What is the best treatment for proud flesh?
PREVENTION. That’s right. PREVENTION by proper wound management from day 1 or as close to day 1 as possible.
In horses, the distal limbs (from the knee down for front limbs and hocks down for hind limbs) are the most problematic area anatomically for developing proud flesh (exhuberant granulation tissue) in horses. While quickly developing granulation tissue allows for rapid healing of wounds, when left unchecked, this healing process oftentimes goes a wry! Leaving a lumpy, bumpy, non-healing, bleeding wound that depending on the location and size of the excess tissue (I have seen softball to basketball sized!) can impede mechanical function of the leg.
A key fact is that skin cannot grow over a mountain or a valley. Skin needs a FLAT structure to grow across until the torn edges meet in the middle of the wound and it is healed.
This is the reason why if at all possible I will try to suture lacerations (to bring the skin edges together) so I can avoid this whole scenario. In my experience I generally only suture minimally contaminated, non-infected wounds which means you need to act quickly after the initial incident, which is where the whole small window of time for suturing myth developed. You can and I have sutured a wound several days after the fact in cases where I have cleaned and examined the wound and the horse is on proper anti-inflammatory and anti-microbial therapy along with proper wound care and bandaging in the interim. This is usually my approach in wounds that are relatively fresh but heavily contaminated. I do not nor do I recommend suturing a wound that is infected.
Sometimes suturing is not possible and you are left with an open wound.
There are many reports out that compare different wound dressings (technology in this is pretty amazing) and many vets have their own favorites. There is also some debate over whether oxygen exposure to wounds or lack there of increase the risk of developing exhuberant granulation tissue.
What I recommend to my clients and has worked for my patients –
1. Stall rest: Many cringe at this, but stall rest is imperative to healing distal limb wounds in horses (even if they are sutured!) because limiting movement reduces wound tension. Everytime the horse moves it moves the skin across the leg and the weakest area will be the area of the wound. So as the skin moves it disrupts healing by increasing surface tension across the wound. This is especially true for wounds across joints. Remember, the goal here is prevention, which will pay off in the long run, even if it is less than ideal in the short run.
2. Bandaging: I recommend keeping a well padded standing wrap on at all times. I will also put a non-stick absorbable pad over the top of the wound secured by conform wrap (white, stretchy mesh gauze bandage). I recommend changing the bandage as necessary depending on the amount of wound drainage, usually every 24 hrs initially and then every 2 days depending on how the wound is healing. Bandaging not only keeps the wound clean, but applies light pressure to the wound to help keep it flat.
3. Cleaning: Remember any type of irritation to the wound will stimulate production of granulation tissue (this includes insects!). So be judicious here (follow instructions by your veterinarian).
4. Wound Ointments: Production of granulation tissue can be inhibited by the use of salves that contain a steroid. I like Animax, Panalog, Quadritop (these are all the same, different names) because it is a steroid, antibacterial, and antifungal. You can also try Preparation H in a pinch, but I have not had as favorable results with this. Apply the ointment after cleaning the wound and then bandage.
Balancing production and inhibition of granulation tissue can be tricky. You want the wound to heal (fill in with granulation tissue – remember skin cannot grow over a valley), but you don’t want too much granulation tissue (proud flesh – remember skin cannot grow over a hill either). So I usually allow the wound to fill in until it becomes flush with the level of the surrounding skin margins, then if there are ANY signs that the area is becoming raised (higher than the level of the skin margins) I will start applying the steroid ointment. I usually apply daily initially, then decrease the frequency to every 2 days if the wound seems like the healing process has slowed.
Following these guidelines has worked for me in my practice, but may not be appropriate in all cases. If you horse sustains any type of wound, call your veterinarian immediately for evaluation and a possible tetanus booster (booster if > 6 months since last tetanus vaccine). Your veterinarian can then recommend the best treatment for your horse.
An ounce of prevention is worth a pound of cure!