A Closer Look At Topical Therapies In Wound Care

John Giurini, DPM, FACFAS, and Allyson Berglund, DPM

   Iodine-based preparations are antiseptic in nature with reported in vitro bactericidal rates of 0.1 to 1 percent.29 Physicians often use iodine preparations for locally infected wounds in conjunction with oral or intravenous antibiotics. Iodine preparations come in many forms, including ointments, solutions and moderately absorptive substances, thereby making iodine useful for many types of wounds, including those wounds that are moderately exudative. Commonly used forms of iodine preparations include Iodosorb (Smith & Nephew) and Betadine (Purdue Pharma). Despite the apparent usefulness and diverse utility of iodine, there is much debate as to whether iodine is effective at managing locally infected wounds.30

Assessing The Roles Of Split Thickness Skin Grafts And Biologics

The aforementioned topical therapies for the most part are cost-effective. Clinicians can apply them quickly to the affected area and patients can perform these dressing changes on their own with proper education.13 That being said, there are certain scenarios when the physician can and should employ split thickness skin grafts (STSG) and advanced topical therapies or biologics. Biologics are composed of living cells or substitutes.31

   Split thickness skin grafts. Autologous split thickness skin grafts require a wound that has a good, well perfused granular base.32 Split thickness skin grafts also require a wound free of infection and it is best to utilize them in non-weightbearing areas of the foot. Common donor sites for a STSG are the ipsilateral thigh or calf. Split thickness skin grafts involve harvesting the epidermis and varying levels of thickness of the dermis with an electric dermatome. After securing the STSG to the affected site with sutures or staples, one would traditionally bolster it down with a negative pressure wound therapy device (NPWT). Researchers have demonstrated successful use of STSGs over free local flaps and muscle flaps, and most importantly, STSGs remain the gold standard for the reconstruction of diabetic foot wounds.31,32

   Xenografts and allografts. Advanced biologics are similar to STSGs in that they require an infection-free, healthy, granular-based wound. Advantages to using advanced biologics over STSGs include not having to take the patient to the operating room and the lack of donor site morbidity.

   Xenografts such as Oasis (Healthpoint Biotherapeutics) are derived from porcine products and contain varying thickness of dermal tissue. Researchers have shown that this modality heals chronic leg ulcers faster than compression therapy alone.33 Similarly, commonly used allografts include Apligraf (Organogenesis) and Dermagraft (Shire Regenerative Medicine), both of which contain neonatal fibroblasts as part of their wound healing components. Both products are widely used and researchers have shown them to have successful wound healing potential.34-35 Similarly, EpiFix (MiMedx) is an amniotic membrane allograft, which contains a myriad of growth factors such as EGF, PDGF and FGF, and has shown potential in healing DFUs.36

   While there are many new and upcoming advanced biologics similar to the aforementioned products, more research is needed to prove the success of most of these products.

In Conclusion

The underlying pathophysiology of DFUs and their associated chronicity are very complex. It is essential that the clinician recognize the potential underlying causes (both systemic and local in nature) of the DFU and manages these causes appropriately. A good clinical examination of the DFU is of the greatest importance as this will help guide the physician toward the most appropriate topical therapy and promoting an optimal wound healing environment.

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