Is it normal for granulation tissue to separate skin edges in a wound?

Granulation Tissue Separating Skin Edges: Normal vs. Abnormal

Granulation tissue separating skin edges is NOT normal and represents either hypergranulation (overgrowth) or a wound healing complication that requires intervention. In normal wound healing, granulation tissue should fill the wound bed from the base upward to support epithelialization across the surface, not separate or elevate the skin edges 1, 2.

Understanding Normal Granulation Tissue

Normal granulation tissue forms as a scaffold within the wound bed to support blood vessel growth and subsequent epithelialization, appearing as pink-red tissue that fills the wound space from bottom to top 1, 2. During healthy healing:

• Granulation tissue should remain level with or slightly below the wound edges, providing a foundation for epithelial cells to migrate across the surface 1
• The tissue consists of small vessels, inflammatory cells, fibroblasts, and myofibroblasts that eventually undergo apoptosis as the wound matures into a scar 2
• Cellularity decreases naturally as granulation tissue transitions to scar tissue through programmed cell death 2

When Granulation Tissue Separates Edges: Hypergranulation

If granulation tissue is visibly separating or elevating skin edges, this represents hypergranulation (overgranulation), defined as excess granulation tissue beyond what is required to replace the tissue deficit 3. This is:

• An infrequent but recognized complication of wound healing 3
• Characterized by granulation tissue that rises above the wound margins and prevents epithelial migration 4, 5
• A barrier to wound closure that requires active management 5, 3

Immediate Management Algorithm

Step 1: Address Contributing Factors

• Verify there is no active infection - clean the wound at least once daily with antimicrobial cleanser and apply topical antimicrobial agents if infection is present 4
• Check for mechanical irritation - if the hypergranulation is around a tube or device, verify proper tension between bolsters and avoid unnecessary movement 4
• Assess moisture balance - use foam dressings rather than gauze to reduce maceration, as foam lifts drainage away from the skin 4

Step 2: First-Line Treatment

Apply topical corticosteroid (triamcinolone 0.05% or clobetasol 0.05%) combined with foam dressing for 7-10 days 4, 5. This approach:

• Achieved hypergranulation resolution in 88/92 patients (95.7%) in a 2024 burn center study, with 41.4% resolving within 2 weeks 5
• Provides compression to the treatment site when combined with foam dressing 4
• Should be applied twice daily directly to the hypergranulation tissue 4

Step 3: Second-Line Treatment for Persistent Cases

If hypergranulation persists after 2-4 weeks of topical corticosteroid therapy, proceed to silver nitrate cauterization 4, 5:

• Apply silver nitrate directly onto the overgranulation tissue 4
• Only 4/92 patients (4.3%) required this escalation in the 2024 study 5
• Be aware this is painful and can lead to scarring 5

Step 4: Advanced Interventions for Refractory Cases

• Surgical removal of hypergranulation tissue for cases unresponsive to conservative measures 4
• Argon plasma coagulation has been described as effective in literature for persistent cases 4
• Negative pressure wound therapy (NPWT) may be beneficial for extensive wounds to promote healthy granulation and wound healing 4, 6

Critical Pitfalls to Avoid

• Never use gauze dressings directly on hypergranulation tissue - they adhere to the tissue and cause trauma upon removal 4
• Do not ignore the underlying cause - hypergranulation often signals infection, excessive moisture, or mechanical irritation that must be addressed 4, 3
• Avoid "wait and see" for tissue clearly separating wound edges - while some hypergranulation may resolve spontaneously, tissue that prevents epithelialization requires intervention 3
• Do not apply NPWT foam directly to hypergranulation without a non-adherent contact layer - this can cause tissue damage during dressing changes 7, 6

Special Context: Open Abdomen Wounds

In the specific context of open abdomen wounds, granulation tissue formation is actually encouraged in Grade 4 wounds where fascial closure is no longer possible, as it creates a suitable surface for skin grafting 7. However, this is a distinct clinical scenario from typical wound healing where granulation separating edges indicates pathology.