Four Stages of Wound Healing | Vohra Wound Physicians (2022)

The complicated mechanism of wound healing occurs in four phases: hemostasis, inflammation, proliferation, and remodelling.

1. Hemostasis

Hemostasis is the first stage in wound healing that can last for two days. As soon as there is a wound on the body, the blood vessels in the wound area constrict to reduce the blood flow. This is known as vasoconstriction. At the same time, clotting factors are released at the wound site to coagulate with fibrin, resulting in a thrombus, which is more commonly known as a blood clot. The clot acts as a seal between the broken blood vessels to prevent blood loss.

2. Inflammation

The second phase of wound healing is called the Inflammatory Phase. It involves phagocytic cells that release reactive oxygen species, lasting for up to seven days in acute wounds and longer in chronic wounds.

During this phase, white blood cells and some enzymes enter the wound area to stave off infection by clearing bacteria and debris and preparing the wound bed for new tissue growth. Physical characteristics of the phase include inflammation or redness at the wound site, edema, heat, and pain.

3. Proliferation

Phase three of wound healing, the Proliferative Phase, focuses on filling and covering the wound. As inflammatory cells undergo apoptosis, wound healing progresses to the proliferation phase, which is characterized by the formation of granulation tissue, angiogenesis (blood vessel formation), wound contraction, and the process of epithelialization.

The new tissue is generally red or pink in appearance due to the presence of inflammatory agents. The time it takes for tissue regeneration depends on the production of collagen proteins by fibroblasts, which is a type of cell found in the connective tissue. This phase of wound healing can last for four days to up to three weeks or more.

4. Remodeling

Scar tissue formation characterizes the final Remodeling Phase (also known as Maturation). It may occur over months or years, depending on the initial severity of the wound, its location, and treatment methods. During this phase, the new tissue gradually becomes stronger and more flexible. Collagen production continues to build the tensile strength and elasticity of the skin. The build-up of collagen in the granulation tissue leads to scar tissue formation, which is 20 percent weaker and less elastic than pre-injured skin.

The four phases of wound healing

The complicated mechanism of wound healing occurs in four phases: hemostasis, inflammation, proliferation, and remodeling. Hemostasis, which occurs just after injury, utilizes clotting factors which prevent further blood loss from the wound site as well as the structural foundation for the future formation of granulation tissue. The subsequent inflammation phase, involving phagocytic cells that release reactive oxygen species, may last for up to seven days in acute wounds and longer in chronic wounds.

As inflammatory cells undergo apoptosis, wound healing progresses to the proliferation phase, which is characterized by the formation of granulation tissue, angiogenesis (blood vessel formation), wound contraction, and the process of epithelialization. The final remodeling phase, characterized by the formation of scar tissue, may occur over a period of months or years, depending on the initial severity of the wound, location, and treatment methods.

Infected wound healing stages

Chronic wounds do not follow the standard progression of wound healing seen in acute wounds, and instead tend to arrest temporarily in one of the wound healing phases (most commonly the inflammation phase). The healing process of an infected wound may also be prolonged compared to that of a non-infected wound. In infected wounds, pathogenic organisms enter the wound tissue and disrupt normal skin flora, leading to increased inflammation and damage of sensitive new tissue growth.

While some infected wounds may resolve without intervention, in order to accelerate the wound healing process and ensure further complications (such as cellulitis, osteomyelitis, or septicemia) do not occur, infected tissues should be treated as soon as possible. Treatment of an infected wound differs in some ways from that of a non-infected wound, as it involves eliminating the infection with oral or topical antibiotics, draining or debriding the wound to remove dead tissue, and applying antimicrobial dressings.

Granulation tissue, composed of endothelial cells, capillaries, keratinocytes, and fibroblasts, is also an important component of wound healing. This connective tissue can provide important indicators of wound healing progress; pink granulation tissue is considered to be healthy and a sign that healing is progressing normally, while dark red tissue may be a sign of infection. Bacterial Overgrowth of granulation tissue, characterized by a white or yellow film, is seen occasionally in infected wounds and must be removed before healing can continue.

Wound healing is a multifactorial process involving blood cell coagulation, inflammatory cell response, and granulation tissue formation. Several factors and conditions may contribute to the occurrence or persistence of a chronic wound, such as weakened immune function, comorbidities, venous insufficiency, and lack of proper circulatory function.

The immune system plays an integral role in wound healing by mobilizing stem cells, promoting cell differentiation, and stimulating growth factors which ultimately result in neoangiogenesis, or the formation of new blood vessels. When immune activities are disrupted through medications or comorbidities, the process of wound healing may become stalled, leading to persistent or chronic wounds.

(Video) Stages of Wound Healing in 2 mins!

Factors that affect wound healing

There are several factors that may impair the wound healing process, including: the pre-existing integrity of the wounded skin due to age or medical treatments, comorbidities, medications, infection, hydration state, nutritional status, lifestyle habits, and pre- and post-operative care if surgery has occurred.

Relevant comorbidities, medications, and lifestyle factors include:

  • Diabetes: A common complication associated with diabetes is peripheral neuropathy leading to foot ulceration. An additional complication is peripheral ischemia secondary to peripheral artery disease. Both complications affect the proliferative phase of healing and lead to the overall slowing of wound healing.
  • Obesity: Obesity is associated with an increased risk of ischemia and inadequate tissue oxygenation, which may lead to slowed wound healing or necrosis.
  • Necrosis: Unplanned tissue death is another factor that may impede wound healing, requiring debridement to remove the affected tissue surgically before healing can proceed.
  • Poor nutrition: Malnutrition (seen frequently in elderly patients), specifically inadequate protein intake, can lead to decreased blood vessel formation, collagen production, and fibroblast proliferation, which ultimately slows the wound healing process.
  • NSAIDs (non-steroidal anti-inflammatory drugs): The mechanism of pain reduction by NSAIDs occurs through the inhibition of PGE2, an inflammation mediator. NSAIDs are known to slow wound healing through the halting of angiogenesis. NSAIDs also increase scar formation, particularly if used during the proliferative phase.
  • Steroids: The anti-inflammatory and immunosuppressive effects of steroids can hinder wound healing by decreasing fibroblast proliferation and collagen production.
  • Radiation therapy: Ionizing radiation beams can damage epithelial cells as they pass through to targeted tissues, causing skin tissue breakdown and slowed healing of existing and new wounds.
  • Chemotherapy: Chemotherapeutic agents affect wound healing by delaying the inflammatory phase of healing and decreasing collagen production.
  • Smoking: Cigarette smoking, specifically the use of nicotine, affects blood flow by causing vasoconstriction. Nicotine also decreases the body’s immune response, which could lead to an increased likelihood of wound infection.
  • Alcohol: Alcohol intake is often associated with poor nutritional habits, which may result in decreased immune function. In addition, alcohol may impair wound healing by decreasing angiogenesis and collagen formation, leading to weaker scar tissue formation and an overall slower healing process. Wound healing may also be positively impacted by the addition of certain supplements such as zinc and vitamin C.

How chronic and acute wounds heal

While acute wounds typically follow the normal healing process of hemostasis, inflammation, proliferative tissue regrowth, and tissue strengthening through remodeling, chronic wounds tend to progress through the healing process at a slower pace. Healing of a chronic wound may arrest for several weeks in one of the four phases–most commonly the inflammatory phase.

There are several known factors that affect the mechanism of chronic wound healing. These factors include: the presence of inflammatory cytokines or growth factors, infection at the wound site, formation of a biofilm over the surface of the wound, hypoxia (often associated with cardiovascular, pulmonary, and vascular diseases), and a nutrient-poor diet.

Research suggests various methods to accelerate the wound healing process, such as ensuring adequate sleep to minimize the effect of pro-inflammatory cytokines, adding nutrient-rich foods to a patient’s diet (foods that contain vitamin A and zinc are particularly helpful), avoiding cigarette smoking, and regularly cleaning and dressing the wound.

Once a wound has healed and begun the scarring process, the American Academy of Dermatology recommends applying petroleum jelly to the wound site to minimize dehydration of the scar and surrounding tissue, as well as applying sunscreen to the site daily to reduce hyperpigmentation associated with scar tissue.

Vohra Wound Physicians is the forefront of management and treatment of chronic and acute wounds

As the elderly population rises, the need for wound care physicians will continue to grow appreciably. Vohra Wound Physicians is the nation’s largest and most trusted wound care physician group and is rising to meet that need. Vohra provides wound care services to over 3000 skilled nursing facilities (SNFs) across the United States and serves as a leading informational source for providers, emerging research, and novel therapies in the field of wound care.

(Video) Wound Healing - Fundamentals of Nursing Principles & Skills - @Level Up RN

As the leader in post-acute wound care, Vohra provides both bedside and telemedicine wound care treatment and management solutions to nurses, physicians, Skilled Nursing Facilities and patients. Physicians considering a career in wound care are invited to explore our open opportunities.

The Vohra@Home Patient Care Program allows physicians to provide telehealth services for patients with both acute and chronic wounds, such as pressure ulcers, diabetic foot wounds, and venous ulcers. This advanced telemedicine platform gives patients and home health caregivers the opportunity to readily access physician consultations to discuss any and all aspects of their treatment.

Nurses also have the opportunity to advance their careers and earn CNE credits by obtaining a Vohra Wound Care Certification, which provides knowledge, skills, and training in chronic and acute wound care (including infected and/or necrotic wounds) for geriatric populations. Learn more about how Vohra is setting the standard in the new world of healthcare.

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FAQs

What are the 4 wound healing stages in order? ›

Wound healing is classically divided into 4 stages: (A) hemostasis, (B) inflammation, (C) proliferation, and (D) remodeling. Each stage is characterized by key molecular and cellular events and is coordinated by a host of secreted factors that are recognized and released by the cells of the wounding response.

How do wounds heal 4 stages of healing? ›

When the skin is injured, our body sets into motion an automatic series of events, often referred to as the “cascade of healing,” in order to repair the injured tissues. The cascade of healing is divided into these four overlapping phases: Hemostasis, Inflammatory, Proliferative, and Maturation.

What are 4 components of a wound assessment? ›

Tissue Loss. Clinical appearance of the wound bed and stage of healing. Measurement and dimensions. Wound edge.

What are the 4 classifications of wounds? ›

Definition/Introduction
  • Class 1 wounds are considered to be clean. They are uninfected, no inflammation is present, and are primarily closed. ...
  • Class 2 wounds are considered to be clean-contaminated. ...
  • Class 3 wounds are considered to be contaminated. ...
  • Class 4 wounds are considered to be dirty-infected.
28 Apr 2022

What are the 4 stages of pressure ulcers? ›

These are:
  • Stage 1. The area looks red and feels warm to the touch. ...
  • Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. ...
  • Stage 3. The area has a crater-like appearance due to damage below the skin's surface.
  • Stage 4. The area is severely damaged and a large wound is present.

Does drinking alcohol affect wound healing? ›

The derangements of the inflammatory response in the presence of alcohol consumption adversely affect the process of wound healing. Many aspects of the inflammatory response are essential to proper healing of dermal wounds, potentially providing multiple therapeutic targets.

What are the 3 main stages of wound healing? ›

Three Stages of Wound Healing
  • Inflammatory phase – This phase begins at the time of injury and lasts up to four days. ...
  • Proliferative phase – This phase begins about three days after injury and overlaps with the inflammatory phase. ...
  • Remodeling phase – This phase can continue for six months to one year after injury.

Does itching mean healing? ›

Does itching mean healing? There's an old wives' tale about knowing that your wound is healing because it itches. This is one piece of folklore passed from generation to generation that's supported by science. Research over the years has shown that wounds both big and small tend to itch when they're healing.

What are the types of wound healing? ›

There are three categories of wound healing—primary, secondary and tertiary wound healing.

What are the 4 types of injuries of the skin? ›

Cuts, lacerations, gashes and tears.

These are wounds that go through the skin to the fat tissue.

What are the three 3 most common types of wound infections? ›

Infections after surgery are caused by germs. The most common of these include the bacteria Staphylococcus, Streptococcus, and Pseudomonas.

What are the 5 types of wound? ›

Types of Wounds
  • Puncture wounds.
  • Surgical wounds and incisions.
  • Thermal, chemical or electric burns.
  • Bites and stings.
  • Gunshot wounds, or other high velocity projectiles that can penetrate the body.

What is the final stage of wound healing? ›

The last stage of wound healing is the maturation stage, sometimes called the remodeling stage. The goal of this stage is to strengthen the repair. Even if your wound is closed and looks healed at the end of the proliferative stage, it takes time for the skin to become strong and more flexible.

What is the first stage of the healing process? ›

The first stage of wound healing is for the body to stop the bleeding. This is called hemostasis or clotting and it occurs within seconds to minutes after you suffer a wound. During this phase the body activates its emergency repair system to form a dam to block the drainage and prevent too much blood loss.

What are the principles of wound healing? ›

All dermal wounds heal by three basic mechanisms: contraction, connective tissue matrix deposition and epithelialization. Wounds that remain open heal by contraction; the interaction between cells and matrix results in movement of tissue toward the center of the wound.

What are the 4 stages of skin breakdown? ›

Stage 1 ulcers have not yet broken through the skin. Stage 2 ulcers have a break in the top two layers of skin. Stage 3 ulcers affect the top two layers of skin, as well as fatty tissue. Stage 4 ulcers are deep wounds that may impact muscle, tendons, ligaments, and bone.

What does a stage 4 wound look like? ›

What Do Stage 4 Bedsores Look Like? Characterized by severe tissue damage, a stage 4 bedsore is the largest and deepest of all bedsore stages. They look like reddish craters on the skin. Muscles, bones, and/or tendons may be visible at the bottom of the sore.

Can Stage 4 bedsores heal? ›

These wounds need immediate attention, and you may need surgery. Recovery time: A Stage 4 pressure sore could take anywhere from 3 months or much longer, even years, to heal.

What causes a wound not to heal? ›

Factors that can slow the wound healing process include: Dead skin (necrosis) – dead skin and foreign materials interfere with the healing process. Infection – an open wound may develop a bacterial infection. The body fights the infection rather than healing the wound.

Which cream is best for wound healing? ›

Elastoplast Wound Healing Ointment can be used at any stage of the healing process on superficial open wounds and damaged skin. A moist healing environment has been clinically proven to aid and speed up the natural wound healing process.

What deficiency causes slow wound healing? ›

Vitamin C has many roles in wound healing, and a deficiency in this vitamin has multiple effects on tissue repair. Vitamin C deficiencies result in impaired healing, and have been linked to decreased collagen synthesis and fibroblast proliferation, decreased angiogenesis, and increased capillary fragility.

What are the phases of wound healing quizlet? ›

Match
  • Hemostasis.
  • Inflammation.
  • Proliferation.
  • Maturation.
  • Remodeling.

What are the 5 factors that delay wound healing? ›

Wound healing can be delayed by factors local to the wound itself, including desiccation, infection or abnormal bacterial presence, maceration, necrosis, pressure, trauma, and edema.

When should you stop covering a wound? ›

Leaving a wound uncovered helps it stay dry and helps it heal. If the wound isn't in an area that will get dirty or be rubbed by clothing, you don't have to cover it.

How long does it take for a deep wound to heal? ›

How long it takes to heal a wound depends on how large or deep the cut is. It may take up to a few years to completely heal. An open wound may take longer to heal than a closed wound. According to Johns Hopkins Medicine, after about 3 months, most wounds are repaired.

Why does my wound hurt more at night? ›

"We know that the actin filaments are very important in allowing cells to move." As a result of these changes, the fibroblasts travel to the site of the injury more slowly at night, when the actin is mostly spherical.

What are the 3 main stages of wound healing? ›

Three Stages of Wound Healing
  • Inflammatory phase – This phase begins at the time of injury and lasts up to four days. ...
  • Proliferative phase – This phase begins about three days after injury and overlaps with the inflammatory phase. ...
  • Remodeling phase – This phase can continue for six months to one year after injury.

What are the 5 types of wounds? ›

The five types of wounds are abrasion, avulsion, incision, laceration, and puncture.

What are the 3 types of wound healing? ›

Primary healing, delayed primary healing, and healing by secondary intention are the 3 main categories of wound healing.

What is correct order of the steps of tissue repair? ›

The complicated mechanism of wound healing occurs in four phases: hemostasis, inflammation, proliferation, and remodeling.

What is the final stage of wound healing? ›

The last stage of wound healing is the maturation stage, sometimes called the remodeling stage. The goal of this stage is to strengthen the repair. Even if your wound is closed and looks healed at the end of the proliferative stage, it takes time for the skin to become strong and more flexible.

What are the principles of wound healing? ›

All dermal wounds heal by three basic mechanisms: contraction, connective tissue matrix deposition and epithelialization. Wounds that remain open heal by contraction; the interaction between cells and matrix results in movement of tissue toward the center of the wound.

What is the first stage of the healing process? ›

The first stage of wound healing is for the body to stop the bleeding. This is called hemostasis or clotting and it occurs within seconds to minutes after you suffer a wound. During this phase the body activates its emergency repair system to form a dam to block the drainage and prevent too much blood loss.

What are the 7 types wounds? ›

Types of Wounds
  • Penetrating wounds. Puncture wounds. Surgical wounds and incisions. Thermal, chemical or electric burns. Bites and stings. Gunshot wounds, or other high velocity projectiles that can penetrate the body.
  • Blunt force trauma. Abrasions. Lacerations. Skin tears.

What are the three 3 most common types of wound infections? ›

Infections after surgery are caused by germs. The most common of these include the bacteria Staphylococcus, Streptococcus, and Pseudomonas.

When should you stop covering a wound? ›

Leaving a wound uncovered helps it stay dry and helps it heal. If the wound isn't in an area that will get dirty or be rubbed by clothing, you don't have to cover it.

What are the 4 methods of wound closure? ›

Wounds can be closed primarily in the emergency department (ED) by the placement of sutures, surgical staples, skin closure tapes, and adhesives.

What are the three most common wound complications? ›

Although not an all-inclusive list, some of the more common complications include infection, tissue necrosis and gangrene, periwound dermatitis, periwound edema, osteomyelitis, hematomas, and dehiscence.

What are the 4 stages of inflammation? ›

The four cardinal signs of inflammation are redness (Latin rubor), heat (calor), swelling (tumor), and pain (dolor). Redness is caused by the dilation of small blood vessels in the area of injury.

What are the phases of wound healing quizlet? ›

Match
  • Hemostasis.
  • Inflammation.
  • Proliferation.
  • Maturation.
  • Remodeling.

Which of the four major tissue types is able to regenerate and repair quickly when injured? ›

Muscle has a rich blood supply, which is why it is the fastest healing tissue listed above. The circulatory system provides all tissues with nutrients and oxygen – both of which enable the tissue to heal. Because muscle gets lots of blood flow, it has a good environment for healing.

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