What Is Proud Flesh in Humans and How Is It Treated?

Proud flesh in humans is an overgrowth of granulation tissue that rises above the surrounding skin surface during wound healing, creating a moist, red, bumpy mound that prevents the wound from closing. Clinically called hypergranulation tissue, it appears as a shiny, fragile mass that bleeds easily and literally “stands proud” of the wound edge. The term originated in equine medicine, where limb wounds on horses are famously prone to this problem, but the same process affects human wounds ranging from burns and surgical sites to the skin around feeding tubes and tracheostomy openings. Treatment usually involves topical steroids, chemical cautery with silver nitrate, or newer approaches like topical timolol, though the best option depends on the wound’s size and location.

What Happens Inside a Wound That Produces Proud Flesh

Normal wound healing passes through overlapping phases. During the proliferation phase, the body fills a wound bed with granulation tissue, a temporary scaffolding made of new blood vessels, connective tissue cells, and collagen. This granulation tissue is supposed to fill the wound to the level of the surrounding skin and then stop, letting the skin’s surface cells migrate across it and close the wound. Hypergranulation occurs when that filling process overshoots: the granulation tissue keeps growing beyond the wound surface instead of leveling off and allowing skin closure.¹

The result is a raised tissue mass, often described as beefy red, glistening, and soft, that protrudes above the wound margin.² Because this mound physically blocks the migrating skin cells from meeting in the middle, it stalls healing. The wound stays open, keeps oozing, and becomes vulnerable to infection. In burn patients, hypergranulation at graft-loss sites has been shown to significantly increase healing time, with a median of 45 days to complete wound closure.²

At the molecular level, the overshoot appears to involve dysregulated activity of growth factors, particularly PDGF and TGF-β, which normally orchestrate the formation and then the orderly shutdown of granulation tissue. When these signals stay elevated or become unbalanced, the tissue keeps building instead of maturing into a flat scar.³

Where Proud Flesh Commonly Shows Up

Proud flesh can develop in virtually any wound that heals by secondary intention, meaning it fills in from the bottom rather than being stitched closed. In practice, certain wound types are far more prone to it than others.

Burns are one of the most common settings. One burn center estimated that roughly 10 to 15 percent of admitted burn patients develop hypergranulation tissue that impedes wound healing, and a separate study at the same unit found a rate of about 17 percent.² Beyond burns, the condition shows up in venous leg ulcers, pressure ulcers, and chronic wounds of various kinds.

Some of the most familiar everyday examples involve sites where something passes through the skin on a long-term basis: the stoma around a gastrostomy feeding tube, the opening around a tracheostomy tube, or the entry point of a long-dwelling IV catheter. Constant moisture, mild friction, and low-grade irritation at these sites seem to provoke the tissue into overgrowing. Ingrown toenails are another surprisingly common trigger. When an ingrown nail creates a chronic wound along the nail fold, a bead of granulation tissue often forms that complicates treatment. Partial or total nail removal, sometimes combined with destroying part of the nail matrix, is the standard surgical fix, but the granulation tissue itself also needs to be addressed.⁴

The Role of Biofilm and Infection

One factor that has received increasing attention is the role of bacterial biofilm in triggering or sustaining hypergranulation. A biofilm is a community of bacteria that coats a wound surface in a slime-like layer, and it can be present even when the wound does not look classically infected with redness, pus, or swelling. Researchers have proposed the term “granulitis” to describe a specific scenario: inflamed, unhealthy granulation tissue that is being driven by a persistent biofilm-induced inflammatory state.⁵

This distinction matters for treatment. If proud flesh is being maintained by an underlying biofilm, simply cauterizing or trimming the excess tissue may not solve the problem because the biofilm keeps provoking regrowth. In these cases, wound cleansing strategies that disrupt the biofilm, along with antimicrobial dressings, may be necessary before the granulation tissue will settle down. If you have a wound where proud flesh keeps coming back after treatment, persistent biofilm is one of the first things a clinician should consider.

Standard Treatments

Treatment depends on severity, wound location, and what is available, but most approaches fall into a few well-established categories.

Silver Nitrate Cautery

Silver nitrate sticks are probably the most widely used first-line treatment for small areas of hypergranulation. The chemical burns down the excess tissue, and the sticks are cheap, portable, and easy to apply in an office or clinic. In the United Kingdom, using silver nitrate to treat hypergranulation tissue around ingrown toenails is a routine practice among podiatrists.⁶

Silver nitrate works, but there is evidence it may not be the fastest path to closure. An audit comparing silver nitrate cautery to topical hydrocortisone cream in burn wounds found that wounds treated with hydrocortisone shrank considerably more than those treated with silver nitrate. In one round of the audit, median wound dimensions decreased by about 14 mm with hydrocortisone but only 5 mm with silver nitrate. A follow-up audit a year later was even more lopsided, with hydrocortisone-treated wounds shrinking by 10 to 15 mm while silver nitrate-treated wounds barely changed.⁷ Silver nitrate also stains surrounding skin black and can cause stinging, which is worth knowing if the wound is on a visible area or in a child.

Topical Corticosteroids

Topical steroids dampen the inflammatory signals that drive tissue overgrowth, and the evidence increasingly suggests they may be a better option than cautery for many wounds. In a case series of burn patients treated with dilute hydrocortisone acetate solution (0.25%, applied via soaked gauze), all cases showed complete regression of the hypergranulation tissue. None of the patients needed to be re-grafted afterward, and no local or systemic side effects were observed.²

The appeal of steroids is that they treat the underlying inflammation rather than just destroying the visible tissue, which may explain lower recurrence rates. The trade-off is that steroids can thin the skin and slow wound healing if used too aggressively, so treatment protocols typically limit application to a few consecutive days before returning to standard wound care. In the burn unit that published the case series above, treatment was capped at four consecutive days per affected area to minimize systemic steroid absorption through damaged skin.²

Choosing Between Them

A literature review on the topic concluded that for hypergranulation tissue that does not respond to silver nitrate, the choice of second-line treatment depends on accessibility, ease of use, cost, and wound location.⁸ In practice, this means silver nitrate is still commonly tried first because it is simple and inexpensive, but topical steroids are an increasingly preferred alternative, particularly for burns, large surface areas, and settings where repeated cautery visits are impractical.

Emerging and Less Common Approaches

For cases that do not respond to silver nitrate or steroids, a handful of alternative treatments have shown promise in smaller studies and case reports.

Topical timolol, a beta-blocker eye drop typically used for glaucoma, has gained attention as a treatment for stubborn hypergranulation tissue. The mechanism is not fully understood, but beta-blockers are thought to reduce local blood vessel growth and inflammation. In one case, a patient with severe hidradenitis suppurativa (a chronic inflammatory skin condition) developed persistent granulation tissue that did not respond to standard interventions. After starting topical timolol, the majority of the tissue regressed within three months and remained flat through 12 months of follow-up.⁹ Other clinicians have reported similar results with timolol gel for refractory cases.¹⁰ The evidence is still limited to case reports and small series, but timolol offers a painless option for patients who have run out of standard alternatives.

An older and more unconventional approach involves sprinkling medical-grade salt directly onto the overgrown tissue around gastrostomy (feeding tube) sites in children. The hypertonic environment draws fluid out of the swollen tissue and shrinks it. In a series of pediatric patients, hypergranulation became nearly flat within a median of seven days. One patient developed mild skin erosion when the salt was left on too long, which led the team to modify its protocol so the salt was rinsed off after 10 minutes.¹¹ This approach is worth mentioning mostly because parents of tube-fed children encounter it frequently and want to know whether it is backed by evidence. It works, but the salt must be applied carefully and briefly to avoid damaging surrounding skin.

When Proud Flesh Might Not Be Proud Flesh

One of the real risks with hypergranulation tissue is misidentifying something else as “just proud flesh.” Two categories of look-alikes deserve attention.

The first is a concept sometimes called epidermal maturation arrest, a term that appeared in some wound care literature to describe wounds where the surface cells seemed to stall without closing over. A review of all the reported cases concluded that there was no convincing histological evidence that this was a distinct entity at all. The clinical descriptions, tissue samples under the microscope, and treatment responses all matched ordinary persistent granulation tissue.¹² If you encounter the term, it most likely means the same thing as proud flesh by another name.

The second, and far more dangerous, look-alike is skin cancer growing within a chronic wound. A non-healing wound, especially one that has been open for weeks or months, can undergo malignant transformation. These are called Marjolin’s ulcers, and they most commonly present as squamous cell carcinoma, which accounted for about 71 percent of cases in one literature review. Basal cell carcinoma and melanoma have also been reported.¹³ The practical takeaway: if what looks like proud flesh does not respond to treatment, keeps growing, has irregular edges, or has been present in a wound that has been open for a very long time, a biopsy should be done to rule out malignancy. Assuming it is “just granulation tissue” and continuing to cauterize it can delay a cancer diagnosis.

How Human Proud Flesh Compares to the Horse Version

People who have worked with horses often arrive at the term “proud flesh” through veterinary experience, so the comparison is natural. In horses, exuberant granulation tissue is one of the most common wound complications, especially on the lower legs where skin is thin and blood supply is limited. The overgrowth in horses can be dramatic, sometimes forming masses that dwarf the original wound.

A comparative histopathology study found both similarities and differences between equine exuberant granulation tissue and human abnormal scarring. Both showed increased numbers of irregularly oriented, thickened collagen fibers in the dermis and a marked increase in fibroblasts. However, only the equine tissue contained myofibroblasts, a type of contractile cell that pulls wound edges together, and only the equine tissue showed a significant presence of inflammatory white blood cells. The human tissue, in contrast, contained distinctive “keloidal” collagen not seen in horses.¹⁴

This underscores an important point: the equine version and the human version share a name and a broad mechanism (granulation tissue that will not stop growing), but they are not identical at the tissue level. The horse version is more inflammatory and more prone to massive overgrowth, while human hypergranulation tends to be lower-profile and more responsive to simple treatments. If someone tells you to treat human proud flesh the way you would treat a horse’s wound, the advice does not translate directly.

Preventing Proud Flesh Before It Starts

Prevention strategies are less well-studied than treatments, but a few principles come up repeatedly in clinical literature and wound care practice.

• Moisture balance: Overly moist wound environments encourage granulation tissue overgrowth. Dressings that absorb excess moisture, like foam or alginate dressings, can help keep the wound bed at a level of dampness that supports healing without tipping into hypergranulation.
• Friction control: Around tube sites and tracheostomies, reducing mechanical irritation with properly fitted securing devices and barrier creams can lower the risk of triggering proud flesh.
• Early recognition: The sooner hypergranulation is spotted, the easier it is to treat. In burn units, wound care teams check for it at every dressing change because a small bump caught early often responds to a few days of topical steroid, while a large established mound may need repeated silver nitrate applications or more aggressive intervention.
• Infection management: Because biofilm can sustain the inflammatory state that drives overgrowth, keeping wounds clean and addressing early signs of infection or biofilm can prevent granulation tissue from getting out of control.

For patients managing wounds at home, the most actionable advice is to pay attention to how the wound bed looks at each dressing change. Healthy granulation tissue is flat or slightly concave relative to the skin surface. If the tissue starts rising above the skin edge, appears unusually red and glistening, or bleeds at the slightest touch, that is the time to contact your wound care provider rather than waiting to see if it resolves on its own. Early treatment with a short course of topical steroid or a single silver nitrate application is far simpler than dealing with a well-established overgrowth weeks later.