Randy Jacobs, M.D. Patient Education

To return to the Patient Education page and read more articles, click here.

Granulation Tissue


Proud Flesh: Persistent Granulation Tissue


What is proud flesh?

Granulation tissue is the pink layer you find under a scab if you pick it off. Proud flesh is also known as persistent granulation tissue, and occurs when the scabs normal granulation tissue does not go away. Proud flesh can persist for years until it is removed, destroyed, or until the cause is alleviated. Often, proud flesh resolves on its own. Proud flesh can be viewed as the result of inadequate healing. It is the opposite of a keloid. A keloid has over-healed. Proud flesh has under-healed. In wound healing, the body produces fibroblasts, capillaries, collagen, healing factors, fibrin, and ground substance working together to heal the wound. This collection of tissue substances is called granulation tissue. If everything goes well, eventually, there is sufficient collagen to fill the wound gaps, and most capillaries are reabsorbed. The fibroblasts revert to a resting mode, and finally, the wound heals. Sometimes the granulation tissue undergoes striking proliferation beyond the wound margins. Physicians call this persistent granulation tissue others call it "proud flesh.”


How does healing occur?

A few hours after an open injury, there is already evidence of connective tissue repair. Fibroblast cells, the collagen and elastic tissue forming cells, become active and begin to proliferate. Buds ("angioblasts") sprout from the damaged capillaries. A fibrin meshwork is formed and becomes the framework on which healing occurs. Typically healing cells invade the fibrin meshwork created during the injury and inflammatory response. Fibrin is fibrinogen released from damaged vessels, and activated by blood clotting cascades when blood meets tissue juices. Fibrin forms the meshwork which controls bleeding, and then becomes the framework for fibroblasts and angioblasts, the healing cells which will form the scar. This new tissue formed is called granulation tissue which is an "immature scar". The fibrin meshwork is said to be undergoing organization. You've seen granulation tissue -- it was the moist, red, jelly-like stuff under the scab that you picked off too soon. Until the new scar is complete, the whole meshwork of immature scar is called "granulation tissue". In healing, a layer of 'granulation tissue' forms over the injured surface, and a new layer of skin will develop over time, replacing the granulation tissue from the edges, inward.


What causes proud flesh?

Proud flesh is usually caused by a failure to heal. Failure to heal may be caused by some type of low grade infection, usually bacterial or fungal. Wound contamination can also cause failure to heal. Unknown factors can also cause it. You may run into granulation tissue that doesn't mature; depending on its location, a doctor may call it "pyogenic granuloma", "inflammatory pseudotumor", or "persistent granulation tissue". Some people pertain to it as proud flesh.


How is proud flesh treated?

Proud flesh can be treated in a variety of ways. It can be surgically removed by scraping or cutting. This is usually, but not always, the first choice. Silver nitrate sticks applied twice a day can help. If proud flesh recurs and persists, a culture can be taken. Dr. Jacobs may take bacterial, fungal, or mycobacterial cultures. Topical or oral antibiotics can be given to fight the infection and can thus alleviate the proud flesh. The proud flesh may recur if the infection recurs, and thus, may need retreatment.