Wound Healing

Back to Nursing Practice

Questions Received:

  1. Is there any evidence for the use of hydrogen peroxide as a debriding agent in sloughy/necrotic wounds?

  2. Please could you tell me if there is any research based evidence to support the use of Tegaderm as a post surgical dressing.

  3. Do you know of any publications that can help me in my task of comparing old wound care remedies with current day wound products?

  4. I'm a home health nurse treating a patient who had cellulitis with ulcerations to bilateral lower extremities. The wound beds are pink, exuding serous sanguinous drainage with greenish blue color. I'm using Polymens foam dressing over wounds. The dressings have an odor when changed but the wounds themselves are nonodorous. I'm concerned with the greenish-blue tint to exudate. Please advise.

  5. Can you tell me if APLIGRAF is available here in London (or elsewhere) for leg ulcers. I have read about it on the internet and am wondering if it is available here and could help me.

  6. My father suffers from leg ulcers and was recently told that there is a lotion or treatment used in Australia - containing pawpaw extract - to treat leg ulcers with a high success rate. I can find no useful information on this other than that the active ingredient might be papain. I wondered if there is any medical evidence on this treatment.

  7. Should a doppler test always give the cause of a leg ulcer, i.e. which kind it is? How critical is a leg ulcer in someone with a deep vein thrombosis (DVT) & diabetes?

Responses:

Is there any evidence for the use of hydrogen peroxide as a debriding agent in sloughy/necrotic wounds?

27th June 1999

(debride: to remove all foreign material and injured, infected, or dead tissue from a wound)

Hydrogen peroxide is less used now as a debriding agent than in the past. When hydrogen peroxide is applied to a wound it combines with catalase produced in the tissues and decomposes into oxygen and water, producing effervescence (Potter and Perry, 1993). The rationale was that this helps to loosen materials that might hinder wound recovery and enables them to be washed off more readily. Six-percent w/v hydrogen peroxide (known as ' 20 volume' solution) liberates twenty times its own volume of oxygen upon decomposition (Thomas, 1990a), and is generally diluted 1 in 3 for the irrigation of wounds. The release of oxygen also kills some anaerobic bacteria such as the tetanus bacillus or Escherichia coli that might otherwise infect the wound. This anti-microbial action of hydrogen peroxide can be amplified 100-fold by the addition of L-cysteine (Berglin et al, 1982).

The problem with hydrogen peroxide and some other traditional debriding agents is that they also damage the healthy cells (keratinocytes and fibroblasts) that are needed for wound healing and inhibit their necessary migration into the damaged area (Tatnall, Leigh, and Gibson, 1990; Tatnall, Leigh, and Gibson, 1991; O'Toole, Goel, and Woodley, 1996). In current practice the emphasis has moved away from the use of cytotoxic materials to those which promote healing, including the use of natural signalling molecules such as platelet-derived growth factor (Higgins and Ashry, 1995). In the British National Formulary (1996) hydrogen peroxide is now listed under "Astringents, oxidisers and dyes", and not as a desloughing agent.

The application of hydrogen peroxide has been replaced with the use of saline wash, substances such as Debrisan and Intrasite Gel for the removal of necrotic tissue, and the application of hydrogel dressings such as Granuflex. Varidase is a desloughing agent with wound cleansing properties, and contains streptokinase and streptodornase (Thomas, 1990b).

References

Suggested Further Reading

Please could you tell me if there is any research based evidence to support the use of Tegaderm as a post surgical dressing.

31st August 1999

Tegaderm is a transparent polyurethane film dressing manufactured by 3M Health Care Limited. It is mainly used to cover clean surgical wounds following minor procedures and also to cover wounds that have been made in order to acquire venous or arterial access. Being transparent it enables the wound to be observed for signs of inflammation and/or leakage without the need to be removed, thus overcoming some of the drawbacks associated with more conventional dressings.

Although transparent dressings are designed to allow skin moisture to evaporate, concern has been expressed regarding the potential for skin organisms to proliferate, particularly if the dressing is used to cover a wound where serous fluid and/or blood later accumulates, for example cannula and catheter sites (Kroper and Daschner, 1991). Under these circumstances accumulation of such fluid may provide the ideal environment for bacterial growth (Wille et al, 1993). The risk of contamination will depend upon the methods used to cleanse the skin before the wound was made and how thoroughly these were applied, and the length of time over which the dressing is allowed to remain in place - the longer the time the greater the risks unless healing has been completed. Careful attention to skin preparation coupled with regular observation and evaluation of the wound after the dressing has been applied should reduce the chances of colonisation by pathogens.

Wound care is benefitting from a variety of new materials that co-operate with biological tissues. This area of research is called tissue engineering. The materials may be synthetic or derived from naturally occurring tissues and cells (reviewed in Szycher and Lee, 1992; Cairns et al, 1993; Sefton and Woodhouse, 1998). Biomaterials are being used to modulate wound healing by inducing cellular responses that might not otherwise occur, by stimulating better vascularisation in preparation for a transplant, or to block natural but unwanted responses such as the immune rejection of cell transplants from other species or the growth factor signals that stimulate scar formation (Hubbell 1995). Generally, synthetic materials such as Tegaderm and Opsite are used as wound dressings over relatively simple and shallow wounds or as coverings over more complex dressings. Their function is one of protection from water loss and mechanical injury. More complex dressings range from dermal replacements made of reconstituted collagen and chondroitan sulfate backed by a polymer layer such as Integraâ , to the complex skin substitute Apligraf (ä ).

In the past, wound management was largely guided by rumour and myth, but now we have a better scientific understanding of the processes that occur (Reiter 1994). Recent research has revealed specific signalling substances and pathways that initiate, control, and terminate healing. The roles of oxygen, nutrition, and growth factors are now better understood, and modern dressing materials may be active, passive, selectively interactive, or inert. Wound management can now responsive to changing wound needs.

For further information on Tegaderm (in the UK), contact 3M Skin Health on 01509 613419.

References

Do you know of any publications that can help me in my task of comparing old wound care remedies with current day wound products?

18th January 2000

Here are some references that will help you compare old and new methods of wound care:

I'm a home health nurse treating a patient who had cellulitis with ulcerations to bilateral lower extremities. The wound beds are pink, exuding serous sanguinous drainage with greenish blue color. I'm using Polymens foam dressing over wounds. The dressings have an odor when changed but the wounds themselves are nonodorous. I'm concerned with the greenish-blue tint to exudate. Please advise.

19th March 2000

It is possible that your patient's wound is infected, perhaps with Pseudomonas organisms. If this has not already been excluded, it will be helpful to take a wound swab for culture and sensitivity tests. You may wish to ask your local tissue viability nurse for advice.

Can you tell me if APLIGRAF is available here in London (or elsewhere) for leg ulcers. I have read about it on the internet and am wondering if it is available here and could help me.

8th March 2000

It will be best to contact the manufacturers of APLIGRAF to find out about the availability of this skin replacement material in the UK. They are Organon and Novartis Pharmaceuticals. Most of the information about this product comes from the US (see for example: www.apligraf.com). An alternative would be to contact a tissue viability nurse attached to a hospital within the London area. We understand that Meredith Lloyd-Evans at mlloydevans@biobridge.co.uk may also be able to give you advice about the availability and use of APLIGRAF in the UK, and also information about a similar product called Dermagraft from Smith+Nephew (licenced from Advanced Tissue Sciences).

The following background information about APLIGRAF is taken from a paper by Beaumont and Anderson-Dam (1998):

Reference

My father suffers from leg ulcers and was recently told that there is a lotion or treatment used in Australia - containing pawpaw extract - to treat leg ulcers with a high success rate. I can find no useful information on this other than that the active ingredient might be papain. I wondered if there is any medical evidence on this treatment.

22nd June 2000

Papaya (also called pawpaw) has long been used as a treatment for skin wounds in a variety of countries blessed with a warm climate where the Carica papaya plant flourishes, for example in African countries (Starley et al, 1999), Ceylon (Wimalawansa, 1981), and the Carribean (Hewitt et al, 2000). Where health care resources are very limited the low cost of papaya combined with its effectiveness have encouraged its use in the treatment of skin ulcers and burns. Usually the pulp of a relatively unripe fruit is chosen, mashed, and placed thickly over the wound on a daily basis. It appears that the papaya pulp enzymatically removes the dead and dying tissue on the surface of chronic ulcers, reduces any pre-existing infection, and encourages healing (Starley et al, 1999; Hewitt et al, 2000). It is worth noting that some patients experience a burning sensation when the papaya extract is applied. There can be difficulties in preparing the fruit consistently and of course it is a non-sterile material when used in this traditional way, but interestingly in the Jamaican study there were no reports of infection being introduced by the treatment (Hewitt et al, 2000). Presumably the Australian product that you have mentioned, but about which we do not yet have any information, will provide reasonable standardisation and perhaps reduce the risk of inadvertently introducing infection into the ulcer.

As you suggest, the proteolytic enzymes papain and chymopapain present in papaya seem to be involved in the facilitation of wound-healing, probably helping to deslough the wound area, and there appears to be a protective antimicrobial activity too. Detailed analyses of the constituents of papaya have been made (Katague and Kirch, 1965; Baines, Stuchbury, and Brocklehurst, 1978).

References

* * * * * * *

Since preparing this answer, we have received further information from the person who asked the question:

"My father has suffered with large ulcers on his lower left leg for many years. He has poor circulation in the area due to the minor blood vessels being crushed when he had the accident that led to the present condition. In the last five years he has been attended once a week by the district nursing service. They have tried many different treatments during this time, with only limited success - some work for a few weeks, others not at all. The most recent treatment has been a dressing using charcoal, supposed to keep the area dry and thus prevent infection build-up. Four months ago, one of the nurses noticed an advert in a medical journal for a product called Medihoney. This is a specially formulated, sterile form of honey (renowned for it's anti-bacterial properties).

"There is a website www.medihoney.com and the product can be purchased from www.goldenglow.com.au. My father decided he would like to try this treatment as there has been much in the health press about the beneficial effects of honey. We sent for some and the district nurse checked to see if it was cleared for use. My father signed a disclaimer to take responsibility for the treatment before he could proceed. The nurse decided the best way to use the product would be to spread it thinly on the dressing then bandage the leg as usual. Over the past twelve weeks, there has been a great improvement in the condition of the leg. The main ulcer has almost completely healed over and the infection seems to have cleared completely. The smaller ulcer was quite deep and prone to exudation at the slightest knock, but within three weeks it was apparent that the wound was becoming much more shallow as the deep infection cleared. Now it seems to be a mainly surface problem which is also healing over. The nurses are very pleased and so is my father.

"The most noticeable element to have disappeared is the smell. Due to the combined effects of drying by the charcoal and the conversion of the exudation to sugars by the Medihoney, the smell has been completely eliminated. Time will tell if this treatment is 100% effective but we are hopeful and will continue to use the product as long as it seems to be doing the job. Although it may seem pricey (with shipping from Australia and the currency conversion, one tube cost £10.00) we think it is worth it.

"On the matter of the papaya, I found a product, also Australian, also on the Goldenglow website, called 'Lucas' Papaw Ointment. It contains Carica papaya 39mg/g fresh fermented fruit, with potassium sorbate as a preservative. It claims to be "a topical application for boils, burns, chaffings, cuts, cracked skin, gravel rash, splinters, open wounds, insect bites and nappy rash". Apparently it is widely used in Australia, although probably as a natural alternative to such products as Savlon or Germolene."

Should a doppler test always give the cause of a leg ulcer, i.e. which kind it is? How critical is a leg ulcer in someone with a deep vein thrombosis (DVT) & diabetes?

9th July 2001

Doppler studies enable the flow of blood through vessels to be estimated and provide information from which the nurse or doctor doctor is able to establish whether arterial or venous flow is impeded. In the case of a leg ulcer, the underlying cause (arterial or venous) can be ascertained. Anything less than a 100% blood flow suggests there will be delayed healing of a leg ulcer.

Any form of wound healing depends upon a person's age, nutritional status, psychological well being, and additional circumstances such as pre-existing disease (for example: cardiac failure, anaemia, or whether a person is immunocompromised). Assuming the leg ulcer to be on the same side as the deep vein thrombosis, much will depend on the size of the ulcer, the results of Doppler studies, and the extent to which a person's diabetes is under control.

It is always important to treat an ulcer. The first step is to search for an underlying cause and commence treatment. Leg ulcers can arise from varicose veins (varicose ulcers) as well as from arterial insufficiency. If the ulcer is venous in nature treatment is aimed at improving venous return, normally by using compression bandages. For an arterial ulcer a surgical approach aimed at improving blood flow is carried out. If this is not possible it may be necessary to surgically remove the ulcer, at the same time making sure that the blood supply to any newly formed wound(s) is not compromised.

For ulceration to develop in someone who has a deep vein thrombosis, assuming the ulcer to be in the same limb, it would be important to prevent the wound from becoming infected and to protect the limb from trauma. Healing is likely to be delayed due to a compromised venous return. Resolution of the thrombosis would improve the rate of healing.

A leg ulcer occurring in someone who has diabetes is serious, mainly because of the risk of supervening infection. In someone with diabetes this risk increases. Infection in turn will produce fever and thus an increase in metabolism. The associated increased demand for carbohydrate carries with it the potential to de-stabilise 'normal' homeostatic control. Also healing is often prolonged in someone with diabetes due to the adverse changes that diabetes has on the microcirculation.

Suggested Reading

Back to Nursing Practice