Current Insights On Treating Gangrenous, Odorous And Painful Wounds

Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

These insightful panelists offer their expertise on dressings, particularly for wounds that are dry and gangrenous, and wounds with strong odor. They also share their perspectives and insights on painful wounds.

Q:

What do you use when you see a dry, gangrenous wound?

A:

When a wound presents with dry gangrene, the most important thing to do is make an immediate referral to a vascular interventionist, according to Desmond Bell, DPM, CWS. Dr. Bell would recommend painting the gangrenous area with Betadine or another antimicrobial prep in order to help keep the bacterial burden in check until further intervention occurs.

   Likewise, Kazu Suzuki, DPM, CWS, often uses a Betadine swab or solution, and then covers the wound with dry, sterile dressings. He notes the alcohol in Betadine desiccates the wound while the povidone-iodine will keep the wound surface relatively sterile. Afterwards, he may take the patient to the OR to remove the gangrenous wounds or elect to continue the Betadine dressings indefinitely if the aim is an auto-amputation for the gangrenous toe to demarcate and fall off on its own.

   James McGuire, DPM, PT, CPed, cites “a great deal of controversy” about treating dry, gangrenous wounds, particularly those involving the plantar or posterior heel. As he notes, the skin develops a hard, dry eschar because of a lack of subcutaneous capillary flow to the area. The depth of tissue damage can be quite shallow or extensive, which often prohibits staging of the wounds, according to Dr. McGuire.

   As long as the escharotic edges are firmly attached to the surrounding skin or minimally separated with no drainage, Dr. McGuire says a simple dry dressing and pressure offloading will suffice. Although some clinicians clean the skin with an antiseptic, apply Betadine to the wound edges or use an antimicrobial contact layer to prevent bacterial colonization along the wound edges, he says there are no studies to show this is necessary. Dr. McGuire says the key is to keep the wound clean and offloaded while the body attempts to build a healthy capillary bed under the eschar, a process that may take several weeks to months.

   Dr. Suzuki has also used Iodosorb gel (Smith & Nephew), a povidone-iodine dressing stored in starch polymer gel, which one can leave in place for a week or longer.

Q:

What do you use for wounds with strong odor?

A:

“Odor is the product of bacterial colonization and necrotic tissue accumulation. Address these and the odor takes care of itself,” says Dr. McGuire.

   Dr. McGuire uses sharp surgical debridement, daily cleansing with a hypochlorous acid wash and a hydrophobic contact layer. If there is a lot of necrotic material remaining after the debridement, he cautions there may still be odor. However, if one uses a collagenase debriding agent, as the necrotic debris loosens, then the odor will decrease, according to Dr. McGuire.

   If one can’t wait for this process to play out and wants more aggressive odor control, Dr. McGuire says BID dressing changes with hypochlorous solution moistened gauze will work well and not harm newly formed granulation tissue.

   For malodorous wounds, Dr. Suzuki prefers to use Xeroform (Covidien), a yellow petrolatum gauze with bismuth, which has mild antimicrobial and anti-odor properties. There are a few specialized pouch dressings with charcoal particles in them but he finds them hard to use. Dr. Suzuki has had good experiences with metronidazole gel (Metrogel), saying this works well for some odors coming from fungating tumors. He does note this is an off-label use. Dr. Suzuki says the brand name Metrogel product is expensive but notes that one can use a compound pharmacy to create a metronidazole gel for a fraction of the cost of Metrogel.

   For Dr. Bell, whether the wound is draining or dry makes a difference in the management of odor as the type of odor can indicate what process is occurring in the wound. As he notes, strong odor is typically accompanied by the presence of infection and this can cover a wide range of organisms, from Pseudomonas colonization to the overpowering odor found with anaerobes. Ischemic (dry gangrene) wounds tend to have a rotting flesh odor. The intensity of the situation as well as the odor should determine what to apply to a malodorous wound, advises Dr. Bell. He has often used Dakin’s solution as a way to get odor under control in many wounds and says iodoform gauze packing has the additional benefit of managing odor.

   In contrast, Dr. McGuire says, “Solutions such as Betadine or Dakin’s, which are sometimes appropriate for odor control in maintenance wounds, are a bit harsh for those wounds in which we want to maximize healing.”

Q:

What do you use for a painful wound?

A:

Dr. Suzuki prefers to manage wound pain with oral medications, saying a judicious use of narcotic pain medication such as hydrocodone bitartrate/acetaminophen (Norco, Actavis), hydrocodone/paracetamol (Vicodin, AbbVie), oxycodone/acetaminophen (Percocet, Endo Pharmaceuticals) and gabapentin (Neurontin, Pfizer) can help in managing most wound pain. That said, he has used a lidocaine patch (Lidoderm, Endo Pharmaceuticals) for exquisitely painful wounds that sometimes occur in sickle cell patients or patients with complex regional pain syndrome. Patients can change these lidocaine patches once every 12 hours as the instruction states but he prefers to keep the patches on for 24 hours for the sake of simplicity.

   Dr. Bell has often used topical lidocaine 5% gel directly on some painful wounds. He says another trick is to saturate an alginate or even a gauze dressing with injectable 1 or 2% lidocaine and apply that to the wound. One can also apply topical pain patches containing lidocaine near a painful ulcer.

   As Dr. McGuire opines, pain control is more complicated than simply using topical or injectable lidocaine for wound debridement and dressing changes. Although researchers have shown that topical anesthetics in high concentrations can inhibit collagen synthesis and delay healing in experimental wounds, Dr. McGuire feels the use of these modalities has little or no effect on wounds clinically.1 “Patients with truly painful wounds benefit a great deal from the use of topical anesthetics and we should not avoid using them when patients really need them,” he says.

   “Pain is obviously subjective and the presence of pain with a wound can be an indicator of serious underlying issues, especially infection and ischemia,” says Dr. Bell. “Systemic pain management is a given but the use of topical agents for painful wounds can be an adjunctive therapeutic measure when the underlying cause of pain is being addressed.”

Q:

Do you have any other pearls regarding dressings?

A:

Almost every day, Dr. Suzuki sees new referral patients who say, “Hey, I have been doing wet-to-dry dressings for six months and I see no improvement.” He emphasizes that “wet-to-dry” gauze dressing is good for mechanical debridement but is not a good wound care regimen.

   “Today, we have literally thousands of wonderful wound dressings to choose from so there is absolutely no reason to use ‘wet-to-dry’ or ‘vinegar soaks’ that were commonly used 20 years ago,” says Dr. Suzuki.

   “Wound dressings and the rules and regulations regarding their use and prescription seem to change almost daily,” says Dr. McGuire. “What we are all interested in are dressings that do what they say they do and are cost-effective for our clinics and our patients.”

   As Dr. McGuire says, some of the new cost-effective and efficacious dressings are hydrophobic dressings for microbial management and hydroconductive dressings for fluid management. He also cites a new collagen dermal template manufactured from sheep forestomachs, which may help wounds heal to the point where more costly tissue supplements may not be necessary. Regardless of the complexity of the dressing, Dr. McGuire emphasizes that offloading and protection of the wound surface, especially for podiatric patients, are still key.

   For Dr. Bell, dressings are still the least important aspect of wound care and are no substitute for addressing the underlying cause of a wound as the focus of treatment. That being said, he feels dressings should be comfortable for the patient and ideally should help maintain an environment that is conducive to optimizing certain aspects of wound healing, such as promotion of angiogenesis, autolytic debridement, and protection of the wound from the bacterial burden of the external environment.

   It is also important to minimize the number of dressing changes, especially when drainage is not a major issue, according to Dr. Bell.

   “A number of dressings perform optimally when they are changed every few days versus several times per day. This tends to make everyone involved happier and can be more cost-effective,” says Dr. Bell.

   Dr. Bell is a board certified wound specialist of the American Board of Wound Management. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

   Dr. McGuire is an Associate Professor and Wound Center Director at the Temple University School of Podiatric Medicine. He is a Fellow of the Academy of Physicians in Wound Healing and certified in wound care by the Council for Medical Education and Testing.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached via email at Kazu.Suzuki@CSHS.org .

   Editor’s note: For related articles, see the online case study, “Addressing A Gangrenous Fifth Digit,” at http://tinyurl.com/pr8kp96 and visit the archives at www.podiatrytoday.com .

Reference
1. Drucker M, Cardenas E, Arizti P, et al. Experimental studies on the effect of lidocaine on wound healing. Am J Surg. 1998; 22(4):394-7; discussion 397-8.

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