Chelsea Law, a podiatrist at Alexandra Hospital, expounds on the management and treatments of diabetic ulcerations and how not to wind up with those painful sores.

Wound care has been the centre of medicine for most civilisations ever since the first written documents were discovered. Early records by the Edwin Smith Papyrus and Ebers Papyrus, which date as far back as 3000 B.C. contain scribes of internal medicine and also evidences of early wound interventions — using raw meats to stop bleeding after surgery, using honey to absorb excess fluid discharge from wounds and applying mouldy bread to wounds as early forms of antibiosis.
 

DIABETIC ULCERATIONS

Diabetic ulcerations account for one of the highest causes of non-traumatic amputations in many countries. They have posed numerous challenges to professionals due to the many possible complications that arise from poor control of diabetes mellitus, namely peripheral neuropathy and vascular diseases.

Poor vascular supply to the lower limb as a result of atherosclerosis predisposes diabetics to ulceration as well as poor healing potential of existing ulcers.

Another element contributing to the vasculopathy is due to microvascular changes, which is unique to only diabetics. Microangiopathy at the arteriolar and capillary level impairs migration of leukocytes across the vessel walls and the flow of blood within the capillaries. As a result of the above, lack of oxygen, nutrients and other essential components for wound healing are absent and thus, the process is interrupted.

In addition, poor neurogenic inflammatory response will impair the inflammation usually obvious in acute wounds. A change in the foot shape and structure as well as atrophy of the intrinsic muscles of the foot will predispose certain areas of the foot to ulceration due to increased pressure.

Other systemic factors that can also have an impact on wound healing include presence of co-morbidities, anaemia, malnutrition, age, etc.
 

TYPES OF WOUNDS

Wound healing involves a complex pathway that involves many overlapping processes. Wounds can also be classified into acute and chronic wounds where most diabetic wounds fall into the latter category.

Both acute and chronic wounds can start with an injury resulting from chemical, mechanical, surgical or radiation harm to the skin and supporting structures. Loss of integrity and function of the skin usually would trigger a reparative process. However, in chronic wounds the reparative process is interrupted by high levels of inflammatory processes and reduced growth factors activities.
 

THE HEALING PROCESS

The risks of prolonged ulcerations can result in limb and life-threatening infections. It therefore essential to maximise the potential for the ulcers to heal and obtain the fastest wound closure with proper cleansing, dressing and offloading techniques.

A wound can heal either by first or second intention. Wounds heal by first intention when the wound edges are in close proximity and second intention when wound edges are not in close proximity.

In comparison, wounds healing by second intention tend to be larger, and heal more slowly. In these wounds, wound healing occurs by formation of granulation tissue from the base of the wound bed until the level where more superficial epidermis then migrate across the wound diameter close the defect. Second intention wound healing usually leads to the formation of scar tissue in the last stage. These processes can be summarised into three phases: proliferative, inflammatory and maturation.
 

TYPES OF DRESSING

At different stages of wound healing, the healthcare professional may prescribe different wound dressings to enhance progression to the next stage. For example, foam dressings may be used on a wound, which is exuding heavily to ensure the wound bed humidity is optimal. A hydrocolloid wafer may be used on an epitheliasing wound to reduce the need for dressing change and to maintain moist wound healing environment.
 

Modern dressings range from non-adherent paraffin impregnated gauzes, alginates, hydrocolloids, hydrogels, hydroactive to foam dressings. Constant researches in enhancing wound healing have also led to the discovery of dressings with antimicrobial properties such as iodine and silver dressings.

Further advances also include modalities such as hyperbaric oxygen, subatmospheric wound dressing technique, use of growth factors, skin substitutes, etc, to enhance the rate of wound healing.
 

PROPER CLEANSING

Wound care usually starts off with proper wound cleansing. They should always be done with a non-toxic solution at our body temperature to prevent trauma to the wound bed (e.g. saline, 0.9% sodium chloride). Gentle circular motion with saline-soaked cotton balls will allow removal of any debris in the wound bed and prepare it for granulation tissue to fill the space. Care must be taken to ensure no fibres are left behind after cleansing as these may prolong the inflammatory phase of wound healing.

Thereafter, appropriate dressings should be applied to the wound and changed according to the condition of the wounds. It is best to change infected wounds daily in order to monitor for signs of deterioration or improvements.

Certain dressings are manufactured to remain in situ for up to seven days. Frequent removal of wound dressings is not recommended as it may damage the fragile granulation or epitheliasation tissue during removal as well as decrease the temperature at the wound site. It may take up to ten minutes after exposing the wound to return it to body temperature, which is the optimal temperature for wound healing to occur.

Constant pressure in the peri-wound areas and directly on the wounds will impair wound healing. Consequently, proper pressure-relief should be adopted to reduce any possible pressure on the wounds, especially when the wounds are on weight-bearing areas, such as soles of the foot. These include casts, special shoes, insoles and walking aids.

CONCLUSION

In summary, wound healing is a complex process and requires a professional who has adequate knowledge to manage it. Simple wound care can be applied at home by following three basic steps:

1. Cleansing the wound with saline-soaked cotton balls
2. Drying the wound
3. Covering wound with sterile gauze or plaster

Always remember to seek medical attention for wounds that appear to be infected (warm surrounding tissue, redness, presence of pain, presence of pus or foul smelling discharge).

 3 'THOU SHALL NOTS':

1. Opening up wounds to expose in order to dry out the wound –This will allow the wound bed to dry out with an overlying scab. However, the underlying tissue may not be healed properly.
 

2. Self-application of traditional medication or coloured ointment on wounds – Previous improper storage of ointment may contaminate them and thus, introduce harmful substances into the wounds. Coloured ointment may mask the presence of pus and redness of tissue, which may indicate infections.
 

3. Self-trimming of the wound bed – Instruments used may not be sterile and may result in trauma to the wound bed.

DRESSING CODE

In 1989, Turner described a list of criteria that proper wound dressings should have. They:
 

1. Should allow gaseous exchange between the wound bed, wound dressing and the surrounding environment.
 

2. Should be able to remove excess exudates and toxic components from the wound bed.
 

3. Should be able to maintain a moist environment between the wound and dressing.
 

4. Should be able to provide sufficient thermal insulation.
 

5. Should be able to protect the wound from external infectious materials.
 

6. Should be free from toxic contaminants or particulate that may be retained after removal of dressing.
 

7. Should allow for removal without trauma to the wound bed.

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