Understanding wounds

Victoria, British Columbia — Dermatologic surgeons are very aware and do an excellent job in the management of wounds; however, wound healing is an area that needs the supervision and expertise of a trained practitioner, according to Gordon E. Searles, O.D., M.D., M.Sc., F.R.C.P.C., F.A.C.P.

Speaking here at the Canadian Dermatology Association annual conference, Dr. Searles compared the traditional training surrounding the management of "cold steel" wounds with those that occur as a result of lasers treatment, and the importance of undestanding the difference.

"For those patients who have dermatologic surgery, the wound is acute; however, the modalities we're using (to manage the wound) are different than the traditional methods that are taught for the surgeons who are using cold steel," says Dr. Searles, clinical associate professor, division of dermatology and cutaneous medicine, department of medicine, University of Alberta.

Cold steel vs. heat infused

A wound caused by a laser's heat is more complicated than an injury caused by fire. The dermatologic surgeon alters the cutaneous vasculature with some types of laser therapies, thereby altering the blood vessel supply and how the skin will heal.

"The thermal damage caused by a laser creates a charred eschar that can act as a foreign body in the wound," Dr. Searles explains. "Furthermore, the sealing of the blood vessels and lymphatics minimizes platelet activation. This activation is critical for starting the release of cytokines that initiate and coordinate the early stages of wound healing."

While lasers are used to help diminish scars from previous wounds — for instance, nonablative lasers are used to treat acne scars, and ablative lasers, such as CO₂ and erbium, are used to treat shallow scars — the lasers themselves can also be the source of significant wounds in certain patients.

"Surgeons are aware of some potential risk factors, such as in those patients with a history of herpes simplex or cold sores," Dr. Searles says. "If they have facial resurfacing, they are at risk of developing cold sore activity within the wound. If there is a known history of this, the patient is usually put on a prophylactic antiviral."

The dermatologic surgeon will also want to avoid cellulitis or impetigo within a wound, because these can impact the healing process. Reaching into an oral cavity or the nose presents additional risks, with the mucous membranes presenting a danger of bacteria feeding into the bloodstream, according to Dr. Searles.

Proper care for today's wounds "With proper postoperative care, wound healing usually results in a cosmetically acceptable appearance," Dr. Searles says. "Currently, we're using moist wound healing techniques that are non-reactive.

"There are many types of dressings that can keep the wound warm and protected from injury, while capturing and donating the wound fluid near the wound surface. This fluid contains many of the growth factors and inflammatory cells that are responsible for proper healing."

Often the dermatologic surgeon will apply topical antibiotics and agents to aid the wound healing process, but these can be potential allergens, Dr. Searles says.

"Frequent washing or debridement is also discouraged — you should encourage the patient to leave the skin alone," Dr. Searles cautions. "For those procedures done in cosmetically obvious areas, we should use something that's not too bulky and is cosmetically pleasing."

Examples of this are thin hydrocolloid sheets, or thin, flexible foam dressings.