When Wounds Stall: Key Considerations To Jump-Start Healing
What steps can one take to treat a wound that has not responded after a certain period of treatment? Our expert panelists discuss guidelines for assessing the efficacy of standard therapy, keys to addressing nutrition deficiencies and considerations for modifying the treatment regimen.
Q: What is the timeline to modify the wound treatment when the wound is not healing as you hoped?
A: All three panelists cite Sheehan’s study of diabetic foot wounds. The study notes that if the size of a wound does not decrease by 50 percent in four weeks, the wound has a 91 percent chance of not healing in 12 weeks.1
Lee C. Rogers, DPM, will attempt standard wound care for four weeks. He says standard care includes ruling out infection and vascular complications, ensuring proper offloading, performing weekly debridements and facilitating a moist healing environment. Dr. Rogers will change the treatment plan if the wound does not decrease by 50 percent in four weeks.
Similarly, if Kazu Suzuki, DPM, CWS, does not see robust healing in three to four weeks, he will rethink his diagnosis and revise the patient’s treatment if necessary. At that point, he also considers advanced modalities such as negative pressure wound therapy (NPWT), skin substitutes and hyperbaric oxygen therapy.
If Dr. Rogers is in the midst of utilizing an advanced therapy like Dermagraft (Advanced Biohealing) and the wound “stalls,” he will stop Dermagraft, perform further debridement of the wound and then resume the interrupted therapy.
Guy Pupp, DPM, has been using the four-week timeline for years. In addition to Sheehan’s study, he cites a meta-analysis by Margolis and colleagues, who evaluated the rate of neuropathic ulcer healing in 10 control groups from clinical trials.2 Dr. Pupp also notes that the American Diabetes Association has concurred that a wound which remains unhealed after four weeks of standard treatment is a cause for concern due to the potential for worse outcomes.3
Q: Do you prescribe any nutritional supplements for wound healing?
A: Dr. Pupp believes patients with poor dietary habits, diabetes, infections and those undergoing dialysis should take nutritional supplements. A patient suffering from poor nutritional status will have a serum albumin below 3 g/dL, a total lymphocyte count below 1,500 cells per mm3 and poor dietary intake, according to Dr. Pupp. Drs. Suzuki and Rogers also advocate checking albumin, pre-albumin and lymphocyte counts.
As far as supplements go, Dr. Pupp notes that Metanx (PamLab) is formally indicated for the nutritional requirements of patients with endothelial dysfunction and/or hyperhomocysteinemia who present with lower extremity ulcerations. Dr. Pupp says physicians can also prescribe Metanx in order to address nutritional issues in patients with endothelial dysfunction who present with loss of protective sensation and neuropathic pain associated with diabetic peripheral neuropathy.
Furthermore, Dr. Pupp notes that deficiencies in arginine can cause poor wound healing. He says arginine triggers the body to make protein and also changes into nitric oxide, which causes blood vessels to dilate.
In regard to vitamins, Dr. Pupp says they can play a key role in facilitating wound healing.
Vitamin E preserves macrophages and polynuclear leukocytes, points out Dr. Pupp. If a vitamin E deficiency exists, Dr. Pupp says there may be impairment of wound healing. He says vitamin C is essential in the formation of collagen and notes that deficiencies can cause weakening and dehiscence of wounds. Dr. Pupp adds that Vitamin A is important for cellular differentiation and proliferation.
Vitamin D is necessary for strong bone healing and normal calcium metabolism, notes Dr. Pupp. He says vitamin B complex is a co-factor in many enzyme systems, collagen strength, protein synthesis and enhanced immune response. Iron is necessary for oxygen transport, collagen transport and is a constituent of hemoglobin, according to Dr. Pupp. He also notes that zinc assists with collagen synthesis, transport of vitamin A and enhancement of the immune response.