Which factors adversely affect wound healing?

Updated: Apr 24, 2020
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
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Answer

In general, factors that adversely affect wound healing can be remembered by using the mnemonic device DIDN'T HEAL, as follows:

  • D = Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and arterial inflow. In addition, even acute loss of diabetic control can affect wound healing by causing diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis.

  • I = Infection: Infection potentiates collagen lysis. Bacterial contamination is a necessary condition but is not sufficient for wound infection. A susceptible host and wound environment are also required. Foreign bodies (including sutures) potentiate wound infection.

  • D = Drugs: Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis.

  • N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc impair normal wound-healing mechanisms.

  • T = Tissue necrosis, resulting from local or systemic ischemia or radiation injury, impairs wound healing. Wounds in characteristically well-perfused areas, such the face and neck, may heal surprisingly well despite unfavorable circumstances. Conversely, even a minor wound involving the foot, which has a borderline blood supply, may mark the onset of a long-term, nonhealing ulcer. Hypoxia and excessive tension on the wound edges also interfere with wound healing because of local oxygen deficits. See, for example, the pressure ulcers shown in the image below.

    Pressure ulcers of the lateral aspect of the right Pressure ulcers of the lateral aspect of the right foot.
  • H = Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit, unrelieved pain, or hypothermia, especially involving the distal extent of the extremities.

  • E = Excessive tension on wound edges: This leads to local tissue ischemia and necrosis.

  • A = Another wound: Competition between several healing areas for the substrates required for wound healing impairs wound healing at all sites.

  • L = Low temperature: The relatively low tissue temperature in the distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites.


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