Woundcare options today ranges from looking for suture alternatives to seeking better modes of compression to manage venous leg ulcers.
Toronto - Stem cells and lasers will likely become part of the armamentarium in woundcare, according to a professor of Dermatology at Boston University School of Medicine and director of the Dermatology Wound Clinic at Boston Medical Center, Boston.
Speaking here at the annual meeting of the Canadian Dermatology Association, Tania J. Phillips, M.D., F.R.C.P.C., covered pearls in woundcare, ranging from basic steps such as using tap water to cleanse wounds, to emerging therapeutic areas, such as cell therapies and light therapies for woundcare.
“If your tap water is drinkable, it’s OK to use it to clean wounds,” Dr. Phillips says.
In woundcare, as in other areas of medicine, there is concern about over use of antibiotics. Research suggests there is no advantage to using topical antibiotics such as bacitracin in surgical wounds. A study that compared the use of white petrolatum to bacitracin ointment in postoperative care showed infection rates were comparable between the two and white petrolatum carried minimal risk of producing contact dermatitis (Smack DP, Harrington AC, Dunn C, et al. JAMA. 1996;276(12):972-977).
Regarding sutures, Dr. Phillips cites a study that found no difference in cosmetic outcome when sutures were performed or not performed following a punch biopsy. It has been traditional practice to suture punch biopsies.
Investigators looked at 4 mm biopsies and 8 mm biopsies. Patients, however, expressed a preference for using sutures after an 8 mm biopsy was performed.
“It will save time and money, for you as well as the patients, if you don’t have to use sutures,” Dr. Phillips says.
Some alternatives to sutures include glues. Dr. Phillips says glues are particularly suitable in surgical wound closure for pediatric patients who have experienced traumatic lacerations.
“They take less time and are less painful,” she says.
An analysis of randomized, controlled trials in deep surgical wounds, however, found sutures were significantly better than tissue adhesives, producing less dehiscence and being significantly faster to use (Coulthard P, Esposito M, Worthington HV, et al. Cochrane DatabaseSys Rev. 2010;(5):CD004287).
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A general principle in woundcare is to keep wounds moist, Dr. Phillips stresses. Data involving shave biopsy sites, Mohs surgical sites and split thickness donor sites all support the importance of maintaining moisture to accelerate healing in acute wounds.
“If you keep the wound moist, it will heal faster,” she says.
Compression remains the mainstay in the treatment of venous leg ulcers, Dr. Phillips notes.
“Compression is better than no compression, and high compression is better than low compression,” she says. “The challenge is getting patients to keep compression on their wounds. We need better modes of compression.”
Depending on the type of compression, patients may find compression too tight, too hard to put on or don’t like wearing it, Dr. Phillips explains. Chronic venous leg ulceration is better managed with surgical treatment of incompetent veins and compression than with compression alone. One study found 12-month recurrence rates of ulcers were significantly decreased in patients who underwent compression and surgery compared to surgery alone (Barwell JR, Davies CE, Deacon J, et al. Lancet. 2004;363(9424):1854-1859).
“You can treat superficial venous insufficiency with surgery and compression,” Dr. Phillips says.
Oral medications are another option for managing venous ulcers. A meta-analysis of randomized trials found that pentoxifylline was more effective than placebo in treating venous ulcers (Jull AB, Arroll B, Parag V, Waters J. Cochrane Database SysRev. 2012;12:CD001733).
“The bottom is that it’s an effective adjunct to compression in the treatment of venous ulcers,” she says.
The caution with the use of pentoxifylline is that it can produce gastrointestinal side effects, so clinicians should start with a lower dose, aiming to titrate to 800 mg three times daily, Dr. Phillips says.
Flavonoids have also demonstrated benefit in improving venous leg ulcers, according to a review of several trials (Scallon C, Bell-Syer SEM, Aziz Z. Cochrane Database Sys Rev. 2013;5:CD006477).
One novel approach to treating venous leg ulcers is the use of cholesterol-lowering agents, which are thought to accelerate wound healing, counteract hypoxia and produce immune-modulating actions. One study found that simvastatin, as an adjunct to standard woundcare, was linked to significantly enhanced healing (Evangelista MTP, Casintahan MFA, Villafuerte LL. Br J Dermatol. 2014;170(5):1151-1157).
New therapies such as light-activated tissue repair and lasers are making inroads in woundcare, Dr. Phillips notes.
Another area of interest is spray-applied cell therapy using human allogeneic fibroblasts and keratinocytes to treat chronic venous leg ulcers (Kirsner RS, Marston WA, Snyder RJ, et al. Wound Repair Regen. 2013;21(5):682-687).
“Patients exposed to the cell therapy did better (than those who were not),” Dr. Phillips says. “This (spray) is a fast way to apply cell therapy to wounds.”
Bone marrow-derived mesenchymal stem cells are also emerging as another means to heal chronic wounds, she says.
Disclosures: Dr. Phillips reports no relevant financial interests.