Introduction
Diabetes Mellitus Type II is a chronic metabolic disorder that affects millions of individuals worldwide. One of the most significant complications associated with diabetes is the development of chronic or hard-to-heal wounds. A chronic wound or a wound that is hard to heal is defined as a wound that fails to progress through the normal stages of healing. This blog post aims to shed light on the impact of diabetes on these hard-to-heal wounds and explore effective treatment strategies. The information presented here is based on scientific evidence from reputable journals and prestigious wound care sources.
Impact of Diabetes on Wound Healing
1. Impaired Wound Healing Mechanisms:
Individuals with diabetes often experience impaired wound healing due to various factors. Chronic hyperglycemia, a hallmark of diabetes, affects multiple stages of the wound healing process. Elevated blood glucose levels can lead to reduced blood flow, impaired immune response, and increased susceptibility to infection, all of which contribute to delayed wound healing.
2.Neuropathy:
Diabetic neuropathy is a common complication characterized by damage to the nerves, which can be a cause of wounds in people living with diabetes and also contributes to their diminished capacity for wound healing. Diabetic neuropathy can present itself as motor neuropathy, sensory neuropathy, autonomic neuropathy or any combination of these.
- Motor neuropathy is caused by damage to the large nerve fibers and results in muscle weakness and imbalances. These muscle imbalances can lead to changes in the shape and function of the foot and toes, resulting in deformities of the foot that increase the peak pressures applied to the foot during weight bearing activities such as walking. In other words, areas of the foot and toes which weren’t built to take pressure when we walk, now have a lot of pressure, which can lead to wounds.
- Sensory neuropathy is caused by damage to the small nerve fibers and results in a loss of protective sensation (LOPS). LOPS can result in diabetic wounds, particularly to the feet, as patients will be unable to feel when they are suffering damage to their skin and underlying tissues. Without input from the sensory nerves in the feet, these wounds could be caused by soaking the feet in scalding hot water, standing on pavement that is too hot, wearing ill-fitting shoes that rub a blister or stepping on a sharp object such as a piece of glass or a nail and being unaware of the injury.
- Autonomic neuropathy is caused by damage to the large nerve fibers and the sympathetic ganglion and causes a decrease in the sweat and oil production of the skin. The production of sweat and oil by our skin is essential for keeping our skin supple and flexible and for protecting us from bacterial infection. Patients with autonomic neuropathy may have dry, inelastic skin with cracks or fissures that are pathways for bacteria to enter their bodies and cause infection.
3.Peripheral Arterial Disease (PAD):
Diabetes is a primary risk factor for PAD, as well as smoking, high blood pressure and high cholesterol. PAD refers to the decreased ability of our blood vessels to supply our extremities with an adequate blood supply. This decreased blood flow is typically the result of the narrowing (stenosis) or blockage of blood vessels from the buildup of plaque on the walls of the arteries; a process known as atherosclerosis. PAD limits the delivery of oxygen and nutrients necessary for wound healing. PAD is more common in the lower extremities than upper extremities and can be a major contributing factor in wounds that are hard-to-heal on the feet and legs.
4.Increased Risk of Infection:
A chronic state of hyperglycemia can weaken the immune system, leaving people living with diabetes more susceptible to illness and complications from illnesses. Elevated blood glucose levels provide a favorable environment for bacteria to thrive, increasing the risk of wound infections. Furthermore, the compromised blood flow associated with diabetes impairs the transport of white blood cells and even antibiotics to the wound site, hindering the body’s ability to fight infections effectively.
Treatment Strategies for Chronic Wounds in Diabetes
1. Optimal Glucose Control:
Achieving and maintaining optimal glycemic control is paramount in managing chronic wounds in individuals with diabetes. Multiple studies have demonstrated the positive correlation between optimal glucose control and enhanced wound healing. Regular blood glucose monitoring, adherence to prescribed medications, and a healthy lifestyle that includes a balanced diet and regular exercise can help achieve optimal glucose control. Athena Specialty Group is looking to partner with companies which offer options for Continuous Glucose Monitoring (CGM) to help the wound care industry better understand how these devices might improve our ability to heal these challenging wounds in our diabetic population.
2.Wound Debridement:
Debridement involves the removal of necrotic tissue, foreign material, and non-viable components from the wound bed. This procedure is crucial in stimulating the wound healing process by promoting the growth of healthy tissue. Depending on the characteristics of the wound, different debridement methods may be employed, including surgical or sharp, enzymatic, biologic, mechanical, or autolytic debridement. Studies have shown that even wounds that appear to be healthy and viable to the naked eye, heal faster with at least weekly serial sharp debridement. One reason for this, is that sharp debridement disrupts biofilm. Biofilms are communities of encased protected bacteria which develop in wounds that have been open for more than 72 hours and can lead to a state of chronic inflammation and prohibit the body’s natural immune response. We will speak more on biofilms in future blog articles.
3. Dressing Selection: Choosing appropriate dressings plays a vital role in managing chronic wounds in diabetes. The primary goals of wound dressings are to maintain a moist wound environment, promote granulation tissue formation, and provide protection against infection. There are thousands of wound care dressing choices out there and the choice depends on factors like wound characteristics, exudate levels, and the presence of infection. When selecting the most appropriate dressing for a particular wound, there is never just one correct answer. Most wound care practitioners will agree that if you put an example of a wound in front of a group of 10 different wound providers, you will get a variety of answers about what to use as a dressing. The key to selecting the correct treatment is about assessment and reassessment. What is the goal you are working towards for that wound, and is your dressing selection going to help you reach that goal? At Athena Specialty Group we offer an organized approach to this decision making process. We prioritize our wound healing goals as follows, based on the individual needs of the patient and their specific wound:
- 1st: INFECTION – is there infection present in the wound? If yes, choose a treatment to help address the infection. If not, move on…
- 2nd: VIABILITY – is there unhealthy or non-viable tissue in the wound? If yes, choose a treatment to help improve the tissue viability. If not, move on…
- 3rd: HEALING – are there signs of healing present in the wound? If not, select a treatment that will help stimulate healing. If yes, move on…
- 4th: MOISTURE BALANCE – Is there excessive moisture in the wound? If yes, choose a dressing to absorb and wick away moisture. Is there excessive dryness or desiccation in the wound? If yes, choose a dressing that will impart or hold in moisture to the wound.
- 5th: AVAILABILITY – We must always consider what is available and feasible for our patients and align our choices with the patient’s goals of treatment.
4.Advanced Therapies: In In cases where conventional wound care approaches fail to facilitate healing, advanced therapies may be considered. These therapies include modalities such as negative pressure wound therapy (NPWT) and low frequency ultrasound (UltraMIST), hyperbaric oxygen therapy (HBOT), and bioengineered skin substitutes. NPWT promotes wound healing by applying negative pressure to the wound bed which stimulates tissue growth, removes excess fluid, reduces edema, and increases blood flow. UltraMIST is a non-contact, non-thermal, low frequency ultrasound therapy utilized by Athena Specialty Group to promote wound healing through wound cleansing and maintenance debridement by the removal of fibrin, yellow slough, tissue exudates, and bacteria. HBOT involves exposing the patient to 100% oxygen in a pressurized chamber, which enhances the oxygen supply to the wound site. Bioengineered skin substitutes provide a scaffold for cellular growth and facilitate wound closure.
Conclusion
Diabetes poses significant challenges in the area of wound management due to impaired wound healing mechanisms, neuropathy, peripheral arterial disease, and increased susceptibility to infections. Our patients with diabetes are more likely to develop wounds and those wounds are more challenging to heal. However, with appropriate strategies and treatment approaches, successful wound healing can be achieved in individuals with diabetes. Helping our patients optimize their glucose control can get them on the right course towards healing. Thorough wound bed preparation, including wound debridement, appropriate dressing selection, and advanced therapies are crucial components of an effective treatment plan that can help us achieve healing in these challenging situations.
Athena Specialty Group has the added advantage of having a wound care provider who is also a Certified Diabetes Care and Education Specialist (CDCES). This offers our clinical team and our patients access to an exceptionally beneficial resource to help us all better understand the management of this complicated disease. By understanding the impact of diabetes on wound healing and implementing evidence-based strategies, healthcare professionals can significantly improve the quality of life for individuals affected by this condition.
References:
- Afonso AC, Oliveira D, Saavedra MJ, Borges A, Simões M. Biofilms in Diabetic Foot Ulcers: Impact, Risk Factors and Control Strategies. International Journal of Molecular Sciences. 2021; 22(15):8278. https://doi.org/10.3390/ijms22158278
- Jeffcoate WJ, et al. Wound healing and quality of life in patients with diabetes. J Wound Care. 2020;29(Sup7):S4-S14. Link
- Lipsky BA, et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg. 2006;117(7 Suppl):212S-238S. Link
- Snyder RJ, et al. Treatment of diabetic foot ulcers. Clin Plast Surg. 2007;34(3): 551-565. Link
- Sen CK, et al. Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair Regen. 2009;17(6):763-77 Link
Note: Please note that the above references are exemplary and not exhaustive. It is always recommended to consult multiple reputable sources and medical professionals for comprehensive information and personalized guidance.
