Fact Sheet: Treatment for chronic non-healing wounds

It is easy to hurt yourself in daily life, but most small wounds can heal by themselves. However, if you cut yourself in the finger with a sharp knife when cooking, or injure yourself more seriously, a plaster might not be enough any more. Some larger wounds need help to close, either with special bandages or suturing. They will still usually heal within weeks.

But some wounds, like bed sores, leg ulcers, or wounds after cancer treatment, can take months or even longer to heal, or don't heal at all. Sometimes wounds break open again. Wounds that do not heal normally are called chronic wounds. Treatment of chronic wounds can take a long time and can be very painful. There are many options, though, to try to help wounds heal and to relieve the pain they cause.

How do wounds heal normally?

Wound healing involves several steps. After an injury the body increases the blood flow to the area that has been wounded. The wound therefore becomes red and warm. Increased blood flow is vital for wound healing as this is how white blood cells (leucocytes) and platelets (thrombocytes) reach the wound. White blood cells help fight off the infection that can start easily in wounds. Platelets activate blood clotting (coagulation). Phagocytes (cells that "eat" dead cells and germs) also travel to the wound in the bloodstream. The blood also brings other substances needed for wound healing such as oxygen and nutrients. After that, cells are produced that form new skin and underlying skin tissue, as well as new blood vessels. Tissue fibres (collagen) and small muscle cells are also produced. This stabilizes the wound, and it helps the edges join together so the wound closes. Depending on how deep the wound is, it heals with or without a scar.

Why do some wounds take so long to heal?

There are many reasons why a wound may heal poorly. Infection can slow down healing and make the wound worse. Bed sores or pressure ulcers can also heal poorly because of continuing pressure on them in people who have to lie in bed. These areas of the body have to be relieved from pressure to help the wound heal.

Poor blood flow to the wound makes it heal poorly. In people with a circulation problem, not enough blood flows to their legs and feet. Therefore, wounds on this part of the body heal especially poorly.
People with narrowing of the blood vessels that transport oxygen (arteries) or chronic venous insufficiency of the leg veins are more likely to suffer from chronic wounds, especially leg and foot ulcers. These ulcers are one of the most painful and slow-healing types of wounds. People with diabetes might not experience the burning pain from these ulcers if they have developed nerve damage (diabetic neuropathy). This is especially dangerous, as they might not realise that an open wound has developed or has become worse.

Not only diabetes, but other chronic diseases like cancer can also make it slower for wounds to heal. Immune suppression, either because of illness or long-term use of some drugs, can also make wounds heal poorly and increase the risk of infection.

It is also harder for the skin to heal as people get older, or when they are not well-nourished. We do not know if a special type of diet or food supplements lead to faster wound healing, but a healthy diet and appropriate treatment of the underlying diseases are essential factors in wound healing.

What are the treatment options if a wound does not heal?

First, the wound is cleaned thoroughly. Sometimes dead cells or inflamed tissue have to be removed (debridement). This can be done with substances such as hydrogen peroxide (a disinfectant) or gel containing enzymes. The removal of dead tissue with a scalpel, spoon, or other instrument is called surgical debridement. The cleaning of a wound with a high-pressure water jet is called mechanical debridement. Debridement is often painful. A local anaesthetic can help ease the pain. Debridement of large wounds is often performed under general anaesthetic.

After cleaning the wound, a dressing is applied. There are various types of dressings, such as foils, and hydrogel or hydrocolloid dressings. The dressings are supposed to keep the wound moist, remove excess wound fluid, and protect the wound from infection. So far, few trials have investigated which type of dressing is best. Wound treatments with growth factors and hormones are also being tested. Some infected wounds are treated with antibiotics.

Some hospitals use technical devices to improve wound healing. These include lasers, hyperbaric oxygen therapy (an oxygen chamber), and vacuum therapy for wounds, which is also called vacuum-assisted wound closure or negative pressure wound therapy. Whether these techniques improve wound healing is not yet known. We will publish research results on treatments for wounds on Informed Health Online in future. Scientists are currently testing growth factors, which are supposed to promote the growth of new tissue.

Some wounds are so large that they cannot heal by themselves. In this case, skin is transplanted from another part of the body (often the thigh) onto the wound, so that it can be closed.

Complicated, poorly healing wounds require close cooperation in a treatment team, and psychological as well as medical aspects have to be considered. Every painful wound requires appropriate pain relief.

What are the pain relief options for chronic wounds?

The pain that chronic wounds cause is often under-estimated by people who have not experienced it. It can make daily life and sleeping difficult, and it can be depressing. Analgesics like paracetamol can help ease the pain. If these are not enough, a doctor could prescribe stronger pain relief that might be able to help better. It is especially important for people with chronic wounds, who are often in pain, to let their doctor and others know if they are suffering pain. In addition, friends and relatives can help by providing sympathy and support.