Why wounds stop healing
Healthy tissue closes a wound without being asked. When that does not happen, there is nearly always an identifiable obstacle, and there are only a handful of candidates:
- Inadequate blood supply — arterial disease, venous congestion, radiation damage or scarring around the wound bed.
- Persistent infection, particularly bacterial biofilm, which conventional swabs frequently miss and dressings alone cannot clear.
- Dead tissue or foreign material left in the wound — slough, necrotic fat, retained suture, exposed mesh or bone.
- Continuing mechanical stress — pressure over a bony prominence, movement across a joint, or an unsupported abdominal wall.
- Systemic factors — uncontrolled diabetes, low albumin and protein intake, anaemia, steroids or chemotherapy, smoking, and undiagnosed malignancy in a chronically ulcerated area.
Investigation before treatment
Changing the dressing more often is not a plan. Assessment establishes the arterial and venous status of the limb, obtains a deep tissue culture rather than a superficial swab, images to determine whether bone or implant is involved, and checks the systemic factors — sugars, haemoglobin, albumin, thyroid and nutritional intake.
A chronic ulcer that has been present for years and has heaped, rolled edges warrants a biopsy. Malignant change in long-standing wounds is uncommon but it is missed precisely because everyone assumes the wound is just chronic.
What modern wound treatment involves
Once the obstacles are identified, treatment is straightforward in principle: remove what is preventing healing, and give the wound the environment it needs.
Debridement — surgical, and repeated if necessary — removes dead tissue and disrupts biofilm. It is the single most effective intervention in chronic wounds and the one most often deferred. Negative-pressure wound therapy, widely known as VAC, applies controlled suction through a sealed foam dressing; it draws out exudate, reduces oedema, brings the wound edges together and stimulates granulation tissue, and has transformed the management of large open wounds.
Beyond that: appropriate modern dressings matched to the amount of exudate rather than to habit, compression for venous ulcers, offloading for pressure sores, correction of nutrition — protein intake is routinely and substantially underestimated — and finally reconstruction where a wound is too large to close on its own, using split-skin grafts or local flaps.
Wounds after previous surgery
A wound that has broken down after an operation carries its own considerations. Infected mesh may need removal, and the abdominal wall then needs reconstruction rather than simple closure. A wound leaking intestinal content is an enterocutaneous fistula, which needs nutritional support, control of the effluent and, usually, definitive surgery months later once the abdomen has settled.
These are difficult problems, and they are managed better with a plan and a timeline than with repeated attempts to close something that is not ready. The most useful thing a patient in this situation can be told is what the sequence will be and roughly how long each stage takes.
When a wound needs surgical assessment
Arrange review if a wound:
- Has not reduced measurably in size after two to four weeks of appropriate care
- Has increasing pain, particularly if the pain has changed in character
- Develops foul-smelling or increasing discharge
- Shows spreading redness, warmth or swelling around it
- Exposes tendon, bone or an implant such as mesh
- Contains black or grey tissue, or has heaped-up, rolled edges of long standing
Spreading redness with fever, severe pain out of proportion to appearance, crackling under the skin, skin blistering or turning dusky, or feeling systemically unwell can indicate necrotising infection. This is a surgical emergency measured in hours — go to hospital immediately.
Recovery — what to expect
Complex wounds heal on a timeline set by their cause. What follows is the usual shape of treatment rather than a fixed schedule, and it is reviewed at each visit.
- Assessment, week 1Full evaluation, deep culture, imaging where indicated, and correction of the systemic factors — blood sugar, anaemia, protein intake — that will otherwise limit everything that follows.
- Weeks 1–4Surgical debridement, sometimes staged. Negative-pressure therapy or exudate-matched dressings. Targeted antibiotics only where infection is genuinely present, rather than continuously.
- Weeks 4–10The wound bed granulates and contracts. Grafting or flap reconstruction where the wound will not close unaided. Compression or offloading continues throughout for venous and pressure wounds.
- After healingPrevention: continued compression stockings for venous disease, pressure redistribution and repositioning for immobile patients, footwear and foot care in diabetes. Recurrence is common without it and uncommon with it.
Common questions
Why has my wound not healed after months of dressings?
Because something is preventing it, and dressings do not address any of the usual causes — poor blood supply, dead tissue, biofilm, continuing pressure or poor nutrition. Identifying which of these applies is the whole of the treatment. Continuing the same dressing regimen without that answer rarely changes anything.
What is VAC or negative-pressure therapy?
A sealed foam dressing connected to a pump that applies gentle continuous suction. It removes fluid, reduces swelling, draws the wound edges inward and stimulates the growth of healthy granulation tissue. Dressing changes are typically every two to three days and it is well tolerated, including at home in selected cases.
Are antibiotics enough?
Only when the problem is genuinely a spreading soft-tissue infection. Antibiotics cannot penetrate dead tissue or biofilm, and prolonged courses in chronic wounds mainly generate resistance. Debridement is what clears infection from the wound bed; antibiotics support it.
Will my wound need surgery?
Most chronic wounds need at least one debridement. Whether they need reconstruction depends on size and depth — small wounds contract and close on their own once the obstacles are removed, while large or deep ones may need a skin graft or flap.
Does diet really affect wound healing?
Substantially, and it is the most under-treated factor. Building new tissue requires protein, and requirements rise well above normal when a large wound is healing. Low albumin, anaemia, and deficiencies of zinc and vitamin C all measurably delay closure and are all correctable.
Can a chronic wound become cancerous?
It is uncommon, but it happens — a Marjolin ulcer arises in long-standing wounds and scars. Any ulcer present for years, with raised rolled edges or a sudden change in appearance or bleeding, should be biopsied rather than dressed for another six months.
Who performs this
Prof. (Dr.) Ashvind Bawa, MS FACS — Director of Surgical Services, Bawa Hospital, Civil Lines, Ludhiana. Relevant to this page:
- MS General Surgery; FACS — Fellow, American College of Surgeons
- Director of Surgical Services, Bawa Hospital, Ludhiana
- ACS NSQIP International Scholar 2025 — surgical quality and outcomes, Cleveland Clinic & Mayo Clinic
This page is general information about surgical conditions and their treatment. It is not a diagnosis and cannot replace an examination. Please seek a consultation for advice specific to you.