Commentary: New Therapeutic Approaches in Wound Healing

This issue of Wounds contains reports that, at first, might look quite heterogenous in their subject matter and not related to one another. Upon closer scrutiny, however, an important running theme exists—one that, in our opinion, will be the focus of increasing investigative work in the next several years. Let us explain that theme by analyzing these reports. There is little doubt that the concept of wound bed preparation has drastically altered the way we view chronic wounds. Before this concept became popular, we tended to think of chronic wounds as acute wounds gone wrong. As a result, even in our therapeutic approach, we thought of using treatments we had successfully tested in acute wound healing models. As we now recognize, this approach was not very successful. We have now come to understand that chronic wounds have their own entity with pathophysiologic principles that are unique. In our review of the subject in this issue, we describe the concept of wound bed preparation, and how this term encompasses many aspects of chronic wound care that can lead to optimal clinical outcomes. It has become clear that debridement does not equal wound bed preparation when one discusses chronic wounds. There is a lot more to chronic wounds than just debridement, and this exciting story is just beginning to unfold. Our review in this issue discusses this in substantial detail. In addition, the report takes the view that, given the context of wound bed preparation, we need to revisit certain therapeutic modalities. We have used debriding agents as proof of principle for this concept, i.e., these agents may also stimulate the overall process of reepithelialization. However, the same concept can be extended to other treatments we presently use, including compression, occlusion, and more. Therefore, we may need to test existing treatments in novel ways to ascertain their full therapeutic potential in the context of wound bed preparation. As we begin to think of chronic wounds as independent entities, and not just an aberration of the normal process of wound repair, we also realize how poorly equipped we have been in measuring their various clinical parameters. For example, we still have no adequate means to repeatedly and safely test for bacterial burden. Despite very substantial progress in our understanding of how chronic wound fluid can be detrimental to extracellular matrix proteins and growth factors, we are only beginning to develop methods to measure these effects. Therefore, the manuscript by Romanelli and his colleagues in this issue is very timely and instructive in this regard. Undoubtedly, as shown by the authors, progress is being made in this field. We now have better ways to assess such parameters as temperature, pH, size, and more. Some of these parameters, like size, are widely accepted as being important. Other parameters have not been studied in detail. Therefore, another challenge will be to find correlations, if any, with other parameters we are now able to measure. One of the most important aspects of wound bed preparation is the recognition that we will need to understand better the cellular phenotype of chronic wounds. In this issue, Li and colleagues examine by gene microarray the gene profile of wounds in an animal model. As is often the case with this type of technology, they were able to identify certain genes that were not expected to play a role in the healing process. Additional work will be necessary to validate their findings. While their report is focused on acute wounds, the principle of the technology is the same for understanding wound bed preparation better. Gene microarray is increasingly being used to understand different patterns of gene expression in various conditions and to identify novel genes that are involved in physiologic and pathophysiologic situations. Perhaps, it will be this type of analysis that will help us elucidate the abnormalities present in chronic wounds and how wound bed preparation can be improved. Several groups are already working in this area. We stated at the beginning that a certain running theme was present in this issue. Perhaps this is more evident now. At the center is wound bed preparation, with the opportunity to rediscover the use of certain therapeutic agents and to find new ways to address the pathophysiologic abnormalities present in chronic wounds. Improved wound bed preparation requires improved ways to measure critical wound parameters and a greater understanding of the cellular phenotype of chronic wounds. Vincent Falanga, MD Section Editor, WOUNDS Professor of Dermatology and Biochemistry, Boston University; Chairman of Dermatology, Department and Training Program at Roger Williams Medical Center