Hypergranulation
Hypergranulation is most commonly seen in wounds healing via secondary intention. Also known as
overgranulation it is the over formation of granulation tissue. For a wound to heal normally, the bed of the
wound needs to grow upwards and fill in the void, so
that the edges of the wound (epithelial cells) can grow
Side view of hypergranulation tissue
and spread over the top of the granulation tissue.
However, epithelial cells are only able to grow
horizontally; therefore if the granulation cells have
grown higher than the epithelial cells, epithelialisation
cannot occur. This results in prolonged wound bed
exposure, thus increasing the risk of infection.
It is generally believed that hypergranulation is
precipitated by a kind of altered inflammatory response. It is an excess of granulation tissue, usually
recognised clinically by its friable, red, often shiny and soft appearance that protrudes above the
surrounding skin. They usually fall into one of the following categories and these underlying causes need
addressing PRIOR to managing specific hypergranulating issues. In many cases hypergranulation will rectify
itself once the contributing factors have been addressed.
Granuloma pyogenicum
This common form of hypergranulation is
commonly associated with post operative surgery.
It is usually solitary and presents as a small
erythematous papule that enlarges and exudes
heavily and can bleed easily.
This will not respond to the recommended
conservative management and will need referral
back to the surgeon or a plastic surgeon.
MALIGNANCIES Malignant tissue can sometimes resemble hypergranulation tissue. Therefore
examine any suspected cases carefully and look for the following signs which could indicate a malignancy
requiring an urgent referral (via GP) to dermatology for investigation. 1.The tissue has been present for
many months or even years, 2. The tissue is hard to touch (may even have a ‘cauliflower appearance), 3. It
grows beyond the wound margins or 4. It does not respond to suggested treatments for hypergranulation
Basel cell carcinoma
Squamous cell carcinoma
Causes and Treatment for Hypergranulation
Cause of
Extra
hyperconsiderations
granulation
Treatment
Practical tips
Further
practical tips
Infection
(increased
bacterial
load in
wound)
When a wound is
infected it enters an
inflammatory
phase, increasing
exudate, and
Treat as per
guidelines
using AMBL
tool and
pathway
Second line
Cadexomer Iodine
(AMBL)
Foreign
bodies/
irritants in
wound bed
What has allowed
this foreign body
into the wound?
Have the risks of it
happening again
been eliminated?
Friction –
usually
related to
tubing,
such as
suprapubic
catheters
etc.
Poorly
managed
exudate
Ensure that you
have identified the
cause, could be keys
rubbing in pocket,
belts, or tops of
clothing rubbing,
especially on
surgical sites
Ensure would
is kept clean,
observe for undissolved
sutures etc,
and remove
with forceps if
visible
Remove cause
of friction
where possible
Safely secure
tubing
First line honey, (see
AMBL tool) though
this increases
moisture levels so
clinical decisions
needed based on each
individual cas.
(likely need a ‘step up’
in absorbent pad)
Only use formulary
products i.e. not
cotton wool or cotton
gauze
If there is excess
exudate due to the
friction, manage this
appropriately with
absorbent pads, and
minimise occlusion
Sorbion Sachet
Drainage, are super
super absorbent
pads and designed
to fit around PEG
sites etc. (FP10)
Occlusion
Commonly caused
by hydrocolloids or
occlusive dressings
which prevent
evaporation or
excess moisture
Check cause of
excess exudate
and treat. E.g.
infection ,
friction
Film dressings
can allow for
some moisture
vapour, but
not if built up
with many
layers
Review absorbent pad
and step up as needed,
likely to require a pad
with ‘nappy
technology’ which
wicks away excess
moisture from the site
Switch to a nonocclusive dressing
(contact Tissue
Viability for details)
Stop using
hydrocolloids, and
layering up dressings
Encourage patients
not to poke, prod or
contaminate the
wound bed
Atraumatic
primary
dressings/alginates,
with a pad, and film
dressings can be
used. Remember
not to layer as this
will reduce vapour
permeability
Topical steroids
should not be the first line management of hypergranulation and
should only be considered when all other treatment options have been explored. Steroids
can be effective at dampening the inflammatory response; however the majority of topical
steroids are not licensed for use in open wounds. It is advisable that you start with a mild
potency steroid and increase potency in the case of no response, though consider the
possibility of a malignancy if it does not improve.
Haelen Tape is available and licensed for use in cases of hypergranulation, however this
should only be used when all other methods have been exhausted, and after discussion with
the Tissue Viability team.
Prevention
As with many issues in wound care, carrying out a thorough and holistic assessment can
help to identity risks which may contribute to the development of hypergranulation tissue. ,
Good wound bed management such as the regulation of bacterial loading, exudate control,
avoidance of dressing adherence/ friction etc will all help to reduce the likelihood of
hypergranulation tissue developing.
References
Dealey, C. (2005) The care of wounds: a guide for nurses 3rd. Wiley Blackwell
Hampton, S. ( (2007) Understanding overgranulation in tissue viability practice. Wound Care
Johnson, S. (2007) Haelen Tape for treatment of overgranulation tissue. Wounds UK 3.3 7074
Stephen-Haynes, J. and Hampton, S. (2011) Achieving effective outcomes in patients with
overgranulation, Wound Care Alliance UK
Stephens, P. and Thomas, D. (2002) The cellular and proliferative phase of wound repair
process. Journal of Wound Care 11. (7) 253-261
Sussman, C. and Bates-Jensen, B. (2007) Wound Care: a collaborative practice manual for
health professionals, 3rd ed Philadelphia, Lippincott, Williams and Wilkins
Vuolo, J. (2010) Hypergranulation: Exploring possible management options. British Journal
of Nursing (Tissue Viability Supplement) Vol19, No6