Minor injuries to our skin usually heal quite quickly on their own. Larger wounds may take longer to heal, and sometimes stitches are needed.
But some wounds close very slowly, keep on opening up, or don't heal at all. This is usually a result of circulation problems or diabetes. Poorly healing wounds are more common on the feet or lower legs.
Doctors consider a wound to be chronic if it doesn't heal within eight weeks. Treatment for chronic wounds often takes a long time and can be painful. In addition to good wound care, it's important to treat the underlying condition that contributed to the development of the wound.
Not all chronic wounds cause constant pain. Large and deep wounds can be very painful, though. Wounds often itch, "weep" (release a fluid) or have an unpleasant smell if left open for a long time. The surrounding skin might be reddish or brownish in color.
Causes and risk factors
Wounds are usually the result of an injury such as a cut or a bump. People who develop chronic wounds often have an underlying condition that causes even minor pressure to lead to wounds that then no longer heal. The main factors that are involved include the following:
- Poor circulation: People with poor circulation – for instance, as a result of peripheral artery disease (PAD) – have narrow arteries. Arteries are the blood vessels that carry oxygen and nutrients to the body’s tissues. Wounds generally heal more slowly if blood can't circulate properly.
- Venous insufficiency: Disorders affecting the leg veins, which transport blood back to the heart, can also increase the likelihood of developing wounds on your lower legs or feet. Venous insufficiency causes the veins to become enlarged, usually resulting in varicose veins. The blood can't flow upwards and it collects in the legs, sometimes causing them to swell. The resulting pressure makes it even more difficult for the blood to circulate and provide the body’s tissues with enough oxygen. Even small injuries may then lead to chronic wounds. Poorly healing wounds on the lower legs are also known as venous leg ulcers.
- Diabetes: Over time, high levels of sugar in the bloodstream can damage blood vessels and nerves that supply the feet. That’s why people who have diabetes often don't feel pain in their feet and may not notice things like minor injuries or pressure from shoes that are too tight. The poor circulation also affects the supply of oxygen and nutrients to the tissue, increasing the risk of wounds becoming chronic.
- Weakened immune system: Having a weakened immune system, for instance due to cancer, is a further risk factor for poorly healing or infected wounds. Wounds often heal more slowly in older people as well, or in people who have a poor diet.
- Accident injuries and destroyed tissue: A severe injury or burn resulting in large and deep wounds may test the limits of the body’s ability to heal itself.
- Mechanical pressure: People who spend a long time lying in bed or sitting in a wheelchair may develop pressure ulcers (bedsores) from the constant pressure put on some parts of their body by their own body weight. For the ulcers to be able to heal, the pressure needs to be taken off the affected area.
Chronic wounds are hard on the body and the immune system. Together with the lack of sleep caused by itching at night, this can make people feel tired and weak. The pain also limits your mobility.
If bacteria get into the wound, it can become infected and tissue may die. Without treatment, the germs may spread, leading to blood poisoning (septicemia).
If the worst comes to the worst, the affected part of the body – for instance, the foot – may have to be amputated (cut off).
Skin injuries and poorly healing wounds don't always turn into chronic wounds. So the doctor will first ask about how long the wound has remained open and might also check for various risk factors such as diabetes, a weak immune system or circulation problems.
The wound is assessed based on the following criteria:
- Its size and depth
- The state of the edge of the wound and the surrounding skin
- Its color (white, reddish, yellow or black)
- Its smell
- Whether fluid is coming out of the wound, and the appearance and texture of that fluid
- The severity of pain and itching
In people who have diabetes, blood sugar levels need to be regulated so the wound can heal normally. Shoes should be large and wide enough to keep pressure off the feet. Regularly caring for your feet can also help to stop wounds from developing or help you notice them earlier.
People with venous insufficiency and varicose veins can use compression stockings or compression bandages (tight elastic bandages) to help prevent wounds. The pressure from the bandage helps the veins to do their job and improves blood circulation, making it easier for existing wounds to heal.
There are also special devices with inflatable air chambers that can be placed around your legs and then gradually pumped up, from the heel to the top of your leg. The resulting pressure is meant to push the blood out of the deep veins in the legs – this is called “intermittent pneumatic compression.” But this approach hasn't yet been fully tested in studies.
Chronic wounds are covered with a dressing for protection. To help relieve itching and stop the wound from drying out, moisturizers can be applied to the edge of the wound and the surrounding area.
There are other treatments in addition to regularly changing the wound dressing:
Cleaning the wound
Medical staff will change the wound dressing and clean the wound regularly. The wound is normally rinsed with a saline (salt) solution or an electrolyte solution. After that, dead cells or inflamed tissue can be carefully removed with tweezers or a scalpel. This is called debridement.
Cleaning the wound can be painful, particularly debridement. A topical anesthetic such as a medicated ointment can be applied to the wound area to prevent pain. If the pain is severe, medication can be taken before the next debridement. It's also possible to perform debridement with a general anesthetic.
After cleaning the wound, the doctor or nurse will put on a new dressing. Things like wet compresses, films or hydrogels are used as wound dressings. Their main purpose is to keep the wound moist, absorb excess fluid and prevent infection.
Some hospitals also use technical methods to help chronic wounds to heal:
- In hyperbaric oxygen therapy, the person with the wound goes into a special chamber to breathe in oxygen under high pressure.
- In negative pressure wound therapy (also called vacuum-assisted closure, or VAC therapy), fluid is continuously drawn out of the wound.
- Ultrasound therapy uses sound waves to treat chronic wounds.
- Electromagnetic therapy involves the use of magnetic cushions or mats that produce weak electric currents near the wound.
Skin grafts may be an option for people with wounds that are too large to close on their own. The surgeon takes skin from another part of the body, often the upper leg, and transplants it onto the wound. Grafts can also be made from human cell products and synthetic materials.
Good pain management is an important part of wound care. The pain caused by chronic wounds is often underestimated.
Painkillers like acetaminophen (paracetamol) or ibuprofen tablets can help relieve mild to moderate pain. If these don’t provide enough relief, doctors can prescribe stronger painkillers.
Wound dressings that contain ibuprofen are also available.
Pain or itching caused by a chronic wound can affect your everyday life and make it difficult to sleep. Cleaning the wound is often painful too. A lot of people worry that their wound smells bad and that others might find it unpleasant. Personal hygiene might be an issue too, for instance because it’s difficult to take a shower. Constant pain and limited physical fitness may cause problems at work or in your personal life, and take an emotional toll.
People with chronic wounds sometimes feel very uncomfortable or embarrassed and withdraw from social situations. This makes good emotional, practical and medical support so important – from friends and family, as well as from the family doctor, wound care specialists and home care nurses. Talking with them about the treatment, the symptoms and their effects can help you find out how best to care for the wound.
Psychological support can also help cope with the pain.
When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.
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