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HYPERGRANULATION IN CHRONIC WOUNDS: AN OCASIONAL PROBLEM BUT NOT AS INFREQUENT.

By Daniel Chaverri Fierro. - Nurse at a Geriatric Unit. Hospital Sagrado Corazón (Huesca). Licensed in Anthropology.
Expert GNEAUPP advanced level, Master in care and treatment of chronic wounds, post grade in Surgical Nurse.

Introducción

The hyper granulation is an occasional but not as infrequent problem that many nurses responsible on the treatment of chronic
wounds get on their common daily practice. This phenomenon can happen in a wide range of wounds from the incisions to the
surgical wounds, stomas (gastrostomies, traqueostomies….) and chronic wounds.

The word hyper granulation describes the exaggerated and overgrowth of the granulation tissue during the proliferative phase into
the healing process. It is an abnormal growth that overtakes the borders of the wound and stops the correct epithelization and the
arrival to the maturation phase.

Despite of being a frequently named problem in the literature, it is not known how extensive it could be because only few articles
and bibliographic references talk about it. Nelson (1) thinks that there are two key factors to explain the lack of investigation works
and hard evidences about it. On one side, the fact that the hyper granulation doesn’t cause discomfort neither supposes an
immediate risk for the patient’s health, doesn’t seems it needs urgent investigations. On the other side, it is difficult to obtain a big
enough sample to get significant study results.
The present article pretends to show physiopathological process of the hyper granulation as well as the more frequent therapeutic
options in the daily practice for the treatment of it.

Physiopathology of the hyper granulation

The granulation tissue is composed by a rich capillary net supported by collagen fibers and a fundamental amorphous substance as
well as different cellular elements the most important of which are the fibroblasts for its capacity of synthesis. The granulation tissue
is generated to fulfill the areas where have been damaged or tissue loss and to obtain so the formation of a scar to re-establish the
skin integrity (2).

Once the necrotic tissue has been debrided and the wound bed is ready, the fibroplasty and the creation of the granulation tissue
will begin, filling the cavity of the wound from the bottom to the top end. When the new tissue gets to the epithelized borders, the
keratinocytes, epithelial cells fenotipically characterized for its migration capacity, will start working to be able to end up the
epithelization process of the wound.

Normally, when the granulation tissue gets nearby the borders of the lesion its production slows down (3). If this last process doesn’t
happen, or if this granulation tissue is not healthy, the keratinocytes will not migrate and we will have the overgrowth of the
granulation tissue above the borders of the wound appearing the hyper granuloma.
The physiopathological mechanism of the hyper granulation isn’t completely clear and defined nowadays. It seems to be due to the
excessive and prolonged inflammatory response which will be the last responsible of the unmeasured and abnormal proliferation of
the granulation tissue.

One the most common locations where the hyper granuloma appears is at the gastrostomy or traqueostomy tube incision site, so
some authors have pointed out the possible etiological agent as the constant friction between the tubes and the stoma (4)(1).
However, it is frequent the appearance of hyper granulomas without the presence of these foreign bodies as is the case of chronic
wounds.

This is the reason why some have tried to find other explicative causes for this phenomenon. There are in vitro evidences that the
use of an occlusive hydrocolloid dressing (2) and the excess of wet in the wound bed, for the bad control of the exudate, or for the
wrong use of tools to get humidity (5)(6)(7), could be the cause that the problem appears.

Within the hypothesis of the infection or the high bacterial load as the developing agent of the hyper granulation it seems to be a
major consensus. The bacterial infiltration in the wound bed could cause an uncontrolled inflammatory answer giving the
hypergranuloma (3) (5) (2) (4). So, Stone suggests that in certain subjects, micro organisms as Staphylococcus and Streptococcus
could be responsible that the polymorfonuclear leucocytes had an excessive and continue inflammatory response, releasing some
peptides which could over stimulate the fibroblast proliferation and the formation of the extra cellular matrix (8).

It is important to emphasize that the malignancy in an ulcer could look like the hyper granulation tissue. The risk of malignancy is
proportional to the chronic of the ulcer (time of the ulcer) and affects mainly to the venous ulcers (9). The malignancy of a chronic
ulcer is known as Marjolin ulcer and the scamous cell carcinoma is the most frequent. The appearance of signs like hyper
granulation and bleeding of the wound bed in chronic ulcers with null or nearly null tendency to the healing must alert us of the
possibility of a malignancy in it, and a biopsy is needed to exclude it (9)(10)(11).

Therapeutical options
There are many hypotheses to explain the cause of the hyper granulation phenomenon but the approach and management of it isn’t
still clear and there aren’t strong evidences to justify one treatment instead of another one.

Within the day by day clinical practice as well as in the different literature, we can find different therapeutical options for the hyper
granulation treatment and we can divide so in traumatic and non traumatic treatment.

The excision and the cauterization with caustic substances (silver nitrate) of the hyper granulation would be the most commonly
used between the traumatic treatments. However, there is controversy about these techniques because apart of causing pain and
discomfort to the patient it can cause as well trauma to the wound bed. This gets the wound to an inflammatory phase which will
start again the healing process and slowing down the closure of it. Other procedures like the argiria have got as well many
disadvantages and some authors explain them (2)(12). Other traumatic alternatives like the use of caustic substances or the
excision of the hyper granulation could be justified as Zitelli said (4) only when the hypergranuloma is like a peduncle and it extends
above the borders of the wound.

The laser treatment and the cryotherapy are other options mentioned in the literature.

Other options could be more conservative and less traumatic trying to reduce the inflammatory response with the use of topical
corticoids or even with substances like the Imiquimod. The corticoids stop the inflammatory response and they can have antimitotic
effects for the fibroblasts and the keratinocytes and slow down the synthesis of the extra cellular matrix components (13). The
advice is to apply them during short periods of time because its prolonged use could alter and retard the healing process for the
effects we mentioned before (12). The Imiquimod is a substance used by the dermatologists for the treatment of neoplasies rich in
blood vessels like the haemangioma. Paying notice in its antiangiogenic properties, the application of this product will reduce the
fibroblasts proliferation and because of that the hyper granulation as well (14). This last therapeutical option is as new as infrequent.
The most conservatives actions will try to find the way to stop the etiological agent causing the hypergranuloma: wet excess with a
good management of the exudate (4)(6), infection or high bacterial load with silver dressings or topical antibiotics (14)(15), and the
correct gastrostomy tube fixation trying to reduce the stress mechanism caused by the friction (5).

Conclusions

Our recommendation to choose the best therapeutical option, after analyzing the literature and in view of the lack of major
investigations about the physiopathology and treatment of hyper granulation, would be the less possible traumatic treatment
depending on the type of hypergranuloma; keeping the more traumatic options for the more severe and bigger size cases.

Last posted:

● Francisco Moreno Roldán

● Fernando Martínez Cuervo
● J. Javier Soldevilla Agreda y Sonia Navarro Rodríguez.
● Daniel Chaverri Fierro

●
 Figure 1-.Detail of a wound with hypergranulation tissue.

Figure 2 -. Hypergranuloma peduncle in a surgical dehisce nearby a colostomy stoma site.

Figura 3-. Aspect of the wound after the excision of the hypergranuloma by cauterization with silver nitratea.

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