A Closer Look At Combination Therapy For Chronic Wounds

Patricia Kim, DPM, and John M. Giurini, DPM

   Peripheral edema often accompanies chronic wounds. This occurs via excessive interstitial hydrostatic pressure, which can compromise skin perfusion. Silver impregnated dressings can decrease edema, thereby improving skin perfusion as well as reducing the pain that patients may experience.

   Silver dressings are relatively inexpensive with multiple varieties. There are few adverse side effects but those include burning at initial application and hardening of dressings over joints.4 This therapy is useful in the clinical setting due to its cost effectiveness, safety and ease of application.

A Closer Look At The Potential Of Medical Honey

Clinicians have historically utilized medical honey for a myriad of ailments but investigators have only recently begun to look at the modality for chronic wounds. Medical honey contains leptospermum honey, which has demonstrated in vitro activity against MRSA.5

   The effectiveness of medical honey is due to its hygroscopic property as well as its low pH. Hygroscopic properties draw moisture out of an environment, thereby dehydrating bacteria whereas other products inhibit or attack the bacterial cell wall or inhibit metabolic pathways. Chronic wounds typically have a pH value >7.3 when colonized by bacteria.5 Honey’s low pH allows acidification of the wound, which inhibits bacteria and speeds wound healing.

   Protease activity is also suppressed as a neutral pH is optimal for proteases to destroy growth factors, protein fibers and fibronectin in the wound matrix. Medical honey also acts as an anti-inflammatory, which decreases wound exudate as well as edema. Nerve endings are sensitized by prostaglandins during the inflammatory phase, which are also decreased due to honey’s anti-inflammatory property.

   Another beneficial effect not often mentioned is malodor, which is commonly present in chronic wounds. Topical medical honey can reduce this unpleasant characteristic. It can be a cost effective treatment method that one can easily use in the clinical setting.

What You Should Know About Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy has been in use for more than 40 years as a wound healing adjunct. With HBOT, a patient goes into a compression chamber under atmospheric pressure greater than one atmosphere absolute of 100 percent oxygen.6 This increased pressure theoretically increases the oxygen level dissolved in the blood, which in turn affects vascular tone and promotes wound healing.

   One would not use HBOT alone but in combination with serial debridements, antibacterials and local dressings. While few well-controlled randomized trials exist documenting the efficacy of HBOT, there is growing evidence that supports HBOT as a successful adjunct in the treatment of chronic diabetic foot ulcers.7 Complications are few but can include oxygen poisoning, claustrophobia or ear/sinus/lung damage.

Emerging Insights On Combining NPWT with Conservative Care

Negative pressure wound therapy is another treatment that one usually uses in combination with antibacterials. The environment created with the apparatus decreases edema by lowering exudate collection. This in turn increases blood flow to the wound bed, allowing the phases of wound healing to continue.

   Dressings are confined to the vacuum-assisted closure (VAC therapy, KCI) dressing. Concomitant antimicrobial dressings are rarely used with VAC therapy. A recent systematic review showed increased healing of diabetic foot ulcers when combining conservative treatments with VAC therapy.8

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