Health Matters: Many causes for chronic wounds

Dec 06, 2023

Aug 29, 2023

Conway McLean, DPM, Journal columnist

Chronic wounds are a tremendous problem in our society, costing our healthcare system the unbelievable sum of about 50 billion dollars a year (yes, you read that correctly). They are also a fascinating topic; how do they occur and why. These have been the subject of intense scrutiny in the last decade or two, as the incidence of diabetes has skyrocketed, and the population aged.

A chronic wound is an opening in our skin which isn’t healing appropriately. Typically, in a healthy individual, some type of skin injury will proceed through the well-studied stages of healing. When it doesn’t follow that timeline, when healing is delayed or stops, there must be a reason. This is the detective work that is part of wound care. Our treatments for these lesions get better results when we know why the wound has stalled.

Make no mistake about it: this is a significant problem with approximately 6.5 million Americans afflicted with a chronic wound. As a science, this component of modern medicine has changed radically over the last few decades. The number of studies on the topic have exploded, as has the variety of technologies, treatments, and products available. Keeping abreast of all of the options takes real dedication, but results in improved healing rates.

Significant advances have been made on all counts: our understanding of the mechanisms for the delay, means by which we can improve them, how to encourage healing. When one of these wounds won’t heal, removing the entire body part is routinely recommended. Saving a limb for which amputation has been recommended is a tremendously gratifying part of the practice of wound care.

With the number of people dealing with a chronic wound of one sort or another, these are significant problems, causing pain, complications, and reduced quality of life. This is clearly reflected in the dollars required for care. Unfortunately, when the medical care provided is less than optimal, these defects in our skin do not heal and problems develop, with amputation being not the worst. When someone with diabetes suffers an amp of a foot or leg, they usually don’t survive more than 3 years. It turns out an amputation is an independent risk factor for mortality.

Identifying the reason a skin injury isn’t healing properly allows us to direct our therapies toward the specific cause of the delay (aka the etiology). One obvious means of identification is location: where on the body is the ulcer found. Statistically, the most common location for a chronic wound is the lower leg, above the ankle. When a non-healing defect is found in this area, typically it is due to a vein problem. The material that makes blood red will leak out of the veins if allowed to idle inside these vessels, instead of continuing its journey back to the heart.

Those afflicted with vein disease often note a brownish discoloration developing in the region of the shins. This may be the first sign of vein disease and begins a gradual poisoning of the skin. The material doing the staining works as it should when inside our red blood cells, but it has a certain toxicity if it builds up in the integument, our outermost layer. Any physical trauma to diseased skin such as this will heal poorly if at all. If sufficiently advanced, an opening may occur without any injury at all.

Another very common type of non-healing skin ulcer is associated with a loss of functioning skin nerves, as is seen with neuropathy (especially with diabetes). Many of those with this common nerve condition are unable to feel pain properly. Chronic pressure to some area, like a bent toe or prominent bone, can reduce the blood flow to the skin and result in skin death, i.e. an open ulcer. In those with proper sensation, the pain from the pressure and the subsequent changes, is significant. The sufferer will make some change to alter this pain, be it shoe removal, padding of the bump, hopping if necessary. Those with impaired sensory nerve function never receive the message that a problem is transpiring. Pain is a great motivator.

Due to the many recognized diseases which produce clogging of our arteries, ulcers that won’t heal because of inadequate blood supply are too common. Arterial disease, for most people, is a gradual process: the skin and soft tissues are already unhealthy from years of deprivation. Healing this type of ulcer requires a restoration of blood supply, often necessitating a surgical procedure. Without improved flow, no medicine, no high tech graft or therapy, will lead to healing. As the saying in wound care goes: “we are held hostage by the blood flow.”

Numerous additional reasons exist for a skin wound that won’t heal besides those mentioned. Many wounds have several causes requiring a different approach. Infection is rarely a cause of an ulcer but is a very common development once an ulcer occurs. The skin provides us with tremendous protection against bacterial invasion, but once an opening is present, bacteria can easily enter the soft tissues of the ulcer. And a malignancy of the skin throws an additional ‘monkey wrench’ into the equation.

Various healthcare providers practice wound care, to some degree or other. How knowledgeable are they about the latest advances, the newest products or procedures? These are important questions, and the answers will vary greatly. Because most ulcers occur below the knee, they lie within the auspices of many podiatric physicians. But determining why some opening in the skin isn’t healing is a vitally important part of the process that is modern, effective wound care. If you or a loved one has a wound of some type and it isn’t closing, don’t delay. The longer the root of the problem goes untreated, the greater the risk of dire complications. See a physician specializing in wounds for that body part for the best chance of healing.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at [email protected].

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