Skin conditions /wound healing

A.THANGAMANI RAMALINGAM PT, MSc(PSY),PGDRM, ACspss, MIAP

Wound

Wound• Tissue damage• Disruption of normal

continuity of structures.•  Loss of integrity

Wound healing• Restoration of

integrity

Wound healing/stages

• Tissue repair : substitution of viable cells for dead cells

• Regeneration : new cells and normal function

• Replacement : new cells and loss some function or scar

• Healing - Primary intension- Secondary intention

Inflammation• It includes vascular response, a

hemostatis response, a cellular response and an immune response.

Tissue repair/proliferation• Here the epithelial and connective

tissue proliferation occurs• Myofibroblasts move towards the

center of the wound• Regeneration of new blood vessels• Collagen synthesis3. Remodeling/maturation (wound contraction) - Scar maturation - Collagen turn over occurs -Organisation of the fibers

stage of matrix formation and remodeling

From 9 days

stage of granulation tissue formation3 to 20 days

stage of inflammation1 to 10 days

inflammation

• (1) Hemodynamic changes

• (2) Increased capillary permeability

• (3) Leukocytic exudation

• Classical signs of inflammation(Cornelius Celsius) are: heat, redness, swelling, pain, and loss of function

• Lewis Triple response:Flush: seen as a dull red line due to vasodilatation.Flare: an irregular red zone due to the surrounding arterioles affected by both nervous and chemical mediators.Wheal : A raised area of skin due to odema ( fluid passing out of blood vessels into extravascular space)

Proliferation phase

• Migration of fibroblast & endothelial cell

• Producing collagen & extra cellular matrix(Collagen synthesis)

• Capillary growth& revascularization(angiogenesis)

• Replacement with granulation tissue (fibroblast, collagen, capillary)

Remodeling phase

• Collagen synthesis and increase tensile strength

• Organisation • Mature scar avascular,

acellular(Scar maturation)

WOUND INFECTION/SEPSIS

• Colonization• Invasive wound sepsis• Sepsis Prevention by aseptic measures• Local anti microbial therapy/systemic antibiotics/wound

debridement• Early excision of necrotic tissues and skin grafting• Treat septicemia

WOUND HEALING

• Stage of inflammation

• Stage of proliferation/tissue repair

• Remodeling

Factors that influence healing• Nutrition - vitamin C• Metabolic status – diabetes

hinders• Circulatory status• Hormones –

steroids/glucocorticoids inhibit

• Infection• Mechanical stress• Foreign bodies• Size, locations and type of the

wound

WOUND DEBRIDEMENT

• Mechanical- wet/dry• Hydrotherapy- immersion/spray• Enzymatic-sutilains• Surgical-sequencial/fascial excision & escharotomies

Proteolysis-fibrinolysis-collagenolysis

WOUND DRESSINGS

• Biological dressings/skin graft• Synthetic dressings• Topical antimicrobials

Abnormal wound healing

• Pressure sore• Diabetic ulcer• Venous ulcer• Arterial ulcer

Pressure sore

Grades of pressure sore

• Involves epidermis & dermis• Heat, swelling,induration,and redness• May be blister formation•10 – 14 days to heal.

Grade 1

• Involves epidermis, dermis and subcutaneous fat• Irregular ulcer•Redness, heat & swelling•3 weeks to 3 months to heal

Grade 2

• It involves epidermis, dermis, subcutaneous fat and adipose tissue and muscle•With infection•Loss of fluid and protein• Joint involvement with stiffness & effusion•Surgery indicated for healing•Local bone inflammation•Necrotic tissues seen in the site.

Grade3

•Soft tissue necrosis down to the bone and joint structures•Osteomyelitis, septic arthritis,subluxation/discolation can occur•Life threatening

Grade4

Scar

• Abnormal healing• Increase collagen synthesis and matrix than normal

Burn Scars - Keloid

Burn Scars - Hypertrophic

HYPERTROPHIC SCAR• Stay within and confine

of origin wound• Above skin level 4 mm• 4 week & regression• Pain , itching , burning

sensation

KELOID• Extend from origin

wound• Occur 3 mo-1 yr• No regression• Black people• Earlobe, presternal,

deltoid

Burn Scars - Contracture

Burn Scars - Contracture

Skin Graft Scars

SCAR MANAGEMENT• Pressure therapy• Silicone gel sheet• Intra lesional injection• Split skin graft• Laser therapy• Cryotherapy• Radi0 therapy• Combination therapy

• Elevation• Itching• Redness

CONTRACTURE MANAGEMENT

Types• Intrinsic• extrinsic

• Splintig/positioning• Skin grafting(early)• Plastic surgery• physiotherapy

UV rays in wound healing

• UV irradiation is divided into four distinct spectral areas, including vacuum-UV (100–200 nm), UVC (200–280 nm), UVB (280–315 nm), and UVA (315–400 nm)

• Basic science advances• UV irradiation causes both beneficial and damaging effects, which depend on wavelength, exposure dose, and UV sources.• The UVA, UVB, and UVC spectral bands differ in their biological effects and in their depth of penetration through the skin layers.• Short-term UVB exposure induces the production of vitamin D in the skin. UVA has distinct effects on cell signaling. Judicious UV

exposure might be beneficial for wound healing and skin homeostasis.• Exposure to solar UV radiation is a major risk in the occurrence of nonmelanoma skin cancer. High doses of either UVC, UVB, or

UVA radiation are harmful to all living organisms in the following order: UVC>UVB>UVA.• The mechanism of UVC inactivation of microorganisms is to damage the genetic material in the nucleus of the cell or nucleic acids

in the microbial cell.• Clinical science advances• The potential of UVC irradiation as an alternative approach for prophylaxis and treatment of localized infectious diseases has been

reported, especially those caused by multidrug resistance pathogens.• With appropriate doses, UVC can selectively inactivate microorganisms, while preserving viability of mammalian cells and promote

wound healing.• UVB has been directly applied to wounded tissue to stimulate wound healing, and irradiation of blood to stimulate the immune

system.• Relevance to clinical care• As striking increase in the average age of the population and the incidence of diabetes continues to rise, new and more efficient

strategies to manage chronic wounds are needed. Light-based technology is a set of growing minimally invasive modalities in wound care.

• UV phototherapy has been associated with both beneficial and deleterious effects to patients with localized and systemic skin disorders.

• UVC is less damaging to human tissue than UVB, which is an accepted option for a large number of cutaneous disorders in humans with excellent safety profile. UVC irradiation offers fast and cost-effective antimicrobial therapy compared to commonly used antibiotics.

• Under excessive repeated UVC irradiation, resistance of microorganisms to UVC inactivation may develop.• UV should be used in a manner such that the side effects would be minimized, while the wound-healing process is augmented.

PMC full text:

Adv Wound Care (New Rochelle). 2013 Oct; 2(8): 422–437.doi:  10.1089/wound.2012.0366

UV rays in skin conditions

• UVC Protocol for Treatment of Infected Wounds (Bactericidal Effect)

• UVB Protocol for Inducing an Inflammatory Reaction in Chronic Wounds

• UVB Protocol for Stimulating Growth of Granulation Tissue

• UVB Protocol to Promote Breakdown and Elimination of Necrotic Tissue

• WOUND HEALING: Alternatives in Management

Third Edition• Luther C. Kloth, MS, PT,

CWS, FAPTAProfessorPhysical Therapy DepartmentMarquette UniversityMilwaukee, WI

• Joseph M. McCulloch, PhD, PT, CWS

Executive Associate Dean and Professor, Physical TherapySchool of Allied Health ProfessionsLouisiana State University Health Sciences CenterShreveport, LA

Wound measurement

• Simple measurement• Wound tracing• Photography

• Stereophotogrammetry(3 dimentional /volume)

• Computerised/digital image analysis