Cuts, grazes, burns, ulcers, skin tears and surgical wounds all require skin to heal efficiently, properly and fully. Skin provides a mostly impenetrable defence against pathogenic bacteria and everyday allergens, irritants and sensitizers, however when wounded, skin becomes vulnerable, open and susceptible to infiltration.
Skin must repair quickly and fully to avoid serious side effects such as infection, necrosis and potential amputation.
Educated wound care and management is therefore paramount to ensuring an acceptable outcome both from a biological and cosmetic point of view.
During each phase of wound healing, wound management practises differ and it’s important to understand each distinct phase to evolve a care plan which is effective and supportive.
The 5 phases of wound healing
In order to heal fully, skin must undergo 5 distinct processes which happen in order, while also overlapping in timing. Each phase will be biologically initiated in intensity and progression dependent on the severity of the wound i.e. surgical wounds will require a heightened level of each whereas superficial cuts and grazes will require a dampened response.
The 5 distinct phases1 of wound healing are;
Haemostasis is initiated as soon as a wound develops. It is classically recognized as a bleeding wound with excreted blood serving to flush away bacteria and pathogens. This helps immediately clear and cleanse the wound. Once flushed, clotting factors begin to work to coagulate the liquid wound into a clot/scab to seal off the damaged area of skin, reinforce its strength and reseal its barrier properties. Haemostasis is viewed as a protecting step in the wound healing cycle2.
Inflammation usually partners haemostasis and can occur within minutes of injury often lasting up to 3 days post injury. While the most obvious form of inflammation is a raised bruise, reddening of the skin and heat are also key indicators of inflammatory healing mechanisms. Chemical messengers released during wound formation release histamine to cause the vasodilation of local blood vessels. This widening leads to an increased delivery of blood and therefore immune entities into the vicinity of a wound i.e. phagocytes enter to consume dead cells.
Migration signals the beginning of re-epithelization. During the migratory phase epithelial cells (tissue forming cells) and fibroblasts (connective tissue forming cells, e.g. collagen forming) begin to regenerate from the outskirts of a wound. Growing inwards re-epithelization is begun underneath the protectively strengthening scab.
Proliferation can occur in synergy with the migratory phase or just after. Proliferation usually lasts for between 2 to 3 days and signals the development of granulation tissue – a type of new connective tissue with microscopic blood vessels causing its colour to be light pink to dark red. Granulation tissue grows up from the base of wounds to the surface of skin trauma. This process signals the thickening of the epithelium and the development of new supportive collagen networks. Taking up to 2 weeks to progress, the red pink colouration of the proliferation phase begins to subside.
Maturation also known as the remodelling phase is when scar outcome is most influenced and determined. The maturation phase of wound healing involves the creation of many more collagen fibres of different types. Most commonly the initial collagen fibres that are formed – type III collagen fibres are replaced by type I collagen fibres. Collagen produced during migration and proliferation phases is usually disjointed and disconnected. During the maturation phase collagen fibres are realigned while also cross linking to each other, improving the strength and elasticity of new tissue.
How to care for a healing wound
Supporting injured skin during its healing phases can significantly impact the speed, healthy progression and cosmetic outcome of a healing wound. Best care practises help to support all 5 stages of healing by mimicking the same effects biology aims to achieve, for example;
- Clean and disinfect wounds
The initial stage of wound healing, haemostasis aims to flush all dirt and debris from the immediate vicinity. This is a quick yet very important process. Naturally both good and potentially pathogenic bacteria live on top of all skin types in a balanced environment referred to as a person’s microflora. If pathogenic bacteria such as staphylococcus aureus enter and proliferate within wounds, they may significantly delay healing times3, provoke increased levels of inflammation and ultimately lead to more serious conditions such as cellulitis.
How to support effective wound healing; Wounds may be disinfected under running water and following this, with a salt water bath. Care should be taken when applying salt water directly to the wound, a gentle dabbing action should be used to apply the solution across and around affected areas.
- Protect wounds against further invasion
The first few days following injury or skin assault are when wounds are most vulnerable to infection and environmental assault. Healthy skin is resilient against bacteria, viruses, allergens and irritants. Wounded skin is easily infiltrated and deeply vulnerable.
How to support effective wound healing; Applying a breathable covering, bandage or plaster to fresh wounds helps reform a temporary and protective skin barrier.
- Allow wounds air to breathe
Moist tissue takes much longer to heal than dry, clean tissue. The initial stages of wound healing require scab formation. Scabs cannot effectively form if the affected areas are moist or continually wet.
How to support effective wound healing; Ensure any dressings applied to wounds are breathable. Apply dressings to wounded areas of skin only when absolutely required. Apply dressings lightly and delicately and prevent all dressings from becoming wet.
- Supply skin with healing vitamins and minerals
Vitamins such as A, C and E all provide antioxidant and anti-inflammatory effects to skin, both of which are important in the progression of wound healing through proliferation and maturation stages. Vitamins A and C in particular are vital to collagen synthesis4 and formation5. The body’s need for vitamin C also increases during times of injury6 where its presence helps to boost immune function7. Small scale studies show that supplementation with all 3 vitamins helps to improve wound healing outcomes8. Minerals such as zinc and copper play important roles within skins healing processes with deficiencies in each being linked to retarded healing times. Indeed zinc oxide is listed by the FDA as a skin protectant and when combined into a calamine solution, it’s listed by the WHO as an essential medicine.
How to support effective wound healing; Keep areas of proliferating and maturing wounds well moisturised with skincare containing vitamins A, C and E, zinc and copper. Taking an oral supplement with one or a combination of these vitamins and minerals will also help support skins healing processes.Rosehip oil is a natural source of vitamin A and can be found alongside natural vitamin E in the griffin+row Nourish natural skin moisturiser.
Can scarring be reduced with proper wound care?
When areas of skin are deeply wounded or thin, or fragile areas of skin are torn, the risk of scarring is increased. Superficial wounds effect only the top layers of skin i.e. the epidermis and therefore cosmetic alterations are turned over quickly via skins 30 day renewal process. The consequence is a relatively quick healing period followed by minimal cosmetic impact.
When areas of skin such as the dermis are affected, the risk of scarring becomes heightened dependent on the depth of damage, a person’s age, health, nutrition and wound care. While carefully following best practises for wound care will minimize the amount and severity of scarring there are a few further steps which may be taken to improve the cosmetic appearance of healing wounds.
- Use mineral sunblock daily
Mineral sunblock’s are comprised of physical sun-blocking ingredients which are the most sensitive and the least reactive in the presence of UV light. These include zinc oxide, which is already noted as helpful for skins healing processes and titanium dioxide. To protect healing skin, a zinc oxide sunblock is the safest and gentlest option. Exposure to sunlight, specifically UV light can aggravate healing wounds by provoking unneeded inflammation, oxidation and collagen degradation. Healing skin often also causes areas of hyperpigmentation to form, these areas will be exasperated by UV exposure.
How to support minimal scar formation; Use a zinc oxide sunblock daily.
- Use pH balanced skincare
Skin’s pH naturally sits between 4.5 and 6.29 meaning rather than being neutral, skins natural pH levels are acidic. Skin that is healthy and well-nourished heals with better cosmetic outcomes, therefore using skincare which is balanced to skins natural pH levels helps to support cosmetic outcomes. Cleansing often causes skins pH to rise. Over 82% of skin cleansers have a pH in excess of 7, with many soaps often having a pH level of up to 1210. When skins pH is heightened it becomes dry and eczematous with resident healthy microflora finding it harder to adhere11.
How to support minimal scar formation; Use a pH balanced cleanser such as the griffin+row Cleanse, skin cleanser.
- Cleanse skin gently, daily
Oxidative impurities build up upon skin daily as a result of airborne pollution. These non-skin-identical impurities actively age skin by forming damaging free radicals12 and therefore negatively affecting wound healing and scar outcome. The most damaging of airborne particulate matter is invisible to the naked eye, therefore although skin looks clean, there may still be several oxidative impurities caught within skins sebum, pores and hair follicles.
How to support minimal scar formation; Use a pH balanced cleanser suitable for sensitive skin, daily.
- Use of skincare containing these natural extracts
Evidence based dermatological studies for scar improvement to date focus on small scale trials, meaning the results are somewhat inconclusive with further large scale studies being required for a definitive result. What is currently indicated as improving the appearance of scarring is;
- Onion extract (extractum cepae) having both anti-bacterial and anti-inflammatory benefits13.
- Indian Pennywort14 (centella asiatica) indicated to help stimulate cell production and collagen synthesis.
- Almond oil with massage15 to aid the appearance of scars by keeping the skin elastic and hydrated, almond oil is also a rich source of vitamin E.
Skincare ingredients helping to improve cosmetic scar outcomes often have anti-bacterial, anti-inflammatory, anti-oxidative effects alongside benefits of collagen production and stimulation.
How to support minimal scar formation; Keep skin moisturised and supple with use of skincare high in antioxidants and anti-inflammatory ingredients. Moisturisers such as the griffin+row Enrich antioxidant night cream, high in natural almond oil may help in the long term appearance of healing wounds.
Sources and references
- Schultz GS. 1999. Molecular regulation of wound healing. In: BryantRA, editor. Acute and chronic wounds: Nursing management. 2nd edition. St. Louis, MO: Mosby. pp 413–429.
- Martin P. 1997. Wound healing—Aiming for perfect skin regeneration. Science 276: 75–81.
- Gilliland EL. 1988. Bacterial colonisation of leg ulcers and its effect on success rate of skin grafting. Ann R Coll Surg 70: 105–108.
- Ehrlich HP, Tarver H, Hun TK. 1973. Effects of vitamin A and glucocorticoids upon inflammation and collagen synthesis. Ann Surg 177: 222–227.
- Linda M. 1991. Nutritional biochemistry and metabolism with clinical applications. 2nd edition. East Norwalk, CT: Appleton & Lange.
- Pugliese PT. 1998. The skin’s antioxidant systems. Dermatol Nurs 10: 401–416.
- Delafuente JC, Prendergast JM, Modigh A. 1986. Immunologic modulation by vitamin C in the elderly. Int J Immunopharmacol 8: 205–211.
- Porto da Rocha R, Lucio DP, Souza Tde L, Pereira ST, Fernandes GJ. 2002. Effects of a vitamin pool (vitamins A, E, and C) on the tissue necrosis process: Experimental study on rats. Aesthetic Plast Surg 26: 197–202.
- Blank HI, Measurement of pH of the skin surface. J lnvrsl Dermatol 1939;2:67-79.
- Correlation between pH and irritant effect of cleansers marketed for dry skin. Baranda L, González-Amaro R, Torres-Alvarez B, Alvarez C, Ramírez V. Int J Dermatol. 2002 Aug;41(8):494-9.
- Natural skin surface pH is on average below 5, which is beneficial for its resident flora. Lambers H, Piessens S, Bloem A, Pronk H, Finkel P. Int J Cosmet Sci. 2006 Oct;28(5):359-70. doi: 10.1111/j.1467-2494.2006.00344.x.
- Pollution and skin: from epidemiological and mechanistic studies to clinical implications. Krutmann J, Liu W, Li L, Pan X, Crawford M, Sore G, Seite S. J Dermatol Sci. 2014 Dec;76(3):163-8. doi: 10.1016/j.jdermsci.2014.08.008. Epub 2014 Sep 16.
- Block L, Gosain A, King TW. Emerging Therapies for Scar Prevention. Advances in Wound Care. 2015;4(10):607-614. doi:10.1089/wound.2015.0646.
- Mallol J, Belda MA, Costa D et al. Prophylaxis of Striae gravidarum with a topical formulation. A double blind trial. Int J Cosmet Sci 1991; 13: 51–57.
- Ud-Din, S., McGeorge, D. and Bayat, A. (2016), Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. J Eur Acad Dermatol Venereol, 30: 211–222. doi:10.1111/jdv.13223