Cutaneous wound healing: Current concepts and advances in wound care

Abstract

A non-healing wound is defined as showing no measurable signs of healing for at least 30 consecutive treatments with standard wound care.[1] It is a snapshot of a patient's total health as well as the ongoing battle between noxious factors and the restoration of optimal macro and micro circulation, oxygenation and nutrition. In practice, standard therapies for non-healing cutaneous wounds include application of appropriate dressings, periodic debridement and eliminating causative factors.[2] The vast majority of wounds would heal by such approach with variable degrees of residual morbidity, disability and even mortality. Globally, beyond the above therapies, newer tools of healing are selectively accessible to caregivers, for various logistical or financial reasons. Our review will focus on the use of hyperbaric oxygen therapy (HBOT), as used at our institution (CAMC), and some other modalities that are relatively accessible to patients. HBOT is a relatively safe and technologically simpler way to deliver care worldwide. However, the expense for including HBOT as standard of care for recognized indications per UHMS(Undersea and Hyperbaric Medical Society) may vary widely from country to country and payment system.[3] In the USA, CMS (Centers for Medicare and Medicaid Services) approved indications for HBOT vary from that of the UHMS for logistical reasons.[1] We shall also briefly look into other newer therapies per current clinical usage and general acceptance by the medical community. Admittedly, there would be other novel tools with variable success in wound healing worldwide, but it would be difficult to include all in this treatise.

Keywords: Compartment syndrome; Diabetes; Mental Health; Obesity; TCOM; UHMS; Wound Healing; hyperbaric; oxygen.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1

Pathophysiology behind improved wound healing of hyperbaric oxygen therapy,[49] HBO2 reduce bubble volumes and elevate cellular pO2 leading to increased production of ROS (reactive oxygen species) and RNS (reactive nitrogen species). GFs (growth factors); VEGF (vascular endothelia growth factor); HIF-1 (hypoxia inducible factor-1); SPCs, (stem/progenitor cells); HO-1 (heme oxygenase-1), HSPs (heat shock proteins).

Figure 2a

This table shows numerous studies from 1987 to 2002 that show the benefit of hyperbaric oxygen therapy (HBOT). HBOT significantly increases the percentage of patients that will heal completely and minimizes the number of amputations relative to standard wound care alone[3]

Figure 2b

The diffusion gradients along the oxygen supply chain to the tissues of normal body at sea level. Modified with permission from Nuu's applied respiratory physiology[11] (Elsevier Publishing Inc.)

Figure 3

Crude and age-adjusted hospital discharge rates for nontraumatic lower extremity amputation per 1,000 diabetic population, United States, 1988-2009[38]

Figure 4

Summary of corporate data by diversified clinical services[48]

Figure 5

Otoscopic findings in middle ear barotrauma related to hyperbaric oxygen

Figure 6

Summary of recommended HBOT treatment protocol for varying indications (per UHMS) with some local modifications for logistical reasons recommended by Diversified Clinical Sciences[19]

Figure 7

Insulin accelerates wound healing and improves re-epithelialization. Excision wounds were performed in C57BL/6J mice, and the healing process was monitored at different time points. (a) Representative images of wounds which were treated with vehicle (30 μl saline solution) or 0.03 u insulin/30 μl saline solution every two days (b) Wound area was quantified every two days and expressed as the percentage of the original wound area (n = 9; Statistics are shown as comparisons between the treatment and control. *P < 0.05). Insulin significantly decreased wound area.[49] HBOT[17]