Many misconceptions in care of chronic wounds
People are living longer than ever before, although this doesn’t mean they are necessarily healthier. Many experts say our diet is killing us and, indeed, diabetes and obesity are at record levels. Cardiovascular disease continues to claim record numbers. One very unfortunate consequence of these too-common chronic diseases is an increased incidence of chronic wounds.
These are openings in the skin that don’t heal in a timely fashion. They’re rarely seen in healthy individuals. Because of the association with some disease state, chronic wounds have become overshadowed by these systemic conditions. One result is the lessened appreciation of the impact of these potentially debilitating defects in our skin.
Chronic wounds were relatively rare prior to the onset of the “diabesity” epidemic of the 70’s and 80’s. Little attention was directed towards their causes or treatment and few physicians specialized in their care. Consequently, to this day, no residency training program yet exists focused on the development and management of these ubiquitous skin conditions.
They affect over 7 million US residents and produce tremendous morbidity and mortality. Roughly one out of every four individuals with diabetes will experience a foot ulcer and many of these become infected, often leading to amputation and eventually death. The longer an opening in the skin goes unhealed, the greater the chance of infection. Clearly, effective treatment is vital.
Unfortunately, because of its late arrival on the scene that is modern medicine, wound care as a specialty is not well understood by most Americans, healthcare providers included. Although research into the field has intensified greatly over the last half century, many of the practices determined to be most effective have not yet disseminated to the general population. Many older techniques, unsubstantiated by any research, continue to be practiced, and even recommended, in homes and clinics throughout the US.
Perhaps the most commonly cited is based on no research whatsoever. In fact, this practice is quite deleterious and leads to many infections, surgeries, etc. The recommendation that a wound needs to “breathe” and should therefore be left uncovered remains common despite the fact that this notion was dispelled more than 50 years ago.
Actually, the exact opposite is true. And there is no debate on the topic. We know for a fact skin injuries heal better when in a moist medium. The explanation is really quite logical. Every cell inside us, meaning those covered by skin, are in a moist, watery setting and require this for health. A wound means some of these tissues, ones that should be covered by our skin, are exposed to the outside. Exposure to air will dry the living cells so revealed, causing them to sicken and die. Not conducive to reproducing, which is necessary to build new tissue so that the defect can heal, which occurs when it becomes covered by skin.
Many people are mistaken when it comes to their own wound care, believing a wound is cured when it is dry. This is not the case since only skin equals healing. The tissues of integument will typically produce a dry, dead coating when not able to proceed through the appropriate stages of healing. But this dead material has a number of negative effects. It blocks the process of repair, inhibiting the migration of skin cells from the edges, but also provides food for bacteria, which is never a positive.
Nature prefers balance in nearly all things. This includes the moisture levels of a non-healing skin injury, where a wet environment also is harmful. This provides enhanced access to the wound surface by local bacteria, making a wound infection more likely. This explains why any wet dressing (like one exposed in the shower) should be promptly changed. Excess, chronic moisture also causes tissue breakdown, loosening the bonds between cells.
Another practice particularly galling is the application of petroleum jelly to a wound, often one surgically created as part of some dermatologic procedure. No good clinical trials exist demonstrating the efficacy of this technique, although it is not without any redeeming benefits: it is probably the least expensive medicine ever recommended for a wound. It can also help to retain moisture in one of these skin lesions, although there are other materials and methods that are equally beneficial while having none of the negatives. Also worthy of note, it’s a man-made, completely inorganic material resulting from the manufacture of gasoline.
At every opportunity, mention should be made of the lack of awareness concerning skin problems to most diabetics afflicted with neuropathy, the nerves problems most experience. Although little emphasis is directed to this “dying-back” of the skin nerves (just the first nerves to be affected), any wounding of the integument (the skin) usually causes no pain. The uninformed will assume it is an injury of no consequence and no action need be taken. Because of compromised immune function, infection is frequently the result.
Because the large majority of these chronic skin wounds occur below the knee, many podiatric physicians have taken a special interest and obtained the specialized training and education to better care for these resistant pathologies. In rural, community medicine, generally a primary care office takes on the responsibility for treatment but, unarmed with the knowledge of best practices, less than optimal care is provided. The effect is the occurrence of more infections, more hospitalizations, more surgeries, more amps, than need occur.
These aren’t problems to be trifled with. Too many of these either markedly reduce the individual’s quality of life or have life-altering consequences. If you or a loved one suffer from a skin injury which is not healing in a timely fashion (regardless of the cause), seeking out a specialist may help to prevent the harmful and dangerous products of a chronic wound. The best care practices will reliably lead to speedier healing and a reduced incidence of the complications of a chronic wound. But be your own health advocate: you are the one living with your chronic wound.
Dr. Conway McLean, DABFAS, FAPWHc, has offices in L’Anse and Marquette. He is a physician who specializes in treating lower leg, ankle and foot problems.