Wound Healing
(Non-Healing Wound)

Non-Healing Wounds

Non-healing leg wounds, a persistently challenging issue in medical care, primarily affect the elderly, diabetic patients, and individuals with circulatory problems. These wounds, often chronic in nature, are characterised by their inability to progress through the normal stages of healing in an expected timeframe, typically more than four weeks. This section deals mainly with non-healing wounds in the legs.

Leading Causes of Non-Healing Wounds

Identifying the reason why wounds don’t heal requires an understanding of the multiple underlying causes which can sometimes be due to presence of one or more of the following factors. This list is not exhaustive but covers the most common causes seen in clinical practice, arranged in a rough order of decreasing frequency. It’s crucial to approach each non-healing wound with a thorough approach considering these diverse causes.

Venous Problems

This is the most common cause. It occurs due to poor return of the blood from the legs, leading to pooling of blood in the lower limb. It can result in ulcers (wounds) which can become chronic as a result of increased pressure in the venous system in the legs. Typically, these wounds are painless and are in the ankle region.

Peripheral Neuropathy

Neuropathy in the feet results in poor or lack of sensation in the skin. Patients with neuropathy are more prone to injury which may lead to an ulcer (wound) because they do not notice their foot has been injured. Diabetes is the leading cause of neuropathy, but other causes are Vitamin (especially B12) deficiency and excessive alcohol intake. Neuropathy can put extra strain on the muscles and the joints in the foot leading to increased pressure and strain which then exacerbate the neuropathy.

Peripheral Arterial Disease (PAD)

Wounds (ulcers) can occur as a result of inadequate arterial blood supply to the legs. Typically these wounds are painful and are in the foot and the toes. See section on Lower Limb Arterial Disease for further information.

Wounds (Ulcers) due to Pressure

These result from sustained pressure, particularly in immobile patients, disrupting blood flow and causing skin injury. They typically occur in the heels being in constant contact with the mattress in unconscious or patients too weak to mobilise.

Chronic Oedema (Leg Swelling)

Chronic heart failure, renal disease, and lymphatic problems can lead to increased swelling in the skin and underlying tissues and increased pressure. This can lead to small breaks in the skin which over time may become larger.

Infection

Chronic or recurrent infections, including bone infection (osteomyelitis) or cellulitis (infection in the skin), can cause wounds which may be slow to heal.

Nutritional Deficiencies

Particularly deficiencies in protein, vitamin C, and zinc can both cause wounds and delay their healing.

Poor Immunity

Due to chronic diseases (e.g., infections, HIV/AIDS), chemotherapy, or chronic steroid use, can lead to wounds which may be slow or non-healing.

Cancer

Skin cancers can sometimes present as non-healing wounds. Common examples are squamous cell carcinoma or basal cell carcinoma masquerading as non-healing wounds. Chronic non-healing wounds may also turn cancerous (Marjolin’s ulcers).

 

Autoimmune Disorders

Such as vasculitis or systemic lupus erythematosus, causing ulceration through small vessel damage.

Radiation Therapy

Radiation therapy for cancer can lead to wounds (ulcers) due to poor blood supply and scarring. See section on Vasculitis, Connective Tissue Diseases, and Raynaud’s.

Excessive Steroid Use

Prolonged use leading to skin thinning and poor healing capacity.

Connective Tissue Disorders

Such as scleroderma or Ehlers-Danlos syndrome, affecting skin integrity and healing. See section on Vasculitis, Connective Tissue Diseases, and Raynaud’s.

Investigations into non-healing leg wounds involve a comprehensive approach. Initially, a thorough medical history and physical examination are undertaken to understand the wound&its duration, previous treatments, and any underlying health conditions. Blood tests may be conducted to check for diabetes, infection, and nutritional deficiencies that could impede healing.


Imaging studies, such as Doppler ultrasound, are crucial for assessing blood flow and the condition of the arteries and veins. A wound biopsy might be performed to rule out malignancy or specific infections. In diabetic patients, regular monitoring of blood sugar levels is imperative.

Management of non-healing leg wounds necessitates addressing the underlying causes. For wounds related to poor circulation, procedures to improve blood flow, such as angioplasty, may be required. In diabetic patients, stringent blood sugar control is essential. Local wound care, including debridement, appropriate dressings, and possibly the use of advanced therapies like negative pressure wound therapy or skin grafts, plays a pivotal role. In all cases, preventing infection and managing any existing infection is crucial.


In conclusion, non-healing leg wounds are a multifaceted problem requiring a multidisciplinary approach for effective management. Early diagnosis and comprehensive treatment addressing the root causes are key to improving outcomes for patients suffering from these challenging wounds.