Roadmap for wound healing

To make progress in wound care we, first of all, have to realise that, even though wound care is clinically focussed on dressings, research is not. This means there is a discrepancy between research and clinical practice. Science provides plenty options and ideas to quickly progress wound healing.

Wound care is about the response of any living organism to a breach in the envelope which divides us from our surroundings. This means wound care actually is a regenerative process the body uses to restore homoeostasis. And it is one of the oldest processes of living systems. Regeneration is a well-regulated process which is divided into four phases: haemostasis, inflammation, proliferation and maturation. This process runs smoothly in almost all wounds. In the rare case a wound does not close or the regeneration process is disturbed it is usually attributable a few general causes; perfusion problems, the immune system or regulation processes are not functioning properly. Most of the time removal of one or several of these processes is sufficient to start the regeneration process.

A biologist knows a well-conserved process implies there are layers and layers of processes stacked on top of each other just to make sure that under any circumstances any breach which expose our inners to the world has to be closed at the shortest possible time.

Scientists from other fields who are entering the life sciences usually first observe the redundancy and robustness of processes in living organisms. This is also one of the main reasons it is so hard to influence wound healing, if you push one way, the system will push you back very quickly. So here is the real reason most wound healing interventions fail, they are simply not able to influence the system.

Now back to why wound care is so very interesting? It is one of the most basic fields, from an evolutionary standpoint it is older than circulation, metabolism or gas exchange. Yet no one has looked into it for the last 50 years so I presume there are some real discoveries waiting to be found.

The initial steps for a roadmap are to discover what processes are actually playing a role in the regeneration of our outer tissues and find out how they are related. Outside of wound care research we are really into researching what is happening in the ageing body. Most problems in wound care however are related to the ageing human. Most “ageing” researchers do not realise a wound not only provides a visible look into what is going on but also a theoretical look on the processes in the body where organisational networks are interacting under stress. All in all we do know how the normal regeneration process runs, we know less about how the regeneration process runs under stressful circumstances. And we know even less about the layering of processes which make regeneration a robust process.

To discover the basic processes and the influence of ageing or stress on them we will have to step up our research with the use of genomics, epi­-genomics, proteomics, lipidomics, metabolomics and what else we have available. All these issues have to be investigated including the biodome.

After that, we may have to ask the help of systems biology to combine the outcomes of all these types of research.

As said above, this is not science fiction but available technology. However, the need is urgent because insurance companies demand and require better underpinning for their expenses. Following our own wound care rules towards evidence, the meta-analyses etc which carry most legal power point in an unfortunate direction.

Therefore, in the meantime it makes sense to use the four levels of wound healing. Each level addresses a different aspect of the regeneration process. Not only does this offer a practical approach and a triage possibility, it also clearly defines the professional domains of people involved in wound healing. The four levels actually function as a sieve.
The level I is about the patient and vigour, level II is about the wound itself, level III is about perfusion and other mechanical aspects related to the wound and level IV is about the regulatory issues. It will be clear to the experienced wound care professional every patient will have to be analysed on these four aspects, In practice most wounds will be in level I and less in level II and so on.

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