DELAYED HEALING

Vohra Wound Care Certif ication Course

Disclaimer:
This presentation is for informational purposes only. Every patient and medical situation is unique, and medical decisions should be
based on standard of care and medical practices. Views expressed in this presentation are the sole opinion of the presenter.

Learning Objectives
• Understand the process of wound healing
• List the local f actors that af f ect wound healing
• List the systemic f actors that af f ect wound healing
• Understand the importance of addressing f actors that delay healing

Normal Wound Healing

Normal wound healing takes place in f our phases, each with its own cellular respons e1,2
• Hemostasis
• Inf lammation
• Prolif eration
• Maturation
When the normal healing process is hindered or interrupted, a chronic wound may develop

Vascular constriction Neutrophils

Platelet aggregation Monocytes
Fibrin formation Macrophages

Collagen synthesis Collagen remodeling

Re-epithelialization Vascular maturation
Angiogenesis

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Delayed Healing Vohra Post-Acute Physicians
Factors that Affect Wound Healing 1
• Local f actors
o Oxygenation
o Inf ection
o Foreign bodies
o Venous insuf f iciency
o Edema
o Repeated trauma
• Systemic f actors
o Age and Gender
o Diabetes
o Medications
o Obesity
o Alcohol and Tobacco
o Poor Nutrition

Oxygenation
Tissue oxygenation plays a key role in normal wound healing. 3,4,5,6 Conversely, tissue hypoxia can severely impair
healing in various ways. 7

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Infection
• Inf ection impairs many components
of normal wound healing. 8
• Bacteria produce inf lammatory
mediators that interrupt the
inf lammatory phase of healing 8
• The inf lammatory response to
bacteria can create a local
environment that is hostile to
healthy tissue
• New tissue growth and
epithelialization cannot occur in the
presence of necrotic tissue8
• In some cases, delayed wound
healing may be the only sign of
wound inf ection

Bacterial wound infection also follows its own progression, if left untreated 9

Prevent or aggressively treat wound infection to allow normal wound healing to occur

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Age
• Several age-related changes af f ect wound healing, relative to younger individuals 10
o Increased platelet aggregation, inf lammation mediator secretion
o Delayed healing, macrophage and lymphocyte inf iltration, re-epithelialization, angiogenesis,
collagen deposition
o Decreased growth f actor secretion, collagen turnover and remodeling, wound strength
o Reduced macrophage capacity
• Fortunately, exercise may improve healing in the elderly

Gender
• Sex hormones decrease with age
• Studies show estrogen can improve age-related impaired healing in both sexes 11
• Malnourished and cachectic individuals may benef it f rom anabolic steroids (oxandrolone) 12,13

Diabetes
People with diabetes have various cellular and hormonal abnormalities that delay wound healing. 14,15

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Delayed Healing Vohra Post-Acute Physicians
Medications
Certain medications impair hemostasis, immune response to wounds, or both16,17
• Non-steroidal anti-inf lammatory drugs (NSAIDs)
• Chemotherapy agents
• Anticoagulants
• Glucocorticoid steroids

Nutrition

Adequate nutrition is essential f or normal wound healing .12,18,19

• Inf lammatory phase

o Vitamin A, C, K
o Iron, Zinc
o Protein
o Fat
o Carbohydrates
• Prolif erative phase
o Vitamin A, C
o Iron, Zinc, Manganese
o Protein
o Fat
o Carbohydrates
• Maturation/remodeling phase
o Vitamin A, C
o Zinc
o Protein

Recommended Reading

Bowler PG, Duerden BI, Armstrong DG. Wound Microbiology and Associated Approaches to Wound
Management. Clinical Microbiology Reviews. 2001;14(2):244-269. doi:10.1128/CMR.14.2.244-
269.2001

Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. May
2007;117(5):1219-1222. doi:10.1172/jci32169

Guo S, DiPietro LA. Factors Affecting Wound Healing. Journal of Dental Research. 2010;89(3):219-229.
doi:10.1177/0022034509359125

Reinke JM, Sorg H. Wound Repair and Regeneration. European Surgical Research. 2012;49(1):35-43.

References
1. Guo S, DiPietro LA. Factors Af f ecting Wound Healing. Journal of Dental Research. 2010;89(3):219-229.
doi:10.1177/0022034509359125
2. Reinke JM, Sorg H. Wound Repair and Regeneration. European Surgical Research. 2012;49(1):35-43.
3. Rodriguez PG, Felix FN, Woodley DT, Shim EK. The role of oxygen in wound healing: a review of the literature.
Dermatol Surg. Sep 2008;34(9):1159-1169. doi:10.1111/j.1524-4725.2008.34254.x
4. Johnson KE, Wilgus TA. Vascular Endothelial Growth Factor and Angiogenesis in the Regulation of Cutaneous
Wound Repair. Advances in Wound Care. 2014;3(10):647-661. doi:10.1089/wound.2013.0517
5. Castilla DM, Liu Z-J, Velazquez OC. Oxygen: Implications f or Wound Healing. Advances in Wound Care.
07/29/received 2012;1(6):225-230. doi:10.1089/wound.2011.0319
6. Hong WX, Hu MS, Esquivel M, et al. The Role of Hypoxia-Inducible Factor in Wound Healing. Advances in
Wound Care. 2014;3(5):390-399. doi:10.1089/wound.2013.0520
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7. Sano H, Ichioka S, Sekiya N. Inf luence of Oxygen on Wound Healing Dynamics: Assessment in a Novel Wound
Mouse Model under a Variable Oxygen Environment. PLOS ONE. 2012;7(11):e50212.
doi:10.1371/journal.pone.0050212
8. Bowler PG, Duerden BI, Armstrong DG. Wound Microbiology and Associated Approaches to Wound
Management. Clinical Microbiology Reviews. 2001;14(2):244-269. doi:10.1128/CMR.14.2.244-269.2001
9. Kingsley A. The wound inf ection continuum and its application to clinical practice. Ostomy Wound Manage. Jul
2003;49(7A Suppl):1-7.
10. Gosain A, DiPietro LA. Aging and wound healing. World J Surg. Mar 2004;28(3):321-326. doi:10.1007/s00268-
003-7397-6
11. Gilliver SC, Ashworth JJ, Ashcrof t GS. The hormonal regulation of cutaneous wound healing. Clin Dermatol. Jan-
Feb 2007;25(1):56-62. doi:10.1016/j.clindermatol.2006.09.012
12. Demling RH. Nutrition, Anabolism, and the Wound Healing Process: An Overview. Eplasty. 02/03 2009;9:e9.
13. Molnar JA, Underdown MJ, Clark WA. Nutrition and Chronic Wounds. Advances in Wound Care. 2014;3(11):663-
681. doi:10.1089/wound.2014.0530
14. Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. May
2007;117(5):1219-1222. doi:10.1172/jci32169
15. Huijberts MS, Schaper NC, Schalkwijk CG. Advanced glycation end products and diabetic f oot disease. Diabetes
Metab Res Rev. May-Jun 2008;24 Suppl 1:S19-24. doi:10.1002/dmrr.861
16. Erinjeri JP, Fong AJ, Kemeny NE, Brown KT, Getrajdman GI, Solomon SB. Timing of administration of
bevacizumab chemotherapy af f ects wound healing af ter chest wall port placement. Cancer. Mar 15
2011;117(6):1296-1301. doi:10.1002/cncr.25573
17. Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: clinical considerations in the
perioperative period. Am J Surg. Sep 2013;206(3):410-417. doi:10.1016/j.amjsurg.2012.11.018
18. Quain AM, Khardori NM. Nutrition in Wound Care Management: A Comprehensive Overview. Wounds. Dec
2015;27(12):327-335.
19. Arnold M, Barbul A. Nutrition and wound healing. Plast Reconstr Surg. Jun 2006;117(7 Suppl):42s-58s.
doi:10.1097/01.prs.0000225432.17501.6c

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