Nonhealing Wound: What to Do When Wounds Don’t Heal

A nonhealing wound isn’t just a nuisance. Research suggests that these affect the quality of life of almost 2.5% of the United States population. It’s not uncommon for patients struggling with non-healing wounds to face issues with mobility, ongoing pain, isolation, and anxiety. This healthcare dilemma undoubtedly poses significant economic, clinical, and even social challenges, especially among the growing aging population. 

America spends over $25 billion on treating wound-related complications, so their gravity shouldn’t be underemphasized. To shed a little more light on this, we’ll explore what non-healing wounds are, what causes them to fail to heal properly, and more. 

What Are Nonhealing Wounds? 

Also called “chronic wounds”, nonhealing wounds is one that doesn’t heal within the expected timeframe. Normally, wounds follow a specific, orderly repair sequence spanning about four to six weeks. 

As a wound care specialist, you expect the healing process to involve overlapping phases of almost instantaneous hemostasis, succeeded by inflammation, proliferation, and finally, the remodeling phase. When this typically linear sequence of events doesn’t happen, it can throw off your entire treatment plan. With chronic wounds, there is no defined timeframe for healing, and the different phases may occur randomly. In fact, some parts of the wound may be in entirely different stages at once. 

A Definition Dilemma 

Interestingly, many researchers find actually defining “what is a chronic wound” challenging. 

In one article, authors shared that examining the expected healing timeframe and creating guidance for nonhealing wounds based on that is artificial. They explained that a better, scientifically suitable definition isn’t yet available, though. 

At this time, coming up with an acceptable explanation is difficult because of how heterogeneous chronic wounds are as they relate to: 

• Etiology 
• Body location
• Size
• Pathogenesis
• Morbidity 
• Host factors
• Limb loss
• And many other variables 

The Different Types of Nonhealing Wounds

It’s important to recognize that all wounds have the potential to become non-healing ones. The different types of chronic wounds are organized by etiology into four categories:

• Venous ulcers 
• Diabetic foot ulcers
• Pressure ulcers
• Arterial insufficiency ulcers 

We’ll dive into each one in a bit more detail below. 

Venous Ulcers

Considered the most common nonhealing wound, venous leg ulcers are believed to appear in between 1.5 and 3 per 1000 individuals. These wounds are characterized as shallow, having no eschar, and being situated in the medial aspect of the lower extremity. It’s believed that venous ulcers are caused by incompetent perforator veins, meaning the veins between the deep and superficial venous systems don’t function properly, so patients may experience venous hypertension or abnormally high pressure in the legs as a result. 

Interestingly, patients don’t usually report this type of chronic wound as painful unless it’s near or over the malleoli (bony protrusions located on each side of the ankle) or nerve-rich periosteum (a fibrous sheath that covers bones). The likelihood of developing a venous ulcer increases with age. 

Diabetic Foot Ulcers

The most studied chronic wound is the diabetic foot ulcer, likely due to diabetes being a significant public health concern. A diabetic foot ulcer is seen as a common complication of the disease, leading to potential lower extremity amputation and even death. In fact, a person with diabetes and a diabetic foot ulcer is over 10 times more likely to have a lower extremity amputation than someone with diabetes without a diabetic foot ulcer. Even more alarming is that these ulcers have a 5-year mortality rate that’s comparable to cancer, 30.5% and 31%, respectively. 

This type of non-healing wound is often located on the toes and soles of feet, is associated with excessive callus formation, and is superficial to deep. Most diabetic foot ulcers are caused by sensory neuropathy, where minor trauma from pressure, mechanical, or thermal injury has occurred, but the patient is unaware of it. 

Pressure Injuries

Pressure injuries are often seen in bedridden patients and have a prevalence rate of 3% to 31% in long-term care facilities. They’re very expensive to treat, costing $20,900 to $151,700 per ulcer. Although pressure injuries are preventable, poor treatment can make them lethal. 

This non-healing wound is often found on the hips and sacral areas, appearing over bony prominences. It may be superficial or deep and is caused by the inability to move, pressure, and/or friction. The likelihood of developing a pressure injury advances with age. It is most often caused by malnutrition, a lack of moisture, or improper blood flow to the skin.  

Arterial Insufficiency Ulcers

Arterial ulcers are a symptom of conditions like peripheral artery disease, which occurs when fatty deposits build up in the arteries (e.g., atherosclerosis). Research shows that they make up approximately 5 to 20% of all non-healing lower extremity ulcers and are less common than venous ulcers. 

Arterial ulcers are usually found on the ankles and toes. While they appear smaller than venous ulcers, they’re generally deeper, reaching the muscle, tendons, or bone. They may have a punched-out appearance and a wound bed that exposes black, necrotic tissue. The skin around them even suffers, revealing a loss of hair and atrophy. The ulcer may look pale and be without peripheral arterial pulses, making it considerably more difficult to heal. Without prompt and proper treatment, a patient may lose a limb. 

What Causes Wounds Not to Heal? 

When wound healing is compromised, several factors are typically involved because so many steps contribute to the process. In explaining the different types of non-healing wounds above, we mentioned how mechanical impacts and vascular deficiencies bring some on. However, let’s examine what may be causing this. 

Some of the most common factors of non-healing wounds are: 

• Immunosuppression 
• Infection
• Ischemic conditions
• Metabolic conditions 
• Radiation 

We’ll expand on each of those below. 

Immunosuppression

It’s understood that a weakened immune system isn’t the best environment for a wound of any kind. Yet, sometimes, medications are prescribed to do just that, particularly when someone has an overactive immune system. 

Corticosteroids, for example, aid with inflammation and pain. However, evidence from human and animal studies reveals that they disrupt nearly all steps involved in healing. Consider what corticosteroids do in each of the wound-healing stages.

• Inflammatory phase: Corticosteroids reduce cytokine expression, a small protein that recruits inflammatory cells. They also decrease the expression of adhesion molecules. Their role is to support the migration and sticking of white blood cells, known as granulocytes, to clear bacteria and debris. 
• Proliferative phase: Corticosteroids cause the levels of transforming growth factor-β and keratinocyte growth factor to decline, impairing fibroblast proliferation and wound epithelization. 
• Remodeling phase: Steroid hormones impede collagen accumulation and turnover, which is crucial because collagen is necessary for maintaining the strength, structure, and elasticity of the skin. 

Chemotherapy drugs can also compromise healing. Let’s quickly consider those that target the epidermal growth factor receptor (EGFR), a protein that plays a role in cell signaling pathways that direct cell division and survival.  The introduction of chemotherapy drugs inhibits the forming of epithelium over a wound area, also known as epithelialization. A wound cannot be deemed completely healed if epithelialization hasn’t happened, leaving cancer patients and others taking immunosuppressant drugs at a higher risk of developing nonhealing wounds. 

Infection

The presence of infection affects the repair mechanisms needed for skin integrity and the skin’s protective barrier. While many bacteria already inhabit the skin’s surface, some are harmful, especially if the body can’t properly manage them. 

A local infection could end up: 

• Causing cell death, triggering a local inflammation response and an extended acute inflammatory phase. 
• Impacting nutrient delivery.
• Decreasing collagen production during the proliferation and remodeling phases.

Without proper treatment, these infections can spread to muscles, organs, and more, causing fever, septic shock, or even death. 

Ischemic Conditions

Ischemia occurs when a part of the body doesn’t receive enough blood. As we mentioned earlier, this condition can cause arterial, pressure, and venous ulcers.  

Here’s a deeper dive into what occurs with these types of non-healing wounds. 

Arterial Ulcers

With arterial ulcers, the metabolic demands to preserve intact skin are greater than the metabolic requirements to heal a wound. There’s diminished blood flow to the tissues, causing a reduction in nutrition and oxygen delivery to the wound. It’s even challenging for metabolic waste products to be removed from the wound bed in this environment. Therefore, even an abrasion from improper-fitting shoes could cause a chronic injury. 

Venous Ulcers

Remember we mentioned venous hypertension earlier? Well, when this happens, the blood movement within the capillaries slows, and leukocytes and erythrocytes become isolated within them. This, in turn, increases pressure and causes a capillary leak. Following that, a collection of fibrin forms from the fibrinogen leaking from the capillaries of the dermis. The fibrin cuff, along with tissue swelling, leads to tissue hypoxia. 

The leukocytes stuck inside of the capillaries then attach themselves to the endothelium, causing: 

• Endothelial damage.
• Capillary elimination.
• Tissue ischemia.

Inevitably, the wound can’t properly heal and a venous ulcer forms. 

Pressure Injuries

If a patient experiences pressure on their skin that’s greater than arteriolar pressure, the delivery of nutrients and oxygen to the tissue is stalled. With a lack of oxygen in the tissue, free radicals and waste products begin to accrue.  This can occur within as little as one to four hours of continuous pressure. 

Metabolic Conditions

Disorders like diabetes and malnutrition negatively impact the body’s ability to process and utilize energy. In cases of malnutrition, specifically, the following may occur a wound may have a prolonged inflammatory phase, as the necessary fatty acids aren’t available to provide the arachidonic acid substrate for regulating inflammation and tissue repair. The lack of proteins may also decrease the proliferation of fibroblasts and collagen deposition. 

Radiation 

Ionized radiation used to treat cancer may impede wound healing by causing cellular damage. It obliterates the double-stranded cellular DNA and releases free radicals, ultimately leading to cell death and tissue necrosis. 

How Should You Treat Nonhealing Wounds? 

According to one study, the management of chronic wounds has dramatically improved, mainly due to significant leaps in understanding the mechanisms behind wound healing, recent technological breakthroughs, and reliable clinical research. 

Today, there are some go-to therapies for treating certain types of chronic wounds. Consider the standard treatment options below if you see them in your practice. 

Treatment for Venous Ulcers

Part of healing a venous ulcer is reducing the patient’s venous pressure. Exercise can help with this. Hydrogel dressings might also be used to absorb fluid from venous ulcers. These dressings have a cooling effect and encourage the body to use its own enzymes to remove dead tissue. 

Other therapies to keep in mind include: 

• Compression
• Elevate foot above heart level while at rest 
• Promote walking, as it encourages calf muscle pump
• Vascular reconstruction 
• Skin grafting/flap surgery 
• Endovascular stenting 
• Immunosuppressive drugs 
• Superficial vein ablation 
• Topical or systemic steroids 

Treatment for Diabetic Foot Ulcers

First, you’ll want to get control of the patient’s blood glucose levels. In addition, research suggests that bioactive dressings are a good option for repairing diabetic wounds. In a study on diabetic foot ulcers, wound dressings with polydeoxyribonucleotide were evaluated, and patients experienced decreased inflammation, better tissue oxygenation, and improved angiogenesis. 

You may also consider: 

• Padding and protection 
• Antibiotics
• Off-loading device
• Debridement of thick callus
• Amputation 
• Metabolic control 
• Vascular/endovascular intervention

Treatment for Pressure Injuries

It’s understood that some level of force causes pressure injuries, so the first step is to address what may be causing them. Pressure redistribution and adjustments to support surfaces are crucial. Hydrocolloid dressings, which lower the pH environment and inhibit bacterial growth, may be used for pressure injuries. 

Wound care specialists can also consider doing one or more of the following: 

• Incontinence management
• Repositioning schedule – ideally every two hours 
• Nutritional assistance
• Encourage mobility – consider physical therapy 
• Surgery
• Pressure relieving mattress 
• Consider home and wheelchair adaptions 

Treatment for Arterial Ulcers

This chronic wound requires treating the underlying cause of poor blood flow first. As a result, a surgeon might perform a vascular bypass, stent, or dilation to improve the blood supply to the area. In some cases, hydrogel dressings might be used to help prevent tissue desiccation and reduce pain. 

Following that, it may make sense to try one or more of the following treatments: 

• Hyperbaric oxygen 
• Tissue debridement
• Topical agents 
• Vacuum therapy
• Skin grafting 

Nonhealing Wound Treatment Strategies Revealed

Non-healing wounds can be devastating and significantly affect a patient’s quality of life. Thankfully, there are approaches wound care clinicians can take to prevent and treat them. With technological advances and evolving best practices, we hope to see a future where unhealed wounds are less common and patients have better outcomes.