, they denature surface pathogens while causing minimal damage to the epidermis and prevent the spread of infections. However, when the same product is applied to a non-epithelialized surface, the cytotoxic effects are on both the microbe and the host. Antiseptic sprays, rubbing alcohol, anti-bacterial soaps, and hydrogen peroxide are ubiquitous in our cabinets and generally a first line for the untrained wound care provider. Patients perceive their wounds are dirty and will take the well-intentioned grandparent advice to apply these common household products to the wound daily. While that kills bacteria, fungi, and viruses, it also kills human cells, putting the patient behind the curve in healing.⁶

Allergic Contact Dermatitis (ACD)

In emergency departments to primary care clinics from India to Italy, I like to snoop around clinic drawers to see what they stock. I have yet to find a non-dermatology examination room without little packets of bacitracin immediately next to the bandages! When given the option between bacitracin or a dry wound, I will reluctantly apply the bacitracin as keeping the wound moist is primary. As ACD experts, however, we know 13% of patients are allergic to neomycin and bacitracin.⁷ Despite what the commercials and grandma tell us, the research indicates that topical antibiotics slow healing time when compared with the use of plain petroleum jelly because bacteria induce regeneration through IL1β-keratinocyte-dependent IL1R/Myd88 signaling.⁸ Talk with your business managers and supply technicians and restock the shelves of your clinic with plain petrolatum. When faced with a red, angry, high-output wound that a medical history unveils was treated with bacitracin, ask the question: Does it itch or hurt? Pain is an indicator of infection, while itch is more consistent with ACD.

New Trends

From scientific laboratories to social media, the pursuit of new methods to improve wound healing is a robust and financially lucrative endeavor. The wound care and plastic surgery literature tout the antimicrobial properties of medi-honey. Recent advances in honey-based nanoparticle wound dressings have incorporated nanomaterials such as gold, silver, chitosan, cellulose, and PVA.⁹ Exosomes are a hot topic and preliminary studies are promising on the positive impact on wound healing and skin regeneration by inducing the release of anti-inflammatory, antioxidant, anti-apoptotic, and pro-angiogenic mediators. Exosome research has been focused on anti-aging and wound care. However, the clinical application has been limited by the scale of production, supply chain, and cost.¹⁰ Hydrocolloid dressings provide a maintenance-free method of post-procedural wound care, but accessibility and affordability are obstacles to widespread use.¹¹

Wound healing will continue to be a multi-billion-dollar endeavor that will drive research breakthroughs. It is our responsibility to stay up to date on the latest research and implement new modalities in a cost-conscious manner.

The author reports no relevant financial disclosures

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