Why won’t chronic wounds heal? The answer is more than skin deep

Consider these 8 factors affecting wound healing and help improve outcomes.

A patient or resident comes to you with a chronic diabetic foot ulcer. They’re morbidly obese with a body mass index of over 40, they’re diabetic, eat a typical diet of fast food and, upon further assessment, you determine the patient is malnourished.

You’ll manage the wound with topical dressings, but what about the rest? What’s really going on with this individual?

6.5 million

People in the U.S. suffer from chronic wounds1

“In order to properly address the wound, it’s important to conduct a holistic patient assessment, identifying the etiology and the risk factors that may affect the healing trajectory and the goal of healing for the patient,” says Dionie Bibat, RN, MSN, CWOCN, Medline Divisional Manager-Clinical Services Division.

By taking a comprehensive approach to wound healing, you’ll set yourself up for a more successful outcome.

The normal wound healing process

Let’s take a step back with a review of how a wound is meant to heal:

At this early stage, the wound is being closed by clotting. When the skin is injured, blood leaks out of the body, and the blood vessels constrict to try to stop the bleeding.

This second stage of wound healing starts right after the injury, causing blood vessels to dilate and allow white blood cells, growth factors, nutrients and enzymes to reach the wound. A natural process, inflammation both controls bleeding, removes damaged cells and debris and prevents infection. Typically, the individual will experience redness, heat and pain to this area.

Proliferative phase
Now, the wound contracts as new tissue is built, made up of collagen and extracellular matrix.

Generally taking place about 21 days after an injury, this is also called the remodeling stage of wound healing, when the wound is fully closing, and collagen is remodeled. It’s also when collagen fibers cross-link, which reduces scar thickness and also strengthens the skin area of the wound. This process may take up to a year or more, and the healed wound regains about 80 percent tensile strength of unwounded skin.

Acute wounds take this normal trajectory, healing within a fairly predictable timeframe. However, wound healing can be delayed by a variety of both systemic and local factors. That’s when a wound may become chronic.

What happens with a chronic wound

A chronic wound fails to progress through the normal healing process and is typically defined as being stalled for more than 30 days. Typical hard-to-heal wounds include venous leg ulcers, diabetic foot ulcers, arterial ulcers and pressure injuries.

“In order to properly address the wound, it’s important to conduct a holistic patient assessment.”
— Dionie Bibat, RN, MSN, CWOCN, Medline Divisional Manager-Clinical Services Division

The reasons the wound fails to progress could be multifaceted, Bibat explains. In addition, an inadequate assessment may lead to inappropriate treatment. Patient non‐compliance to a care plan can also have a negative impact on healing outcomes.

Biofilm and chronic wounds

“With current research now focused heavily on biofilms, some research is stating that chronic wounds equal chronic infection, and treatment should proceed as such,” Bibat notes.

Understanding the science behind biofilm and treatments to fight it is an important part of the discussion on chronic wounds, as well as acute wounds. Learn more about an innovative strategy to fighting biofilm.

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Local versus systemic factors of wound healing

Local factors are those that can influence the characteristics of the wound. On the other hand, systemic factors involve the state of the wounded person’s ability to heal.

Local factors may be manipulated with the right tools and strategies. For example:

  • Desiccated wounds require hydration.
  • Infected wounds call for treatment of the underlying bacterial burden.
  • Maceration would warrant attention to the periwound to reduce the effects of excess drainage.
  • Necrotic tissue is non‐viable, and you may consider some form of debridement if appropriate for the patient’s goal.
  • Pressure is managed by offloading and repositioning.
  • Tissue trauma can be reduced by protecting the fragile wound bed with appropriate products and techniques.
  • Edema on the lower extremities may call for compression dressings with a provider’s orders.

Systemic factors are more difficult to change, but can sometimes be managed, modified or eliminated to help negate or reduce complications that delay wound healing. These factors include:

  • Age
  • Body type
  • Chronic disease
  • Immunosuppression
  • Radiation
  • Lab values
  • Venous insufficiency
  • Nutritional status

Below, we dig deeper into the systemic factors that affect wound healing.

8 systemic factors of wound healing you need to know

It’s important to know when your patients are at a higher risk for chronic wounds, so you can provide the best care.

1 | Age

While you can’t change the age of your patient, there are some typical characteristics of older patients that may affect wound healing. For instance, older skin is often thinner and drier.

To help: Look for gentle, pH-balanced cleansers, moisturizers and barriers that are free of ingredients such as parabens, sulfate, and phthalates that may dry and irritate the skin.

2 |  Body type

People who are obese or emaciated may or may not signal protein malnourishment. These body types can compromise wound healing because of poor blood supply or low levels of oxygen and nutritional stores.2

To help: While there isn’t a lot to do to change body type immediately, you can collaborate with other specialists, such as a dietician, to encourage changes in lifestyle.

3 | Chronic disease

Studies have shown that many of the body’s natural processes related to inflammation and healing are blocked in people with chronic diseases, such as diabetes.3 Other chronic diseases that may interfere with wound healing include cancer and conditions that affect blood circulation such as coronary artery disease and peripheral vascular disease.

To help: Patients with diabetes and other diseases may need additional follow-up and more aggressive treatment options to help their wounds progress.

4 | Immunosuppression

“Autoimmune disorders and the medications used to combat them, and particularly the use of steroids, can affect the body’s natural inflammatory response,” Bibat notes.

To help: Be sure you know your patient’s medications so you’re aware of their negative effect on wound healing.

5 | Radiation

In people ages 60 and older, cancer rates are more than 1,000 per 100,000 people. Radiation therapy for cancer can cause skin to become dry and peel.

To help: Use gentle skin care with patients who are going through radiation as well as those whose treatment has ended, because damage can last beyond treatment.2

6 | Laboratory values

Laboratory values such as a low hemoglobin level could indicate poor oxygen-carrying capacity of the blood. High white blood cell counts might be due to an infection.2

To help: Be aware of lab results that may mean wound therapies need to be more aggressive.

7 | Venous insufficiency

Untreated venous stasis may stall wound healing because it prevents nutrients in the blood from getting to the wound.

To help: Addressing the underlying cause of venous insufficiency may require refferal to a vascular specialist.

8 | Nutritional status

Poor nutrition can have a negative influence on wound healing because protein is needed for cell growth.2 High wound exudate loss can result in a deficit of as much as 100 grams of protein in one day.5 Such a high protein deficiency can contribute to increased skin fragility, decreased immune function, poorer healing and longer recuperation from illness in older adults.6

There’s no one thing that defines adult malnutrition, but two or more of the following characteristics are an indication:4

  • Insufficient energy intake
  • Weight loss
  • Loss of muscle mass
  • Loss of subcutaneous fat
  • Localized or generalized fluid accumulation that may sometimes mask weight loss
  • Diminished functional status as measured by hand grip strength

Because a person’s external appearance may not tell a reliable internal story, be sure to assess and monitor nutritional levels regularly.

Also, remember that older people who live alone might not be consuming enough nutritional foods or water.

To help: Liquid nutritional supplements can help provide a concentrated source of protein when diet alone isn’t enough.

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Key takeaway

Answering the why of a chronic wound can be a puzzle. Every patient is different, and there are many systemic factors that have a significant impact on the wound healing process. Some factors cannot be modified, but others may be reduced. Knowing your patient’s history and comorbidities can help improve wound healing so you can achieve better outcomes.

More resources to help you manage chronic wounds:
Medline University course: Wound Assessment and Documentation for Nurses (1.0 CE for Nurses)
How to prevent skin breakdown: why you need a holistic approach
Watch the webinar—Management of chronic wounds: Chronic wounds are chronic infections caused by biofilm
What’s on their plate? Learn how proper patient nutrition can improve wound healing
Biofilm-based wound care: tools and strategies to help manage chronic wounds


  1. Sen, C. K., Gordillo, G. M., Roy, S., Kirsner, R., Lambert, L., Hunt, T. K., Gottrup, F., Gurtner, G. C., & Longaker, M. T. (2009). Human skin wounds: A major and snowballing threat to public health and the economy. Wound Repair and Regeneration, 17(6), 763–771. Available at
  2. Thomas Hess, Cathy BSN, RN, CWOCN Checklist for Factors Affecting Wound Healing, Advances in Skin & Wound Care: April 2011 – Volume 24 – Issue 4 – p 192. doi: 10.1097/ Available at
  3. Poor immune response impairs diabetic wound healing. (2020, October 6). National Institutes of Health (NIH). Available at
  4. White JV, Guenter P, et al. Consensus Statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Characteristics Recommended for the Identification and Documentation of Adult Malnutrition (Under-nutrition). JPEN J Parent Ent Nutr. 2012; 36:275-283.
  5. Russell L. The importance of patients’ nutritional status in wound healing. British Journal of Nursing. 2001; 10(6 Suppl): S42,S44-49. Available at:
  6. Chernoff R. Protein and older adults. Journal of the American College of Nutrition. 2004;23(6 Suppl):627S-630S. Available at:

Additional source:

Atkin, L., Bucko, Z., Conde Montero, E., Cutting, K., Moffatt, C., Probst, A.,….Tettelbach, W. (2019). Implementing TIMERS: the race against hard-to-heal wounds. JWC International consensus Document, 28(3). Available at: