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First Posted May 21, 2010
Jul 31, 2010

Proud Flesh or Exuberant Granulation Tissue

by Debora Johnson


"Wound Worries"/Equus Caballus Magazine Follow this link to view photos showing a 28 day cycle from initial wound to proud flesh growth to surgical removal to healing process.
Photo by Christa Moody

We have all heard the term "proud flesh" in relation to the healing process of the horse. So, what is proud flesh? It is not a mystery, but rather a normal tissue that has gone amuck. When there is a wound the surrounding tissue responds by attempting to heal the wound as quickly as possible. What happens then is there is too much tissue formed. When granulation tissue grows out and protrudes from the wound, then the granulation tissue is known as proud flesh. "Proud flesh is not conducive to wound healing as it prevents the wound from epithelializing (the process of the skin cells covering the wound)....The granulation tissue can become so large it appears to be a tumor, usually obliterating the original wound. Granulation tissue in this excessively exuberant form usually occurs within wounds on the distal (lower) leg of the horse, such as wounds over the cannon bone or pastern area. Granulation tissue in this form can be very difficult to manage." Proud Flesh/by: Christina Cable, DVM, Dipl. ACVS Proud flesh is most likely to occur in places with lots of movement: over joints, or when there is a complication such as infection that slows the healing process.

Note: It should also be noted that proud flesh or the exuberant granulation tissue tends to be resistant to bacterial infection. When referring to the distal limbs that means below the knee or hock.

Because the lower leg of the horse does not "have much muscle or underlying tissue, capillaries and small blood vessels in these areas will develop the proud flesh. After these vessels grow into loops the developing granulation tissue is invaded by other types of cells such as fibroblasts. Collagen is formed from the fibroblasts and then effectively fills the wounded and injured areas. Epithelial or skin cells can migrate along the surface provided by the granulation tissue. Skin defects are repaired by these cells, but they can only grow in one direction. These cells can not grow down into a wound or up over a lump. However, epithelial cells can grow across the surface of a large wound that has been filled in by granulation tissue which allows the skin to recover in that specific area."

"...Skin gains its elasticity from the development of collagen which is carried in fibroblasts. This helps provide the basic framework of wound contraction. However, there is a bad side to this tissue which helps a horse heal itself. The problem is when the process becomes too much and gets out of hand. When more tissue is produced than needed for wound healing it can become a problem. When too much of the tissue is produced it can grow up over the skin level and develop into a large, red mass that is unsightly. When bumped, rubbed or traumatized in any way the proud flesh will bleed excessively. The presence of this tissue also prevents the growth of skin cells across the injury and slows the healing of the wound. The excessive tissue needs to be removed in these situations. You should also seek aggressive treatment in order to get the best outcome."

The formation of this proud flesh is not only unsightly but can also interfere with the horse's performance depending upon where it develops and also interfere with the proper healing of the wound. Horses are the fastest healing of all land mammal!. The outer surface of a wound can cover over in a matter of hours. The internal injury can begin to fill in within three days.

Preventive Measures to Reduce Proud Flesh

  1. Clean and treat the wound immediately
  2. Suture the wound ASAP
  3. Use Pressure bandages: they reduce tissue growth and hold the wound's edges together as well as increase the amount of carbon dioxide at the surface of the wound.
  4. Antibiotics guard against infection
  5. Apply an antibiotic cream to the outer edges of the wound and work towards the center
  6. Cortisone slows the healing process and reduces the formation of proud flesh
  7. The use of n-butyl-cyanoacrylate (used in the veterinary glues Vetbond and LiquiVet and skin glues like Indermil and Histoacryl)
  8. Leave the scab formation alone. Do not remove it.
  9. The use of anti inflammatories helps with wound healing
  10. Stall rest for your horse as the healing process takes place

Treatments to Remove Proud Flesh

  1. Have the vet trim back any proud flesh formation. Note that proud flesh bleeds profusely, however, know that the horse feels no pain when the proud flesh is trimmed. There are no nerves in proud flesh.
  2. Chemical removal using astringents to cauterize or burn the cells. This is risky as it slows down the healing process and also destroys healthy tissue. Never do this yourself! Always consult your vet. Some of the astringents used are strong iodine, lye or sulfur.
  3. Surgical removal
  4. Use pressure bandages
  5. Use topical cortisone preparations along with antibiotics. Cortisone shrinks proud flesh, but also can slow healing. Always consult your vet.
  6. If possible, immobilize the area to facilitate healing.
  7. Laser surgery

For More Information:

Proud Flesh/by: Christina Cable, DVM, Dipl. ACVS
Proud Flesh and How to Prevent It

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