Delayed wound healing

Healing time depends on the type of wound. A superficial epidermal abrasion may heal within a few days, whereas a deep surgical wound or ulcer requires many weeks. There is no single timeframe appropriate for all injuries.

The following are considered particularly concerning:

• lack of gradual reduction in wound surface area and depth,
• absence of healthy, red granulation tissue growth,
• persistence of necrosis, exudate, or signs of inflammation,
• re-separation of the edges,
• deepening of the defect or exposure of a tendon, muscle, or bone,
• lack of expected progress within approximately 2-4 weeks of proper treatment.

Wounds persisting for more than 4 weeks are often described as hard-to-heal, while the term “chronic wound” is sometimes applied to a defect that has not progressed properly through the subsequent phases of repair and typically persists for at least 6-12 weeks. Definitions vary depending on the etiology and adopted guidelines.

In diabetic foot ulcers, the change in wound surface area is an important prognostic indicator. A reduction of less than approximately 50% after 4 weeks of proper management should prompt a re-evaluation of blood supply, infection, offloading, and diagnosis. This does not mean that the wound should be observed for a month without consultation. In a patient with diabetes, limb ischemia, or immunocompromise, diagnostics should begin earlier.

Delayed healing may be the first noticeable manifestation of a systemic disease. The most important causes include:

• diabetes, especially uncontrolled, coexisting with neuropathy, foot deformity, or arterial disease;
• atherosclerosis and peripheral arterial disease, causing ischemia;
• chronic venous insufficiency, leading to venous hypertension, edema, and leg ulcers;
• heart, kidney, or liver failure;
• anemia and deficiencies of iron, vitamin B12, or folates;
• protein-energy malnutrition and malabsorption disorders;
• neoplastic and hematological diseases;
• autoimmune diseases, vasculitis, and pyoderma gangrenosum;
• chronic infections, including osteomyelitis;
• immune disorders;
• neuropathies limiting the sensation of pain and pressure;
• less commonly, connective tissue disorders or congenital defects in tissue repair.

Wound assessment should include not only its appearance, but also the evaluation of pulse, limb temperature and sensation, the presence of edema, the character of exudate, and the tissues at the base of the wound bed. Depending on the clinical presentation, tests performed include complete blood count, glucose and HbA1c levels, inflammatory markers, nutritional parameters, and vascular/blood flow assessments.

A wound with an atypical appearance that does not heal despite proper treatment may require a biopsy. It allows for ruling out skin cancer, malignant transformation of a chronic ulcer, vasculitis, or another dermatosis. Wounds with raised, indurated, or easily bleeding edges require special caution.

Effective treatment requires identifying the wound etiology. There is no single preparation or treatment suitable for every patient. Basic management includes:

1. wound cleansing and, where indicated, debridement of necrotic tissue;
2. infection control without the unjustified use of antibiotics;
3. selection of a dressing that maintains a beneficial moisture balance;
4. offloading of neuropathic ulcers;
5. compression therapy for venous ulcers after ruling out significant ischemia;
6. vascular assessment and possible revascularization in case of ischemia;
7. control of blood glucose, edema, pain, and comorbidities;
8. smoking cessation and improvement of nutritional status;
9. regular measurement of the wound's area, depth, and characteristics.

In selected wounds, a specialist may use negative pressure wound therapy, advanced dressings, skin substitutes, grafting, oxygen therapy, or other supportive procedures. These are an adjunct to causal treatment, not a replacement for it.

Treatments available at Ambasada Urody related to tissue regeneration include autologous therapies and non-invasive physical technologies. Autologous procedures include:

• PRP platelet-rich plasma,
• HD PRP Angel System high-concentration platelet concentrate,
• I-PRF platelet-rich fibrin,
• CGF preparations,
• autologous exosomes, and
• a combination of PRP with Dermapen 4.0 microneedling.

Platelet preparations contain mediators released from platelet granules, including PDGF, TGF-β, and VEGF, which participate in the regulation of angiogenesis, cell migration and proliferation, fibroblast activity, and extracellular matrix remodeling. However, the composition, concentration of platelets and leukocytes, and biological activity of the preparation depend on the harvesting system used; therefore, individual autologous products should not be treated as biologically equivalent.

A supplement to regenerative management may include INDIBA® Deep Care, INDIBA® Elite NS Intima, and BeautyTek.

• INDIBA utilizes capacitive-resistive therapy at a frequency of 448 kHz, conducted in a thermal or subthermal range. Its action is associated, among others, with local changes in blood flow, temperature, and tissue metabolism, as well as the modulation of cellular processes involved in inflammation and repair. The technology can be applied in properly qualified recovery following surgical procedures and injuries, as well as in the treatment of edema, pain, limited tissue mobility, adhesions, and scars, including scars from Caesarean sections and episiotomies.
• BeautyTek utilizes controlled bioelectrical stimulation tailored to tissue properties. In clinical practice, it is primarily used as a supportive method for the management of postoperative, post-traumatic, and post-acne scars, edema, as well as impaired elasticity and mobility of scar tissue.

A clear distinction must be made between a biologically plausible mechanism of action and efficacy confirmed in high-quality clinical trials. PRP and other autologous preparations are not a universal treatment for every hard-to-heal wound, and the results achieved depend on the etiology of the defect, its vascularization status, the presence of infection, and the method of preparation. Clinical data regarding the direct impact of INDIBA and BeautyTek on the closure of active wounds also remain limited. These technologies should be treated as complementary management, especially during the recovery and scar remodeling phase, rather than as a replacement for causal treatment.

Microneedling, fractional lasers, or other procedures intentionally disrupting skin integrity are not performed within an active, infected, bleeding, or ischemic wound. In the case of INDIBA and BeautyTek, the possibility of initiating therapy, its treatment area, and parameters should be determined individually by a physician or qualified therapist, especially in the early postoperative period. Laser therapy, microneedling, and other scar remodeling procedures generally apply to a later stage, once the defect has closed and re-epithelialization is complete.

Current guidelines emphasize the priority of wound cleansing, debridement of necrotic tissue, infection control, offloading, appropriate topical treatment, assessment of vascular status and potential revascularization, as well as the treatment of the underlying disease. Regenerative treatments may only be introduced as part of an individualized management plan if they do not delay or replace methods of proven efficacy.