Immunocompromised patients represent a significant challenge to wound care. A well-functioning immune system is considered essential for optimum wound healing. The absence of a functional immune system is a well-documented risk factor for delayed wound healing. Prolonged infections, sepsis, and hypothermia are feared complications in immunocompromised patients which negatively impact wound healing outcomes.

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Wound care specialists and podiatrists need to be aware of the specific challenges and best practices involved in providing wound care to immunosuppressed patients. This article provides an overview of wound care principles that clinicians should keep in mind when treating immunocompromised patients.

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How Immunosuppression Delays Wound Healing?

A competent immune system plays a crucial role in the orchestration of normal wound healing. Tissue injury results in the immediate recruitment of immune cells at the wound site, which later drive the various complex processes involved in the restoration of skin integrity. 

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Cells of both the innate and adaptive immune systems have been implicated in wound healing physiology. Innate immune cells include neutrophils, macrophages, and dendritic cells while T and B cells constitute the adaptive immune system. Neutrophils are the first-line responder to any tissue injury, and protect the wound against bacterial invasion. Macrophages, another cell type of the immune system, have a well-documented role in wound healing. They play a critical role in promoting angiogenesis and fibroblast proliferation during wound healing.

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Several conditions can impair the functioning of immune cells. Some of these conditions include diabetes mellitus, HIV/AIDS, cancer, autoimmune disorders, the use of immunosuppressant drugs, and organ transplantation. Therefore, patients with these conditions experience a significant delay in wound healing.

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Principles of Wound Care In Immunocompromised Patients

Despite the perceived challenge of treating chronic wounds in immunocompromised patients, there is a lack of available clinical guidelines that can help wound care specialists and podiatrists provide a structured treatment. Therefore, clinicians need to rely on their clinical judgment to make the best treatment choice for their patients. 

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Following wound care principles should be kept in mind when providing care to immunocompromised patients:

• Aseptic technique

Immunocompromised patients are at an increased risk of infections. Therefore, it is essential to follow the aseptic technique when providing wound care to these patients. Aseptic technique refers to the use of sterilized equipment and sterile gloves when dealing with wounds. The skin surrounding the wound is cleaned with disinfectants and covered with sterile drapes. Following proper aseptic techniques can significantly reduce the risk of wound infection.

• Selection of appropriate wound dressing

The choice of wound dressing depends upon the individual characteristics of the wound. An ideal wound dressing should keep the wound moist, and free from external contaminants, infections, and physical damage. Wounds should be kept clean using irrigation. It is important to keep in mind that excessive wound moisture results in maceration which can increase the susceptibility to wound infection. Therefore, the selected dressing should maintain an optimum moisture balance in the wound bed. Suitable dressings include foams, hydrocolloids, and alginate dressings.

• Continual wound assessment

A continual and regular assessment of wounds is essential to detect early degenerative changes. Through regular assessment, wound care clinicians can determine the stage of wound healing. Different dressing types are appropriate for different stages of healing, so regular wound assessment and evaluation can help clinicians modify wound dressings accordingly. 

• Use of antimicrobial and antibiotic agents

Immunocompromised patients are at an increased risk of infection. All wounds, regardless of etiology, are susceptible to bacterial contamination. The clinical signs and symptoms of wound infection might be less apparent in immunocompromised patients. Therefore, clinicians should obtain regular wound swabs and monitor the antimicrobial sensitivity profiles of these patients. This will allow wound care specialists to provide empirical antibiotic therapy that is tailored to the wound culture results. 

• Nutrition

Adequate nutrition is essential in the promotion of wound healing and assists in the early recovery of patients. Patients should be encouraged to take a diet rich in protein and vitamin C. If dietary intake is insufficient to meet patient demands, total parenteral nutrition may be advised. 

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Advanced Wound Care Solutions

Wound care technology has rapidly progressed in recent years. Many innovative treatment options are now available that can promote wound healing in immunosuppressed patients. Some of these treatment options include:

• Growth Factors

Recent advances in molecular biology have highlighted the role of growth factors and various cytokines in the process of wound healing. Immunocompromised patients have a deficiency of growth factors, and can therefore benefit from the topical application of growth factors at the wound site. Some of the growth factors involved in the wound healing process include epidermal growth factor, platelet-derived growth factor, and fibroblast growth factor. 

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One thing to be kept in mind before administering growth factor therapy is to ensure that the growth factors are deficient in the wound. In addition, growth factors need to be administered in sufficient quantity and duration to produce the desired results.

• Skin Substitutes

Patients with Immunosuppression are less likely to experience tissue rejection. Therefore, artificial or live skin substitutes can be used for the closure of large wounds. Skin grafts can improve wound healing through wound closure, decreased infection rates, and early wound healing. Skin grafting should be done after the removal of excess, non-viable tissue from the wound site. Some examples of skin substitutes include Vivoderm, Dermograft, and Apligraf.