• linkedin
  • Increase Font
  • Sharebar

    Critical factors in healing acute wounds

    Base decisions on well-done clinical trials to provide best patient care

     

    Stress matters

    Stress impedes wound healing by as much as 40%, according Dr. Kirsner.

    “The mechanism is pretty well worked out. A physiologic or psychologic stressor causes the pituitary gland to release adrenocorticotropic hormone, which stimulates the adrenal gland to release steroids and catecholamines. Specifically, with regard to steroids, this causes a reduction in the number of circulating inflammatory cells and production of pro-healing cytokines,” Dr. Kirsner says.

    The clinician, therefore, should aim to create a stress-free environment for patients with wounds, according to Dr. Kirsner.

    “If somebody is really stressed or is having a stressful event in their lives and is having an elective procedure, perhaps postpone the procedure until the stress has passed,” he says. “Importantly, pain can induce stress, so just by reducing pain during surgery and postoperatively, we may speed wound healing.”

    Smoking matters

    Dermatologists should encourage patients to stop smoking a month or more before surgery to improve wound healing.

    Some say the damages from smoking can’t be reversed, but study results disagree, according to Dr. Kirsner.

    “It turns out, there’s a fair bit of data that suggests smoking causes problematic healing, not only in the skin but in the bones and in the cornea. And if a person stops smoking for about a month, that will restore some of their inflammatory cellular function, reducing risk of infection. So, even stopping smoking for a relatively short time before surgery can be beneficial,” Dr. Kirsner says.

    Pretreating with tretinoin matters (and hair reduction might matter)

    Data going back three decades suggests that by applying topical tretinoin nightly for a month prior to surgery, patients’ wounds heal faster, compared to placebo cream. Dermatologists should consider the approach when doing different types of wounding procedures, like chemical peels and dermabrasion, according to Dr. Kirsner.

    “Experimentally, people have been doing other things to speed healing prior to creating a wound. They’ve plucked or shaved the hair to stimulate follicular stem cells. They’ve waxed the hair. And at least in animal models, this seems to speed healing,” he says.

    Age matters

    Age matters, as does preparing patients for age-related wound healing challenges.

    “All patients heal differently,” Dr. Kirsner says. “Young patients heal faster, but they scar more. Older people heal more slowly but scar less.”

    The culprit seems to be estrogen, in men and women. Researchers have shown that by giving an elderly patient hormone replacement therapy, one can shift the patient from an older person’s healing phenotype (slow healing with less scarring), to a younger person’s healing phenotype (faster healing, more scarring), he says.

    “The most important tip there is to understand expectations and, in theory, if you really were interested in the cosmetic effect on the patient, perhaps, if they were on hormone replacement, you might want to stop it during the procedure. If you’re worried about slow healing in a patient, you may want to add hormone replacement therapy. But that’s experimental,” Dr. Kirsner says.

    One caveat: Estrogen’s effect may depend on the type of wound.

    “We do know the deeper wounds scar more, so, maybe, the estrogen has a more profound effect on the fibroblasts deep in the dermis, as opposed to superficially,” he says.

    Suture type matters

    The type of sutures dermatologists use could impact patients’ wound healing.

    Sutures coated with antiseptic seem to reduce infection, at least in the oral mucosa. They also reduce bacterial counts and pain, according to the dermatologist. Some studies suggest sutures made from novel materials, such as chiton, may accelerate wound healing.

    Occlusion matters

    Covering a wound with an occlusive dressing speeds wound healing, especially for partial thickness wounds. Other benefits of occlusive dressing are improved cosmetic results and less pain. Studies have not shown an increased infection risk with occlusion, according to Dr. Kirsner.

    The benefits of using an occlusive dressing on wounds versus no occlusive dressing seems to be mediated through downregulation of inflammatory cytokines and certain keratin proteins, he says.

    Postop wound tension matters

    Researchers at Stanford developed a dressing, called Embrace (Neodyne Sciences), which reduces the tension—the pulling forces away from the wound.

    “Normally, when you suture a wound together, there are forces that pull it together that make the scar wider. This is a special dressing that prevents that pulling of the wound …” Dr. Kirsner says. “They studied it in animal models and in human models with abdominoplasty and breast scar reduction—all finding that if you use this dressing you have less wide scars and more cosmetically acceptable scars.”

    Some have tried using Botox [Allergan] to reduce tension across the wound, he says.

    “There are some animal models to suggest Botox can improve the scars by reducing wound tension,” Dr. Kirsner says.

    Next: These factors DO NOT matter

    Lisette Hilton
    Lisette Hilton is president of Words Come Alive, based in Boca Raton, Florida.

    0 Comments

    You must be signed in to leave a comment. Registering is fast and free!

    All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

    • No comments available

    Latest Tweets Follow