Chronic wounds

Chronic wounds are defined as wounds that show no tendency to heal even after eight weeks of good care. The typical causes are circulatory disorders of the arteries and veins, diabetes mellitus, malnutrition and infections. Chronic wounds are stressful and lead to physical and mental exhaustion. They are much more common than generally assumed, especially in old age. Treatment and prevention are important.

What are chronic wounds?

The most common chronic wounds affect the lower legs and soles of the feet. Venous congestion on the inside of the lower leg is the most common cause of chronic wounds. Wounds caused by arteriosclerosis can be found on the outside of the lower legs and on the back of the feet. Diabetes mellitus, smoking, high blood lipid levels and high blood pressure are typical risk factors for accelerated arteriosclerosis. Diabetic foot ulcers (= “malum perforans”) are found on the sole of the foot. They occur when the foot nerves are destroyed, most frequently due to diabetes mellitus. Pressure sores (bedsores) occur almost exclusively in cases of malnutrition.

Chronic wounds – frequency and age

Chronic wounds are one of the most common conditions in Switzerland. Doctors assume that around one percent of the population will suffer from an “open leg” (leg or ankle ulcer) in the course of their lives. This is a common type of chronic wound. Among 80-year-olds, the figure is already more than three percent. Poorly controlled or undetected diabetes mellitus can damage the foot nerves, resulting in a loss of sensation in the soles, which can lead to punctual overloading and diabetic foot ulcers (= malum perforans).

Chronic wounds: Causes and risk factors

The causes of chronic wounds are usually other underlying diseases. They cause wounds to develop more quickly – sometimes even with slight pressure – and then no longer heal. The most important diseases and risk factors associated with the development of chronic wounds:

• Peripheral arterial occlusive disease (PAD, PAD, smoker’s leg): The abbreviation PAD refers to circulatory disorders caused by narrowed or blocked arteries (arteries). The arteries are vessels that transport oxygen and nutrients to the skin, muscles and bones with fresh blood. Four main risk factors accelerate arteriosclerosis: poorly controlled diabetes mellitus, smoking, high blood lipid levels and high blood pressure.
• Chronic venous insufficiency (CVI ) due to varicose veins or after deep vein thrombosis in the legs: the blood can no longer drain properly from the veins and “sinks” into the legs. The overhydrated skin and muscle tissue hardens and becomes more susceptible to chronic wounds.
• Diabetic foot syndrome: A long-term elevated blood sugar level damages the blood vessels and nerves, especially in the feet. Due to the reduced sensation of pain, diabetics do not feel pressure points – for example if their shoes are too tight – or minor injuries. In addition, blood circulation is reduced and the tissue does not receive enough blood, oxygen and nutrients. This increases the risk of chronic wounds. Diabetic foot syndrome is the most common cause of lower leg amputations.
• Weakened immune system: There are many factors that weaken the immune system, for example diseases such as cancer or infections. They can impair wound healing and promote chronic wounds. The immune system is also often weakened in older people – due to age itself, but sometimes also due to a poor diet.
• Malnutrition combined with frequent sitting or lying down: Some people are bedridden for long periods of time due to old age or illness. This means that the skin is under constant pressure from your own body weight, increasing the likelihood of pressure ulcers (decubitus ulcers). People who are confined to a wheelchair also have an increased risk of this type of chronic wound. Malnourished people have a significantly higher risk of developing pressure sores. Nutrition and skillful storage are therefore particularly important for chronically ill and weakened people.
• Due to accidents: Accidents are usually accompanied by bruising of soft tissues and limbs. Depending on the extent of the soft tissue damage, there may be either primary or secondary open injuries to the skin and underlying tissue, such as subcutaneous fatty tissue, muscle, tendons or bone. An open wound caused by an accident with a surrounding area of bruised skin can result in difficult wound healing. As a rule, the blood supply to the soft tissue is damaged locally. This means that wound healing can be delayed, as reduced blood flow is associated with a decrease in local oxygen saturation and the transport of the necessary wound healing components. If there is also a bone fracture in this bruised area of skin, the healing of the fracture may also be adversely affected, depending on the extent of the vascular damage caused by the accident.

Symptoms: Chronic wounds are often painful

Most chronic wounds are – with a few exceptions – painful. The patient’s sleep is very often disturbed. Pain and lack of sleep wear you down and lead to depression. The skin around the chronic wound is often inflamed. The causes are manifold. The surrounding skin most frequently shows eczema, for example due to the moisture around the wound or due to allergies. It is not uncommon for the wound bed to be colonized by a significant amount of bacteria, which can impede wound healing if present in large quantities.

Other symptoms of chronic wounds are

• Itching
• Leeking
• Unpleasant odor due to infection with bacteria or dead tissue
• Yellowish, greasy or black coatings
• Skin discoloration around the wound – reddish to brownish
• Swelling around the wound
• Limited mobility due to pain and swelling
• Sleep disturbances due to the pain and itching

Always visit your doctor if you have a wound that won’t heal. The causes are investigated and the wound can be treated professionally.

Chronic wounds: There are different types

We distinguish between several types of chronic wounds. The most important are:

• Ulcus cruris (“open leg”): The chronic wound forms on the lower leg. Venous and arterial circulatory disorders are responsible for 80 percent of these wounds. The remaining 20 percent are caused by inflammation and skin diseases.
• Diabetic foot syndrome and, more generally, neuropathic foot syndrome: Most of these wounds are located on the soles of the feet, typically under the bony heads of the forefoot, or on the tips of the toes, or on the outer edge of the foot. Poorly controlled diabetes mellitus damages the long motor and sensory nerves of the feet, and causes a second problem in the arterial supply to the periphery, e.g. the feet.
• Pressure ulcer: A pressure sore that forms over the coccyx, hip bones, heels, upper spine and shoulder blades due to prolonged lying or sitting. Patients are usually malnourished and no longer have a subcutaneous fat pad.

Chronic wounds: Prevention, early detection, prognosis

Most chronic wounds are caused by one or more underlying diseases. You must have these treated sufficiently to prevent chronic wounds. Not every acute wound has to develop into a chronic wound – as a measure for early detection, consult your doctor in good time if a wound has not closed after about four weeks.

Some tips on how to prevent chronic wounds:

• Diabetes: Make sure your blood sugar is well controlled. Choose shoes that are not too tight – otherwise pressure points may occur. Due to the nerve damage, you will not feel minor injuries and wounds. Visit a chiropodist regularly, as experts can recognize the smallest wounds immediately. A visit to the chiropodist therefore also serves the purpose of early detection. In addition, chiropodists know some protective measures to prevent wounds from developing in the first place.
• Chronic venous insufficiency (CVI ): Compression stockings or compression bandages (bandages) help to prevent chronic wounds. Varicose veins should be treated. Today, most varicose vein treatments do not require surgery.
• Antibiotics, debridements and possibly a vacuum dressing help to heal a heavily infected wound.

Progression and prognosis of chronic wounds

The course and prognosis depend on the cause, type and extent of the chronic wound. Most chronic wounds heal as soon as the necessary countermeasures have been taken.

Chronic wounds can have a number of consequences, for example:

• A chronic wound is very unpleasant for most people, not only because of its appearance, but often also because of its odor. Some withdraw into their own four walls and are socially isolated – and their psyche suffers too.
• The pain reduces enjoyment of life and quality of life. They also restrict mobility in everyday life and reduce the radius of action.
• Pain and itching often occur at night and rob you of sleep. Many people feel tired and exhausted the next morning.
• In addition, an unclosed wound puts a strain on the body and the immune system on top of the underlying disease that is usually already present.
• Bacteria can penetrate an open wound and cause inflammation. There is a risk that the tissue will die. Without treatment, the germs can spread via the bloodstream and there is a risk of blood poisoning (sepsis) – which is life-threatening.
• Sometimes amputation of a limb is unavoidable in the case of an open wound.

Chronic wounds: Treatment with multiple measures

Chronic wounds are best treated by a team of professionals who specialize in wound treatment and have a lot of experience with it. The treatment aims to promote wound healing, improve quality of life and prevent recurrences of healed wounds.

The therapy consists of a combination of several measures. Which one we choose depends on the type, location and extent of the chronic wound. Your general state of health also plays a role. In general, wound treatment often takes a lot of time and requires a lot of patience from everyone involved.