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Exuberant Granulation Tissue (Proud Flesh)
Caity Cosentino, DVM, ECVMMP

Wound healing occurs in several stages. The first stage hemostasis is where the body actively tries to stop bleeding using platelets to form a clot and constricting blood vessels in the area to decrease blood flow. The inflammatory stage immediately follows where immune cells work to clean the area. This stage is characterized by heat, swelling and pain. The following stage is the proliferation stage where new red tissue, granulation tissue, begins to fill the wound bed.

Granulation tissue is an important part of wound healing and begins to form approximately 3-5 days after the wound occurs. When it forms it brings a new blood supply along with the necessary nutrients for healing. It is also a protective barrier that is very resistant to infection. In horses however, there can be excessive formation of this tissue preventing the next stage, epithelialization, where new skin cells are formed and travel across the bed of granulation tissue. When the granulation tissue grows too high it is often called proud flesh and it blocks the new skin cells that are trying to come across the wound from the edges.

Proud flesh occurs most commonly on the lower limbs of horses (below the carpus and hock) where there is a lot of tension in the skin and often a great deal of mobility. There are many instances on lower legs where a wound cannot be healed using primary intention (sutured or stapled skin edges together) due to lack of excess skin in the region or significant swelling leading to the need to rely on secondary intention healing and managing an open wound. Anything that prevents efficient wound healing and causes prolonged inflammation like infection, motion, repeated trauma to the region (like lying on the wound), or poor bandaging techniques make proud flesh more likely to occur. Without treatment the wound will be unable to fully heal and become a chronic problem.

Treatment depends on the amount of granulation tissue present along with the wound’s severity and length of time it’s been present. Treatment may include topical medications, especially ones containing corticosteroids, bandaging and limiting motion. Other more aggressive forms of treatment may be necessary where the wound bed is debrided or trimmed so the granulation tissue is brought back below the level of the skin, allowing epithelialization to occur. Though very vascular, granulation tissue lacks nerve endings so the procedure can be done often with the horse standing as it’s not painful for the horse to trim off. The area usually does bleed quite a bit due to the abundant vessels present and after debridement a pressure bandage is often applied.

Most wounds can be resolved with a combination of the above techniques, but if the wound is not responding fully to the treatment protocol advanced techniques may be needed to complete the healing process. Complications in wound healing are more easily resolved by a veterinarian if addressed early in the healing process, so consulting a veterinarian before the wound develops complications like proud flesh formation is always recommended. Early treatment can not only improve healing time but also reduce the amount of scar tissue formed and result in a better cosmetic outcome.

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