Debridement and advanced wound care

Complex and non-healing wound care in Puerto Vallarta

A wound that has not closed in the time it should is rarely a problem of the skin alone. Underneath there is usually dead tissue, infection, high blood sugar or poor circulation keeping it open. The visit looks at both the wound and the reason it is staying open, and treats what needs treating: debridement, dressing changes, control of blood sugar and, when it is needed, surgery.

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When a wound stops behaving like an ordinary wound

A wound that is healing normally improves week by week: it gets smaller, drains less and hurts less. These signs mean something is holding it back, and it should be looked at:

• A surgical wound has opened, partly or completely, when the stitches came out or even before.
• Cloudy fluid or pus is draining from it, or the wound smells bad.
• The redness around it is spreading, the pain is getting worse instead of easing, or there is fever.
• A sore on the foot, heel or leg that has gone weeks without getting any smaller.
• A black scab or yellowish tissue stuck to the base of the wound that dressing changes do not lift.
• Skin on the leg that is hard, darkened and swollen, with an ulcer that opens and closes over and over.
• In someone with diabetes, a foot injury that does not hurt: the absence of pain does not make it minor.

When specialized treatment is needed

Some signs should not wait for an appointment: fever with chills; redness that spreads over a matter of hours; pain far out of proportion to the wound; new blisters or purple or black patches of skin; swelling that grows quickly; a crackling or bubbling feeling under the skin; blood sugar that suddenly goes out of control; or feeling generally unwell and confused. The same goes for a surgical wound that drains enough fluid to soak through the dressing, splits open suddenly, or opens far enough that you can see tissue coming through it. In any of those situations, go to an emergency room instead of waiting for an office visit. Outside of those situations: a wound is called chronic when it does not move through the normal stages of healing in the time it should, despite the care it is getting. A surgical wound that opens (dehiscence) or gets infected needs to be examined, not simply re-dressed. A surgical site infection usually shows up in the first days after an operation, though it can appear up to a month later, and later still if mesh or an implant was placed, and it often has to be opened, drained and cleared of tissue that is no longer viable. Leg ulcers and foot wounds in people with diabetes work the same way: two questions come before any decision about treatment, whether enough blood is reaching the area and whether infection is involved. That is why the assessment includes checking the pulses and studying the circulation with an ankle-brachial index, or with toe pressures, which are more reliable when the arteries are calcified, something common in diabetes and in kidney disease, along with a look at blood sugar control and nutrition. If the circulation is poor, dressing changes are unlikely to close the wound until blood flow is restored, and that is assessed together with vascular surgery. A wound with no clear explanation, or one that does not respond to correct treatment, may also need a biopsy.

How the wound is managed

Management follows a sequence of steps, and it is adjusted at each visit according to how the wound is responding.

1. The wound is measured and described, its size, depth, the kind of tissue at the base, how much it drains, the state of the edges, and the circulation and sensation in the area are checked. The visit also looks for whatever is holding it back: blood sugar out of range, infection, pressure on the area, poor nutrition, smoking, medications. If there is reason to think the infection has reached bone, or that the wound does not fit a usual cause, imaging or a biopsy is ordered.
2. Removing the dead tissue, the scab and the fibrinous material covering the wound. This is one of the steps that counts most in preparing the wound bed: as long as non-viable tissue stays, the wound rarely progresses and infection has somewhere to hold on. It is done in the office under local anesthesia when the extent allows it, and in the operating room when the tissue to be removed is extensive or deep or when the infection is suspected to have reached deeper planes or bone. It usually has to be repeated over several sessions, and you are told which applies in your case, and why, before anything is done. Two things are worth knowing beforehand: it can bleed and can be uncomfortable even with anesthesia, and once the non-viable tissue is gone the wound sometimes looks bigger than it did before, without that meaning it has gotten worse. Not all black tissue comes off right away either: when circulation to the foot or leg is compromised, a dry, firm scab with no signs of infection may be left in place while the blood flow is studied, because debriding it at that point can make the injury worse.
3. An open wound is not necessarily an infected wound; they are different things and are treated differently. When there is infection, any collection is drained and a culture is taken if it is called for. Antibiotics by mouth or by vein are prescribed when the findings justify them, not as a routine, and they are not something to start on your own: taken without an assessment they mask the picture, and they do not take the place of drainage or cleaning when those are what the wound needs. Topical antiseptics are used for a limited time and then reassessed, rather than left on indefinitely.
4. The dressing is chosen according to how much the wound is draining, to keep it moist without macerating the edges, and it changes as the wound changes. A wound left to close by secondary intention is packed from the inside out, and the dressing keeps the skin from closing over the top before the base has filled in. Large or heavily draining wounds may be supported with negative pressure therapy, the kind often called a wound VAC. It does not suit every wound, it does not go over dead tissue, over exposed vessels, nerves or organs, over untreated bone infection or over a tumor, so it is decided case by case.
5. For an ulcer on the sole of the foot caused by loss of sensation, taking the pressure off is usually the first measure, normally with a device that reaches up to the knee, because the wound rarely closes if you keep walking on it; when infection or poor circulation is involved, those are dealt with first and a device that can be removed is chosen instead. In venous ulcers, compression is the basis of the treatment, and arterial disease is ruled out before it is prescribed, because compressing a leg with poor circulation can damage it. Surgery comes in when tissue has to be removed in the operating room, when a wound that is now clean can be closed with a graft or a flap, or when blood flow has to be restored, which is coordinated with vascular surgery. And in some cases, when the tissue can no longer be saved or an infection threatens the limb or life, an amputation, often limited to a toe or to part of the foot, is the procedure that solves the problem and makes it possible to keep the rest.

Blood sugar control and circulation decide whether a wound closes. High blood sugar over time weakens the defense against bacteria and gets in the way of forming collagen and new blood vessels; in people with diabetes, poor control is associated with more surgical wound infections. And if enough blood is not reaching the area, the tissue has little to repair itself with, however careful the wound care is. That is why treatment always works on these two fronts, with internal medicine, endocrinology or vascular surgery when their input is needed. Left alone, they set the limit: dressing changes may hold the wound steady, but they rarely close it.

What to expect during treatment

Closing a complex wound is measured in weeks or months, not days, and how long it takes depends on the person and on the cause, so no date can be committed to at the outset. It heals from the inside out: first the base fills in, then the edges pull together, and last of all the skin covers it. You are seen at regular intervals so the wound can be debrided again if it needs it and the dressing changed as the wound changes; needing several cleanings does not mean the treatment is failing. You are shown how to do the dressing change at home, what you should expect to see, what you should not, and which signs mean you should call or come in before your next appointment. At each visit the wound is measured against the last one, and that is what tells you whether it is progressing. It also has to be said plainly: some wounds do not close despite correct treatment, and some close and open again, and in those cases the diagnosis and the plan are reconsidered. The scar goes on maturing for months after the wound has closed. Once it is closed the work turns to prevention, daily foot checks and suitable footwear if you have diabetes, compression stockings for venous ulcers, blood sugar control, quitting smoking, because these wounds come back easily when the cause is still there.

Frequently asked questions

How long does a wound that was left open take to close?

It depends on the size, the depth and above all on the cause. A wound closing by secondary intention fills in gradually from the base and can take weeks or months; in the same patient, correcting blood sugar that is out of range or a lack of circulation changes that time completely. No one can give you a date at the start or promise a deadline, but at each visit it can be measured whether the wound is getting smaller. If it has not shrunk after several weeks of correct treatment, the diagnosis is reconsidered; and there are wounds that do not close even when everything is done right.

My surgical wound opened. Can it just be stitched closed again?

Sometimes yes, sometimes no; it depends on why it opened and how much time has passed. If it opens within the first hours, the problem is with the closure itself, and there is no infection or damaged tissue, it can be closed again. When there is infection, dead tissue or tension on the edges, re-stitching usually ends in it opening a second time: in those cases the wound is cleaned and left to close from the inside out, and closing it is considered later on. Either way, it is worth being seen soon rather than waiting for your follow-up appointment. And if the wound splits open suddenly, soaks through the dressing, or opens far enough that you can see tissue coming through it, that is an emergency: go in right away.

How do I know if my wound is infected?

Pain that gets worse instead of easing, redness that spreads, the area feeling warmer, drainage that is cloudy or smells bad, and fever all raise the suspicion of infection. A wound being open does not mean it is infected, and clear drainage does not mean it either. Some signs call for an emergency room the same day rather than an office visit: fever with chills, redness spreading within hours, pain out of proportion to the wound, new blisters or purple or black patches, a crackling feeling under the skin, or feeling generally unwell and confused. Starting antibiotics on your own is a bad idea, including any you brought with you or bought over the counter: they mask the picture and do not take the place of drainage or cleaning when those are what the wound needs.

Does a diabetic foot wound always end in amputation?

Not always, and most do not. The outcome depends largely on three things that can be acted on: whether enough blood is reaching the foot, whether there is infection, and whether the pressure on the area can be taken off. That is why being seen early matters so much: a small injury that does not hurt, because the sensation is reduced, can get worse without you noticing. And the full picture has to be given: in some cases, when the tissue can no longer be saved or the infection threatens the limb or life, an amputation, often limited to a toe or to part of the foot, is the treatment that solves it and makes it possible to keep the rest. No outcome can be guaranteed. What can be said is that treating the wound early, with the circulation studied and the blood sugar under control, gives it better conditions to close.

I had surgery back home and the wound opened while I am in Puerto Vallarta. Can you take over the care?

Yes. Wound care that started somewhere else can be continued here, which is common with patients who spend part of the year in Vallarta. Bring whatever you have from the original operation, the operative report, discharge instructions, culture or pathology results, your list of medications, and the dressings you have been using. At the first visit the wound is assessed from scratch, along with the circulation and your blood sugar control, and you leave with a plan: what is done that same day and what has to be checked. Notes in English can be provided for your physician at home, and if you are traveling back before the wound closes, the dressing plan and the handover are prepared ahead of the trip. Patients with major medical expense insurance are seen; whether your own policy covers care in Mexico, and whether it pays directly or reimburses you afterward, is something to confirm with your insurer before the visit.

Is there a cream or ointment that will heal a wound that will not close?

No ointment closes a chronic wound by itself, and some of the products used out of habit, hydrogen peroxide among them, irritate the new tissue or hide an infection. Over-the-counter antibiotic ointment does not solve it either, and home remedies do not belong on an open wound. What moves a wound forward is removing the tissue that is no longer viable, keeping the right level of moisture with the dressing that suits that wound at that moment, controlling infection if there is any, and correcting the underlying cause. The dressing is chosen according to how much the wound drains and is changed as the wound changes; there is no single product that works from beginning to end.

Wound assessment in Puerto Vallarta

If you have a wound that has gone weeks without closing, a surgical wound that has opened, or a foot injury that is not improving, the assessment is done at the office at De Los Tules 168-10, Jardines de Las Gaviotas, in Puerto Vallarta. During the visit the wound is examined, the circulation is assessed and a plan is set out: what is done that same day, what studies are needed, and which other specialties it makes sense to coordinate with. The assessment consultation costs $800 MXN, and patients with major medical expense insurance are seen. Consultations are in English and Spanish. If you have a high fever, redness that is spreading quickly, severe pain, or a surgical wound that opens suddenly, go to an emergency room.

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