Wounds and Immunosuppression

As technology improves and patients with more complicated problems are living longer, treating wounds in these patients is becoming more challenging, not because of the wounds specifically but because of the comorbidities and associated treatments. Our center regularly sees patients with a wound or ulcer who are also undergoing immunosuppression therapy. Patients with pulmonary disease, inflammatory diseases such as rheumatoid arthritis, skin diseases, and others take medication that influences the immune system. The more challenging patient population involves those who have received a transplant. In our practice in Alabama, there are many patients who have had kidney transplants due to the high rate of diabetes and renal failure, but we also have seen patients with wounds who have had liver and pancreas transplants. All these patients have wounds or ulcers and are on immunosuppressive medications to preserve their new organ or to treat their diseases.

The wound healing process involves multiple steps that must occur if healing is to progress. Many of these immunosuppressive medications will interfere with the healing process via their effects on the immune system.¹ The medical community is most aware of steroid medications. Cortisone, which naturally occurs in the adrenal gland, was first identified by Edward Kendall and Harold Mason in 1936.² It was found to be effective in the treatment of rheumatoid arthritis in 1949, and subsequently became a life-changing therapy for patients with asthma.³ Unfortunately, the delayed wound healing, increased incidence of wound infection, and dehiscence of operative wounds were soon reported in patients taking these medications.⁴ Further research showed these chemicals interfered with the action of several growth factors and cytokines, resulting in the wound healing and infection problems noted.⁴ Most immunosuppressive medications used in treatment delay healing by their effects on fibroblast proliferation and angiogenesis.⁵

There are other immunosuppressive agents that impact wound healing, which health care providers might not consider. Some of these agents have been shown to worsen or cause dyslipidemia, diabetes, and hypertension, resulting in endothelial damage and endothelial dysfunction.⁶ As a result of these possible changes, it is imperative that the vascular status of the patient be investigated when beginning therapy and reevaluated if healing slows after a period of successful therapy.

It is reported in the literature that certain immunosuppressive agents can cause the new onset of diabetes, with the incidence ranging from 2% to 53%.^7,8 Diabetes that develops in a patient with immunosuppression may not act the same as diabetes developing in a patient without immunosuppression and may require a more specialized approach.⁹

As can be seen, treating wounds in patients with immunosuppression, especially in those who have received transplants, will require a more attentive and flexible approach to the wound healing process to achieve healing. Even then the outcome may not be as favorable as the clinician had hoped.⁶ As wound care providers, we must strive to heal wounds or ulcers in these patients as we anxiously wait for more research and guidance to be published in the literature.

Terry Treadwell, MD, FACS
Editor-in-Chief, Wounds
woundseditor@hmpglobal.com