Several nutrients, such as arginine, zinc, vitamin A, vitamin E and vitamin C, play a key role in wound healing and preserving tissue viability. However, while current research doesn’t confirm consuming mega doses of any of these minerals or vitamins, there are studies supporting combining adequate amounts of these nutrients in an oral nutritional supplement to facilitate wound healing.

Amino Acid Supply and Wound Healing and Repair

Once the person with wounds is consuming the increased energy requirements needed, protein intake is key to support collagen synthesis and wound contraction. As I have discussed previously, when the body experiences periods of extreme trauma or stress from thermal injury, sepsis, surgery or wounds, conditionally indispensable amino acids become essential. The physiological demands of recovery may result in the need for these conditionally indispensable amino acids to be greater than the body’s ability to produce them. As a result of these demands, the body’s supply of these amino acids (arginine, cysteine, glutamine) must be provided by the diet. Arginine is a donor of nitric oxide, which increases blood flow and also acts as an immune response mediator, promotes collagen synthesis, and transport of amino acids into the cells.

Vitamin C is essential for tissue repair and regeneration, plus it is important for iron absorption and the activation of copper. Both vitamins C and E are antioxidants that counteract oxidative stress. Zinc is also an antioxidant and has many functions including promoting protein synthesis and cellular growth. Copper is vital for the crosslinking of collagen fibers to rebuild tissue.

Several large, multicenter, randomized placebo-controlled studies, one focusing on malnourished individuals and one on non-malnourished individuals with stages III, IV or multiple pressure ulcers, reported improved healing rates with a concentrated enriched nutritional supplement. The concentrated oral supplement offered in the treatment group for both studies was a high protein, arginine-enriched nutritional drink with 20g of protein, 3g L-arginine, 250mg of vitamin C, 38mg of vitamin E, 9mg of zinc, and 675mcg of copper per 200ml. 200ml was offered three times a day in the non-malnourished study and 100ml was offered four times a day in the malnourished study. The supplement was offered between meals and in both studies the pressure ulcer size was significantly reduced earlier in the group consuming the fortified, enriched drink versus those who drank the high protein supplement in the control group. The individuals in both studies received standard wound care plus the supplements. Both studies concluded that the efficacy of these nutrients in wound healing is likely synergistic because there is no evidence supporting an independent effect when given alone.

Pressure Ulcer Guidelines and Supplements

The NPUAP, EPUAP, PPPIA Pressure Ulcer Prevention and Treatment Guidelines evaluated the research and published the following recommendation: Supplement with high protein, arginine and micronutrients for adults with a pressure ulcer Category/Stage III or IV or multiple pressure ulcers when nutritional requirements cannot be met with traditional high calorie and protein supplements. (Strength of Evidence B)

As noted, the high protein, arginine and micronutrient supplement should not be the first option considered for an individual with a pressure ulcer, but is an option to consider when considering an algorithm of nutritional interventions. First consider offering a diet increased in calories and protein to meet the individual’s needs (30-35kcal/kg of body weight and 1.2-1.5g protein/kg of body weight). When nutritional requirements cannot be met with diet alone, then consider adding a high protein, high calorie supplement between meals. When the individual has a stage III or IV or multiple pressure ulcers and you still cannot achieve the nutritional requirements, this may be the time to consider a high protein, arginine and micronutrient supplement. Remember: supplements are designed to supplement the diet—not replace the diet—so always offer them between meals and not with a meal.

References
1. van Anholt, R., L. Sobotka, E. Meijer, et al. (2010). "Specific nutritional support accelerates pressure ulcer healing and reduces wound care intensity in non-malnourished patients." Nutrition 26(9):867-72.
2. Cereda E, Klersy C, Serioli M, Crespi A, D’Andrea F; for the OligoElement Sore Trial Study Group. A Nutritional Formula Enriched with Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers: a Randomized, Controlled Trial. Ann Intern Med 2015; 162(3):167-74.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Advisory Panel and the American Dietetic Association's Unintentional Weight Loss work group.