How is hypergranulation tissue in a wound managed?

Management of Hypergranulation Tissue in Wounds

Hypergranulation tissue should be treated with topical corticosteroids as first-line therapy, which is more effective than silver nitrate cautery for promoting wound healing and reducing complications. 1, 2

Understanding Hypergranulation Tissue

• Hypergranulation (also called overgranulation) is characterized by vascular, friable tissue that extends above the level of surrounding skin, bleeds easily, may be painful, and impedes normal wound healing 1
• Common causes include excess moisture, friction, movement from poorly secured tubes/devices, and critical colonization or infection 1

First-Line Treatment Options

Topical Corticosteroid Therapy

• Apply topical corticosteroid cream or ointment (such as 1% hydrocortisone) for 7-10 days in combination with a foam dressing to provide compression 1
• Topical steroids show faster healing in hypergranulation wounds compared to silver nitrate cautery, with median wound size reduction of 14-15mm versus 0-5mm after one month of treatment 2
• A 50/50 mixture of triamcinolone and Polysporin topical ointment is effective, with 41.4% of hypergranulation areas resolving within 2 weeks 3

Foam Dressing Application

• Polyurethane foam dressings can significantly reduce hypergranulation tissue height by approximately 2mm within two weeks 4
• Foam dressings are preferred over gauze to reduce skin maceration in exuding wounds 1

Advanced Interventions for Refractory Cases

Chemical Cautery

• Silver nitrate can be used for refractory cases, but is associated with more pain and potential scarring compared to topical steroids 3
• Only 4.3% of cases treated with topical corticosteroids required escalation to silver nitrate or surgery 3

Surgical Management

• Surgical debridement should be considered for extensive or persistent hypergranulation tissue that fails to respond to conservative measures 1
• For tube-related granulation tissue, consider stabilizing the tube or switching to a low-profile device 1

Special Considerations

Protection of Granulation Tissue

• Use non-adherent contact layers to prevent disruption of newly formed granulation tissue during dressing changes 5
• Minimize dressing changes to prevent trauma to the healing wound bed 1

Negative Pressure Wound Therapy (NPWT)

• For extensive wounds with hypergranulation tissue, NPWT may be beneficial to promote healthy granulation and wound healing 1
• When using NPWT, place a wound contact layer (e.g., non-adherent silicone layer) between the NPWT wound filler and the wound bed to prevent damage to granulation tissue during dressing changes 6

Management Algorithm

1. Clean the affected area at least once daily using an antimicrobial cleanser 1
2. Apply topical corticosteroid (1% hydrocortisone or triamcinolone) to the hypergranulation tissue 1, 3
3. Cover with foam dressing to provide gentle compression 1, 4
4. Apply barrier film or cream to protect surrounding skin, especially if the wound is exuding 1
5. For persistent hypergranulation after 2 weeks of treatment, consider silver nitrate cautery or surgical debridement 3, 7

Common Pitfalls to Avoid

• Avoid excessive manipulation of granulation tissue, which can cause bleeding and pain 1
• Do not use gauze dressings directly on granulation tissue as they can adhere to the tissue and cause trauma upon removal 1
• Replacing tubes with larger-diameter tubes is generally ineffective and can result in an enlarged stoma tract with more leakage 1