The Globalisation of Wounds, Burns, Ulcers and Related Injuries: Threatening the Intactness of the Skin1

The prevalence of wounds globally can only be guessed at. Figures exist only for some of the problems addressed even for individual countries and are most often hospital based. It is known that some wounds are alarmingly highly prevalent such as those from land mines, road accidents, burns, pressure ulcers, leg ulcers, diabetic foot ulcers and the breakdown of the tissues from infections either because of virulent organisms or due to loss of immunosurveillance as in AIDS.

One would like better data if only to convince governmental agencies that resources are needed but, as stated in discussions on evidence-based medicine, case histories are compelling. This topic of wounds uses a language and illustrative material that is instantly understood by all.

In assessing global needs it is appropriate to address prevention, first aid, measurement, repair and regeneration, disability impairment and handicap and palliative care.

The causes of delayed healing in the wound or in the host and the problems of access to care show geographical variation and there is a great difference from what happens to a wound in a rural village of the developing world and a wound care unit in a major hospital in a well resourced city. This is partly due to the availability of trained manpower, the optimal care being provided by a team of experts. The availability of funds influences all aspects of management. The “expert” team is very expensive, they will use a range of technology not often available to the poor. Under the heading of poverty (or no resources available), one must select low technology locally and sustainably 2available at low cost. One must also remember that there are several systems of medicine in the world and integrated medicine is a desirable objective.

There must be investment in education in order to influence the management of all wounds and problems such as pressure ulcers in hospitals or leg ulcers in the community. Such education must be to all in health care.

The point of emphasizing prevention in this review is to suggest that experts can have the greatest effect by aggressively giving good advice to governance who, being usually non-medical, cannot be expected to know without being told. Similarly constant review of dogma by experts is necessary to ensure gold standards are understood and appropriate technology is under constant review for the educational needs of manpower down to the level of self help.

Access to first aid like access to care in general has acquired information technology and the mobile phone. These are increasingly available down to village level. In the authors experience it is not always the wound itself that is the main threat to life. Hypothermia in the sea or air or on a mountain side is a threat to the wounded that can be prepared for and prevented quite cheaply with a little advanced thinking.

Some aspects of recent aspects of measurement use low technology. Thus better management of pain in an ulcer has resulted from recording terms such as continuous, intermittent, at night, when dressings changed, localised or nonlocalised, deep or superficial, stabbing or burning.

Many of the causes in the wound are because “nature abhors a space”. The wound edges are separated by space occupying necrotic tissue, a haematoma, a collection of pus, or a foreign body. Inadequate blood supply is a major cause of nonhealing, but in this respect too little attention 4is given to the demands for oxygen by inflammation and repair. The skin at rest, when not in repair mode is undemanding, and a hairless non-sweating, atrophic skin in the atrophic arteriosclerotic limb protected from injury, can survive almost no arterial supply. By contrast, inflammation and repair have to grow a new organ that is granulation tissue that requires a great increase in arterial perfusion well above normal needs.

The general causes of nonhealing include malnutrition, anaemia and neoplasia. There are a few specific to malnutrition such as the non-healing wounds of scurvy or Noma in infancy. The worldwide epidemic of obesity is of course also a malnutrition but its association with diabetes explains a rising incidence of diabetic foot ulcer. Here low technology demands are for simple instruction of foot care and caution about too quickly calling for amputation.

Infection is a cause of wounds and a factor delaying healing. Tropical diseases include the mixed infections of the tropical ulcer, usually of the legs of young men in the wet season. There is the Buruli ulcer due to Mycobacterium ulcerans and the ancient diseases of leprosy and leishmaniasis. Drugs such as steroids and immunosuppressive agents may play parts in healing of all age groups. Genetic disorders of regeneration and repair that survive in utero are rarer, but congenital malformations such as spina bifida are significant causes of severe morbidity. Genetic diseases such as the haemoglobinopathies show geographical variation and in Jamaica for example a leg ulcer in a young adult is likely to be due to sickle cell anaemia. There are often multiple factors at work and a foot ulcer due to neuropathy that leads to immobility may develop ulceration of the leg due to venous disease. Long-term ulceration predisposes to squamous epithelioma and lymphoedema to lymphosarcoma.

Problems of access relate to distance, transport, the ease of access to and the knowledge of the carer and indeed whether any such carer is available. The equipment dressings and devices as well as drugs available and their costs are always a determinant of care. There is also the patient who may vary in concordance and compliance and whose priorities may be determined by a different set of beliefs to the carer.

The classification and increased interest in disability, impairment and handicap has been led by by the World Health Organisation. It has increased the awareness of Quality of Life. No longer is it just the distance walked or manual dexterity that is measured but awareness of how 5welcome those affected are in their community has become a dominant feature of management. It is still, however, only the developed world that activates access to wheel chairs to public buildings. But as recently the disasterous affects of flooding in the Southern States of America or from the Tsunami in Asia has alerted us that it is the poor that are least likely to receive optimal help even in well off locations.

Much patient care in the past depended on the family and this factor is a major variable undergoing rapid global change. Long life and smaller families is one factor but the need for all members of the family to go out to work is another. There is interest in income generation that involves the individual interacting with the community and giving occupation to the retired while still in good health and to the older child as a carer of the youngest is a topic undergoing review.

In all these fields one has to control the attraction of the best resourced activities for the scientist and clinician which are for example the cosmetic or the demands of the pharmaceutical industry or the laboratory investigation of the genome, growth factors and cytokines. In for example the control of obesity world wide it is human behaviour rather than genes that needs moderating. The public health issues of population and influencing behaviour is less well funded. It is also very difficult to influence. Blood supply and wound healing are impaired by smoking but only in a few countries has their been a reduction. Overall in the developing world tobacco marketing is adding increasingly to impairment of healing.

Themes promoted in wound healing laboratories during the last 50 years include the advantages of moist wound healing versus dry, heating versus cooling, foetal versus adult, growth factor stimulated, and vacuum assisted. They have created a large industry that has focused on elite units providing higher technology developments, Several of these have low technology ways of delivering their effects but these are difficult to fund.

Practitioners of biomedicine also fail to give credit to other systems of medicine. There is a huge resource in both the Chinese traditional medicine and the Indian systems of medicine. Not only is this so in numbers available but it is often not realised that the traditional medicine practitioners undergo a long training and have often read standard biomedical texts such as Gray's anatomy. Their skills include acupuncture for anaesthesia and pain control, many antiseptic herbal preparations, and local knowledge that is often helpful in palliative care or in giving a culturally acceptable understanding of the wounds and their management. The Zimbabwe surgeon Salatheil Mzezewa described at the Oxford congress of the European Society of Tissue Repair how a severely burned patient whose straw hut was struck by lightening had little chance of survival until a healer had been brought to his bedside to explain in cultural terms the meaning of the event. Especially in the field of burns management countries such as Vietnam have experience of effective remedies such a frog skin and herbals now backed up by laboratory studies.

Sometimes in the developing world there is a belief that developed world medicines must be best. This is found amongst those indoctrinated by religious organisations who promote traditional as witch doctoring and those who go to secondary school who are told that traditional is unscientific. In promoting the use of Larval therapy for Africa some of us were keen to show efficacy safety and utilization in Europe and the USA so that Africans, who would benefit most, do not think we were offering second best therapy. Now this very low cost provision of huge numbers of meticulous surgeons has its greatest market in Germany with a very good safety record. It is not always appreciated how by comparison the safety profile of developed world drugs is poor. The percentage of hospital admissions because of drug reactions is especially high in the most prestigious hospitals.

Some agents used to heal wounds have a very long history and they also have global availability and utilisation. Laboratory investigation of an agent such as honey has shown how it may work (Preventing water availability to bacteria, low pH, generation of hydrogen peroxide (H₂O₂), the presence of constituents such as flavenoids and interference 7with bacterial genes) but it is not widely promoted by units funded by the Pharmaceutical industry. Other agents such as Gauze are widely used but have not one trial showing anything but that it delays healing.

The provision of artificial legs and wheel chairs in the developing world has to overcome not only the availability of the prosthesis but usually a difficult terrain.

As a dermatologist the author's first commandment is “oil it”. This is because washing and emollients restore the intactness or barrier function of the skin, switch it from repair mode and its demand for oxygen, and reduce entry points which bypass its barrier and immunosurveillance systems.