Dear Mr. Rossi, his injury does not heal because you keep it too covered, it needs fresh air maybe the sun, or rather I advice you removing the dressing and exposing it to the sun, see that improvement … . ” Wise words of the Doctor XY.

“My dear Mr. Bianchi , the best therapy for his nasty injury by falling down the stairs, is the magic dust alpha: put it on 2 times a day and see that brilliant results; first the wound did not throw more the fluid that scrubs pants and then it will form a “beautiful” hard and dry scab that will give you much satisfaction, you will see a good result when the scab will fall – if it will fall. … ” Wise words of the Doctor WZ.

I wanted to start this article with the pearls of wisdom that poor patients are forced to listen when they want to drink at the source of medical knowledge: the doctor. Given that my remarks are very general and not targeted at any particular medical profession, I would like to emphasize that in 2016 some distinguished Colleagues can have a vision of the healing process so “archaic” that we should check their identity card tracing  the year of birth and “perhaps” find a justification for their claims; I say maybe because the real task of the physician is the continuous and timely scientific updating in order to carry out its mission more precisely and adhering to the therapeutic needs of the patient.

Taking this concept (therapeutic needs) of demand for care, I’d like to meet some Colleagues dealing with a complex skin lesion, able to  admit their lack of competence in the field, addressing the patient to a more reasonable course of treatment ,  if only in the name of scientific evidence and guidelines. But some Colleagues, faced with complicated wounds, pontificating and advise obsolete and incongruous local dressings in order to ” dry out ” the injury, forgetting (or not knowing exactly … ) that the keratinocytes move “slipping “. So I find myself, urged by friends and Colleagues but mainly from medical incomprehensible prescriptions , damaging local therapies , incredible stories of patients , images of absurd  wound dressings, to try to make things clear, simple and direct for those who are primarily interested in the health of patients and secondarily to the enrichment of their own culture.

The right local moist enviroment  is essential for the wound healing, if it is past the concept that the keratinocytes (epidermal cells able to migrate) “flap” usually from the periphery toward the center of the lesion , it is not however the  only factor that intervenes in the healing process . Cells migrate if they are enabled to do this: the correct microclimate of a wound and also its pH (acidity or alkalinity) act by activating a number of actors and key mediators ones used to create the land suitable for the cells ” migration “. Let us summarize briefly and clearly the series of events, at the wound level, that a properly acid and wet environment can unleash . As part of the tissue repair, in the microclimate of injuries play a strategic role the following factors: the pH value, the concentration of metalloprotease (MMPs) , the level of activation of redox systems (Inos and Ros) and the entity of the bacterial load. These four variables are closely related  and the oscillation of their weight interferes positively or negatively on the progress of the wound healing process.

A paradigmatic example is represented by the intervention of MMPs in reparative cascade: proteases are in fact responsible for the proper formation and stability of the extracellular matrix by degrading the exuberant or imperfect part ; easy to understand the abnormal effects on the healing mechanism, produced by excessive and uncontrolled protease activity: persistent local inflammation and inability to progression to the proliferative stage. The complex redox systems, sometimes underestimated and poorly studied , held at the physiological stage of activation a very positive function as they promote the expression of genes that synthesize antioxidant molecules and participate in antimicrobial defense; excess of Inos – Ros systems activation leads to the chronic tissue inflammation , the arrest of reparative and to the degeneration of the newly formed tissue.

The pH and the bacterial load are two interdependent factors , high bacterial colonization causes a significant degradation of tissue (the predatory attitude of micro-organisms) and the increase of the Ammonium produced by urease causes a rise in pH value; the increase of the latter slows down the action of macrophages, actives bacterial proteases and damages  the physiological mechanisms of bacterial killing resulting in further development of the microbial load.

The continuous degradation of the extracellular matrix, the permanence of an active bacterial load, the alkalinization of the microenvironment and the malfunction of the oxidation-reduction processes lead to chronic skin lesion that will be defined after a certain number of weeks, “non-healing”. Bacterial presence will reorganize itself  “ad hoc ” and  we’ll call it the Biofilm, this restructuring form of life not only has a different architecture, but above all a different more appropriate functional attitude to changing local conditions; Biofilm abandon the predatory character of the individual components to take the parasitic habit of the entire bacterial newly formed organization. The difficulties of the Vulnologist to find an appropriate therapy begins when the wound’s Social-microbiology changes, as a result of mutations of pH, moisture, protease and redox systems.

The “Planktonic” paradigm gives way to the Biofilm that has a subtle , non-aggressive behavior : the structural organization and its life cycle is targeted to resistance to biocides and antibiotics. The scenario has changed and our Hi-tech weapons are apparently the same: a looming defeat of epochal dimensions … .

“Thinking outside the box” , the metaphor used by Steve Jobs, can come to the rescue: disassemble and reassemble the puzzle piece by piece , this is the therapeutic secret ; enter the ” box” and change the rules of the puzzle fitting . In summary, the high road is not to change the type of dressing but changing the microclimate of the wound, just so we can raise some hope to stand up to the supreme intelligence of the survival forms orchestrated by the Nature.