Why is my wound not healing?

Wound healing is one of the most intricate processes in the human body. There is a variety of cell types with distinct roles in each phase of wound healing namely hemostasis, inflammation, proliferation, and remodeling. This is how the body heals a wound naturally within around 4-6 weeks however, there are cases when wounds become chronic and refuse to heal as expected leading to complications and frustration. Non-healing wounds are those with prolonged healing time and resistance to conventional treatments available which will then require specialized care.

There are diverse factors contributing to or causing wounds to not heal to name a few, poor blood circulation, chronic conditions, surgical complications, and infections. Insight into these factors and understanding how they affect wound healing will help tailor suitable and effective wound management.

What could be preventing wound healing?

• Poor circulation

Problems with blood flow including plaque buildup, blood clots, or narrowed blood vessels can cause poor blood circulation. When obstacles or narrow paths slow down blood flow, it gets difficult for the body to send blood to every part of the body, especially to the peripheries. This poor circulation will impede the delivery of blood with the essential nutrients and oxygen required for healing.

A more defined condition for poor circulation is peripheral arterial disease (PAD) restricting blood supply to a wound or it can cause an arterial ulcer that is slow to heal.

Wound healing can be helped with therapies for improving blood flow, wound debridement, medications, and arterial procedures including angioplasty and stenting or a laser atherectomy.

• Diabetes

Diabetes impairs nerve functions known as neuropathy and also affects blood circulation as high blood glucose levels help fatty deposits form in blood vessels, both of which affect wound healing. Diabetic foot ulcers are common to diabetic patients as wounds are often overlooked secondary to neuropathy. Neuropathy causes loss of sensation leading to the inability to withdraw the foot from pain due to friction, skin tearing, or other traumatic mechanisms resulting in wounds. It can also manifest with excessive sweating keeping skin too moist, and raising the risk for skin infections.

This will require regular diabetic foot checks, wound care, blood glucose control, and effective infection management.

• Venous insufficiency

Venous insufficiency occurs when there is poor venous return to the heart resulting in blood pooling most commonly in the legs leading to pain, swelling, itching, and skin breakdown. If left untreated, this will build up pressure and excess fluid will inhibit wound healing and can cause more venous ulcers.

Treatment for wound healing will be compression, wound dressings, leg elevation, and venous procedures like radiofrequency ablation (RFA), sclerotherapy, phlebectomy, or vein ligation and stripping.

• Infection and biofilm

Ongoing infection alters both the inflammatory and proliferative phases of wound healing. The body will shift its focus on fighting the infection triggering an immune response causing inflammation and tissue damage thus impeding wound healing. On the other hand, biofilms are mostly bacterial communities forming on wounds together with debris resisting topical treatments.

This is addressed with appropriate antibiotics and debridement to eradicate bacterial communities and disrupt the biofilm.

• Malnutrition and impaired healing

Nutritional deficiencies will delay healing. Certain vitamins and minerals are essential for the phases of wound healing. Protein, Zinc, and Vitamin A play a significant role in every phase of wound healing providing the wound with a groundwork for repair, coagulation, inflammation, immune defense, re-epithelialization, and cell and tissue growth to fibrosis/scar formation. Nutritional deficiencies will delay recovery.

Wound healing will need nutritional support, dietary adjustments, and supplements.

• Chronic inflammatory conditions

Chronic inflammation will interrupt the healing process as the purging of cell debris and potential pathogens in the inflammatory phase will continue damaging tissue and hinder the formation of new tissue to start the recovery and function of the wounded skin. Certain conditions like rheumatoid arthritis compound the inflammation making wound healing more difficult.

These conditions will require management of the inflammation or underlying conditions and the use of immunosuppressants.

• Pressure ulcers or bedsores

Prolonged pressure on skin especially on the bony prominences will eventually result in skin breakdown and tissue damage, more so with immobility. Excessive and sustained pressure at the wound site will impede blood supply to the surrounding tissues and delay healing. These pressure sores can lead to severe infections and complications.

Management would be pressure offloading with the use of an air loss mattress, gel cushions or wedges in bedbound or wheelchair-bound patients, wound cleansing, keeping the area dry, and infection control.

• Radiation therapy-related wounds

Radiation therapy can damage healthy tissue by causing loss of tensile strength due to reduced production of collagen and altered function of collagen which is the building block of the skin essential for wound healing.

This is addressed with specialized and tailored wound care, hyperbaric oxygen therapy (HBOT), or surgical interventions.

• Medication side effects

Certain medications including corticosteroids slow down wound healing by inhibiting primary wound healing processes and delaying the formation of granulation tissue. Chronic use of steroids tends to weaken skin integrity causing dehiscence of surgical incisions, increased risk of wound infection, and delayed healing. Some drug interactions and potential side effects can also affect wound healing.

Wound healing can be helped with medication dose and frequency adjustments or alternative treatment to necessary medications.

• Surgical complications

Surgical wounds can reopen due to poor suturing or other underlying issues leading to wound dehiscence. This complication poses higher infection risks and delayed healing.

These complications will be treated with surgical repair, wound care, and infection control.

Addressing the underlying causes of chronic non-healing wounds while still promoting healing will entail a comprehensive wound care plan. Wound care specialists offer a range of therapies tailored to patient’s needs for healing. If you think you have a chronic non-healing wound and suspect underlying causes, see your primary care provider or a wound care specialist to jumpstart healing before developing complications.

Author

Jenna Wishnew Dr Wishnew is a Board Certified General Surgeon practicing in the North Texas area She specializes in general surgery, gastroparesis, wound care, vein concerns and robotic surgery.