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Factors delaying wound healing
Many factors have been recognised that reduce or delay healing, the following are identified as some of the main causes for delay in wound healing.

• Poor circulation Delayed healing and tissue breakdown is frequently associated with poor circulation. This may be due to local pressure, vascular disease or diabetes.

• Poor nutrition/malnutrition Nutrition has a significant impact on wound healing. Lack of protein will result in insufficient building blocks for cell regeneration. Deficiency of vitamin C which is essential for collagen synthesis, will delay healing. Zinc deficiency will cause slowing down of epithelialisation and collagen synthesis.

• Drug therapy Anti inflammatory drugs suppress initial inflammatory process. Systemic and topical corticosteroids can suppress both multiplication of fibroblasts and the immune system.

• Immune response Allergy to topical applications, e.g. iodine may delay healing. Irritants and allergens include lanolin (wool alcohols), topical antibiotics, emulsifiers such as cetyl alcohol, rubber, parabens group of preservatives, colophony, fragrance mix or balsam of Peru.

• Age Cell replication is slower (senescence) and the skin’s resistance to injury decreases with increasing age.

• Obesity Adipose tissue has poor vascularity. No known mechanism is responsible for increased infection and wound breakdown in obese surgical patients, but these patients are at high risk of postoperative wound problems.

• Psychological Increases in hormone levels, particularly glucocorticoids (occurring in stress and anxiety for example) may suppress the inflammatory phase and affect healing in both acute and chronic wounds. Reducing stress has been demonstrated to reduce postoperative wound infection.

• Infection Local or systemic infection inhibits healing. Resistance to infection is related to physiological ability and the patient’s physical health. Bacterial toxins are potent inhibitors of healing. Some have more devastating effects than others.

• Moisture Based on the work of Winter (1962) a moist environment allows the optimum environment for healing. Epithelial cells will migrate over living tissue and this process can be delayed by dehydration. A wound surface that has been exposed to air for a lengthy period suffers cellular dehydration, tissue necrosis and increase in wound depth. When a wound has to be exposed for examination by the medical staff cling film can be used to prevent dehydration and help protect and maintain temperature. Most modern dressings have been designed to allow ‘moist healing’. The use of the most appropriate dressing will maintain a moist environment at the wound surface without causing maceration of the surrounding skin. The wound exudate that forms under occlusive dressings is highly bactericidal and prevents infection but in some wounds can be detrimental to healing.

• Temperature The optimum temperature for cellular activity and division is 37ºC. Frequent dressing changes, application of cold solution and leaving the wound exposed can decrease the local temperature.

• Chemical Inappropriate use of chemicals, for example, Eusol or equivalent, dyes or antiseptics, can damage the wound and retard healing. This practice should be discouraged.

• Mechanical Unnecessarily disturbing the wound bed can damage the developing granulation tissue. Inappropriate dressings can also damage the granulation tissue. Mechanical cleansing of the wound is not required.

• Malignancy Malignancy can inhibit healing as can a range of anti-neoplastic therapies

• Local factors Poor surgical technique such as over use of diathermy or poor choice of suturing material are among factors that will delay healing of a surgical wound (Leaper and Gottruo 1998) Poor assessment or some wound care practices may predispose to delayed or non healing. Inappropriate choice of wound dressing, the use of fibre shedding materials like cotton wool or gauze swabs, tight bandaging can all lead to deterioration in the wound.

• General factors Poor assessment of the cause of the wound can lead to inappropriate treatment and this will lead to poor healing.