Chapter 8: THE SKIN: DISEASES, SWELLINGS AND WOUNDS

What this Chapter contains:

1) Diagnosis of Skin Abnormalities

2) Skin Diseases
3) Lumps and Swellings
4) Skin Tumours
5) Principles of Inflammation and Wound Management
6) Standards of Care “Harness and Saddlery”

For External Parasites – Please see “Parasitology” Chapter

1) DIAGNOSIS OF SKIN ABNORMALITIES

There are many things which cause lumps and swellings on the skin. It is important
to differentiate between infectious skin disease, and lumps and swellings from other
causes.

Infectious Skin disease is usually seen by multiple smaller lumps/swellings

distributed over a wider area of the body and due to an infectious cause (may be other
animals affected)

Large lumps and swellings can be due to the physical accumulation of fluid and
infection under the skin and are usually singular and affecting only one animal

Q: You are presented with lump(s) on the skin. How do you go about diagnosing
the cause of this lump?

A: Determining whether the lump(s) are due to skin disease or some other cause
(abscess, haematoma) is the first step.

i) Take a good “skin” history as part of your usual history and clinical exam:

- When did the owner first notice the lump(s)?

- Are they getting bigger/smaller/increased/decreased number with time?
- Has the animal had these lumps before?
- Association with season/stabling/change in food etc?
- Is there one or many lumps?
- Do they feel hard or soft?
- Is there associated hair loss?
- Is there associated pruritis? (Itching)
- Are any other animals affected?
ii) Further diagnostics are often used in order to determine the cause of the lump:

a) Aspiration of fluid
b) Skin scraping
c) Cytology
c) Biopsy or lumpectomy

a) Aspiration of fluid

Fluid aspiration is a technique that can provide valuable information about the type of
lump, and possible cause.

The most common types of fluid aspirated are:

Pus (Abscess)
Blood (Haematoma)
Serous Fluid

1) Shave a small area of hair off at the most dependent point of the lump

2) Clean and disinfect the skin

3) Choosing a small needle, quickly but gently insert down to the hub, and observe
the fluid which comes out

4) You may have to move the needle around in order to get fluid, especially if the
lump has been there a few days and fibrosis has already started.

6) Cytology is also a useful method of diagnosis (see below). Use a syringe to

acquire a small amount, then spray aspirated fluid onto a glass slide. Stain with Diff-
Quik and examine

b) Skin Scraping

These are usually done if you suspect a parasitic skin infection such as mange.

1) Materials required for a skin scraping:

- Glass slide and coverslip

- Sharp scalpel blade
- Oil/paraffin
- Microscope – and the ability to know what you are seeing underneath it!

2) It is important to do a number of scrapes from different areas.

3) Put a small amount of paraffin on the scalpel blade. Parting the hair of the animal,
scrape the skin carefully (do NOT cut it!) but firmly so you get redness and slight
bleeding.
If you do not do it firmly the animal will move about since it tickles, and you may
cause more harm by cutting it (or yourself!) accidently.

4) When trying to diagnose mange, often the mites burrow quite deeply, hence the
requirement to get the skin to bleed slightly in order to have the best chance of seeing
mites.

5) Place a coverslip over the area, and look under the microscope. As well as
different types of blood cells and debris, you may be able to detect mites (see picture
below)

c) Cytology

This is a simple, fast diagnostic test that is underused in evaluating skin disease. With
practice, you can identify the presence of yeasts, fungal hyphae, bacteria, different
types of inflammatory cells and neoplastic cells – all are useful in determining a
diagnosis.

HISTOLOGICAL PICTURES OF EACH OF THE CELL TYPES AND WHAT

THEY INDICATE

Obtaining the smear:

i) Direct impression smears -

These are best on moist areas:

-Underside of crusts
-Areas of exudate/discharge
-Open areas of pustules, vesicles or papules

Firmly press the glass slide directly onto skin surface. Stain with Diff-Quik and
examine when dry.

ii) Swab Smears-

Good for dry, superficial areas:

Crusts
Hairless patches of skin
Ear canals

Moisten cotton tipped applicator with saline and rub briskly over area to be examined.
Roll cotton tip over surface of glass slide and examine after staining with Diff-Quik.

iii) Sticky tape preparations-

Also good for dry areas, however interpretation can be slightly more difficult unless
cell types/organisms are present in large numbers:
Firmly press sticky tape on to the skin in a number of different areas. Place few drops
Diff-Quik onto glass slide and press tape onto slide, distributing the stain evenly
underneath the tape with your fingers.

d) Biopsy or “Lumpectomy”

These two words refer to a surgical procedure in which a part (biopsy) or the whole
lump (lumpectomy) is removed.

Biopsy: Surgical removal of a small sample of the lump for laboratory assessment.
This is used as an investigative tool, for example if you want to know for sure what is
causing the lump, or if you are considering removal but do not want to go ahead with
it until you know for sure it makes long term clinical sense to remove it.

Lumpectomy: This is COMPLETE removal of a lump. This is often done as a

CURATIVE technique, eg in a suspected tumour, or to make the animal more
comfortable ie if the lump is in the way of a harness etc and is constantly
bleeding/secondarily infected. If you are removing a tumour, you must be sure that
you remove it completely for the operation to be worthwhile – this also involves a
knowledge of the types of tumours which occur, which one this would most likely be
and whether complete excision is possible given the size and position of the tumour
on the animals body, and its relation to underlying tissues.

There are many things to consider before you attempt this type of surgery:
1) Do you have a suitable area in which to carry out the procedure?
- CLEAN Environment where the animal can also recover – free from
dust, flies, mud
- QUIET Environment where the animal will respond well to
sedation and undergo minimal stress
- ADEQUATE recovery facilities where the animal will not injure
itself on recovery, and the owner is responsible and will look after it
until fully recovered from the sedative

2) Do you have adequate drugs and equipment for a surgical procedure?

- Sedation/GA and Local Anaesthetic
- Sterile Kit
- Sterile suture materials
- Materials to shave and disinfect the area
- Analgesia, Antibiotics and Anti-tetanus toxin

3) Do you have access to a laboratory where analysis of the biopsy can be carried out?

4) Is the lump SUITABLE for biopsy/removal?

- Is there evidence of infection/inflammation which could hinder the

healing process?
- Is the lump in a suitable site that allows for healing – ie not in a
dependent or highly mobile area which would cause breakdown
 - If you wish to remove the whole lump, possibly for curative reasons,
are you confident you can do this successfully? Think about possible
complications of incomplete removal – if the lump is firmly attached
to underlying structures your chances of complete excision are small.

YOUR PRIMARY RESPONSIBILTIY IS TO THE ANIMAL

What are you trying to achieve by surgical intervention of the lump?

Will BENEFIT ultimately outweigh the HARM in the long term?
YOU need to look at the whole picture to make this INFORMED decision!!

2) INFECTIOUS DISEASES OF THE SKIN

There are many skin diseases which occur in working equines. These are due to any
of the following causes:
- Bacteria
- Virus
- Fungal
- Parasitic
- Hypersensitivity “Urticaria”

However, for practical diagnostic purposes, it is easier to categorise according to

appearance. Remember that a good history and clinical exam is the most accurate
process of diagnosis, since many causes of skin disease can present with a variety of
clinical signs. For simplicity:

i) SKIN DISEASES CHARACTERISED BY PRURITIS

ii) NON-PRURITIC SKIN DISEASE CHARACTERISED BY ALOPECIA,

SCALING &/OR CRUSTING

iii) NODULAR SKIN DISEASE WITH ULCERATION AND EXUDATION

iv) NODULAR SKIN DISEASE WITHOUT ULCERATION AND

EXUDATION
i) SKIN DISEASES CHARACTERISED BY PRURITIS

Pruritis = Itching, with associated redness and hair loss

a) Insect Hypersensitivity “Sweet Itch”

Causes: - Biting insects; Culicoides is most documented in equines throughout the

world, but any biting insect can cause this type of hypersensitivity reaction.

Appearance: - Multiple fluid swellings over the body (“Urticaria”)

- History will give most likely cause (eg seasonality)
- May have associated pruritis and evidence of excoriation
- Plaques or wheal formation with well defined edges

Treatment: - May well resolve within 24-48 hours

- Antihistamines or steroid treatment will help
- Fly control necessary as insects are indicated as cause

b) Food Allergy/Adverse Reaction “Urticaria”

Causes: - Drug reactions

- Poisonous plants
- Food allergy

Appearance and Treatment is the same as for Insect Hypersensitivity – Again,

the history will give the most likely cause and help with prevention.

c) Secondary Bacterial Infection

** Remember, SECONDARY bacterial infection is very common in all skin

afflictions, regardless of the primary cause**

Staphylococcus species of bacteria are commensal organisms on the skin – this means
that they are always present on the skin and do not normally cause a problem.
However, if there is a break in the integrity of the skin surface, such as a wound, this
means that the bacteria which normally do not cause a problem are able to colonise in
the damaged tissue and this leads to a problem.

Cause: Variety of skin commensals due to break in skin integrity, eg Staphylococcus

Appearance: Wet looking skin and associated discharge in the area of insult
 Pustule formation (small pus-filled lumps)
Signs of pruritis and discomfort to animal, may lead to self excoriation

Distribution: Anywhere there is a problem: parasites, wounds, dirty padding,

poorly-fitting harnesses (contact dermatitis) etc

Treatment: Remove/Treat underlying cause

Shave the affected area and clean with dilute antiseptic
May require application of topical anti-bacterial; in severe or chronic
cases use systemic antibiotics

d) Parasites – Lice, Mange etc – Please see Parasitology Chapter (unless it fits
better here?)

ii) NON-PRURITIC SKIN DISEASE CHARACTERISED BY ALOPECIA,

SCALING &/OR CRUSTING

Alopecia = Hair Loss

Remember, many of these conditions can also have pruritis due to secondary
bacterial infection!

a) Dermatophilosis - “Mud Fever” or “Rain Scald”

This is a common, superficial skin infection

Cause: Dermatophilus congolensis

Appearance: Small crusty lumps with hair standing up in between

Spreads and causes matted clumps of hair
Underlying skin moist and inflamed

Distribution on body: Common on caudal pastern due to hobbles or muddy

environment
Can also affect other areas: Under harness, back, flanks

Treatment: Remove the underlying cause (wet, muddy environment)

Shave the affected area
Apply dilute antiseptic and leave open to the air to dry out
b) Dermatophytosis - “Ringworm”

This is most common in young animals and those kept in dirty conditions, as fungal
spores are found in the soil. Incubation period is 1-4 weeks so may spread slowly
amongst a group of equines.

** Remember this is a ZOONOSIS!

Cause: Fungal species which utilise keratin – Trichophyton and Microsporum. These
organisms produce spores which are transmitted between animals by
harnesses, grooming kits etc

Appearance: Crusting and scaling

Multifocal areas of hair loss – classically a coin-shaped appearance
Can appear like a raised lump in initial stages
May have associated pruritis

Distribution: Anywhere on body, commonly girth/harness region and head/neck

Treatment: Most animals recover after several months, however they are a source
of infection to others (including humans) during this time
Topical antifungals may be indicated if severe, however follow
instructions
Iodine wash daily (10%) effective – don’t forget harness etc
Systemic antifungals not usually indicated – side effects

iii) NODULAR SKIN DISEASE WITH ULCERATION AND EXUDATION

Examples of ulceration and exudation of the skin can be seen in the pictures
below. Most of these diseases are covered elsewhere in this manual, since this
presentation is usually associated with another underlying disease mechanism.

a) Glanders – “Farcy” presentation

See under “Infectious diseases” section

b) Epizootic Lymphangitis

See under “Infectious diseases” section

c) Proud Flesh

See “Wounds” Section 5 of this chapter

d) Habronemiasis

See “Parasitology” Chapter

iv) NODULAR SKIN DISEASE WITHOUT ULCERATION AND

EXUDATION

A variety of different skin tumours could be included here (melanoma, sarcoids)

however they are covered in a section 4 of this chapter.
(Unless for practical diagnostic purposes, you want the tumours included here?)

a) Papillomatosis “Warts”

Usually affects young equines (under three years old)

Cause: Papillomavirus

Appearance: Multiple raised nodules “cauliflower-like”

Not usually associated with ulceration or exudation unless pressure

Distribution: Usually lips and nose, eyes and ears sometimes affected
Can spread to sheath/vulva and limbs if severe

Treatment: Self-limiting, animal mounts an immune response and disappears over

time
May require “placebo” treatment to pacify owner if concerned about
appearance

** PLEASE ENSURE YOU PUT IN ANY OTHER INFECTIOUS SKIN

CONDITIONS YOU COMMONLY SEE FOR INCLUSION HERE IF I HAVE
FORGOTTEN SOMETHING!!**

3) LUMPS AND SWELLINGS OF THE SKIN

a) Abscess

An abscess is the accumulation of bacterial infection (pus) under the skin. Typically
an abscess presents as a hot, swollen painful area of the skin, and there is sometimes
evidence of an injury such as a penetrating wound.

Causes
- Systemic infection eg strangles, glanders
 - Penetrating injuries eg wire, animal bites
- Iatrogenic (caused by the vet) eg puncture wounds from dirty needles
- Continuous rubbing of poorly maintained equipment
- Foreign body may cause a discharging sinus, possibly presenting as a recurring
abscess

Appearance

- Heat
- Pain on palpation
- Gradually increases in size and sometimes ruptures, after which the heat/pain
disappears
- Pus on aspiration (do not insert a needle if the history suggests this could be a
hernia or rupture – see below)
- If the abscess does not rupture, the defense mechanisms of the body (inflammatory
processes – see chapter 4 under “Anti-inflammatory Drugs”) will cause a fibrous
reaction resulting in the “walling off” of the infection. In this case the abscess will
lose its hot swollen acute appearance and a small, firm lump will be the result.

Treatment:

- Bathe the area with warm salt water/iodine solution to encourage “pointing” at
lance spot
- Clip or shave the area and clean with antiseptic
- Lance with a scalpel blade in a VERTICAL line from centre to most ventral part.
You may wish to use local anaesthetic for this
- Flush out the pus with large volumes of warm salt water/iodine
- You may need to insert a drain – see “Wound management”
- Treat as open wound – see “Wound Management”
- Tetanus Antitoxin (TAT) or start course of Toxoid injection

** IMPORTANT – Before lancing, be 100% sure this is an abscess, not a

hernia/rupture!! A fine needle aspirate (see above) is recommended if you are
not sure to double check there is pus inside.

Think about the anatomical positioning of the lump on the animal’s body and consider
the history (been there since birth vs. a recent event).

b) Hernia and Rupture

Hernia = Swelling due to fat, omentum or intestine protruding through a NATURAL

opening in the body wall and sitting under the skin eg Umbilical, Inguinal

Rupture = Swelling due to fat, omentum or intestine protruding through an

ACQUIRED opening in the abdominal wall eg Accidents
Appearance:

- Soft swelling of varying size depending on how much content is involved

- Usually no heat/pain on palpation
- Contents can be pushed back internally, can feel defect in muscle “hernial ring”
- If intestine trapped, animal will have signs of colic due to interrupted blood supply

Treatment:

- Most do not affect the animal in any way

- If rupture suspected, bandaging may help to keep contents inside while it heals
- Surgery NOT recommended: Difficult to reduce the hole since high tension on
surrounding muscles and wound breakdown common. High risk of peritonitis.

Remember never to lance a swelling if it looks like a hernia/rupture!

c) Haematoma

Cause:

- Blunt trauma (fall/kick) ruptures small blood vessels under the skin, causing
subcutaneous bleeding
- This blood clots, forming a lump (haematoma) over the next few days which
eventually fibroses and shrinks to a small hard lump

Appearance:

- Sudden onset swelling following a history of trauma

- Heat and pain on palpation
- Blood/Blood tinged serum on aspiration
- Chronic stages show small firm lump which no fluid can be aspirated from

Treatment:

- NSAIDS reduce pain and swelling in initial stages

- Naturally resolve over a few weeks. Lancing not recommended as leaves wound
open to secondary infection (abscess formation), and most will reform
- Antibiotics unnecessary

d) Seroma

Cause:

- Usually following surgery, especially if a lot of dead space left underneath suture
line
- Sometimes secondary to injury, foreign body etc
Appearance:

- Similar to a lump from haematoma or abscess, usually without associated pain/heat

- History will help in diagnosis
- Aspiration of fluid results in clear, serous exudate

Treatment:

- Allow serum to drain by removing 1-2 ventral sutures, or take out sutures altogether
and allow healing as an open wound
- Drainage of a closed seroma not conducive to healing, will just reform

e) Oedema

Oedema is a fluid swelling under the skin, with different appearances and distribution
according to the underlying cause. Generally it is due to build up of pressure in the
venous and lymphatic systems for a variety of reasons.

Causes: - Localised circulatory disturbances:

- Lower limb swelling due to standing for long periods
- Poor venous circulation and lymphatic drainage
- Unsuitable bandaging methods

- Major circulatory disturbances eg heart disease, anaemia (see circulatory

section)

- Hypoproteinaemia due to liver disease, parasitism, malnutrition

Appearance: - No swelling or pain

- Distribution depends on underlying cause, most often in dependent
areas eg ventral abdomen/chest, sheath, lower limbs if localised
- May “pit” on palpation, ie leave an indent when pressed
- Aspiration does not usually give fluid

Treatment: - For localised distal limb oedema, walking the animal will help resolve
- Generalised oedema will require a thorough clinical examination of the
animal for signs of underlying heart/liver disease or other causes of low blood protein.
Only by correction of the underlying problem will the symptom of oedema resolve
- Drainage not recommended: will lead to further circulatory
disturbances and exacerbate hypoproteinaemia if present

f) Cellulitis

Cellulitis is inflammation and infection of the subcutaneous tissue and muscle. It is

often associated with abscessation or infection from wounds.

Please see MUSCULOSKELETAL chapter for more information if you suspect

cellulitis.
4) SKIN TUMOURS

As with skin diseases, there are many tumour affecting equines. I have included the
following as ones commonly seen in the field, again if you feel there are ones I have
missed out, please write a note here!!

a) Squamous Cell Carcinoma

Cause: Exact cause not known, although solar radiation(sunlight) is involved. It is

also thought that lack of pigment (“pink” skin, especially in white/piebald animals)
predisposes to this type of tumour.

Appearance: - Mild inflammation and swelling in the early stages

- Later, these become irregular, ulcerated inflamed masses
- Secondary bacterial infection common: odour and necrosis

Distribution: - Commonly around EYE: Eyelids, third eyelid and medial canthus
- MUCOCUTANEOUS JUNCTIONS: Nostrils, prepuce, vulva

Treatment: - Surgical excision (GA) in some cases can help, although recurrence
common and wide margins required (Practicalities, esp eye?)
- Removal of third eyelid often curative
- Do not usually metastasise to other areas
- Treat secondary bacterial infection if present

If you choose to surgically excise, think about PROGNOSIS (recurrence) and

COST VS BENEFIT to the animal!

b) Melanoma

Cause: Benign or malignant tumours of the melanocytes. Common in older (>15yrs)

grey or white horses. Giemsa staining of fine needle aspirate will show melanin
granules in tumour cells.

Appearance: - Firm, nodular swellings

- Single or multiple
- Slow growing, although some are more aggressive and metastasise
quickly, including to internal organs such as lungs, GIT

Distribution: - Common in perineal region and under the tail

- Vulva and prepuce
- Head (including eye), neck and parotid area

Treatment: - None recommended, surgical excision not successful if fast-growing

form
- If causing a problem with harness (ie around tail base) try treating with
antibiotics for secondary infection and advise the owner on alternatives
c) Sarcoids

Cause: Suspected viral involvement (Bovine papillomavirus or retrovirus C). They

are benign (do not metastasise) however are locally aggressive and can become
secondarily infected.

Appearance: - Firm nodules which can become ulcerated and look like proud flesh or
squamous cell carcinoma (fibroblastic type)
- Alternatively, can look like ringworm (verrucose type)
- Can be a mixture of the two

Distribution: - Any part of the body

- Head (especially around eyes), groin, ventral midline and axilla
common

Treatment: - Leave alone!

- If small and interfering with harness/animal’s welfare can excise,
however most will recur due to locally invasive nature
- Some studies indicate a protocol of injections with BCG, however
varied success rates

5) PRINCIPLES OF INFLAMMATION AND WOUND MANAGEMENT

Working equines are subjected to wounds from many different causes:

• Kicks
• Beatings
• Accidents
• Harness and saddle wounds
• Wire, metal
• Hobbling lesions
• Local healing – Firing, Blistering

Wounds are an extremely common, and in many cases preventable, presentation

to Brooke clinics. Knowledge of inflammation and the healing process, along
with understanding the underlying causes, are essential if we are to manage
wounds properly and decrease their occurrence in the future.

i) Acute Inflammation and its relation to wound healing

Inflammation = Body’s response to injury

Injury can be due to a variety of causes, including physical trauma, chemical (burns,
local treatments such as blistering), biological (infection) and immunological
(hypersensitivity reactions). In terms of wounds, it is physical trauma which causes
the inflammatory response. Inflammation can be acute or chronic.
The Five Signs of Acute Inflammation:

1) Heat - increased blood flow

2) Redness - Blood accumulation

3) Swelling - Accumulation of exudate

4) Pain - Exudate, sensitisation of nerve endings

5) Loss of function - Pain, vascular disturbances

It can be seen above that BLOOD SUPPLY is the major causative factor for these
signs. When injury occurs, chemical mediators are released into the bloodstream,
causing INCREASED BLOOD FLOW to the affected area. Blood carries with it
major defence and healing substances which help fight infection and heal the area. It
can be thought of as similar to an army mobilising its troops to the area of attack!

Prostaglandin is one of the main chemical mediators which results in increased blood
flow at the site of injury.

PROSTAGLANDIN = VASODILATION AND SENSITISATION OF NERVES

Therefore, decreasing the amount of prostaglandin results in decreased signs of

inflammation

Why do we want to control Pain and Inflammation?

Inflammation is the body’s natural response to injury, however if this is excessive or

prolonged it results in discomfort, loss of function and can lead to depression and
anorexia.

Pain also produces a rise in blood cortisol levels, which induces a stress response in
the body and delays healing, therefore pain management is an important part of
helping the body to heal itself.

How do we control Pain and Inflammation?

Phospholipids ------------- Arachidonic Acid -------------- Prostaglandin

Cyclo-oxygenase

The above pathway is known s the COX-1 pathway for prostaglandin production

NON-STEROIDAL DRUGS (NSAIDS) such as Flunixin and Phenylbutazone

block Cyclo-oxygenase, resulting in decreased Prostaglandin production
Therefore, if we decrease prostaglandin production, we decrease the five signs of
acute inflammation making the animal more comfortable and helping decrease the
heat and swelling to that area.

How do wounds heal?

If we remember that blood carries with it important defense mechanisms, we can see
why blood supply is essential for wound healing. This becomes important in the
principles of wound management.

1) INFLAMMATORY PHASE

This phase begins immediately once the injury has occurred:

- Bacteria killed, foreign matter and toxins removed and damaged tissue is walled off
- Migration of cells involved in tissue regeneration begin “fibroblasts”

Clinically, you will see the 5 signs of acute inflammation

2) PROLIFERATIVE PHASE

This phase begins 2-3 days after injury has occurred:

- Migration of fibroblasts to the site which are responsible for laying down collagen
- Aim of this phase is to fill the depth void; this occurs until wound deficit filled
- Good blood supply, poor nerve supply
- PROUD FLESH = a result of excessive granulation tissue and is important to
consider in equids (see below)

Clinically, you will see Granulation tissue which has a pink appearance

3) EPITHELIALISATION & CONTRACTION

This is the final stage of wound healing:

- Epithelial cells from all edges of the wound margin migrate across the granulation
tissue, meeting in the middle to cover the granulation tissue
- Contraction takes place simultaneously, sometimes a scar is left

Clinically, you will see hairless skin coming in from the edges and eventually
covering the defect left by the wound

Knowledge of how wounds heal is important if we wish to consider how long the
wound has been there for, how we can help heal it and give a good prognosis to the
owner. From the above stages, it can be seen that many different types of cells are
required for wound healing, and these are brought by the blood. If a wound does not
have good blood supply (necrotic tissue) it will not heal.
How to deal with a wound

There are many things to consider when thinking about wound management:

1) Tissues affected – bone, tendon, joint or ligaments involved?

2) Stage of wound healing – Fresh or Old?

3) Degree of contamination – Clean, contaminated, infected or maggots?

4) Position on animal’s body – Head, Body or limbs?

5) Size and shape – Ragged, straight, shallow, deep, skin flaps?

Remember the Golden Period? This is a theoretical time frame of about eight
hours, after which a contaminated wound is described as infected. This has
implications if you are considering suturing a wound.

a) OPEN WOUND MANAGEMENT

Must be used in the majority of wounds:

• Dirty/Infected wounds (>8hrs old)
• ALL puncture wounds
• Maggot infestations
• Chronic wounds
• Saddle and Harness wounds
• Wounds with large deficits
• Wounds over joints
• Wounds below the carpus
• Sutured wounds which have broken down

Steps in managing open wounds:

1) Remove Contamination or Infection

- Trim/Shave hair from wound edges to decrease the amount of dirt/flies etc around
the wound edges
- Remove any maggots or foreign bodies
- Clean from centre, keeps dirt from edges moving further into wound
- Flush with large volumes of salt water daily. Showing the owners how to do this and
using materials which they have available encourages them to do this too.

***DILUTE Iodine is fine, but should be the colour of WEAK TEA. Any darker
than this, or strong antiseptics including spirit or purple spray is too concentrated and
results in damage to the delicate epithelial tissues.

“Dilution is the solution to pollution!”

2) Debride the Wound

- Use a scalpel blade to clean up edges and stimulate blood supply

- Only necrotic tissue should be removed
- Gently scrape surface with back of blade to stimulate spots of blood, this too helps
with healing so long as it is done gently

3) Protect the Wound

“Open” wound management DOES NOT mean you do not need a bandage!

- Mild antibiotic cream or vaseline preparation is best if you must use a topical
application. Powders dry to form a sticky coat which attracts flies and damages
epithelial cells
- Wound must still be washed daily even if applying topical treatment
- Corticosteroid creams should NOT be used in the majority of cases as it slows
wound healing. The exception is with proud flesh (see below).
- Keep flies/dirt away with bandage if possible, ensure harness or padding is not over
the top of the wound. A cotton sheet can be used on areas that are hard to bandage
such as the withers or neck.

A CLEAN wound ensures fast, natural healing - think about implications in

working equines in terms of their working environment!

Proud Flesh (Excessive Granulation Tissue)

We know that wounds heal via granulation from the depth and epithelialisation from
the edges. Usually these two act in synchrony resulting in a fast healing process, but

PROUD FLESH occurs if Granulation > Epithelialisation

This is seen as excessive pink tissue forming a large protruding growth and
preventing the wound from healing over. It is common on the distal limb but can
occur anywhere. Equines are prone to this due to their excessive inflammatory
reactions, and it must be dealt with if the wound is to heal:

1) Using a scalpel blade, trim the excess granulation tissue back to just below the skin
surface. Remember granulation tissue has an excellent blood supply, so will bleed
profusely, however poor nerve supply means local anaesthetic not usually indicated.

2) The aim is to encourage epithelialisation so the wound heals. Apply

CORTICOSTEROID cream to the CENTRE of the wound only, keeping it away from
the delicate edges to inhibit further granulation.

3) FIRMLY BANDAGE the wound

4) You many need to repeat the process until the wound is fully healed
b) CLOSED WOUND MANAGEMENT (SUTURING)

Due to the previously mentioned excessive inflammatory reactions of equines, sutured

equine wounds have a high rate of breakdown. Only suture a wound if it is:

1) Fresh – Less than eight hours old (“Golden Period”)

2) Clean

3) No tension – any tension on the skin will result in breakdown

Even if a wound has all three of these, there are some instances where it should still
not be sutured, see the above stipulations of “Open wound management”.
Conversely, in some situations even if a wound is older or contaminated, it may still
require suturing, eg severed tendons.

Principles of suturing:

i) Needle Choice – Only use cutting needles for the skin

ii) Suture Material – Absorbent under the skin (will dissolve)

Non-Absorbent for the skin (will need removing 10-14 days)
Monofilament if to be left in the body a long time (eg tendons)
Multifilament, non-braided materials (eg silk) risk infection
Size is important – ensure it is not going to pull through (too
thin) or affect healing (too thick) – 3/0-1 (2-4 metric) are best

iii) Suture Pattern – Simple interrupted, cruciate or mattress suture patterns best (see
surgical textbooks)

iv) Tightness – NOT TOO TIGHT!! Wound edges should just touch; remember
that within 24 hours swelling will occur, so if your knots are too tight the wound will
break down. Tying the throws down over a pair of haemostat forceps will ensure the
sutures are not too tight. (see diagram)

The body has a powerful healing mechanism. If in doubt, leave it to heal as an

open wound!

Surgical drains:

Surgical drains are used if there is DEAD SPACE underneath the suture line. Dead
space is created by a defect in the underlying muscle or subcutaneous tissues due to
missing tissue. Drains produce a means for blood/serum to exit from a wound,
preventing post-operative swelling, infection and suture breakdown. A drain can also
be used for flushing a cavity to remove pus, dirt or blood clots.

The best materials for surgical drains are latex or flexible plastic tubes. Gauze or
bandage in the wound is not recommended as they provide poor drainage, damage
healing tissues and act as a “wick” for infection. Penrose drains are commercially
available or one can be made from drip tubing or urinary catheters.
The drain should be placed in the wound and attached by a suture through the skin.
Exit the drain through a separate stab incision at the most ventral part of the cavity,
below the suture line, attaching with a second skin suture. Remove after fluid has
stopped leaking from the wound (usually 2-3 days). Do not exit the drain through the
wound or suture line, as it will prevent healing. (SEE PHOTOS)

Long Term Prevention of Wounds – Owner Communication

In many cases, for example harness and hobbling wounds, owner communication is
the key. You have a responsibility to teach owners how to recognise, clean and
minimise the recurrence of these types of preventable wounds. Some rules of thumb:

1) Remember the bigger picture: What will that small superficial wound (or
even patch of hairless skin) look like in a week’s time? What about in 6 month’s
time?

2) Always think of the underlying structures – especially important in lesions over

joints (eg carpal lesions) and hobbling wounds where the tendons could be affected.

3) Think too about the root causes of wounds; the picture below tells a thousand
words about the possibilities of lameness, imbalanced cart or poor roads being the
reason for these wounds (consider the different stages of wound healing at the brisket
compared to over the shoulders, and the unilateral nature of the shoulder wounds).
3) Always show the owner how to clean a wound, don’t just tell them as they may
not understand. Remember to use materials they have at home: do not use a lot of
gauze swabs, spray bottles, fancy creams etc, as they may be discouraged.

4) Explain to owners the importance of keeping harnesses and padding clean and
well-fitted. Blood, sweat and dirt all rub on the skin and predispose to skin injury.
Grooming the animal daily will remove the dirt and sweat which can exacerbate
wound formation

6) Resting the animal if wounds are over joints/places of increased mobility will
speed up healing.

7) Elevation - Use of a “doughnut” to help wound recovery if it is under a harness etc

8) Think carefully about drug use. Antibiotics are NOT a substitute for good
wound management and hygiene!! Do not use them on superficial wounds!!
Also remember PAIN RELIEF and TETANUS ANTITOXIN if you feel it is
necessary.

Standards of Care will be attached later (they are on my computer in the UK

which I am currently not at!) I welcome any comments about the content or
presentation of this chapter. Please, as usual, send in any photos you have of any
of the conditions explained here. Let me know if you want external skin
parasites included here!

Cheers, Anna.