Too Much of a Good Thing?

One of the things that wound care practitioners look for in a healing wound is the presence of granulation tissue, which is a combination of fibrous connective tissue and new blood vessels that grow from the wound bed. For the most part, we are relieved at its appearance because this is generally a sign that the inflammatory phase is over, the wound has entered the proliferative phase, and the wound will proceed to epithelialization and healing. Unfortunately, as everyone knows, this is not always the case. Sometimes the granulation tissue becomes hypertrophic, which means it has become soft, elevated above the wound base—sometimes even becoming a raised mass of tissue—and bleeds easily on manipulation. In this state, the tissue is usually called hypertrophic granulation tissue, overgranulation tissue, exuberant granulation tissue, or proud flesh. This change is associated with excess moisture in the wound bed, friction or recurrent minor trauma to the wound surface, continued inflammation of the wound bed, increasing bacterial bioburden, presence of foreign bodies in the wound (ie, sutures, etc.),  and low oxygen tissue levels, especially in a patient with diabetes.¹  Unfortunately, hypertrophic granulation tissue impedes healing by slowing cell migration across the wound bed due to the abnormal structure of the tissue and/or an interruption of the normal cellular signaling by cytokines and other signaling molecules.

So, how do we treat this abnormal tissue causing problems with healing? In 1999, a physician in England felt that hypertrophic granulation tissue was a temporary problem that would resolve on its own and recommended a “wait and see” approach to its management.² However, this does not seem a reasonable approach to most of us.

One of the most frequent treatments for hypertrophic granulation tissue is silver nitrate,¹ which coagulates and destroys abnormal granulation tissue and will kill any bacteria that might be associated with its development. Silver nitrate is especially useful in treating hypertrophic granulation tissue associated with indwelling catheters such as feeding tubes.

If the areas of hypertrophic granulation tissue are large or extensive, operative removal may be the best choice. I recently had treated a large nodule of hypertrophic granulation tissue at the edge of a diabetic foot ulcer. The nodule was resistant to silver nitrate therapy, but it was easily managed with operative removal. Along this line, if there are retained sutures or other foreign bodies in the wound causing hypertrophic granulation tissue formation, these should be removed. This usually resolves the abnormal tissue formation in these instances.

Additional treatments mentioned in the literature with varying degrees of success include applying topical steroid creams to the granulation tissue, injection of steroids into the hypertrophic tissue, compressing the abnormal tissue with a polyurethane form dressing (especially one containing methylene blue, gentian violet, and silver), or treatment with a pulsed-dye laser.³ If silver nitrate therapy fails, the choice among these treatments would depend on the condition of the patient, which treatment might be available for use, the location of the wound, the comfort of the practitioner in using the treatment, and the cost of the procedure.

Since hypertrophic granulation tissue cannot be ignored if satisfactory healing is to be achieved, this is truly a situation where too much of something is not necessarily good.

Terry Treadwell, MD, FACS

Editor-in-Chief, Wounds

woundseditor@hmpglobal.com