Proud flesh is an excessive growth of granulation
tissue that has the appearance of cauliflower. It usually
develops over an open wound, and most often occurs in
areas of excessive tension and motion. Proud flesh
usually is seen in injuries of the distal limbs (below
the knee or hock) due to the lack of underlying soft
tissue structures, which allows for an excessive amount
of tension in those areas. These distal areas mainly are
comprised of bone, ligaments, and tendons, and lacks
underlying muscle. This anatomy causes the skin surface
to be tense, which increases the risk of proud flesh
because of the difficulty for skin to grow back over a
wound.
The best treatment of proud flesh is prevention, and
the best prevention is performing a primary closure
(suturing) of the wound immediately, or as soon as
possible, after the wound occurs. Proud flesh can become
a problem when primary closure is not an option, and the
skin has to heal through second intention healing. Second
intention healing is when the skin has to heal first by
granulation tissue forming over the wound, then the skin
grows over the granulation tissue. It is at this point
you get proud flesh. Another preventative method is to
limit the motion in the area of the wound as much as
possible. This is generally done by bandaging, or placing
the lower limb in a cast. By reducing the motion in the
area, you speed the healing process allowing skin to grow
over the granulation tissue, which greatly reduces the
occurrence of proud flesh.
If proud flesh does occur, there are a couple of
options for the horse owner. First, surgical removal of
the exuberant granulation tissue generally provides the
best results. In this process, the granulated tissue is
excised to be level with the skin's edges. In some
horses, sedation is not necessary as granulation tissue
is devoid of a verve supply. While there are no nerve
endings in the tissue, there is a tremendous blood
supply. Once the tissue is debrided, a pressure bandage
is applied to help stop the bleeding. This debridement
process might need to be performed more than once,
depending on the size of the wound and how much proud
flesh is present.
The second option in treating proud flesh is to use a
caustic substance to eat away the granulation tissue.
There are several caustic products on the market. The
problem with caustic substances is that their purpose is
to destroy cells, and in addition to destroying exuberant
granulation tissue, they also destroy healthy cells and
might cause further damage to the wound. Using a caustic
substance slows the healing process when compared to the
surgical treatment of proud flesh. The surgical method is
generally preferred because it removes much of the
unwanted granulated tissue and leaves healthy tissue
underneath, whereas the caustic method destroys all cells
whether or not they need to be destroyed.
Once the excess granulation tissue is removed, a
steroid cream or ointment is applied to the area.
Steroids have been shown to inhibit the formation of
granulation tissue without inhibiting epithelialization.
Epithelialization is the process of skin cells growing
from around the edge of a wound and slowly covering the
damaged area.
The healing process all depends on the size of the
wound, and how large the proud flesh area has become.
Since skin cells have to grow from the edge, the larger
the wound, the more time it takes to heal. If the horse
is put in a cast to restrict his movement, it generally
takes two to three weeks. However, in most lower limb
wounds, it is usually a minimum of three to four weeks if
a bandage is applied, but it could be as long as several
months.
Another factor that affects the healing process is the
physical condition of the horse. If the horse is in peak
condition and is having all of his nutritional
requirements met, then the immune system is working at
peak performance and the healing process will be
shortened. But, if you have an older horse, or one that
has been nutritionally compromised, then the healing
process will take longer.
In some cases where large wounds are involved, skin
grafting is performed to try and aid in the healing
process. With large wounds, proud flesh often leaves a
hairless scar that will crack and bleed. Skin grafting
improves the healing of these large wounds by decreasing
scar tissue. This also leaves an area that is more
cosmetically appealing.
Although not a common complication, there is a small
risk that a sarcoid could develop. A sarcoid occurs when
the scar tissue changes its characteristics to become a
benign skin tumor. While not common, it has been reported
and is occasionally seen in association with proud flesh.
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