Wounds that don't heal can lead to other health problems

Normal wounds heal within weeks, but for people with health problems, the injuries may fester for much longer. In the worst cases, persistent wounds that aren't treated can infect the bone and even lead to amputation. Dr. Kapil Gopal, vascular surgeon and assistant professor of surgery at the University of Maryland School of Medicine and medical director of the Maryland Wound Healing Center at the University of Maryland Medical Center's Midtown Campus, talks about treatment options for severe wounds.

What is a healthy amount of time for it to take a wound to heal?

The amount of time it takes to heal a wound is variable and depends upon several factors. These include the cause and size of the wound, nutritional status of the patient and their overall medical condition. Decreased blood flow can play a critical role in how fast a wound heals. The presence of active smoking, uncontrolled diabetes, persistent pressure, infection or cancer in the wound, along with the patient's environment and current wound-dressing regimen, can impair the process of healing. However, in an otherwise healthy patient, a wound should be completely healed or show significant signs of healing within four weeks.

When should a person become worried about a wound and go to see a doctor?

The skin is the largest organ system in the body and functions as a barrier. When a wound is present, there is an opening in this barrier, and the longer it remains open, the greater the chance that bacteria can cause an infection. This can affect not only underlying structures like bone, but also cause a life-threatening systemic reaction known as septic shock. In those dire and emergent situations, the only treatment is removal of the infected tissue. This could sometimes mean limb amputation or having a very large wound on your back.

When a wound develops, it is important to keep it clean and dry. There should be evidence of significant healing within four weeks with development of a scab and or new skin. If the wound has excessive drainage or foul-smelling drainage, redness and pain then it may be infected. Fever and chills are signs of the infection spreading to the body. It is best to seek medical treatment if the wound is enlarging, deep, has no pink tissue at the base or has black covering that is getting bigger. Early medical intervention allows for more treatment options as well as increased chances to preserve limbs and improves quality of life.

What kind of underlying issues may cause wounds to heal slowly in some people?

There are two factors that are required for optimal wound healing: oxygen and nutrition. Oxygen helps sustain all our body functions at the cellular level. The body needs adequate nutrition to build new tissues to repair the wound.

Circulation problems, diabetes, infection or cancer with or without history of radiation to the area may prevent wounds from healing. These disorders can decrease the levels of oxygen in the wound. In some cases, certain medications interfere with tissue and wound healing. Inadequate nutrition and vitamin levels can also prevent tissue regeneration. For example, zinc, which is an essential mineral, is an important co-factor for many of the mechanisms of healing and without sufficient levels can prevent or slow wound closure.

If the wound is too moist or too dry then cells are prevented from working properly. Bacteria can form an invisible wall, known as biofilm, which helps protect them from antibiotics. Persistent pressure to the wound can not only cause a wound, but also prevent it from healing.

How are wounds that don't heal treated?

The first and most important step is a thorough history and physical assessment for the different medical and social factors described above. We want to get blood work, X-rays and any vascular tests to assess for nutritional status, diabetes, infection or circulation issues.

Then we can formulate an individual treatment plan involving specialized dressings, ointments or equipment to maximize the chances of healing. Initially, we often have to make the wound bigger by removing unhealthy tissue that may be present to help the healing process. Most often we can do this at the wound center with local anesthesia, but sometimes it may need to be done in the operating room. It may also be necessary to improve inadequate blood flow through minimally invasive procedures with balloons and stents, or with traditional open surgery. The wound should be reassessed and cleaned of unhealthy tissue on a weekly basis. This way the progress is monitored by experienced and certified wound specialists and they can adjust the treatment as needed.

Patients with non-healing wounds and low oxygen content in their wound despite maximizing their blood flow may benefit from hyperbaric oxygen therapy treatment. This type of treatment allows for increased oxygen delivery directly into the wound. There are certain risks associated with it, so it is not for everyone. However, when appropriate it is an adjunct therapy that may finally help heal the most difficult wounds.

Who is most at risk for these types of wounds?

Patients who have diabetes are at particularly high risk for these types of wounds, as they often have issues with circulation and malnutrition. Radiation damages the smallest blood vessels and keeps oxygen levels low in radiated tissues, putting cancer patients at increased risk. Additionally, patients with history of heart disease usually have decreased circulation in the legs. Finally, elderly patients present with a combination of the above factors and are particularly at high risk for pressure ulcers.

How do you handle more complicated cases?

The two campuses for the University of Maryland Medical Center are intricately connected, and this helps give our patients more options for treatment. Previously, patients who presented with complicated very large wounds and infections that require intensive therapy including hyperbaric oxygen therapy had to be admitted to the hospital for their entire treatment. Now, their care can be transitioned to an outpatient setting at the Maryland Wound Healing Center where we have two mono-place or individual hyperbaric oxygen chambers. Similarly, patients can be referred downtown to Shock Trauma if their wounds cannot be treated adequately as an outpatient.

andrea.walker@baltsun.com

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