Wound Healing, Infection and Herbal Medicine

Wound Healing, Infection and Plant Medicine

Before using herbal methods to treat wounds and manage infection whether at home or in the field, basic first aid skills are essential.  These basic first aid skills can be learned from a variety of schools such as the local Red Cross.  However, I recommend taking a the wilderness first aid (or wilderness first responder) version of any first aid course in order to understand how to respond with first aid in situations where there are limited resources.  This is a more practical starting place for learning first aid and if you understand how to provide competent first aid with a minimum of supplies or equipment, you will have far less problem doing so when you have plenty of resources available.  At my school, we teach an 8-hour, 16-hour and 32-hour wilderness first aid course that is certified through the Emergency Care and Safety Institute.  We also teach an 72-hour wilderness herbal first responder course that combines first aid with herbal first aid.   Steps for initial management of wounds include but are not limited to:

• Stop bleeding in the case of an open wound; or set, reduce (in the case of a dislocation) or otherwise aligne bone and soft tissue in the case of a closed injury
• Assess and manage shock if present
• Irrigate and clean an open wound thoroughly if appropriate (i.e. not an arterial bleed that requires bleeding stoppage above all else)
• Inspect and test for any further functional damage (nerve, connective tissue, vascular)

Once it has been determined that the wound is as clean as the setting allows, medical plants can be introduced to assist it in healing as rapidly and wholly as possible.  This article  focuses on the healing and infection management of an open wound (closed wounds and burns entail different protocols).  This is the worst case scenario as the danger of infection is much greater of course once the outer layers of skin have been compromised as in a laceration or deep abrasion.

The following outline of four phases of wound healing provides a useful way of analyzing the body’s healing process. This is one wound healing paradigm out of several, but it can help guide the herbalist to make herb choices that work successfully throughout the full process

Four Phases of Wound Healing

• Hemostatic Phase:

From the moment the dermis and underlying tissue are compromised,  the wound immediately begins to clot.  Platelets (thrombocytes), clotting factors (blood proteins) and the vasculature itself (endothelial cells and sub-endothelial matrix) control the regulation of blood flow into a damaged wound site, create platelet “plugs” (platelet-to-platelet binding interactions) and activate a cascade of events (clotting cascade) to stabilize the platelet plugs.This phase can last a few minutes to a few hours depending on the severity of the wound, the health and age of the injured person, and other factors.

• Inflammation Phase:

The inflammation phase begins very closely on the heels of the hemostatic phase, usually within minutes or hours.  The physiological goal of inflammation around a wound area is primarily to neutralize toxins that have made their way into the region.  This permits the tissue to regain local homeostasis.   The underlying mechanisms of inflammation generally relate to permeability of various tissues which allow for the migration of immune-system cells (initially, macrophages and neutrophils) into the wound area to begin “clean up.”

However, a prolonged state of inflammation in tissue can become counterproductive to tissue healing.  Additionally, it can be difficult to distinguish between normal tissue inflammatory response that is appropriate vs. the onset of infection (see Table 1).

Indeed, there is always going to be some minor infection involved in any open wound, but the goal should be to normalize tissue homeostasis and function as quickly as possible so that the risk of any spread or increase of infection is reduced. If infection does spread, the more balanced tissue state makes it much more quickly noticeable.  It is important to note that a prolonged inflammatory response actually has a deleterious effect on wound healing as it promotes an environment that allows rapid, pathogenic bacterial infiltration and proliferation.

• Proliferation Phase:

This phase of wound healing can begin within a few days to a few weeks after the initial wound depending on wound severity, immune health, etc.   During this phase, the structures around the wound change.  Instead of permeable, inflamed tissue flooded with white blood cells, the predominant attending cells are fibroblasts begin their own cycle of proliferation, and start to lay down a collagen matrix within days.  Concurrently with fibroblast activity, neovascularization begins.  Angiogenesis (formation of new blood vessels from old blood vessels) is as important to the wound healing process as the actual creation of new tissue itself, vascularization is critical to proper wound healing.

However, the patterns that occur in the rebuilding of the tissues around the wound are focused on quick recovery rather than perfect organization.  The immediate goal of the body in wound healing is to grow tissue back in whatever pattern follows the quickest function of molding the subdermal and dermal layers together in order to quickly protect the body from further infection and injury. 

• Remodeling Phase:

Once the tissue has regrown and closed the wound site, the phase of remodeling begins.  This can start weeks or even months after the initial trauma, and can last for months to years.  This process is often never really finished completely, which is why some people end up with scars over their wound sites.  During this phase, the comparatively chaotic latticework of the fibrin and collagen matrices are slowly replaced by the correct tissue type and structure in order to regain full strength and function in the wound area.  Scar tissue left behind during the proliferation phase is never an ideal state of tissue, and for long-term health of the wound area it is important to minimize scar tissue as much as possible.  There is little to no vascularization in scar tissue and the general strength of the tissue itself is considerably less than the non-scarred area around it.  For this reason, it is prone to further injury and infection.  As an example, in the many cases of cellulitis I have attended to over the years, the infection more often than not occurred under or near an old scar.

Herbal Wound Healing

There are hundreds, if not thousands, of herbs that can help the body during the various phases of wound healing.  Below is a list of some of my own favorites, but bear in mind that this is a small fraction of herbs that are useful depending on availability, ecosystem, etc., and that there is a much larger list of plants that we have either forgotten (as a species) or never learned, that are also very effective.  It is important not to limit oneself to the use of one particular plant, but rather to learn a wide variety of medicinal plants that work across one or more of the phases of wound healing. Add and experiment with new ones for this purpose constantly.  Always assume that you may not have your “ideal” medicinal plants available in the case of an acute injury or illness.

Infection

Infection can occur at any time during any of the stages listed above.  Usually, if infection presents during recovery of an open wound, it happens during or around the inflammation stage.  This can create further difficulty in determining the difference between infection vs. normal inflammation.  Table 1 indicates some of the differences (and similarities) in assessing between infection and inflammation.

One of the most important aspects of dealing with infection in the field is not only the initial wound hygiene (cleaning and covering the wound), but the ability to clean the infected tissue of pathogenic bacteria once an infection has started to dominate the wound area.  Cleaning the wound and restoring vascularization to the area is more effective than simply putting a bunch of anti-bacterial herbs onto a wound that is already overloaded with foreign debris.

Activated charcoal works extremely well for cleaning out a wound area.  Charcoal is the equivalent of a micro-sponge made of highly porous carbon.  Like a sponge, the charcoal actually has to come in contact with the wound surface to do any good.   Also like a sponge, it is more effective if the pores are clean to begin with and not clogged with other material.  For this reason, the most effective manner of using charcoal is as a poultice mixed with clean (preferably distilled) that can be directly applied to the infected tissue area and dressed with a sterile bandage.   Allow this a few hours to draw out the bacteria and micro-debris, then repeat.  Within the first few bandage changes, there should be a noticeable difference in the appearance of the infected tissue.  Gently rinse out the wound area in between bandage changes.  The area will be blackened a little from the charcoal, but that is not of concern.  Continue this treatment as needed.  Depending on the severity of the infection, it can take a few hours to a few days to restore the area to a non-infected tissue state.  Although we make activated charcoal in my survival and homesteading (blacksmithing) classes by burning hardwood chips without oxygen, I prefer to buy powdered activated charcoal online. This is a higher, U.S. Pharmacopeial Convention-grade charcoal which has been through an acid wash, and is superior in quality for wound cleaning (and internal) use. You can make your own activated charcoal using brine, acidic or basic soaks. We teach this hands-on in our Austere Medicine Courses as well.

At the point that the tissue has recovered from infection, charcoal should be discontinued and herbs can be used both to speed tissue proliferation as well as fight bacteria. This is where treatment would start for an uncomplicated (uninfected) wound and could include herbs such as Echinacea angustifolia (Echinacea – root), Larrea spp. (chaparral – leaf and flower), Phytolacca spp. (poke leaf) leaf and Acmella oleracea (Spilanthes – leaf, flower or root).  These are best administered as a poultice, keeping the herb material separated from the wound itself by sterile gauze and allowing a water-soaked poultice to drip in and around the wound area like a wet tea bag.  Tissue generally regrows most effectively in a warm, moist environment.  It is important not to allow a wound to become too wet (boggy) or too dry.  But the problem with a warm, moist environment is that it is also ideal conditions for bacterial growth.  For this reason, it is very important to start any non-infected wound treatment using herbs that are lymph-stimulating and/or anti-bacterial such as those listed above while also being anti-inflammatory and tissue-proliferating.

Several plants  are  excellent at drawing out infection from a wound as well as increasing (in some cases) macrophage activity around the wound area.  I prefer to use them more for toxic infections (i.e. where there are cell-lysing toxins other than bacteria present)—for instance as a poultice on an ulcerated and infected brown recluse spider bite—but they work for a laceration infection too, but not quite as well as charcoal.  Some of the top herbs on my list for this purpose are:  Opuntia spp. (prickly pear), Plantago spp. (plantain), Echinacea angustifolia root and Verbascum thapsus (mullein) leaf.

Many different anti-bacterial herbs are useful to counteract infection.  I like to use them more as synergistic or “adjuvant” herbs to maintain a higher degree of anti-bacterial activity in an area rather than using them directly in the same manner as pharmaceutical antibiotics.  The reason for this is that herbs are rarely of the same potency as antibiotics and are far more effective when used as part of an overall approach to wound healing that includes restoring tissue homeostasis.  If the tissue can be kept clean, vascularized and given homeostasis support, it will heal without infection, heal quickly and heal very well, often with minimal or no scarring.  This is a more thorough approach to healing the wound itself that requires attention to detail and more oversight than simply taking an antibiotic and ignoring the wound.  Note that there are herbs that are directly anti-bacterial due in part to constituents like berberine (e.g. Berberis spp, Coptis chinensis, Mahonia spp.), and there are also adjuvant or helper herbs that are very effective at limiting pathogenic bacteria’s ability to defend itself.  Examples of constituents like this are baicalein/baicalin found in Scutellaria baicalensis (baikal skullcap) and plantain, or MHC (5’ Methoxyhydnocarpin) found usually in the roots or leaves of berberine-containing plants like Algerita, barberry, and Oregon grape root. A few other strong anti-infective herb examples that include biofilm inhibitors are Uva Ursi (Arctostaphylos uva-ursi), Pomegranate rind (Punica granatum) and Andrographis (Andrographis panniculata)

A final set of herbs for treatment of both wound healing and infection include herbs that help stimulate the immune system and lymph activity.  Increasing the number of white blood cells (such as macrophages and neutrophils) as well as lymph activity assists in a similar process to vascularization- that is, cleaning the wound area out, except through the lymph system rather than the cardiovascular system.  I usually mix a strong lymph-mover such as Phytolacca spp. (poke) root with a mild lymph-supporting herb such as Galium aparine (cleavers), and add in a decent diuretic and liver support herb like Taraxacum officinalis (dandelion) root and/or Arctium lappa (Bburdock) root to help clear out the toxins from both the lymph as well as circulatory system, and then excrete them.

In closing, the most important services you can provide for a wound in the field are to keep it clean from the onset (hemostasis through inflammation phases) and keep it vascularized and protected (proliferation phase). A wound wants to be moist (not wet, not dry) and clean in order to heal properly. If you keep it clean, then the vascularization will generally take care of itself.  In an old, non-healing or ulcerated wound, it helps to use counter-irritants such as Zanthoxylum spp. (prickly ash), Juniperus spp. (juniper) or Capsicum spp. (cayenne).  However, following the maxim of keeping the wound clean will generally take care of the need to use these, and you can instead focus on inflammation and tissue proliferation with plant medicine.  Above all, familiarizing yourself with tissue state and learning to identify infected tissue as early as possible will give you the greatest chance of successfully using herbs to assist wound healing.

Table 1:  Differences between inflammation and infection

	Inflammation	Infection
Swelling	Swelling present, generally uniform around wound area	Swelling present, not necessarily uniform (circumferentially in the case of an extremity) around wound area but may be more swollen directly around infected area
Color	Can be normal skin color, pale or slightly red.  Usually uniform and once it has reached a certain size, does not continue to grow or spread.	Generally red to bright red.  Often wounds will have a brighter reddish hue to them along the edge of the wound where there is minor infection present, vs. more normal or pale skin color of inflammation that exists near the wound edge.  In the case of deeper wound infections, the red can be a bright, glossy or waxy sheen.   A patch of color that grows (regardless of the hue), is also generally a sign of infection.  Drawing a boundary around the area of color with a marker is one way to determine if the color (and swelling) is spreading. Streaks of red traveling toward the heart (infection that is becoming systemic and spreading via venous circulation) is  a sign of advanced (and dangerous) of infection.
Tenderness	Tender to the touch, but usually more of a general tenderness across the entire wound area.	Specific pain that is generally sharper, directly on and around the infected area – especially when pressed or touched even lightly.  In the case of deeper wound infection that may not be as visible on the surface, if the area has been rested and then starts to move (such as a leg wound that has been elevated), the pain can be specific, sharp and severe at first upon movement, lessening after some continued movement.
Heat	General heat around the injury, usually low grade	Increasing heat around the wound area.  May start out as low grade and then become high grade.
Exudate (pus)	No exudate	Exudate present. Wound will usually begin to drain on its own if it can (and should be allowed to).
Systemic	No systemic signs	Fever, chills, nausea, malaise, flu-like symptoms (generally appearing in later stages of infection, and a sign that the infection is critical).

Herbs for the Hemostatic Phase

• Larrea spp. (chaparral)
• Achillea millefolium (yarrow)
• Lantana camara (lantana)
• Capsella bursa-pastoris (shepherd’s purse)
• Hamamelis virginiana (witch hazel)
• Geranium (wild geranium root)
• Quercus (oak)

The list of hemostatic herbs is an extremely long one, but basically any astringent herb will stop minor bleeding.  Generally, I only use herbs to stop bleeding in the case of simple, minor cuts, and I prefer to use herbs that are also anti-microbial.  In the case of a deeper wound, I prefer to use a pressure bandage for the bleeding itself, combined with anti-microbial herbs (as a poultice).  I would not advise using herbs as a “clotting powder,” put directly into the wound, although there are cases where packing a wound in this way can be very effective using certain herbs.

Clotting powder as a concept is not practical, whether as plant medicine or otherwise.  If the bleeding is severe, even pharmaceutical grade clotting powders will wash away before stopping the bleeding.  If not, the wound still has to be cleaned eventually of the debris, which will likely re-open the wound and bleeding.  Therefore, it is far preferable in the case of a wound that is bleeding heavily to use pressure bandaging and (if using herbs) place a covered hemostatic and anti-microbial poulticethat will seep an herbal “tea” into and around the wound tissue.  It is important to note that I only do this when the wound is clean and fresh (within the first few minutes).

If the wound is obviously dirty or has been open for more than about 20 minutes uncovered, I don’t bother with any herbs.  I’m far more concerned with infection in a field environment at that point, and adding even anti-microbial herbs into the mix is asking for trouble.  In this case, clean the wound thoroughly, bandage and cover it and watch it closely.  If the wound is healing nicely, leave it alone for a day or two before putting on anti-inflammatory, anti-microbial and tissue-proliferative herbs.

If the wound begins to show any signs of infection, treat for infection immediately (see below).

External herbs for the Inflammation Phase

• Larrea (Chaparral) – External as poultice
• Plantago spp. (Plantain) – External as poultice
• Commiphora spp. (Myrrh) – External as poultice
• Quercus spp. (Oak) – External as poultice
• Lobelia inflata (Lobelia) – External as poultice
• Opuntia (Prickly pear) – External as poultice
• Vaccinium myrtillus (Bilberry) leaf – External as poultice

Internal Herbs for Inflammaton Phase (best as a formula with all herbs together in 1:1 ratio, 5-10 mL per day)

• Harpagophytum procumbens (Devil’s Claw) – 1:3 tincture
• Plantago spp. (Plantain) – 1:3 tincture
• Filipendula ulmaria (Meadowsweet) – 1:3 tincture
• Zingiber officinalis (Ginger root) and/or Zanthoxylum spp. (Prickly Ash berry, bark or root bark) – Fresh (as close to 1:1 as possible) or dry (1:3) tincture

Inflammation around an open wound should be considered different than inflammation of a closed injury (i.e. sprain, strain, etc.). The goal of the herbalist should be to slowly reduce inflammation (permeability) while increasing normal vascularization of the wound area and limiting the possibility of infection, thereby allowing the normal replacement of circulation to the area to clean out debris and toxins.

For this reason, I tend toward herbs that are anti-inflammatory (and/or “drawing” herbs) more from a vulnerary standpoint, while also being anti-microbial.

External Herbs for the Proliferative Phase

• Larrea (Chaparral) – External as poultice
• Plantago spp. (Plantain) – External as poultice
• Symphytum officinalis (Comfrey) – External as poultice
• Equisetum arvense (Horsetail) – External as poultice
• Calendula officinalis (Calendula) – External as poultice
• Lantana camara (Lantana) – External as poultice

Internal Herbs and Nutrition for the Proliferative Phase

• Vitamin C (crucial in collagen formation)
• Vitamin A (avoid any deficiencies in this vitamin, also to ensure healthy collagen formation)
• Zinc (avoid any deficiencies)
• Protein (50% – 150% increase in protein intake depending on the severity of the injury)

Internal formula – 1:1 ratio of each herb in the formula, 5-10 mL per day of the full formula:

• Symphytum officinalis (Comfrey leaf) – Controversial because of pyrrolizidine alkaloids, but I use internal comfrey leaf tincture (20% alcohol) internally for no more than 2-3 weeks at a time (usually in formula with other herbs). Fresh tincture of the leaf, juiced to as close to 1:1 as possible, with 20% alcohol added to preserve.
• Equisetum spp. (Horsetail)- Also should only be taken 2-3 weeks at a time. I use a 1:3 alcohol tincture.
• Plantago spp. (Plantain) – Fresh (1:1 if possible) or dry (1:3) tincture
• Silybum marianum (Milk Thistle seed) – Fresh (1:1 if possible) or dry (1:3) tincture

The key to this phase is to speed up wound healing while also making sure that there is no infection being locked in under the skin that is healing.  For this reason, it is very advisable (especially in the field) to choose herbs externally that are highly anti-microbial.

For instance, although comfrey and calendula are high on  the list as tissue proliferators, I would never use either by themselves on an open wound without other, strong anti-bacterial plants in a formula with them.

Herbs for the Remodeling Phase

• Symphytum officinalis (Comfrey) – externally only, be aware of the toxicity issues around pyrrolizidine alkaloids (“PA’s”)
• Centella asiatica (Gotu Kola)
• Vaccinium myrtillis (Bilberry leaf)
• Vitamin E oil
• Calendula officinalis (Calendula)
• Aloe vera
• Zanthoxylum (Prickly ash)
• Capsicum (Cayenne)
• castor oil

Remodeling the scar tissue involves breaking up the tissue with massage and using salves, lotions and oils to help increase vascularization to the area while helping micro-proliferation of tissue that is broken down during physical manipulation – thereby slowly changing the scar tissue back into healthy tissue.

Top 3 Herbs

Three of my most favorite and all around useful herbs in the field (especially for wound infection management) are:

• Echinacea (Echinacea angustifolia root or a mix of purpurea tops and angustifolia root)
• Chaparral (Larrea tridentata)
• Algerita (Berberis trifoliolata), Barberry (Berberis vulgaris) or most other species in the Berberis genus

These three herbs give a very broad spectrum of anti-microbial skin and mucosa healing and are useful for acute infection.  Echinacea is an immune stimulating, anti-infective, toxic-heat clearing powerhouse when used correctly.  Chaparral is an anti-inflammatory, tissue-proliferating, anti-viral (esp. herpes family), anti-bacterial wonder-herb.  Algerita (root and leaf together, 1:2 or even 1:3 ratio of root to leaf is fine) is a superb anti-microbial (bacteria, virus, protozoa) for the gut as well as being extremely useful for skin or mucosal infections topically.  Additionally, it is a very effective liver and gallbladder decongestant, and the leaf is a very potent anti-nauseal.

FOR PAIN:

Depending on the person and the severity of the wound, pain may be difficult to manage.  There are different types of pain as well, and the classic definitions of visceral vs. somatic vs. nerve pain is an approach that can work when using herbs, both from a standpoint of inflammation as well as anxiety around an injury that adds to the awareness of the pain. Some of my favorite (legal) pain herbs that can be taken internally for the somatic pain of an (open) wound are:

• California poppy (Eschscholzia californica) – especially the root, use the whole plant
• Prickly poppy (Argemone spp.)
• Wild lettuce (Lactuca spp. – especially virosa species) – especially as Lactucarium, see my video on YouTube for more on this.
• Corydalis (Corydalis yanhusou) – requires a multi-fractional extraction using ACV, honey, water, alcohol and glycerin for effectiveness
• Skullcap (Scutellaria lateriflora) – anxiety
• Passionflower (Passiflora incarnata) – anxiety
• Devil’s claw (Harpagophytum procumbens) – somatic, muscle pain and inflammation
• Ox-Knee (Achyranthes bidentata) – somatic muscle pain and inflammation

Some of the most effective pain management herbs are also highly toxic (e.g. Gelsemium sempervirens, external Datura stramonium) and require much more detail on their responsible usage.  The herbs listed above that are low toxicity are useful, but may or may not be as effective as OTC pain medications such as NSAIDS, aspirin, etc.

For more of this type of information, programs and courses that range from clinical herbalism to austere and wilderness medicine, family medicine and doula certification and advanced botanical medicine making, visit our school, Herbal Medics Academy.