MAN­AGE­MENT Why proud flesh forms

EQUUS - - Consultant­s -

Q:I am an orig­i­nal sub­scriber. Back in the early years---maybe 1979 or 1980--- EQUUS ran an ar­ti­cle that de­scribed get­ting rid of proud flesh. It was very timely for me be­cause my horse had just in­jured his hind leg with a nasty rope burn, and it was not heal­ing. In­stead, lumpy, yel­low proud flesh had formed. I was at my wits’ end, but with the in­for­ma­tion in EQUUS, I was able to turn the sit­u­a­tion around, and he healed quickly.

Re­cently my mare sus­tained a cut on her leg. For­tu­nately it’s not a huge wound, but I no­ticed over the week­end that it looked like proud flesh might be form­ing. I haven’t been able to get my vet­eri­nar­ian out yet, and I am not com­fort­able with some of the ad­vice I have been get­ting from my friends, if you know what I mean.

Can you re­mind me again how to pre­vent proud flesh in a lower leg wound? And what should I do if I think I see it? This seems to be a topic that af­fects many horse own­ers. Cindy Loverde Bal­ti­more, Mary­land

A:For many years peo­ple held the per­cep­tion that proud flesh was al­most an in­evitabil­ity in horses, par­tic­u­larly for wounds on the lower (dis­tal) limbs. Text­books and anec­dotes dat­ing to the mid-19th cen­tury de­scribe the char­ac­ter­is­tic fea­tures of this distress­ing fail­ure of wound heal­ing. How­ever, the fact re­mains that there is no evo­lu­tion­ary ad­van­tage for an animal to in­cur wounds that do not heal, so when proud flesh de­vel­ops, it in­di­cates some pathol­ogy in the wound bed.

In nor­mal healthy heal­ing, the bot­tom of a wound fills in with gran­u­la­tion tis­sue, a mix of blood ves­sels and col­la­gen that has a bumpy red or yel­low­ish ap­pear­ance. The growth of gran­u­la­tion tis­sue is stim­u­lated by an in­flam­ma­tory re­sponse within the ex­posed tis­sues of the wound. Once the gran­u­la­tion tis­sue has filled the de­fect, the in­flam­ma­tion “switches off,” trig­ger­ing other changes,

in­clud­ing the con­trac­tion of the edges of the wound (to be­gin clos­ing the space) and the growth of ep­ithe­lial (skin) cells across the gap.

Proud flesh oc­curs when a lowlevel in­flam­ma­tory re­sponse con­tin­ues within the wound. Without the “switch off,” the wound edges do not con­tract prop­erly, new skin does not form, and gran­u­la­tion tis­sue con­tin­ues to grow, some­times form­ing mounds that rise above the sur­face of the sur­round­ing skin. Once it reaches this state, both con­trac­tion and ep­ithe­lial­iza­tion be­come im­pos­si­ble, and the wound will not heal on its own.

Pre­vent­ing proud flesh is far bet­ter than try­ing to cure it. Through re­search, I have iden­ti­fied 12 fac­tors that de­lay or stop a wound from heal­ing and cause proud flesh to form. These might oc­cur in­di­vid­u­ally or in com­bi­na­tion. The re­al­ity is that, un­less you re­move any and all of these ob­sta­cles to heal­ing and re­in­state the nor­mal in­flam­ma­tory cas­cade with its ap­pro­pri­ate “switch off” stage, the proud flesh will not go away. Here are the fac­tors that con­trib­ute to proud flesh, along with ad­vice for mit­i­gat­ing them:

• In­fec­tion. An in­fected wound is red and an­gry-look­ing, ex­ud­ing pus and/or has a foul odor. For most wounds, topi­cal an­tibi­otics and an­ti­sep­tics are not re­quired to pre­vent in­fec­tion. Sim­ply clean­ing a wound to re­move de­bris is likely to be enough. Call your vet­eri­nar­ian if you can­not get an in­fec­tion un­der con­trol.

• Move­ment. Tis­sues that are stretched and pulled with every step will have a harder time heal­ing. Ban­dages or casts may be needed to im­mo­bi­lize some wounds. Stall rest may help in some cases, too.

• For­eign bod­ies. Hair, sand or other con­tam­i­nants in a wound can cause in­fec­tion and slow heal­ing. The horse’s body will at­tempt to ex­pel the for­eign

ma­te­rial but heal­ing will be stalled in the mean­time. In­spect the wound closely and re­move any de­bris you find. Em­bed­ded ob­jects can be dif­fi­cult to de­tect. X-rays may be use­ful to find glass, bone chips or other hard de­bris.

• Dead tis­sue. Any tis­sue within a wound that is dead (necrotic) or is so dam­aged that it is likely to die quickly will pre­vent heal­ing and must be re­moved. In smaller wounds, this may be ac­com­plished by flush­ing with wa­ter or saline, but a vet­eri­nar­ian may need to cut away (de­bride) the af­fected tis­sue.

• Con­tin­ued trauma. A wound will not heal if it is ag­gra­vated by chronic rub­bing, scratch­ing or other dis­rup­tion whether from tack, ban­dages or ac­tiv­ity. To en­cour­age heal­ing, take mea­sures to pro­tect a wound---for ex­am­ple, by keep­ing the horse on softer foot­ing, giv­ing him time off from train­ing or us­ing a dif­fer­ent tech­nique for ban­dag­ing.

• Loss of blood sup­ply. Circulatio­n is nec­es­sary to nour­ish heal­ing tis­sues, but some in­juries may com­pro­mise blood flow to the area. If this is the case, it may take longer to heal as the blood sup­ply “grows back” into the wound bed.

• Poor oxy­gena­tion. To heal, wounds need oxy­gen, both from the blood sup­ply and from the sur­round­ing air. Leav­ing a wound un­cov­ered ex­poses it to air, but ban­dag­ing has ben­e­fits, too: If a wound doesn’t re­ceive oxy­gen from the air, the body may com­pen­sate by bring­ing in more through the blood­stream, and that sup­ply will reach the deep­est heal­ing tis­sues. If you’re not sure which ap­proach is best for your horse’s wound, ask your vet­eri­nar­ian for guid­ance.

• Miss­ing tis­sue. If a sig­nif­i­cant amount of tis­sue was gouged out of a wound, heal­ing will take longer as the nor­mal gran­u­la­tion fills in the de­fect. Larger wounds may ben­e­fit from high-tech wound dress­ings that cre­ate bi­o­logic “scaf­folds” to help new tis­sue fill in the de­fects more ef­fi­ciently. Call your vet­eri­nar­ian for help with a wound like this.

• Poor health or nu­tri­tion. Mal­nu­tri­tion and ill­nesses such as PPID (pi­tu­itary pars in­ter­me­dia dys­func­tion, also called Cush­ing’s dis­ease) can re­duce a horse’s im­mune func­tion, which may slow heal­ing and leave him more sus­cep­ti­ble to in­fec­tions. These days nu­tri­tional de­fi­cien­cies are rare, but a horse does need ad­e­quate pro­tein to build new tis­sue as he heals. Ask your vet­eri­nar­ian to re­view your horse’s diet if you think he might need more pro­tein.

• En­vi­ron­ment. Con­di­tions in­side and out­side of the wound can in­flu­ence the rate of heal­ing. Weather ex­tremes--hot or cold, wet or dry---af­fect the ac­tiv­ity of the cells in the wound. In­side the wound, pock­ets of pus or other flu­ids or

an un­even tis­sue bed can im­pede heal­ing. Each con­di­tion needs to be ad­dressed ap­pro­pri­ately---such as with warm, moist dress­ings in a cold dry en­vi­ron­ment, or by bring­ing the horse into a dry stall dur­ing rainy or hu­mid weather.

• Tu­mor trans­for­ma­tion. In some cases, what looks like proud flesh is ac­tu­ally a tu­mor. A horse who has sar­coids some­where else on his body may also de­velop a sar­coid in a wound. This can look ex­actly like proud flesh, but it’s im­por­tant to dis­tin­guish be­tween the two con­di­tions be­cause the treat­ments are di­a­met­ri­cally op­po­site. While proud flesh needs to be de­brided, try­ing to cut out a sar­coid only makes it worse; in­stead, the tu­mor needs to be treated with chemo­ther­apy. I think it’s a good idea to have a vet­eri­nar­ian test every sus­pected case of proud flesh, just to make sure it’s not a tu­mor.

• Ia­tro­genic id­iocy. In my ex­pe­ri­ence, one of the most com­mon in­hibitors of heal­ing is ia­tro­genic id­iocy---my own term for “un­nec­es­sary things peo­ple put on their horses,” in­clud­ing com­mer­cial prod­ucts as well as home­made prepa­ra­tions that are ap­plied to a wound in the ex­pec­ta­tion that it will help it to heal. Al­most all of the ap­plied ma­te­ri­als act as an in­hibitor of heal­ing and bias the wound to­ward a non-heal­ing state. An­ti­sep­tic so­lu­tions and manuka-honey dress­ings have ben­e­fits in cer­tain sit­u­a­tions, but nei­ther is ap­pro­pri­ate for use on fresh wounds.

Most wounds need noth­ing more than flush­ing with warm wa­ter or saline and maybe a sim­ple dress­ing that con­tains a wa­ter-based gel to keep the sur­face of the ex­posed tis­sues evenly moist. Like­wise, once healthy heal­ing is un­der­way, avoid in­ter­fer­ing. Scrub­bing or pulling off scabs can dam­age frag­ile new tis­sues.

The ob­jec­tive of a clin­i­cian at­tend­ing a wound is to con­vert an ac­ci­den­tal wound into a sur­gi­cal wound and then close it with ap­pro­pri­ate mea­sures to ad­dress any of the other in­hibitors that could be present. If this is done, the wound will heal---of­ten in­cred­i­bly well.

Once ex­ces­sive gran­u­la­tion tis­sue forms, the wound needs an as­sess­ment, based on the heal­ing-in­hibitors I have out­lined, to de­ter­mine what went wrong. When any prob­lems are cor­rected, the wound may be left to heal in a nat­u­ral way, or, in some cases, surgery

may also be needed to cut away the ex­cess tis­sue and “re­set” the wound to a state where heal­ing can pro­ceed nor­mally. Your vet­eri­nar­ian or vet­eri­nary tech­ni­cian can usu­ally give you ap­pro­pri­ate guid­ance.

On the other hand, proud-flesh treat­ments that at­tempt to burn back ex­cess tis­sue with acid, cop­per sul­fate or an­other caus­tic ma­te­rial are doomed to fail. Ap­ply­ing caus­tic chem­i­cals or strong an­ti­sep­tics and dis­in­fec­tants do noth­ing to help the wound---in­deed, these treat­ments would prob­a­bly cause sig­nif­i­cant harm.

Thus I rec­om­mend that you think very care­fully about how you man­age this---or any---wound your horse sus­tains. Treat every one, large or small, as you would treat sim­i­lar wounds on your own body: If it’s mi­nor, flush the wound, keep it clean and de­ter­mine whether a ban­dage would be ben­e­fi­cial; if it is sig­nif­i­cant, get the ad­vice of a pro­fes­sional and take the ap­pro­pri­ate ac­tion to get the wound to close quickly and ef­fec­tively. The longer the wound per­sists, the big­ger the scar will be, and the greater the chal­lenge and the costs, both in terms of sub­se­quent vet­eri­nary care and the loss of use. Derek Knot­ten­belt, BVM&S, PhD,

DECEIM, DACVIM Equine Med­i­cal So­lu­tions Stir­ling, Scot­land

HOCK WOES: This wound was man­aged poorly from the start, and it failed to heal for many months. Gran­u­la­tion tis­sue was re­moved re­peat­edly without any progress. Move­ment was con­trolled with ban­dag­ing and cast­ing, and tis­sue deficits were treated with skin grafts. As soon as proper care was pro­vided, the wound healed quickly and well.

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