The inflammatory phase

The inflammatory phase simultaneously launches hemostatic mechanisms and

pathways that create the clinically recognizable cardinal signs of

inflammation: rubor (redness), calor (warmth), tumor (swelling), dolor (pain),

and functio laesa(loss of function).

Injury to vascular tissue initiates the extrinsic coagulation cascade by releasing

intracellular calcium and tissue factor that activate factor VII. The resulting fibrin plug

achieves hemostasis aided by reflex vasoconstriction. This plug acts as a lattice for

the aggregation of platelets, the most common and “signature” cell type of the early

inflammatory phase.

Platelets elaborate a number of proinflammatory substances, such as adenosine

diphosphate, tissue growth factor beta (TGF-ß), and platelet-derived growth factors

(PDGF). These growth factors act on surrounding cells and stimulate chemotaxis of

neutrophils, monocytes, and fibroblasts to the area of injury.  [3] 

Injured tissues, through activated phospholipase A, simultaneously catalyze

arachidonic acids to produce vasoactive prostaglandins and thromboxane,

collectively known as eicosanoids. Eicosanoids mediate activity influencing platelet

plug formation, vascular permeability, and cellular chemotaxis to influence wound

healing. For example, thromboxane A2 mediates vasoconstriction and platelet

aggregation. [3] 

After initial vasoconstriction, the classic signs of inflammation manifest from

increased vascular permeability. Rubor results from vasodilation, mediated by

prostacyclin (PGI2), prostaglandin A (PGA), prostaglandin D (PGD), and

prostaglandin E (PGE). Tumor and calor develop as vascular endothelial gaps

enlarge, allowing the egress of plasma protein and fluid into the interstitial space.
These changes are potentiated by PGE2 and prostaglandin F2α (PGF2α) and allow

the ingress of inflammatory cells into the area of injury, including cells that elaborate.

Dolor is sensed as PGI2, PGE, and PGE2 act on peripheral nociceptors.  [4] 

In the second stage of the inflammatory phase, leukocytes supplant platelets as the

dominant cell type, attracted by chemotaxis. White blood cells (WBCs) are the

predominant cells for the first 3 days after wounding; their numbers peak at

approximately 48 hours. Polymorphonucleocytes (PMNs) are the first to begin

bactericidal activities using inflammatory mediators and oxygen free radical

metabolites. However, normal wound healing can occur without PMNs. Another

leukocyte, the helper T cell, elaborates interleukin-2 (IL–2). IL-2 promotes further T

cell proliferation to augment the immunogenic response to injury.

As PMN leukocytes begin to wane after 24-36 hours, circulating monocytes enter the

wound and mature into tissue macrophages. These cells debride the wound on the

microscopic level and produce a wide variety of important substances, such as IL-1

and basic fibroblast growth factor (bFGF). IL-1 stimulates the proliferation of

inflammatory cells and promotes angiogenesis through endothelial cell replication.

bFGF is a chemotactic and mitogenic factor for fibroblasts and endothelial cells.

Unlike PMNs, macrophage depletion severely impairs wound healing, as

debridement, fibroblast proliferation, and angiogenesis all diminish.

Toward the end of the inflammatory cycle, the evolving milieu of eicosanoids in the

wound interact with the cell types present, resulting in fibroblast synthesis of collagen

and ground substance (from increased ratio of PGF2α to PGE2). Additionally, the

macrophage-derived growth factors are now at optimal levels, strongly influencing

the influx of fibroblasts and then keratinocytes and endothelial cells into the wound.
As mononuclear cells continue to replace WBCs and macrophages, the proliferative

phase begins.

The proliferative phase

Two to three days after wounding, fibroblasts migrate inward from wound margins

over the fibrinous matrix established during the inflammatory phase. During the first

week, fibroblasts begin producing glycosaminoglycans and proteoglycans, the

ground substance for granulation tissue, as well as collagen, in response to

macrophage-synthesized bFGF and TGF-ß, as well as PDGF.

Fibroblasts soon become the dominant cell type, peaking at 1-2 weeks. They

generate not only collagen molecules but also cytokines such as PDGF, TGF-ß ,

bFGF, keratinocyte growth factor, and insulinlike growth factor-1. Fibroblasts also

assemble collagen molecules into fibers, which are cross-linked and organized into

bundles. Collagen is the major component of acute wound connective tissue, with

net production continuing for the next 6 weeks. The increasing content of wound

collagen correlates with increasing tensile strength.  [5, 6] 

Keratinocytes and endothelial cells also proliferate during this time, eventually

producing autocrine growth factors that maintain their growth. Endothelial expansion

contributes to angiogenesis, as intact vessels generate buds in granulation tissue.

Neovascularization facilitates growth of the advancing line of fibroblasts into the

wound, providing them with necessary nutrients and cytokines.

Degradation of the fibrin clot and provisional matrix is accompanied by the deposition

of granulation tissue (ground substance, collagen, capillaries), which continues until

the wound is covered. Decreasing hyaluronic acid (in ground substance) levels and

increasing chondroitin sulfate levels slow fibroblast migration and proliferation while
inducing fibroblast differentiation, transitioning to the maturation phase of wound

healing.

The maturation phase

For the first 6 weeks, new collagen production dominates the wound healing

process, deposited randomly in acute wound granulation tissue. As the wound

matures, collagen is remodeled into a more organized structure with increased

tensile strength. Gradually, type I collagen replaces type III until the normal skin ratio

of 4:1 is achieved. As remodeling continues, matrix metalloproteinase collagenolysis

achieves a steady state with collagen synthesis. Tensile strength plateaus at 80% of

the original strength approximately 1 year postinjury.  [7, 8, 9] 

Superficial to this activity, epithelial cells continue to migrate inward from the wound

edge until the defect is covered. At this point, contact inhibition induces

transformation of fibroblasts into myofibroblasts, which contain contractile actin

fibers. Wound contraction follows, replacing injured tissue volume with new tissue,

although the exact role of the myofibroblast has not been fully elucidated.  [4]

Deterrents to wound healing

Acute wounds generally proceed through an orderly and timely reparative process

that results in a durable restoration of anatomic and functional integrity. However,

various physiologic and mechanical factors may impair the healing response,

resulting in a chronic wound that fails to proceed through the usual stepwise

progression. Local infection, hypoxia, trauma, foreign bodies, or systemic problems

such as diabetes mellitus, malnutrition, immunodeficiency, or medications are most

frequently responsible.
All wounds are contaminated, but most successfully resist invasive infection. When

the concentration exceeds 100,000 (105) organisms per gram of tissue or the

immune system becomes compromised, infection frequently ensues.  [10] Cellulitis

prolongs the inflammatory phase by maintaining high levels of proinflammatory

cytokines and tissue proteases, which degrade granulation tissue and tissue growth

factors, and by delaying collagen deposition.  [11, 12] 

Debridement (surgical, enzymatic, and/or by dressing changes) and antibiotics are

the mainstays of antibiotic treatment. Debridement removes devitalized tissue, which

can be a source of endotoxins that inhibit fibroblast and keratinocyte migration into

the wound. Foreign bodies may also require removal, as the presence of a silk

suture reduces the number of bacteria required to incite infection 10,000-fold.  [12] (For

a detailed description of technique, see Medscape Reference article Wound Foreign

Body Removal.)

Cellular hypoxia retards wound healing through various means. Collagen fibril

crosslinking requires oxygen to hydroxylate proline and lysine and fails when tissue

pressure is below 40 mm Hg. [13] The bactericidal potency of leukocyte oxidative

phosphorylation also suffers in a hypoxic environment, reducing the threshold for

infection. Measures to improve oxygen delivery depend on the etiology. Tobacco

use, which causes vasoconstriction and increases platelet adherence, should be

stopped. Angioplasty or arterial bypass grafting may be required for peripheral

vascular disease. Adjunctive measures to improve systemic perfusion in cases of

cardiac failure may be indicated. Hematocrit value less than 15% should be treated

and euvolemia restored, as needed. Venous stasis or lymphatic insufficiency may be

improved with compressive garments.

Systemic disease can dramatically prolong or interrupt wound healing. Glycosylation

in diabetes mellitus impairs neutrophil and macrophage phagocytosis of bacteria,

prolonging the inflammatory phase. The proliferative phase is also protracted in the

same disease as erythrocytes become less pliable and less able to deliver oxygen to

the wound for tissue metabolism and collagen synthesis.  [14] 

In a multicenter study of 1000 patients with chronic leg ulcers, Jockenhöfer et al

found that comorbidities in these individuals included arterial hypertension (70.5%),

obesity (45.2%), non-insulin dependent diabetes (27.2%), dyslipidemia (24.4%), and

metabolic syndrome (18.4%). [15] 

Malnutrition results in diminished fibroblast proliferation, impaired neovascularization,

and decreased cellular and humoral immunity. Wounds exert heightened metabolic

demands, particularly within granulation tissue. Amino acids such as methionine,

proline, glycine, and lysine, are essential for normal cell function and the repair of

cutaneous wounds. Fatty acids are critical constituents of cell membranes and are

the substrate for the eicosanoids that mediate the inflammatory process. Essential

fatty acids linolenic and linoleic acid must be supplied in the diet, as the human body

is incapable of de novosynthesis of these molecules. [16] 

Adequate vitamins and minerals must be available for cell metabolism, acting as

cellular signals and cofactors. Vitamin C (ascorbic acid) and iron are required for the

hydroxylation of lysine and proline, which crosslink and stabilize the triple helix

structure of collagen; copper also plays an role in stabilizing collagen. Vitamin A

(retinoic acid) plays an important role in modulating collagen production and

degradation and is particularly important in epithelialization. A potent antioxidant,

vitamin E (alpha tocopherol) appears to accelerate dermal and bone healing in

animals, and supplementation may have a role in humans. Trace metal, particularly
zinc, deficiency is also associated with poor wound healing; this should be

replenished, as appropriate. [17] 

Ovid purportedly wrote, “medications sometimes heal, sometimes kill.” This is

certainly true regarding wound healing. Corticosteroids blunt the processes of the

entire inflammatory phase. Vitamin A (topically or 25,000 IU/d orally) mitigates the

detrimental healing effects of corticosteroids, but hepatotoxicity may result from

prolonged use (ie, >1 mo). Nonsteroidal antiinflammatory medications (NSAIDs) also

interfere with arachidonic acid metabolism and, therefore, wound healing.

Additionally, NSAIDs inhibit platelet function, one of the earliest processes in the

inflammatory phase. [18] 

A study by Sutcliffe et al suggested that upregulation of the gap junction protein

connexin is common to chronic wounds. Examining connexin in three types of

wounds—venous leg, diabetic foot, and pressure ulcers—the investigators found that

each type of wound displayed upregulation of epidermal connexin 43, connexin 26,

and connexin 30, as well as dermal connexin 43.  [19]