Derm

Wound

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Wound, Wound Healing, Skin Wound

  • Physiology
  • Wound Healing Stages
  1. Hemostasis and Coagulation (days 0-3)
    1. Bleeding stops with Vasoconstriction and Clotting Factors
  2. Inflammation (days 1 to 25)
    1. Wound site is red, swollen, warm and painful as a result of influx of cytokines, growth factors and white cells
    2. Chronic Wounds are typically stuck in this stage
  3. Proliferation (days 1 to 25)
    1. Type III collagen is deposited, granulation and epithelialization, and Angiogenesis result in wound closure
  4. Maturation and Remodeling (days >20)
    1. Scar remodels with type 1 and 3 deposited, resulting in increased scar strength
  • Classification
  1. Class 1 Wound
    1. Surgical incisions in a sterile environment, not involving gastrointestinal, genitourinary or respiratory tract
  2. Class 2 Wound
    1. Surgical incisions into normal tissue that is colonized with Bacteria
    2. Involves gastrointestinal, genitourinary or respiratory tract
  3. Class 3 Wound
    1. Wound contains foreign or potentially infectious matter (typical Laceration)
  4. Class 4 Wound
    1. Infected wounds
  • Prognosis
  • Factors associated with impaired Wound Healing
  1. Chronic Disease
    1. Diabates Mellitus
    2. Peripheral Vascular Disease
    3. Chronic Renal Failure
  2. Malnutrition
    1. See Nutrition in Wound Healing
  3. Immunosuppression
    1. Topical Corticosteroids (e.g. Triamcinolone)
    2. Systemic Corticosteroids over 10 mg per day
    3. Chemotherepeutics (e.g. Methotrexate)
  4. Petrolatum or vaseline (however, good skin protectant)
  5. Topical antiseptics
    1. Topical Alcohol
    2. Hexachlorophene
    3. Povidone-Iodine 1% (Betadine 1%)
    4. Hydrogen peroxide 3%
    5. Chlorhexidine 0.5%
  6. Topical hemostatic preparation
    1. Monsel's Solution (Ferric Subsulfate)
    2. Aluminum Chloride 30%
    3. Silver Nitrate
  • Prognosis
  • Factors associated with improved Wound Healing
  1. Skin Lubricants and ointments (e.g. Eucerin, Aquaphor)
  2. Silver sulfadiazine (Silvadene cream)
  3. Topical antibiotic (e.g. Bacitracin)
    1. Avoid neosporin due to Allergic Contact Dermatitis
    2. Bacitracin is also associated with Hypersensitivity Reactions
  4. Nonadherant Dressing (e.g. Telfa)
  5. Honey
    1. Partial thickness burns heal more rapidly
    2. Effective on C-Section surgical sites
    3. Effective on herpes and zoster lesions
    4. Decreases Diabetic Foot Ulcer odor
    5. Antimicrobial activity
      1. MRSA activity (Manuka honey)
      2. E. coli
      3. Pseudomonas
      4. Salmonella typhi
      5. Streptococcus Pneumoniae
      6. Vibrio species
      7. Candida
    6. References
      1. Jull (2015) Cochrane Database Syst Rev 6(3): CD005083 +PMID: 25742878 [PubMed]
  • Management
  1. See specific wound types
  2. See Wound Cleansing
  3. See Wound Debridement
  4. See Wound Dressing
  5. Indications for hospital management (or emergent Consultation)
    1. Sepsis
    2. Critical Limb Ischemia
    3. Necrotizing Fasciitis
    4. At risk for Sepsis or Critical Limb Ischemia
      1. Progressive, refractory local infection
      2. Large area of involvement (e.g. Burn Injury)
      3. Insurmountable barrier to outpatient management (e.g. homeless, financial limitations)
      4. Osteomyelitis (esp. exposed bone, probe to bone positive)
  6. Indications for urgent wound clinic evaluation
    1. Wounds requiring significant debridement (e.g. grossly infected wounds, necrotic material, deep wounds)
      1. Typically refer to general surgery
    2. Full thickness Burn Injury
      1. Refer to burn center if >9% involvement
  7. Indications for non-urgent wound clinic referral
    1. Stable, Chronic Wounds with barriers to healing
      1. Scars from prior wounds, radiation
      2. Higher risk locations (e.g. creases)
    2. Specialized equipment or advanced therapy needed
      1. Off-loading measures (e.g. full contact Casting, advanced Wound Dressings)
  8. Other referrals
    1. Vascular surgery
      1. Critical for ischemic limbs before debridement, compression
    2. Dermatology (or biopsy)
      1. Atypical wounds suspicious for cancer, vascular lesions
    3. General surgery
      1. Extensive surgical debridement
      2. Large hematomas
      3. Hidradenitis Suppurativa
    4. Podiatry
      1. Diabetic Foot Ulceration
  • Course
  • Wound Healing
  1. Epithelialization (Sealing of wound) by 48 hours
  2. Peak collagen formation by 7 days
  3. Expect wound to be 30% smaller by 4 weeks, and healing by 12 weeks
    1. Wound tensile strength 20% of full by 3 weeks
    2. Wound tensile strength 60% of full by 4 months
    3. Wound tensile strength never exceeds 80% of full
  4. Mature scar forms by 6 to 12 months
  5. Factors suggesting increased Wound Healing time
    1. See impaired Wound Healing above
    2. Increased wound width
    3. Wounds created by destructive technique
      1. Cryosurgery
      2. Electrosurgery
      3. Laser surgery
  • References
  1. Cole (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)
  2. Bello (2000) JAMA 283(6): 716-8 [PubMed]
  3. Degreef (1998) Dermatol Clin 16(2): 365-75 [PubMed]
  4. Findlay (1996) Am Fam Physician 54(5): 1519-28 [PubMed]
  5. Habif (1996) Clinical Derm, Mosby, p. 810-13
  6. Knapp (1999) Pediatr Clin North Am 46(6):1201-13 [PubMed]
  7. Krasner (1995) Prevention Management Pressure Ulcers
  8. Lewis (1996) Med-Surg Nursing, Mosby, p. 199-200
  9. Lueckenotte (1996) Gerontologic Nurs., Mosby, p. 800-7
  10. PUGP (1995) Am Fam Physician 51(5):1207-22 [PubMed]
  11. PUGP (1994) Pressure Ulcer Treatment, AHCPR 95-0653
  12. Way (1991) Current Surgical, Lange, p.95-108