Angie Parks-Miller, CWCA, Henry Ford Hospital, Detroit, MI
Whether recovering from Carbon Dioxide Laser Excision Surgery, Traditional Excisional Surgery, or managing open wounds and drainage from flaring of Hidradenitis Suppurativa (HS) activity, your diet is important to provide an environment that optimizes your healing. Even small wounds can alter the way your metabolism processes nutrients.
To understand the importance of nutrition in wound healing, we will first discuss how a wound heals and what happens during the wound healing process.
There are 4 phases to the process of wound healing, and there are factors that can impact the rate at which these phases occur, such as smoking, other health issues such as diabetes and size of the wound.
Phase I is called Hemostasis. Hemostasis is the shortest phase of wound healing and is an immediate process by which the body attempts to control bleeding by creating blood clots. Taking medications such as blood thinners or NSAIDS can affect the body’s ability to control bleeding.
Phase II is called the Inflammatory Phase. This phase occurs after trauma to the skin, such as after the rupture of an HS lesion, or after an excisional surgery, or injury. In the Inflammatory phase, nutrient rich blood is sent to the wound, which causes swelling and warmth or redness at the site of the wound. The body also signals cells, growth factors and proteins needed to begin the healing process, and to fight infection. This also begins a process called angiogenesis whereby blood vessels begin to reform. The Inflammatory Phase is the phase when the most exudate, or drainage, is experienced from a wound.
Phase III is called the Proliferative Phase. This phase generates granulation tissue in the bed of the wound and cells called fibroblasts are at work to produce collagen to aid in healing.
Skin cells leap frog over each other to reform a new surface layer of skin. Granulation tissue, which is tissue that is pink to red and beefy in appearance, is a necessary component of wound healing. However, it can be problematic if it becomes elevated above the surrounding plane of skin, making it difficult for skin cells to continue the leap frog process, and thus can delay wound healing. Too much granulation tissue can be caused by excessive amounts of moisture, whereas not enough granulation tissue can be the result of a lack of moisture.
Phase IV is called the Remodeling Phase. This phase occurs in the tissue as the wound is closed. A scar is formed and collagen remodels over a period of 24 months. Think of a stretch mark. Initially, it is red or purple, but over time it fades to white. This is what happens as a result of the remodeling phase.
Caption: Above are the 4 phases of wound healing and the general timeline that healing follows.
Photo Source: www.woundeducators.com
Fibrin is a substance seen on the top of a wound and is a vital part of wound healing. Fibrin are rod-shaped molecules that form chains of proteins. The appearance of fibrin depends on two factors; moisture and lack of moisture. In a moist environment, Fibrin will appear as a stringy, yellowish, mucus-like substance. This is normal and should not be mistaken for pus. In a dry environment, Fibrin will appear as a solid, or hard scab, on the top of a wound. An example of this would be a skinned knee. If you skin your knee and do not apply moisture, you will form a hard scab. When you take a shower, that hard scab becomes wet and the appearance can change to a more mucus-like appearance.
Figure 2 Caption: A skinned knee: Left – moist appearance of fibrin / Right – dry appearance of fibrin
Photo Source: www.woundeducators.com
Figure 3 Caption: Fibrin is seen as the mucus-like yellow substance on a moist wound and should not be confused with pus.
Photo Source: www.woundeducators.com
Moisture balance plays a large role in the healing of a wound and also in control of pain.
If a wound is too moist, it can cause excessive granulation tissue to form, can cause the periwound, or perimeter of the wound to become macerated or tear, and increase the size of the wound. If a wound is too dry, it can result in a lack of granulation tissue, allowing fissures, or tears to form in the wound bed, resulting in pain and slower healing. Closely following the instructions of your medical provider, while caring for your wound, can prevent either issue from occurring.
Figure 4 Caption: Proper moisture balance is essential to wound healing.
Photo Source: www.woundcareeducators.com
Physicians and patients alike can use the acronym TIME in the assessment of wounds.
T = Tissue
What is the appearance of the tissue?
Black/White = necrotic or dead tissue
Pink = healthy tissue
Red = inflamed tissue
I = Inflammation
Is visible inflammation present? Is the wound indurated (swollen)?
M = Moisture
Is the proper moisture balance present in the wound?
How much exudate (drainage) is present?
Remember the amount of drainage present should influence your dressing choice.
E = Edges / Epithelialization (regrowth of skin)
Is the edge of the wound flat or raised? Is the center of the wound flat or raised?
Raised = Can delay healing, preventing the migration of skin cells to close the wound.
Flat = Allows the migration of skin cells across the wound bed to close the wound.
Knowing how to recognize signs of infection can help prevent complications.
It is a normal response of the body to run a low-grade fever during the 1st 48 hours after a surgical procedure, and is very unlikely to be due to an infection. An oral temperature above 100.4, or a fever persisting beyond 48 hours should be evaluated by a physician.
Redness, warmth and some swelling of a surgical site are again normal for the 1st 48 hours following a surgical procedure. You can minimize swelling by elevating the affected area, and maintaining a firmly wrapped dressing.
Those with HS report many tricks when discussing dressings, such as use of feminine hygiene products.
Proper wound dressings should consist of 3 layers;
The depth of your wound, and the amount of exudate (drainage) will influence the type of dressing. In particular, this will most influence your contact and absorbent layer.
Dry Wound = Hydrate It
Wet Wound = Absorb It
Shallow Wound = Cover It
Deep Wound = Fill & Cover It
Now that we have discussed the phases of wound healing, we can begin to understand how nutrition can impact the process of healing1.
The Catabolic Phase is another important aspect of wound healing. This occurs during the Inflammatory and Proliferative Phases. By definition, Catabolism is a breakdown of molecules into simpler ones, along with a release of energy. During Catabolism the body diverts resources such as carbohydrates, fats, proteins and antioxidants among others, while also releasing stress hormones.
The catabolic phase must not be in excessive duration, as the diversion of resources like protein, can result in Protein Energy Malnutrition (PEM). In PEM, diverted proteins are sent to the wound and not to other organs, which can cause reduced muscle mass, or delay healing.
Protein is the most important aspect of nutrition for wound healing. A wound can loose up to 100 mg per day of protein through exudate, or drainage. During wound healing, your body is competing for protein. Your body’s organ systems need protein to function AND your wound needs protein to heal. Increasing your protein intake during wound healing can make for less competition.
Protein can come from animal sources such as meat, eggs, or dairy products like cheeses. Non-animal sources of protein are legumes and nut based products, such as peanut butter.
Aim for 20 to 30 grams of protein at each meal and 10 to 15 grams of protein with each snack.
Fatty acids create cell membranes during healing. One cup of yogurt or one ounce of cheese are examples of healthy fats to take in during wound healing.
Carbohydrates are important for preventing the body from depleting protein for energy during wound healing. However, care should be taken to ensure healthy carbohydrates are eaten in proper amounts. Limiting starch based and white sugar based carbohydrates would be beneficial. Examples of healthy carbohydrates are whole grains such as oats and wild rice.
Vitamin C is an antioxidant. Vitamin C plays a role in strengthening your healing wound, creating Collagen, new blood vessels and also helps with iron absorption.
Total recommended intake of Vitamin C for wound healing is 200 mg per day.
Vitamin A is also an antioxidant and helps to control the inflammatory process during wound healing. Red fruits, vegetables, eggs, fish and green vegetables are sources of Vitamin A. Vitamin A can be toxic if taken in large amounts, so incorporating Vitamin A through foods in your daily diet is all that is needed. You do not need to take additional supplements of Vitamin A.
Zinc is a mineral that aids in the division of cells to make new tissue. Most people consume Zinc through meats, and are not deficient in Zinc. However, if you are a vegetarian, it is important to consume other foods rich in Zinc.
It may be beneficial to consume 15 mg to 50 mg per day of Zinc. Your physician can direct you on the amount for your situation.
It is so important to stay hydrated! Drinking 8-10 8 oz glasses of water per day will aid in flushing out toxins from the body and help circulation.