Wound care

Optimum wound healing requires adequate nutrition. Nutritional deficiencies delay the normal processes that allow progression through the stages of wound healing⁴. Poor nutritional status can be a cause of wound development. For example, patients with poor dietary intake and low body weight have been shown to be at increased risk of pressure ulcer development⁶.

The Effects of Malnutrition and Wound Healing

Nutrient deficiencies can prolong the inflammatory phase by decreasing the proliferation of fibroblasts and formation of collagen as well as reducing tensile strength and angiogenesis⁷. A 2005 meta-analysis by Stratton et al8 showed that the provision of oral nutritional supplements (250-500kcal per serving) given over a period of 2 to 26 weeks was related to a significantly lower incidence of pressure ulcer development compared with standard care.

Nutritional Screening of Patients at Risk of Chronic Wounds 

Nutritional screening of all patients at risk of chronic wounds is recommended in order to prevent complications of malnutrition¹. MUST (Malnutrition Universal Screening Tool) is a universally accepted valid and reliable screening tool that can be used in all care settings and has been recommended by the 2026 European Pressure Ulcer Advisory Panels (EPUAP & NPIAP) 2026 Guidelines⁹ and the HSE National Wound Management 2018 Guidelines¹. 

Poor nutrition leading to nutrient deficiencies will interfere with wound healing, mostly by delaying the healing response. Evaluation of a patient's nutritional status through assessment and the provision of a nutritionally appropriate diet is one of the first principles to healing¹⁰.

Wound nutrition is essentially whole-body nutrition, and the goal is to maintain body mass, limit weight loss and provide adequate nutrients to promote healing. 

A significant number of studies have investigated the potential value of specific nutrients in regulating wound healing as follows:

Energy (kcal)

EPUAP & NPIAP⁹ and the HSE¹ recommends a minimum of 30-35kcal per kg body weight per day as a general guideline for patients with pressure ulcers. 

This must be assessed and adjusted based on weight loss and level of obesity. Patients who have lost weight may require additional calories, while patients with obesity should have their caloric goals adjusted appropriately¹⁰.

Protein

Protein is necessary for the synthesis of enzymes involved in wound healing, proliferation of cells and collagen, immune function and the formation of connective tissue. Inadequate protein intake, often in conjunction with excessive losses of protein via wounds exudate, can lead to protein deficiency¹. 

The recommended intake of protein associated with wound healing 1.25-1.5g/kg body weight/day for individuals with chronic wounds¹⁰. If the patient is severely catabolic, with more than one wound, or with a stage III or IV pressure ulcer, they may require 1.5-2g/kg body weight/day (monitoring of hydration status and renal function recommended)^1,10.

Arginine

Arginine is a conditionally essential amino acid that contributes to wound collagen synthesis.  As a donor of nitric oxide, it increases tissue blood flow and can improve immune response¹¹.

There is on-going evidence to show that Arginine can significantly improve the rate of healing in pressure ulcers when used as part of an enriched nutrient formula^11,12,13,14. 

Fluid

The HSE wound management guidelines recommend providing adequate water intake to aid blood flow to healthy and healing tissue¹.

Vitamins, Minerals and Trace Elements

Various micronutrients are required for normal health and physiological function. Vitamin C, A, zinc and iron are particularly important in wound healing¹⁰:

• Vitamin C functions in the synthesis of collagen and as an antioxidant. Vitamin C deficiency results in an impaired immune response and increases the risk of wound dehiscence¹. 

• Vitamin A has an anti-inflammatory effect in wounds. Deficiency of vitamin A results in impaired collagen synthesis and reduced immune function⁷.

• Zinc plays a key role in protein synthesis and in tissue growth and healing. Zinc deficiency has been associated with delayed wound healing, reduced skin cell production and reduced immune system function¹¹. 

• Iron is a co-factor for collagen synthesis. It is required for oxygen transport, and it is a component of many enzymes required for wound healing. Low haemoglobin concentration due to iron deficiency may be a factor in tissue hypoxia, impaired hydroxylation of collagen and reduced immune response¹⁰.

• Other nutrients which have important functions in association with wound healing include vitamin E, vitamin K, vitamin B complex, copper, manganese, chromium and essential fatty acids. 

The Synergistic Role of Specific Nutrients in Wound Healing

Research has shown that 8 weeks supplementation with an oral nutritional formula enriched with arginine, zinc and antioxidants improved pressure ulcer healing when compared with controls¹³. International and HSE wound healing guidelines have recommended considering providing a supplement that contains high protein, arginine and micronutrients for adults who are malnourished with a pressure ulcer stage II, III or IV or multiple ulcers for at least 8 weeks.^9-11.

There is also evidence to support a role for arginine, zinc and antioxidants enriched oral nutritional supplements in the healing of diabetic foot ulcers, and leg ulcers¹⁴. 

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1. HSE National Wound Management Guidelines 2018. 

2. Gorecki C, Brown J, Nelson E et al. Impact of Pressure Ulcers on Quality of Life in Older Patients: A Systematic Review. JAGS, 2009; 57;1175-1183.

3. Gillespie, P & Mcintosh, Caroline (2016). Estimating the Healthcare Costs of Wound Care in Ireland. Poster presented at EWMA 2016.

4. Merryfield C. In: Gandy J. Manual of dietetic practice. Oxford: Wiley Blackwell Publishing, 2014. 

5. McDermott-Scales L, Cowman S, Gethin G. Prevalence of wounds in a community care setting in Ireland. J Wound Care 2009;18:405–17.

6. Neloska, L., Damevska, K., Nikolchev, A., Pavleska, L., Petreska-Zovic, B., & Kostov, M. (2016). The Association between Malnutrition and Pressure Ulcers in Elderly in Long-Term Care Facility. Open access Macedonian journal of medical sciences, 4(3), 423-427.

7. Quain, A. M. and Khardori, N. M. (2015). Nutrition in Wound Care Management: A Comprehensive Overview. Wounds, 27, 327-35.

8. Stratton RJ, Ek AC, Engfer M, Moore Z, Rigby P, Wolfe R, Elia M. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev 2005; 4(3):422-50 

9. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel & Pan Pacific Pressure Injury Alliance (2025–present). International Pressure Injury Guideline (4th edition, online). Available at: View International Guideline

10. Irish Nutrition & Dietetic Institute Nutrition Support Reference Guide 2015

11. Cereda, E., Gini, A., Pedrolli, C. and Vanotti, A. (2009). Disease - specific versus standard, nutritional support for the treatment of pressure ulcers in institutional older adults: A randomised controlled trial. Journal of the American Geriatrics Society, 57(8): 1395-402.

12. Cereda, E., Klersy, C., Serioli, M., Crespi, A. and D'Andrea, F (Oligoelement Score Trial Study Group). (2015). A Nutritional Formula Enriched with Arginine, Zinc, and Antioxidants for the Healing of Pressure Ulcers A Randomised Controlled Trial. Annals of Internal Medicine; 162: 167-174. 

13. Cereda E, Neyes J, Caccialansa R, Rondanelli M, Schols J. Efficacy of a disease-specific nutritional support for pressure ulcer healing: A systematic review and meta-analysis. J Nutr Health Aging 2017; 21(6): 655-661

14. Neyens J, Cereda E, Rozsos I et al. Effects of an Arginine-enriched Oral Nutritional Supplement on the Healing of Chronic Wounds in Non-Malnourished Patients; A Multicenter Case Series from the Netherlands and Hungary. J Gerontol Geriatr Res, 2017; 6(2).