Randall Bentley, D.O., M.S., F.A.C.O.I.
Acute wounds typically heal in highly orchestrated, orderly, staged processes, although sometimes with considerable overlap. If these processes were separated, they would progress in the following order: the immediate hemostasis stage, the inflammatory stage, followed by the proliferative stage, and lastly the maturation stage. Delays in progressing through the normal healing process often occur as a result of infection, edema, uncontrolled blood glucose and metabolic processes, biofilms, malnutrition, medications, and tissue hypoxia; factors that result in chronic nonhealing wounds.{1}
In chronic wounds, healing often stalls in the inflammatory phase and does not progress to the proliferative stage. The proliferative stage is defined by new epithelial and vascular growth, new connective tissue, and granulation tissue. Viable epithelial growth normally originates from basal cells from intact skin edges and progresses over a healthy bed of granulation tissue under the influence of various growth factors and cytokines.
In treating patients with chronic wounds, it is helpful to identify new epithelial growth. New epithelium often depicts the success of eliminating the processes that hinder the normal progression of wound healing. When one observes such a finding, one often develops a sense of accomplishment and assurance that processes impeding the body’s ability to heal are eliminated.{1} Finding new epithelium is often a relatively late finding and fairly obvious when seen. A clinical observation I call the “wrinkle sign of epithelialization” or just “wrinkle sign” is a finding seen early in the course of epithelialization.
New epithelium is often noted as a thin, adherent, pearl gray to white covering of granulation tissue. New epithelium characterized by the wrinkle sign is often a subtle finding. It appears as fine wrinkles along the course of the epithelial covering. It may be seen without provocation; however, when deliberately sought, one can apply slight longitudinal pressure to the wound in various directions, gently compressing the wound along its axis to exaggerate the wrinkles. Fibrinous slough in the wound may give a similar appearance, but it will not show fine wrinkles. Slough will frequently be moist and will not be as adherent to the wound base as is epithelium. Slough needs to be debrided; new epithelium needs to be protected.
The following illustrations demonstrate chronic wounds progressing to the proliferative stage with healthy progression to closure when all impediments to healing are corrected.
Figure 1
Figure 1 illustrates a wound now covered with a thin film of epithelium. The epithelium can be seen as a pearly gray tissue that has fine wrinkles extending across the wound bed, the so-called “wrinkle sign”. The wound has a small amount of stress applied to amplify the wrinkles.
Figure 2
Figure 2 illustrates a different wound with new epithelium showing the wrinkle sign, pearly gray in color, encircling a red, mildly hypergranular bud of granulation tissue. The wound is in a relaxed state with no stress applied along the wound axis.
Discussion:
An internet search for the term “Wrinkle Sign of Epithelialization” was performed. Keywords used were wrinkle, wrinkle sign, epithelial wrinkles, wrinkle sign wounds. It does not appear to be described or to be a published finding in the literature. There are some interesting similarities to other physical findings, as well as a test called the wrinkle test. It appears to be unrelated, however.
The wrinkle test described is attributed to O’Riain’s or Leuken’s wrinkle test. It is a test of peripheral nerve function. In this test, fingers are placed in warm water for 5 to 10 minutes. If the fingers do not wrinkle, this is a sign of loss of peripheral nerve integrity in finger injuries. [2],[3].
There is an orthopedic wrinkle sign seen in ankle fractures, suggesting underlying osseous deformity with resultant wrinkling of the overlying skin. [4]
There are the well-known wrinkles of aging. These are more reflective of loss of underlying subcutaneous tissue and collagen fibers that occur with age.
There is also a wrinkle line, created by the constant frowning and moving of underlying muscles over the years.
Lines of tension, also known as Langer’s Lines, are related to the wrinkles resulting from the natural orientation of underlying collagen fibrils and were discovered in 1861 by Austrian anatomist Karl Langer. These lines correspond directly to the directional axes of greatest skin tension.
Although not based on microscopic study, the wrinkle sign of epithelialization appears related to the inherent intracellular tension of epithelial cells. At the early proliferative stage of healing, collagen bundles are still in the disarray of being laid down and would not be expected to reflect the lines of tension.
Further histological studies might prove interesting, but clinically, I think they would be unnecessary. The wrinkle sign is a consistent finding of a healing wound. Distinguishing slough from granulation tissue juxtaposed with new epithelium is a wound management challenge at times. When encountered, a conservative approach of keeping the wound moist, delaying debridement, and monitoring maturation of the epithelium might be prudent.
References:
- Paul J. Sheffield, Ph.D. and Caroline Fife, M.D.; Wound Care Practice. Flagstaff, AZ. Best Publishing Company, 2007, pp 197-198
- Jeff Konen, et al., Special Tests for Orthopedic Examination, pp 35-38
- Raoul Tubiana, et al (1998), Examination of the Hand and Wrist, CRC Press, pp 340-341
- Binns, J. Howard. Wrinkle Sign, British Medical Journal 24 November 1973
