Barriers to wound healing
fgarati
January 10, 2023
As humans, the body is equipped with innate healing mechanisms to repair and recover from wounds. This natural healing process involves complications and stimulating factors that are involved in wound repair and wound bed healing. Chronic wounds, which are wounds that fail to heal within 12 weeks, result from the inability of the body to address the underlying problem.
Chronic wounds impact the quality of life for both you and the caregivers, as they impair mobility, increase the risk of infections and sepsis, and result in increased healthcare costs.
Understanding the barriers to wound healing and implementing effective wound care management strategies can improve health outcomes and reduce healthcare expenditures.
Table of contents: Barriers to wound healing
Factors Affecting Wound Healing
Wound healing is central to the process of maintaining a healthy body. The healing process involves multiple phases that aim at restoring normal tissue architecture and function. These stages include hemostasis, inflammation, proliferation, and maturation. Factors that affect wound healing can be categorised into local and systemic factors. Local factors are related to conditions within the wound itself, while systemic factors relate to your overall health that affects the healing process.
Local Factors
Local factors contribute significantly to impaired wound healing. These factors include the presence of wound-bed infection, non-viable tissue, inadequate blood supply and wound dehiscence. Researches show that the incidence of wound infection increases the probability of wound failure by 70%.
Chronic wounds are commonly found on the legs and feet, and these wounds (like diabetic foot ulcers, venous leg ulcers, and pressure injuries) result from different types of vascular disorders. For instance, blood flow is impaired if you are living with peripheral vascular disease, resulting in reduced perfusion to the skin and a high risk of ulceration.
Furthermore, venous leg ulcers are the result of venous insufficiency and result from blood pooling in the veins, leading to the formation of fibrin and clot formation in the vessels. This then leads to skin damage in the lower extremities, which can ultimately lead to ulceration.
Systemic Factors
Systemic factors include a variety of cell types that impact overall health. These factors can be influenced by comorbidities, overall health status, age, sex and lifestyle choices that range from acute or chronic alcohol use to chronic obstructive pulmonary disease (COPD).
People living with diabetes are more likely to develop a chronic wound due to poor circulation, neuropathy, and high blood sugar levels.
Obesity also contributes to delayed wound healing, as it impairs blood circulation and causes inflammation.
Additionally, wound closure after surgical procedures can be complicated by systemic issues such as hypertension, anaemia, or poor clotting status.
Barriers to Wound Healing
Chronic wound care is complex because it addresses a variety of factors that contribute to the wound’s progression, including local, systemic, physical, and psychological barriers. These barriers prevent or delay the healing process, leading to chronicity, infection, and complications. Understanding the challenges that lie in managing chronic wounds is crucial in developing successful wound care strategies that promote healing outcomes.
Local Barriers
Local barriers refer to any factor that impedes the healing of wounds within the wound bed. These barriers include: wound bed infection, non-viable tissue, inadequate blood supply, and wound dehiscence. Delayed wound healing arises as a result of the presence of these barriers, and therefore, interventions must be implemented to overcome these challenges. Among the major local barriers to healing are exudate, infection and biofilm.
Exudate
Wound exudate is the fluid that is produced by the wound. It contains growth factors, cytokines, and enzymes necessary for the wound healing process. However, excess exudate in the wound bed can delay healing by causing maceration of surrounding skin, reducing the circulation of nutrients and inhibiting wound closure.
Addressing this issue involves choosing the right optimal dressing that can manage exudate effectively; some dressing options include the use of foam or alginate dressings. When managing exudate, it is essential to balance moisture correctly to prevent peri-wound maceration. Wound care clinicians should observe for maceration and wetness at the peri-wound area and dressings that adhere to the dry wound bed during reassessment to facilitate a moist wound environment.
Infection
The presence of infection in the wound is one of the most common local barriers to wound healing. Infection is a critical factor that contributes to delayed wound healing or, in some cases, leads to chronic wound development. Infection delays wound healing by releasing various enzymes and toxins that impair wound repair and the growth of granulation tissue. Consequently, it is essential to maintain a sterile environment and use appropriate wound care dressings, such as silver dressings or compression bandaging, to reduce bacterial load and protect the wound from further infection.
Biofilm
Biofilm formation is a critical factor that contributes to local barriers to wound healing. Biofilm is a bacterial community embedded within an extracellular polymeric matrix that protects the bacteria from antibiotics and immune system defenses. Chronic wounds often exhibit biofilm formation and prevent healing by impeding the growth of granulation tissue and impairing collagen synthesis.
The presence of biofilm in the wound bed requires special attention and treatment requires identification and removal of the biofilm. Dressings play a significant role in the management of biofilm in the wound bed, and the use of an antimicrobial dressing such as Aquacel Ag Plus Extra Dressing has been shown to be effective in preventing reformation of biofilm.
Sleep disturbances, depression and anxiety
Sleep disturbances can lead to metabolic changes and immune system stimulation that impair wound healing. Additionally, psychological issues such as depression and anxiety can impair wound healing as these conditions generate stress hormones such as cortisol and catecholamines that lead to vasoconstriction and overall impaired healing. It is therefore essential to address these psychological and environmental factors when managing chronic wounds.
Overcoming Barriers to Healing
Overcoming barriers to healing requires an understanding of the principles of wound bed preparation. Wound bed preparation involves the management of local and systemic factors that contribute to the wound’s progression. These principles include adequate exudate management, management of wound bed infection, maintaining a moist wound environment and attending to social factors.
Principles of wound bed preparation should be implemented alongside the right wound dressing to create a favourable environment for wound healing. Dressings should be chosen based on their fluid handling capability and ability to hold exudate, ensuring an equilibrium between the right amount of moisture at the wound bed and protecting the peri-wound skin.
Effective wound bed preparation requires a holistic assessment of the wound and the patient to identify the factors that contribute to delayed healing. Identifying the barriers to healing is the first step in developing relevant interventions to overcome those obstacles and promote improved healing outcomes.
Conclusion
Chronic wounds are a significant health problem that requires the implementation of successful wound care strategies to reduce healthcare costs and improve patient outcomes. A holistic approach to wound care management that addresses patient-related factors and identifies local and systemic barriers to healing is crucial in reducing delayed wound healing and persistent chronic wound development. Understanding how exudate, wound infection, and biofilm can impede the healing process is key to promoting rapid wound repair. Evidence-based approaches and the right wound dressing choice are necessary to address the factors that affect wound healing, promote perfusion, and aid in wound bed healing. Finally, effective wound bed preparation should be paired with psychological and environmental factors that affect the overall healing process to facilitate rapid wound healing and improved patient outcomes.
References
Australia Medical Association. (2022). Solution to the Chronic Wound Problem in Australia. Retrieved from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.ama.com.au/sites/default/files/2022-08/research-report-solutions-to-the-chronic-wound-problem-in-australia.pdf
Boateng, J., & Catanzano, O. (2015). Advanced therapeutic dressings for effective wound healing—a review. Journal of pharmaceutical sciences, 104(11), 3653-3680.
Frykberg, R. G., & Banks, J. (2015). Challenges in the Treatment of Chronic Wounds. Advances in wound care, 4(9), 560–582. https://doi.org/10.1089/wound.2015.0635
Team, V., Bugeja, L., & Weller, C. D. (2018). Barriers and facilitators to participant recruitment to randomised controlled trials: a qualitative perspective. International wound journal, 15(6), 929-942.
