When you get a wound you can see like a burn or a cut, we get to see the healing process take place. But what happens under the skin?
By observing and understanding how wounds heal will also help you to understand what happens with injuries and diseases under the skin that you cannot see.
There are many factors that influence wound healing. If these are not attended to, the healing of your body may take longer or your body may not heal very well.
The Healing Process consists of four highly integrated and overlapping phases
Haemostasis
Proliferation
Tissue remodelling or resolution.
For your body to heal, all four phases and their physiological functions must occur in the proper sequence. These phases are precise and highly programmed to happen at a specific time whilst continuing for a specific duration at an optimal intensity.
These four phases overlap. i.e. the next phase commences before the previous phase is fully complete.
The term wound is defined by the Webster dictionary as ‘an injury to the body (as from violence, accident, or surgery) that typically involves laceration or breaking of a membrane (such as the skin) and usually damage to underlying tissues,’
A similar healing process takes place in many other conditions that damage the body except there is no skin broken and therefore no external pathogens. Internal pathogens such as viruses and bacteria can invade the body therefore a lot of information about wound healing applies to the numerous conditions that affect the body and that I see in my clinic.
Factors that influence wound healing.
I would like to classify factors that influence would healing into local and systemic. Systemic conditions can affect the whole body.
Local Factors:
There are a number of local factors that can impact on healing to a particular part of your body.
These include oxygen level (oxygenation) and blood flow (venous sufficiency) to the site of wound, infection, foreign body in wound, skin moisture and swelling (oedema).
Systemic Factors:
Age and gender
Sex hormones
Stress
Ischemia (reduction in blood flow)
Chronic Diseases:
Diabetes, keloids, fibrosis, hereditary healing disorders, jaundice, uremia
Obesity
Medications: glucocorticoid steroids, non-steroidal anti-inflammatory drugs, chemotherapy
Alcoholism and smoking
Immunocompromised conditions: cancer, radiation therapy, AIDS
Haemoglobin levels
Nutrition
Patient behaviours
Local Factors:
Oxygenation (level of oxygen in blood)
Oxygen is important for cell metabolism and critical for nearly all wound-healing processes. The early (wound) healing process uses high levels of oxygen, and the injury site can become depleted of oxygen.
Gentle massage around the region of the injury can aid vascular flow in and out of the area supporting the oxygenation of the area.
Venous sufficiency (reduction in blood flow)
When pressure at the wound site is excessive or sustained, the blood supply to the capillary network may be disrupted. When there is vascular insufficiency, massage may help to increase local blood supply and lymphatic drainage and thus improve healing.
Vascular insufficiency is a common cause of ulcers.
Infection
Keeping a wound clean is critical to fighting infection as well as preventing the prolonging of the inflammatory phase. The inflammatory phase involves the killing of invading pathogens and disposing of damaged tissue and once this is nearing completion it stimulates the next phase to lay down new tissue.
If infection is present, visit your doctor who may take a wound culture to identify the offending bacteria and guide antibiotic therapy. In some instances, dead tissue must be removed.
Foreign body
A foreign body inserted into the skin, such as a splinter or tick, needs to be removed for the wound to heal. Your doctor may be able to help you remove the foreign body
Skin Moisture
Skin needs an adequate amount of fluid and moisture to be viable. If you’re prone to dry skin (especially common in the elderly) you may be at risk for skin lesions, infection, and thickening which will all impair wound healing. On the flip side, if the skin is too wet, you’re at risk for developing maceration (soft or soggy skin) and/or infections, so maintaining an optimal level of skin moisture is imperative for healing wounds. A moist environment allows wounds to heal faster and less painfully than a dry environment
Massage may help to move fluids around the area of the wound provided broken skin and open wounds are avoided.
Oedema (swelling)
When your ankles are swollen for a while or you constantly use parts of your body that are inflamed, the oedema thickens and becomes sluggish and adheres to surrounding tissue including fascia and nerve tissue.
Gentle massage and exercise can help reduce oedema and free fascial adhesions.
Systemic Factors
Age and gender
Wounds in older patients may heal slower compared to younger patients mainly because of comorbidities (multiple diseases in one patient). Older patients may have inadequate fluid intake, altered hormonal responses, poor hydration, and compromised immune, circulatory, and respiratory systems.
Gentle exercise has been reported to improve cutaneous (skin) wound healing in older adults. This could be due to an exercise-induced response to resolve inflammation.
Sex hormones
Aged men have been showed to have delayed healing of acute wounds compared to aged women. This can be related to estrogen regulation.
Stress
Psychological stress causes a substantial delay in wound healing. Seeking appropriate medical and psychological support can aid the healing process. If you have no mental illness, gentle massage and gentle exercise can help your body to heal when you are feeling stressed.
Ischemia (reduction in blood flow)
Ischemia is where the blood supply is disrupted. Consult your doctor urgently.
Chronic Diseases
Diabetes, keloids [excess of a protein (collagen) in the skin during healing], fibrosis, hereditary healing disorders, jaundice, uremia (abnormally high levels of waste products in the blood)
Coronary artery disease, peripheral vascular disease, cancer, and diabetes mellitus are a few of the chronic diseases that can compromise wound healing. Patients with chronic diseases should be followed closely through their course of care to provide the best plan.
Impaired hepatic, renal and thyroid functions can adversely affect wound healing.
Diabetes can impair wound healing. This involves multiple complex pathophysiological mechanisms such as hyperglycaemia, oxidative stress, and dysregulation of cellular functions involved in all four phases of the healing process.
If you have diabetes and sustain an injury, consulting your physician promptly to seek support may be critical in healing the injury,
Obesity & Malnutrition
Body type may also affect wound healing. An obese patient, for example, may experience a compromise in wound healing due to poor blood supply to adipose tissue. In addition, some obese patients have protein malnutrition, which further impedes the healing. Conversely, when a patient is emaciated, the lack of oxygen and nutritional stores may interfere with wound healing.
Obesity affects the immune and inflammatory response. Seek support from your doctor.
Medication
Medications that can adversely affect healing include anticonvulsants, steroids, antibiotics, angiogenesis inhibitors, and non-steroid anti-inflammatory drugs. Drugs known to promote healing include insulin, vitamins, thyroid hormone, and iron.
Anticoagulants have the capacity to disrupt blood clotting, while immunosuppressants may weaken the immune system and enhance the risk of infection.
Non-steroid Anti-inflammatory Drugs (NSAID)
Over the counter medicines such as aspirin and ibuprofen, can interfere with the inflammation stage of the healing process. Consult with your doctor and pharmacist to verify the dosing and administration for your specific condition and comorbidities as well as check for potential drug-drug interactions.
Glucocorticoid Steroids
Consult your physician about the pros and cons of using glucocorticoid steroids because sometimes they help and sometimes they inhibit the laying down of new tissue and reduce wound contraction.
Smoking
Smoking of substances, such as nicotine and tobacco can also adversely affect wound healing as they contain thousands of toxic compounds. Nicotine usage can delay wound healing by lowering wound tensile strength, increasing risk of wound rupture, wound leakage, death of damaged tissue and infection.
Smoking decreases blood flow resulting in decreased oxygen supply in chronic wounds. Carbon monoxide in nicotine and tobacco smoke affect haemoglobin and oxygen carrying abilities reducing oxygen levels.
Alcohol
Alcohol use impairs wound healing due to reduced angiogenesis (formation of new blood cells), a higher incidence of infections, and an increased risk of bleeding. It effects all four phases of healing.
Consult your doctor for support.
Immunocompromised conditions: cancer, radiation therapy, AIDS
Consult your doctor for support as these conditions and treatment may affect wound healing
Haemoglobin levels
High levels of iron may negatively affect wound healing while low haemoglobin (anaemia) levels can affect wound healing through insufficient oxygen.
Consult your doctor if have high or low haemoglobin levels.
Nutrition
Nutrition can be helpful in healing of your body. Listen to what your body needs and does not need and consult with someone who has expertise in nutrition and wound healing. Malnutrition can affect cell growth.
Patient behaviours
Some patients contribute to delayed wound healing through lifestyle behaviours:
Smoking or excessive alcohol drinking
Lack of adequate sleep
Failure to elevate affected area
Not properly cleaning the wound
Inadequate wound dressing procedures
Not keeping the wound moist and not moving enough
Massage may help you to relax and unwind and therefore promote deeper sleep.
Gentle massage therapy when appropriately applied has been shown to support the resolution of the last three phases of the Healing Process helping the body heal quicker and cleaner. Also read How to resolve Inflammation?