The wound that will not close: when it stops being a matter of patience

There is a phrase that comes up again and again in the consultation and that costs people months: "I just heal slowly."

It almost never is that. A wound that has gone more than four to six weeks without closing is not a slow wound: it is a wound with a cause behind it that is still acting. Finding that cause is half the treatment, and until it is found no cream is going to help.

Why the body does not close it

The commonest chronic wounds are the diabetic foot ulcer, the venous leg ulcer, the pressure ulcer — the bedsore — and complex wounds after trauma, surgery or infection.

They all have something in common: the body is capable of closing them and does not, because something is preventing it. It may be poor blood supply, sustained pressure on the area, infection of the bone, uncontrolled blood sugar, dead tissue, malnutrition or smoking. It is almost always more than one at once.

If you cover a pressure ulcer without relieving the pressure, graft a diabetic foot without investigating the circulation, or close a wound over infected bone, failure is only a matter of time.

That explains what most frustrates patients and their families: wounds that close and open again within months. It is not bad luck. It is that the wound was treated and the reason was not.

The diabetic foot, which in Peru is the most serious case

With the prevalence of diabetes we have, the diabetic foot is the commonest cause of chronic wounds and also the one that produces the most avoidable amputations.

What makes it dangerous is that it does not hurt. Neuropathy removes protective sensation, so a blister from a new shoe, a stone inside a trainer or a badly cut nail go unnoticed. By the time the wound is seen it has been open for weeks and has sometimes reached the bone.

When to be seen the same day, not next week

• Any wound on the foot of a person with diabetes, however small it looks and even if it does not hurt.
• Redness spreading around the wound, or a red line running up the leg.
• A bad smell, pus, or tissue turning grey or black.
• Sudden swelling of the foot, with or without fever.
• Visible bone or tendon at the base of the wound.
• A sudden loss of blood sugar control with no other explanation: sometimes it is the first sign of a deep infection.

What is done, and in what order

The order is what separates a treatment that works from one that passes the time:

1. Find the cause. Circulation, pressure, bone infection, metabolic control, nutritional state. The first consultation is not about which cream to use, but about why this wound will not close.
2. Correct it. Restore blood flow if it is lacking, offload the area if there is pressure, treat the osteomyelitis, adjust the blood sugar, improve nutrition, stop smoking.
3. Clean it. Remove the dead tissue, which is a physical obstacle and a breeding ground.
4. Close it. Directly, with a graft or with a flap, according to what lies underneath. This comes last, not first.
5. Prevent. Adapted footwear, support surfaces, repositioning, regular checks.

Offloading is the part most often skipped

And it is the one that most determines the outcome. A sole ulcer will not close if you keep walking on it, however good the dressing. A sacral sore will not close if the patient keeps sitting on it six hours a day.

It is tedious, it is uncomfortable, and it decides whether the wound closes or opens again. In a bedbound patient the responsibility falls on the family, and that is worth saying openly from the start.

What is not promised

The hard part has to be said too. In advanced diabetic foot disease with bone infection or poor circulation, amputating a toe or part of the foot may be the correct treatment, and sometimes the only one that prevents losing the whole limb later. Saying so beforehand is part of dealing honestly.

A permanent closure is not promised, nor skin like the original: the aim is to close the wound stably and preserve function. And in the diabetic foot and the bedbound patient, the checks are for life. Prevention does not end.

One thing worth repeating: almost all the amputations we see arrived late. Six weeks is the threshold. If you have diabetes, do not wait six weeks: come with the blister.