Chronic wounds

Wounds often itch, "weep" (release a fluid) or have an unpleasant smell if they don’t heal for a long time. The surrounding skin might be reddish or brownish in color.

Chronic wounds typically hurt because the affected tissue and nerves are damaged. Large and deep wounds are generally more painful. But there are some exceptions. For instance, people who have diabetic foot problems often don’t feel any pain even if they have a big wound. This is because the diabetes has damaged the nerves in their feet over time, so the nerves no longer send any pain signals, or hardly any.

The pain often gets worse if the wound becomes infected or when you move. It can hurt when the dressing is changed too, particularly if the dressing is stuck to the wound. Many people sleep poorly because the pain and itching are especially bad at night.

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 well. The following factors play an important role here:

• Poor circulation: People with poor blood flow – 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 turn into 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. As a result, people who have diabetic foot problems 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.
• Size and severity of the wound: A severe injury with a lot of destroyed tissue – or a 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.

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 (sepsis).

In the worst case, 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 doctors first ask about how long the wound has remained open and check for various risk factors such as diabetes, a weak immune system or blood flow 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

It is important to treat any underlying medical conditions that increase the risk of chronic wounds:

• In people who have diabetes, blood sugar levels need to be kept in check properly. Shoes should be big enough and wide enough to keep pressure off your feet. You should wash and moisturize your feet every day. Regular medical check-ups and professional foot treatment help to prevent wounds or help you notice them earlier.
• People with venous insufficiency and varicose veins can use compression stockings or compression bandages (tight elastic bandages). The pressure from the bandage helps the veins to do their job and improves blood flow towards the heart, making it easier for existing wounds to heal.
• Blood flow problems can be treated with medication and certain procedures, such as surgery to widen a blood vessel. Lifestyle changes like getting more exercise and giving up smoking can improve your blood circulation too.

Measures to prevent pressure ulcers are also important, particularly in people who need nursing care. These measures include reducing pressure on vulnerable parts of the body, for instance with special mattresses or by regularly changing their sitting or lying position.

Chronic wounds are covered with a dressing for protection. To help relieve itching and stop the wound from drying out, you can put a moisturizer on the edge of the wound and the surrounding area.

Healthcare professionals change the wound dressing and clean the wound regularly. Dead cells or inflamed tissue can be carefully removed with tweezers or a scalpel. This is called debridement.

In certain situations, other treatments might be used as well:

• Negative pressure wound therapy (also called vacuum-assisted closure, or VAC therapy): Fluid is continuously drawn out of the wound using a pump.
• Skin grafts: The surgeon takes skin from another part of the body (usually the upper leg) and transplants it to the wound.
• Hyperbaric oxygen therapy: The person with the wound goes into a special chamber to breathe in oxygen under high pressure.

If the wound is infected with bacteria, it can be treated with antibiotics. Pain can be treated too, for instance with painkillers.

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. People with chronic wounds sometimes feel very uncomfortable or embarrassed, causing them to withdraw from social situations. Constant pain and limited physical fitness may lead to problems in everyday life and take an emotional toll.

Because of this, it’s important to have good emotional, practical and medical support – 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. In our topic "Health care in Germany" you can read about how to find the right doctor – and our list of questions can help you to prepare for your visit to the doctor.