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.

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