Introduction

The concept of wound hygiene has grown traction recently as clinicians increasingly adopt an antibiofilm-oriented approach to wound care. Despite the increase in recognition of wound hygiene as a four-step protocol, many definitions for wound care terminology evolve as clinical understanding grows and new wound care protocols continue to emerge.¹

Understanding key terminology is vital for health care treatment plans, and wound care is no exception. Therefore, the following terms are discussed as they relate to wound hygiene and related concepts^1-4:

• Biofilm: Wound biofilm is a complex growth of different species of microorganisms, which can include bacteria and fungi. Biofilm can cause local, subclinical, sustained, wound infection, but it can also withstand the host’s immune response and be tolerant of antibiotics and antiseptics. Biofilm can form within hours and reach maturity within 48 to 72 hours.
• Chronic wound: Historic definitions characterize the term ‘chronic wound’ as describing a persistent wound that does not heal in a timely fashion due to an aberration within the phases of wound healing. When framing wound healing in an antibiofilm approach, this term is being used less in favor of the term ‘hard-to-heal wound.’
• Complex wound: This type of wound presents with complicating factors, such as medical, clinical, psychological, or socioeconomic, that put the wound at risk of failing to heal, even with acceptable wound care practices.
• Hard-to-heal wound: A hard-to-heal wound presents with multiple factors that may prevent healing. The differentiating aspect of this term lies in the chronology. These challenging factors may be present at any time, meaning a wound can be described as hard to heal from the start. Examples of underlying factors that contribute to classifying a wound as hard to heal include difficult anatomical locations, the presence of biofilm, or minimal response to a treatment plan that incorporates best practices.
• Wound hygiene: This concept promotes approaches to healing for hard-to-heal wounds, and does so with the intent that a wound can be hard to heal early in its course due to issues such as biofilm that can proliferate rapidly. It includes four tasks that should be completed regularly and repeatedly to optimize healing conditions; wound cleansing, mechanical debridement, refashioning of the wound edge, and biofilm-targeted management and prevention.

How to Identify Wound Tissue Types

In addition to the above terms, it’s vital to understand the different types of wound tissue that one might encounter. Each individual wound may contain multiple tissue types. These include the following¹:

• Epithelialization: This tissue type is found when new skin forms on the surface of a wound or along the edges. Epithelialization represents the final stage of wound healing, as this new skin closes the wound. Epithelializing tissue is fragile and may visually appear paler than other areas of skin.
• Granulation tissue: Granulation tissue is healthy tissue, typically with a bright red, shiny, moist appearance. Granulation tissue is a prerequisite for epithelialization.
• Hypergranulation tissue: This tissue type forms due to abnormal wound bed conditions and may extend above the surrounding skin. Hypergranulation may develop for multiple reasons, including in the setting of granuloma, chronic infection, or as a tumor manifestation.
• Necrotic tissue: Necrotic, or devitalized, tissue, nonviable, dead tissue which results from a lack of blood supply (ischemia) to the wound bed or infection. Clinicians will note that necrotic tissue is generally black or brown, and can be either hard, dry, and leathery or have a soft and wet texture. This tissue may firmly or loosely adhere to the wound bed. One should not mistake necrotic tissue for scabbing, crusting, or hematoma.
• Slough: Slough often appears as yellow or white material in the wound bed. Otherwise, it can vary between wet or dry, and thick or thin. Of note, it may be challenging to distinguish slough from anatomic structures such as exposed tendons, joint capsules, and deep-dermal or full-thickness burns.
• Unhealthy granulation: This type of tissue may not appear to be unhealthy, in fact, it appears to be granular but may not be progressing toward healing. The differences may be subtle. Unhealthy granulation tissue is often darker than healthy granulation tissue, although it may still appear pale if blood supply to the wound bed is lacking. These wounds may be friable and bleed easily on contact. This tissue type may also indicate infection, ischemia, untreated pathology, or biofilm.

In a typical healing trajectory, wounds may progress from least viable to most viable (necrotic, slough, granulation, epithelialization), although this pathway is not necessarily linear.¹ Therefore, understanding these definitions, identifying the proper tissue types, and learning about the associated interventions will help clinicians move wounds along a healing pathway. Indication-specific treatment and biofilm-focused approaches at all stages and types of tissue are important for clinicians to know.

Conclusion

The first step to implementing this wound hygiene approach is understanding many of the key terms within its framework. Once the clinician has the adequate vocabulary, they can use these terms in documentation and in clinical decision making to properly choose treatment details within a wound hygiene pathway. Published algorithms exist that outline applicable intensities of cleansing and refashioning wounds, along with appropriate methods of debridement based on tissue type.¹

References

1. Murphy C, Atkin L, Vega de Ceniga M, Weir D, Swanson T. International consensus document. Embedding Wound Hygiene into a proactive wound healing strategy. J Wound Care 2022; 31:S1-S24.
2. Mills JL, Conte MS, Armstrong DG et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on wound, ischemia, and foot infection (Wlfl). J Vasc Surg 2014:59(1): 220-234.e1-2.
3. Health Improvement Scotland. Adapted Waterlow Pressure Area Risk Assessment Chart. 2019. https://tinyurl.com/36n83j5c (accessed November 2022).
4. Evans, K. UpToDate. Overview of treatment of chronic wounds. Wolters Kluwer. 2022. https://www.uptodate.com/contents/overview-of-treatment-of-chronic-woun….

The views and opinions expressed in this vlog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.