Current Insights On Treating Gangrenous, Odorous And Painful Wounds

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

   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.

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