CLIN CAL REVIEW
Skin cooling, pain and chronic
wound healing progression
Jeannette Muldoon
Jfiiiinclic Miiliiooii /.v /Vi'/ixv/c, Svri'icvs (ClUmal).
Aftiiv HcaUluarv
T
he coniplex mechanism of wotind heahn^ is
dependent on many factors (Gottrtip, 20(11). and
most practitioners tisc well-known nierliods to
detertnine accurate assessment and to implement the opti-
mtitn environment tor wotind healing. However, it has been
suggested that not enough is kiiown about some ot tbe tac-
tors that contribute to wound bealing (Motlatt, 21)04),There
are still many areas where tbeory does not always tnatch the
practical situation and confiision often arises when all factors
are not considered.
Two factors about vvbicb there are contlittint; beliefs are
skin cooling and pain. It is received wisdom that skin eool-
ing will reduce the rate ot ceU division and so slow healing.
Does this mean a wound should never be cooled? This
article examines sotne ot the evidence.
Pain is poorly understood in relation to chronic wounds,
and is rarely dealt with in a systematic way,Yet it may affect
wound healing in direct and indirect ways, which this article
will examine.
Skin cooling
Concerns about excessive cooling and the possible effects
on wound progression bave led to the development of some
therapies that are based on the warming of the wound bed
to encourage granulation.
Certainly,, research confirms tbat cell division and the
action of fibroblasts is reduced at temperatures below 33°C
{Lock, 1979), and researcb confirms tbat wounds cool down
during dressing changes. A study by McGuiness et al (2004)
examined these temperature variations. The researchers
measured wound bed temperature before and after dress-
ing change, and external dressing temperatures from tbe
time the dressing was applied until it reached pre-change
temperature. Wound bed temperatures dropped an average
of 2°C during dressing changes, and took an average of 23
minutes to returti to normal.
However, most studies of this nature have concentrated
on acute wounds, whicb behave differently from chronic
wounds in terms of cellular and biochemical activity'
(Moore, 2005). In the Lock study, tbe wounds were either
traumatic or caused by surgical debridenient .iiid ranged
from about 4—12 days old.
The question to ask is, tbereforc, does temporary skin
cooling necessarily have an impact on chronic wound beal-
ing? When deciding on treatment methods, should tempera-
ture be considered in isolation to other factors? Or are there
Wound Care, March 200b
Eiihiil:
situations where skin cooling can have a beneficial effect?
Tbese qtiestions need to be asked wben critically assessing
the aims of management and tbe needs of the patient.
One area where skin cooling has a demonstrable positive
etfect is in reducing pain. When faced with a patient with
a hot, inflamed, painful wound, the clinician may find it
hard to justify avoiding a product that can provide a cool-
ing, soothing remedy, Cellulitis, btirns and radiotherapy skin
damage all respond very well to skin cooling, pro\'iding
nuicb-needed pain relief to the sufferer (Wilkinson, 2004).
Wet wrapping techniqties using cool, wet bandages have
been the mainstay in the management of acute eczema in
children (Bcattie, 2005). Another efTective (thougb now less
common) treatment is the apphcation ot cool zinc paste
bandages, which when itsed in conjunction witb sustained,
graduated compression are not only comfortable for tbe
patient, but also a useful topical preparation for varicose skin
conditions (Cameron, 1998).
Cooling dressings have recently been shown to bave a
beneficial impact on pain in cbronic wounds. Young and
Hampton (2005) examined the effects of a hydrogel on
pain in leg ulcers. Two pilot studies and a patient audit
evaluated the effectiveness of a sheet hydrogel dressing in
reducing pain by cooling atid soothing, and by batbing the
nerve endings in a moist environment. Patients described
variotis pain types, and assessment was based on acbe, burn
and sharp pain. Although such evaluations are subjective,
statistically significant reductions in pain were identified
wben using the dressing.
Young and Hampton speculated that 'the reduction of
pain depended mainly on the inhibition of local inflamma-
tory changes', and it was suggested that there was potential
for the dressing 'to dampen the inflammatory response tbat
created pain'.
ABSTRACT
There are many areas of wound care where theory does not always match
the practical experiences of the patient. This article discusses the effects
of two factors - skin cooling and pain - on chronic wound healing, and the
role of pain and inflammation on the overall wound healing process.
KEYWORDS
Temperature change Pain • Inflammation • Wound healing
• Concordance
S21
 CLINICAL REVIEW
Wound pain
Wound pain has been the subject of many discussions and
studies m recent years. Pam m wounds can arise from sev-
eral sources, including adherence of dressings and bacterid
infections. Most recent investigations have concentrated on
the pain experienced during traumatic dressing removal (e.g.
Hollinwortb, 2002). This area is one that can be controlled
easily by the practitioner who decides on the treatment,
and there are now many treatment regimes that can be
implemented to minimize this trauma, such as the use of
non-adherent dressings.
Just as pain is being recognized as a relevant concern in
wound care, it is being set in the wider context of qual-
ity of hfe for people with vvotinds. The Enropcan Wound
Management Association has published a position document
(EWMA. 2002) which highlights the need to recognize
improvements in quality of life in terms of pain, maceration,
tratnna and comfort, without the previously heavy reliance
on complete wound healing. It is well-doctiniented that
pain reduction occurs with effective wound healing treat-
ment (Hollinworth. 1999). but there is now also evidence
to show that effective healing can occur witb pain reduc-
tion (Hampton, 2004),Tiie effects of pain on overall wound
healing can be far-reachmg when certain psychological and
physiological changes take place.
Effects of pain
Tiie gate control theory (Godfrey, 2005) suggests that injury
and pain influence homeostasis and behavioural activity,
reinforcing the relationship between stress and pain with
resulting adverse efTects on the immune system. For exam-
pK', correlation between stress and delayed wound healing as
a result of a prolonged inflammatory stare was discussed in
a case study on stress response in a paraplegic patient with
pressure ulcers (Jones, 2003). Much bas also been written
about tbe effects of tbe anticipation of pain, especially unre-
lieved pain in patients who has already experienced a painflil
episode (Mangwendeza, 2002).
Low self-esteem and depression caused by a non-healing
or malodorous wound can often be the cause of delays in
the healing process (Budgen. 2004; Charles. 2004).This may
PAIN
Problems with
Concordance
Inflammation
DELAYS
in
HEALING
S24
be related to the release of stress hormones, which can delay
healing (Young and Hampton, 2005). When sleep depriva-
tion sets in as a result of persistent pain, the stress hormone
cortisol is released, and this bas an impact on healing: direct
hnks between stress and tbe immune system have been
noted in several studies higblightcd by Jones (2003). So
begins the vicions cycle of pain causing sleeplessness, wbich
in turn delays bealing. leading to yet more pain from the
unhealed wotind, and so on {F{^iirc I).
Pain-related problems with assessment
and concordance
Pam IS not restricted to wounds, and may indirectly affect
wound heahng. Often physical pain is subjective and difficult
to measure (Coyle, 20lO), however, the "vvatl of pain" that is
experienced by some patients may cause confiision and a
blurring of systemic symptoms which can be indistingtiisha-
ble ffom local wound p.iin.The presence of associated paiiifiil
conditions also complicates tbe assessment process, especially
in areas such as leg ulcers where painful iscbaemia can co-
exist alongside wound pain (Hofinan and Cooper, 2005).
If a patient is in a great deal of pain, it is often difficult for
the assessor to obtain a coherent history in order to make
the correct diagnosis, and there bave been cases when the
limb has been too painful to allow a Doppler assessment to
be conducted in order to establish the vascular status before
the application of compression therapy (Collins, 2005). In
this case study, constant wound pain meant it was not pos-
sible for tbe patient to tolerate the necessary compression,
resulting in tbe persistence of venous hypertension, and the
ulcer failed to heal. Once tbe pain had been reduced with
a pain-reiieving dressing, tbe patient was able to tolerate tbe
compression bandage and the wound progressed to bealing.
This case shows how local wound management, coupled
witb a systemic approacb, pro\'ides tbe best otitcome for tbe
patient who might otberw ise have been labelled "non-corcord-
ant". Previous bad experiences of ceitain treatments may affect
belief in the current treatment and the practitioner (Motfatt,
2004), I'ractitioners now agree that giving a patient some
control over their pain relief treatments will improve their
diy-to-day quality of life (Ariiiitage and Roberts, 2004),
Patients often find it difficnlt to follow tbe advice given
by tbe nurse because of tbe overwhelming pain that diey are
experiencing (Edwards. 2003). In patients witb venous insuf-
ficiency, venons return is promoted with good ankle mobility'
(Lindsay, 2004) and correct exercising, bnt this is not always
possible wben severe pam inhibits mobility'. As in the case
discussed above, the correct compression system, tbe sympa-
thetic ear of tbe practitioner and sound patient education all
play a vit.il role in helping patients to accept and follow the
prescribed treatment (White. 2005). The knock-on effect of
concordance with compression tberapy and effective mobil-
it\' will be reduction of oedema, whicb in itself can be a cause
of pain, by 'stretching' the tissues and reducing the supply of
ntitrieiits and blood to the wound (1 lampton. 2flO4).
Effects of delayed healing
Pain is the result of a comple.x interplay of chemical messen-
Wound Care, March 200b

gers. Excessive pain mediators, including pro-inflammatory
inctiiaturs. .iir known to impede healing (Clay and Chen,
21)1)5). Clay and Chen have reviewed the consequences
on healinj^ of indirect pain mediators such as bradykinin.
prostaglandins, leukotrienes, nerve growth tactor, histamine
and serotonin, which sometimes interact with each other to
amphf^' their effects (C!ay and Chen. 2005). Tiiese interac-
tions have a major role to play in blood flow abnormalities,
inflammation, tissue breakdown ,ind pam geneiatiuii.
Inflammation and exudare play a vital role in the wound
healing process (Beldon, 2(101; Grabam, 2)104). It is weli-
documented that wound healing follows a set pattern of
intlammation, proliferation, granulation, maturation and
contraction. These stages should occur within certain time
scales. The pmblem of the chronic wound occurs when the
wound tails to progress through tbe stages to ftill healing,
and the most common stage that is prolonged is the inflam-
matory stage leading to excess inflammation and exudate.
Inflammation, excess slough and exudate can lead to the
p!-odnction of inflammatory mediators sucb as histamine
which, in excess, can turther delay healing. If the wound
fails to heal and remains in the inflammatory stage, tbe risks
of infection are increased. Increased levels of exLidate can be
another source of pain when maceration and excoriation
affect the peri-wound area (Fletcher, 2003). Dressings that
address the moisture balance are tbe treatment of choice, but
if the underlying cause of the infection and inflammation
are not identified and treated tben these are simply short-
term measures. Protracted inflammation manifests itself in
an increased number of inflammatory' lenkocytes with a
resultant release of tissue-damaging proteinases (Hart, 2002).
and this continued inflammation and infection will result in
new episodes of pain. In this way the pain cycle continues
with the possible consequences of a static wound and a very
depressed patient, leading to flirther exacerbation of pain.
To break the pain cycle it is essential that all treatment
regimes are considered.This may include the application of
a cooling prtiduct, which would not only soothe tbe inflam-
mation within the wound, but also influence tbe patient's
psychological state, leading to increased immunity and heal-
ing Clones, 2003; Clay and Chen, 20(15)
Conclusion
It is becoming evident that patients with chronic painfiil
wounds aa' being dcilt a dotibie blow. Not only are they hav-
ing to endure debilitating, depressing episodes of pain, but they
also run the risk of protracted. non-he.Jing wounds which
will continue to cause pain tor as long as they are present.
The management ot pain is a ditRcult aira tor practitioners,
as certain tvpes of pain may never be resolved, and the prac-
titioner needs to accept that palliative care may be the only
option. Greater awareness of wound pain and its effects on
heding, combined with etfecrive management regimes that
mdudt' topical and systemic intervention have the poteiiti^d to
improve patient qti;i]ir\- ot lite and healing rates. B)CN
DvcLinjtioii of intacs': lite atitltor is iin etiiployev ojActifit I Icnllitiiirc
Lid. btii ihii ariicic is ttoi sponsored hyAilivd Heahhdtrv Lid
Wound Care, March 2006
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KEY POINTS
*Skin cooling does not always delay healing.
•Pain assessment is essential for effective diagnosis and treatment.
• Pain often affects concordance.
• Pain has a significant effect on wound healing not just on quality of life.
• It may be possible to interrupt the pain/delayed wound healing/pain cycle
to encourage wound progression.
n
S25