Regardless of your healthcare discipline, patients may come to you looking for advice on their wound or wounds. They may be wondering how quickly their wound will heal and whether it’s likely to scar. Dr Justine Hextall, consultant dermatologist and specialist in the field of aesthetic dermatology, explains, “The longer a wound takes to heal the worse the scar in my experience. Keeping the wound clean, avoiding stretching and stopping infection are key in preventing healing delays.” Nevertheless, whilst there are different treatments available, there are seven factors affecting wound healing, which we advise to bear in mind when offering patients a solution. It’s useful to ask open questions which explore these different factors, in order to offer the most appropriate advice to encourage the wound healing process.
Before discussing the seven different factors, it’s recommended to consider the three stages of healing:
The three stages of wound healing
1. The inflammatory phase
This is when the body forms a clot to stop any bleeding. After haemostasis has occurred, the blood vessels allow essential cells, such as white blood cells and nutrients, to reach the wounded area. This is where your patient may experience inflammation, erythema (redness), heat, oedema (swelling), pain and, depending on the area, there may be some restricted movement.
2. The proliferation phase
This is when a new healthy granulation tissue is formed, as a result of the blood vessels receiving sufficient amount of oxygen and nutrients, hence rebuilding the wound. When a wound heals healthily, the tissue does not bleed easily. Whilst you are observing the wound, look for a red or pink colour – this shows it is healing effectively. Dark tissue, however, could be indicating an infection. At the end of this stage, the new skin cells should resurface, moving on to the maturation phase.
3. The maturation phase
This occurs when the wound fully closes and the scar begins to fade – referred to as “remodelling”. It generally begins about 21 days after an injury and can continue for a year or more. It’s worth noting that the healed wound area will, in most cases, only regain 80% of the original strength of the surrounding skin . Dr Justine Hextall additionally shared, “The resulting scar tissue of a wound often never attains the appearance of the surrounding skin, and hair follicles and sweat glands at the scar site will not grow back.”
It is important to remember that healing is not always linear and often wounds can progress backwards and forwards through the phases, depending on a number of the below factors:
Whilst patients may be aware of the visible signs of ageing on their skin, they may not realise that the structure and function is also affected. Collagen fibers and elastic tissue in the outer dermal layer of our skin provide strength and flexibility. They are required for cellular development and help tissue recover to its original state. As people age, their skin loses elasticity, even if they are making healthy life choices. This is largely due to elastic tissue and collagen fibers breaking down. The reduced elasticity means that the skin has a harder time returning to its natural shape and colour. This means older patients will have a higher risk of scarring from a wound.
Asking your patient open questions relating to their diet can help determine if different food choices could accelerate the repair of their wounds. In particular, foods high in protein, zinc, glucose and vitamins C and A can help promote faster healing:
- Protein found in foods such as lean meat, fish, dairy products and beans helps the body repair damaged tissues
- Zinc can help boost your immune system and maintain the durability of skin. It can be found in many foods including red meats, lentils and nuts
- Glucose found in carbohydrates in food such as pasta and rice provides energy for white blood cells and improves collagen production
- Vitamin C helps form new collagen. Foods high in vitamin C include citrus fruits, dark leafy vegetables and peppers
- Vitamin A helps maintain a normal inflammatory response. Sources it can be found in include eggs, sweet potatoes, kale and carrots
Related to nutrition, people who suffer from obesity often experience a longer wound healing process and are also more likely to experience complications. It has been suggested that obesity negatively affects the immune system, enhancing the likelihood of infection. Whilst this may be a sensitive topic to discuss with your patients, it is worth having a conversation about what steps they can take to improve their daily lifestyle. Consider moving to a private space if you feel this may be a topic they would prefer to discuss in confidence.
A lack of moisture at the surface of a wound can prevent the maintenance of healthy cells and decrease the addition of oxygen to the blood. If your patient is trying to recover from a wound, it’s best to encourage them to drink more water than usual. Keeping hydrated can help supply oxygen and the nutrients needed to aid the wound healing process.
If your patient has experienced multiple wounds or undergone surgery, their body’s defence mechanisms may be limited, and wound repair can slow down. Specifically, wounds that continue to be damaged due to a force or pressure against the surface will take longer to heal.
As blood delivers the necessary components to tissue for wound healing, patients with low blood pressure, vascular disease or edema often experience slowed or complicated healing. Diabetes can also slow wound repair due to the high levels of glucose in the blood. 8
This is not an exhaustive list. In a consultation, be sure to bring up your patient’s medical history to discover any conditions that could affect the healing of their wounds. There are also multiple treatment options available to help chronic wounds heal such as special wound dressings, regular cleansing, antibiotics, negative pressure wound therapy (NPWT) and hyperbaric oxygen therapy (HBO).
Finally, some prescription medications can have a negative effect on healing. For instance, nonsteroidal anti-inflammatory drugs, such as aspirin and ibuprofen, can affect healthy inflammation and immunosuppressants may also weaken the immune system and enhance the risk of infection.
Dr Justine Hextall’s practical tips to help patients care for their wounds:
Once you have identified the factors that may affect the speed of wound recovery of your patient, it could be helpful to share some practical tips to encourage them to self-care. Dr Justine Hextall explains, “Following a wound or medical procedure, there is a window of opportunity to help ensure a scar heals well. To minimise infection:
- Keep any dressings on unless advised to remove them.
- Keep the wound dressing dry (damp dressings leave the area susceptible to infection).
- Wrap cling film over the dressing site when showering.
- If the wound is exposed, salt water bathing daily is helpful, ensuring the area is gently dried afterward.”
Overall there are a range of different factors that affect wound healing. To improve the chances of a healthy wound healing process, healthcare providers should focus on having open conversations with their patients. This will help to manage expectations and identify any underlying causes which may reduce the time it takes for a patient to heal.
Resources for Healthcare Professionals:
Bio-Oil Professional has several free resources for healthcare professionals on the topic of scarring, free to download:
Resources for your patients:
1. Advanced Tissue.com “Understanding the Healing Stages of Wounds” (2014) https://advancedtissue.com/2014/08/understanding-healing-stages-wounds/ viewed 10/9/19
2. Landen et al (2016) “Transition from inflammation to proliferation: a critical step during wound healing”
3. Ireton et al (2013), “The Role of Wound Healing and Its Everyday Application in Plastic Surgery: A Practical Perspective and Systematic Review”
4. Advanced Tissue.com, “Age and Its Effect on Wound Healing.” (2014) https://advancedtissue.com/2014/11/age-effect-wound-healing/ viewed 10/9/19
5. Advanced Tissue.com, “Nutrients Essential for Wound Healing.” (2015) https://advancedtissue.com/2015/07/nutrients-essential-for-wound-healing/, viewed 10/9/19
6. Pierpont et al, (2014), Obesity and Surgical Wound Healing: A Current Review
7. Advanced Tissue.com (2014), “How Hydration Impacts Wound Healing.” https://advancedtissue.com/2014/06/hydration-impacts-wound-healing/, viewed 10/9/19
8. Hess et al (2011), “Checklist for Factors Affecting Wound Healing” https://journals.lww.com/aswcjournal/Fulltext/2011/04000/Checklist_for_Factors_Affecting_Wound_Healing.10.aspx, viewed 10/9/19
10. Healthline.com, (2019) “What’s the Connection Between Diabetes and Wound Healing?” https://www.healthline.com/health/diabetes/diabetes-and-wound-healing#what-leads-to-slow-healing, viewed 10/9/19
11. InformedHealth.org (2006), “What are the treatment options for chronic wounds?” https://www.ncbi.nlm.nih.gov/books/NBK326436/, viewed 10/9/19
12. Beitz (2017), “Pharmacologic Impact (aka “Breaking Bad”) of Medications on Wound Healing and Wound Development: A Literature-based Overview”, https://www.o-wm.com/article/pharmacologic-impact-aka-breaking-bad-medications-wound-healing-and-wound-development