TLC for Chronic Wounds

For 7 million Americans, chronic, hard-to-heal wounds are a big problem. Chronic wounds are those that haven’t healed completely in four weeks, even with standard care. They’re most common in seniors and people with circulatory disease, cancer, and spinal cord injuries. Americans with diabetes are particularly at risk because of poor circulation (bringing less blood and oxygen to the wound) and a weakened immune system (increasing the risk of infection, which stalls wound healing). One million people with diabetes develop a foot ulcer every year.

Unhealed wounds—including diabetic ulcers, vascular ulcers, pressure ulcers, radiation wounds, nonhealing surgical wounds, and the like—are a major problem. They’re painful. They often drain and emit odors, and have unsightly dressings. They can lead to disability and amputation. They’re even linked to dying. Having a chronic wound is more predictive of death over a five-year period than having breast or prostate cancer.

Care can be hard to access

If you have a chronic wound, you need the best care possible to stabilize and heal. But topnotch care isn’t always easy to get. Chronic wounds are a largely unrecognized and underserved problem for a few reasons:

• They disproportionately affect seniors and minorities, neither of whom have a major voice to lobby for resources for wound care from the government, insurance companies, and other sources of funding.
• They often affect areas that aren’t typically seen, like the foot and the buttocks. Out of sight, out of mind.
• There is no medical specialty devoted to healing wounds. Rather, they are treated by several categories of physicians (like dermatologists and vascular surgeons), podiatrists, nurses, and physical therapists. These health professionals approach chronic wounds without a nationally standardized curriculum of training or a consistent, consensus-driven pathway of care.

When a wound doesn’t heal

There are four phases of wound healing. If one or more of them are incomplete, you develop a chronic wound.

1. Hemostasis. After an injury, blood vessels constrict to reduce blood flow, and clotting factors like fibrin are released at the site.
2. Inflammation. Immune cells like phagocytes and white blood cells enter the site to kill bacteria, remove debris, and prepare the area for new tissue growth. With all the activity, the site becomes red, swollen, hot, and painful.
3. Proliferation. New blood vessels and tissue form to close up the site. Collagen, the protein that maintains the integrity of skin, is the main player.
4. Remodeling. The tissue becomes stronger and more flexible, and a scar forms.

Goals for healing

There are several things you can do to make sure you and your chronic wound get the best possible care.

Find a wound care center. Given the inconsistency of care for chronic wounds, it’s best to see a health-care provider at a wound care center. Do an online search using the phrase (in quotes) “wound care center” and the name of your city or town.

Maximize the five steps of caring for a chronic wound. The wound care center should systematically address your wound with five key steps—while also maximizing your ability and that of your family to deliver effective wound care.

1. Debridement. Debridement is the removal of dead tissue. Early, aggressive, and consistent (weekly) debridement is the cornerstone of wound care.
2. Infection control. Infections are the No. 1 reason why wounds don’t heal. But figuring out what bacteria is infecting the wound (so the doctor can prescribe the appropriate antibiotic) is iffy, with only a 20 percent accuracy rate from taking a culture with a swab. DNA identification, on the other hand, is 100 percent accurate. And remember not to touch your own wound with bare hands. Always wear gloves, just like the health professionals.
3. Dressing management. Dressings protect, moisturize, reduce pain, improve appearance, compress (for better venous circulation), immobilize, and offload pressure. There are many dressings to choose from based on your wound: Some add moisture, some improve drainage, some fill a space or cavity.
4. Grafting. One way to heal a chronic wound is by grafting tissue to the wound for rapid coverage. There are many types of grafts to choose from.
5. Pain management. A chronic wound is usually painful, and managing that pain is important for well-being. In fact, research shows that when pain is managed, wounds heal faster. Start with a nonsteroidal anti-inflammatory drug, such as ibuprofen. If that doesn’t work, your physician may add an opioid, like codeine or tramadol. If this combination doesn’t work, your doctor may use a more potent oral narcotic.

Have a range of goals for healing. It may not always be possible to achieve complete healing of a chronic wound. But you can stop the wound from becoming bigger. You can make it smaller. You can prevent infections. You can prevent an amputation. Those are good goals, too.

Eat a nutrient-rich diet and hydrate. If you’re not getting a recommended level of protein, vitamins, and minerals, your body can’t maintain healthy tissue. For example, without adequate protein, vitamin A, vitamin C, and zinc, the body can’t adequately synthesize collagen, the protein that supplies structural integrity to skin.

The Mediterranean-style diet—rich in poultry, fish, vegetables, fruit, beans, and whole grains—is a good diet for wound healing. In a study in the Journal of Vascular Nursing, published in September 2021, patients with skin ulcers had a better rate of healing if they adhered to the Mediterranean diet. They also healed faster if they drank more than 1 liter (34 ounces) of water daily.

Double-check your medications. Several classes of medications can impair wound healing. They include anticoagulants, chemotherapeutic agents, corticosteroids, disease-modifying antirheumatic drugs (DMARDs) for rheumatoid arthritis, and immunosuppressants. If you’re taking one or more of these classes of drugs, talk to your wound care professional about how to minimize their impact.

The Healing Power of Hyperbaric Oxygen Therapy

In hyperbaric oxygen therapy (HBOT), you sit in a chamber and breathe pure, pressurized oxygen. HBOT is best known as a treatment for scuba divers with decompression sickness, or “the bends”—the shortness of breath, dizziness, confusion, and other symptoms that can occur when a diver stays too long at depth or ascends too quickly, and toxic nitrogen bubbles form in the blood and other tissues. HBOT compresses those bubbles, they dissolve, and the symptoms usually disappear. But pure, pressurized oxygen is Medicare-approved for more than a dozen other health problems, including wounds, says Joseph Cavorsi, MD, medical director of the Carl Webber Center for Wound Care and Hyperbaric Medicine, at White Plains Hospital in White Plains, New York. And it can be extremely effective in chronic wounds for which nothing else has worked.

Right now, the oxygen content of the air you’re breathing is about 21 percent. In a hyperbaric oxygen chamber, the air is 99 to 100 percent oxygen. And it’s also pressurized at a level two to three times higher than oxygen at sea level. These two factors boost the level of oxygen in the blood 20-fold. And this hyperoxygenation improves circulation, allowing chronic wounds to heal.

Medicare has approved HBOT for several types of chronic wounds, including:

• Diabetic foot osteomyelitis. A chronic, unhealed foot ulcer in diabetes becomes infected, the infection spreads to the bone, and nothing is working to solve the problem. This condition (chronic refractory osteomyelitis) often leads to amputation. But in many cases, HBOT can help stop the infection—and prevent the patient from losing their foot.
• Diabetic wounds of the lower extremities. 15 percent of diabetics will develop a diabetic foot ulcer. And any type of diabetic wound of the lower extremity that hasn’t healed with standard therapy is a candidate for HBOT. In a study in the Journal of Vascular Surgery in February 2020, people with a diabetic foot ulcer who didn’t get HBOT were more than twice as likely to undergo amputation.
• Radiation-induced skin injury. The medical term for this condition is soft tissue radionecrosis. It typically occurs when radiation treatment for cancer kills skin tissue and the tissue doesn’t regenerate. HBOT can turn the situation around.
• Flesh-eating disease. The medical term for this type of infection is necrotizing fasciitis—when bacteria quickly eat away at skin and underlying tissue. HBOT can help stop and reverse the process.