Wounds
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Nonhealing WoundsA Therapeutic Dilemma
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ARTICLE
10.1177/1534734603254690
CHAUHAN
LOWER
NONHEALING
EXTREMITY
ET AL
WOUNDS
WOUNDS 0(0); 2003
Chronic wounds of the lower extremity are a therapeutic dilemma. In India, chronic wounds are caused by factors other
than impaired circulation and diabetes, which account for
most of this clinical problem in Western societies. A study of 2
topical agents, placental extract and phenytoin powder, is
presented in this paper. One hundred fifty patients were randomly assigned to these treatments or to saline dressings
(control). It was observed that patients receiving active topical treatments responded better than those in the control
group. The importance of this finding should be viewed with
hronic wounds are a drain on health care resources. Such wounds challenge health care providers to define and create more effective intervention
strategies. Clinically, wounds are categorized as acute
or chronic dependent on their time courses of healing
and tendencies to relapse. In practice, the duration of
healing is very variable; hence, the distinction between
an acute and a chronic wound is arbitrary, dependent
on variables including the site and the cause of the
wound and the age and physical condition of the patient.1 Most chronic wounds are associated with welldefined clinical entities, particularly diabetes mellitus,
pressure necrosis, and venous hypertension. In India,
leprotic ulcers are the most common cause of
nonhealing wounds.2
Cutaneous tissue repair is a complex, dynamic process involving 3 main overlapping phases:
The inflammatory phase begins within 6 hours of injury.3 The disruption of blood vessels leads to clot formation and the phagocytosis of microorganisms by the
released neutrophils, macrophages, and enzymes.
40
NONHEALING WOUNDS
Diabetes Mellitus
Chronic foot ulcers are the leading cause of amputation among diabetic patients.5 The risk for lower extremity amputation is 15 times higher among diabetics
compared to nondiabetics. Although the fundamental
pathophysiological factors leading to ulcer formation
remain ill understood, the triad of neuropathy,
ischemia, and infection is considered the most important in the development of ulcers.
Below the knee, the blood vessels commonly involved in diabetic angiopathy are the posterior and anterior tibial vessels, the peroneal vessels, and the small
vessels in the foot. There are multiple risk factors involved in the development of diabetic peripheral vascular disease, of which smoking, hyperglycemia, hypercholesterolemia, and hypertension are the most
important.
At the Indian National Institute of Diabetics in
Mumbai, > 10% of all admissions for diabetes are primarily for foot management; at least 70% require surgical intervention, and of these, at least 40% are toe or
limb amputations.6
Venous Ulcers
Chronic venous insufficiency (CVI) is often restricted to the end clinical stage of the syndrome of venous hypertension, limb swelling, pigmentation,
induration, and ulceration. Venous ulceration represents the end stage of the disease process and only a
small proportion of the disease spectrum. Fibrin cuffs
around capillaries were proposed as a cause of local oxygen and nutrient deprivation, thereby leading to ulceration.7,8 This hypothesis has largely been discredited because fibrin deposition occurs in many
ulcerated and nonulcerated tissues. It has also been
suggested that susceptibility to ulceration in CVI may
be due to release of humoral and toxic substances from
white blood cells trapped in subcutaneous capillaries
because of increased venous back pressure.9
Leprotic Ulcers
Plantar ulceration is a common complication of an
insensate foot among patients with leprosy. The sites
affected are areas of the sole that come under pressure
while walking. Excessive walking, often on bare feet,
causes injury to the tissues, which are unable to offer
feedback on account of being insensate. The injury produces inflammation, which accentuates the damage,
resulting in an open wound.10 Open wounds are frequently infected with pathogenic organisms; the infec-
41
CHAUHAN ET AL
desquamation or moist maceration followed by its exfoliation and the subsequent resurfacing of the epidermis along with the remodeling of collagen and elastic
fibers and the deposition of glycosaminoglycans during the repair process in the dermis. Numerous agents
have been used over the years. However,
trichloroacetic acid (TCA), phenol, and salicylic acid
are chemicals in use today.
MATERIALS AND METHODS
Study Design and Setting
NONHEALING WOUNDS
Table 1. Mean Surface Area (cm2) With Standard Deviations for All Treatment Groups
Group
Before Treatment
Group 1
Group 2
Group 3
After Treatment
At 2 wk
At 4 wk
At 6 wk
At 8 wk
Group 1
(%)
10.00
40.00
52.50
67.50
Group 2
(%)
Group 3
(%)
6.06
39.39
45.45
48.48
Values
3.33
3.33
20.00
23.33
Group 1 vs
Group 2
At 2 wk
At 4 wk
At 6 wk
At 8 wk
0.61
0.05
0.60
1.64
Group 1 vs
Group 3
1.07
3.54***
2.76**
3.66***
Group 2 vs
Group 3
0.51
3.44***
2.14*
2.07*
43
CHAUHAN ET AL
1
2
3
4
5
6
7
8
9
MAGS Score
Before Treatment
53
18
33
39
44
65
31
41
51
Mean MAGS
score
41.66 13.88
MAGS Score
After Treatment
53
34
49
57
49
73
46
33
65
51.00 13.06
ported the use of topical phenytoin in diabetic foot ulcers among 50 patients compared to controls. Both
groups improved, though the wounds treated with topical phenytoin healed more rapidly, the mean time to
complete healing being 21 and 45 days for the treatment and control groups, respectively. These reports
are consistent with the observations in this report using
topical phenytoin.
Other Aims
This study showed that leprosy is the most common
cause of chronic wounds in this health district served
by the authors, followed by diabetes mellitus. This may
have implications for health care planning, because the
incidence of diabetes is increasing in India, as it is
worldwide. The faster healing obtained in this study
should encourage the use of simple topical treatments
that are inexpensive and available locally.
In the subset of patients from group 1 (n = 9) who received topical Placentrex, there was an increase in
mean angiogenic scores with treatment. A comparison
of the means showed the increase to be statistically significant (P < .01). Details are presented in Table 4.
Twenty cases of nonhealing wounds had hyperkeratotic edges. In 10 of these 20 cases, TCA or carbolic
acid was applied on the edges at weekly intervals, with
immense benefits showing the advantage of this methodology over surgical debridement. Another advantage
in favor of chemical peeling is that no formal training is
needed, compared to the skills essential to conduct
44
sharp surgical debridement. This observation is interesting and needs to be developed in future studies.
This study suggests the potential of placental extract
and phenytoin powder in the management of
nonhealing wounds. Future studies should follow
wounds through to closure in order to gain a fuller understanding of the potential of these topical therapies.
It is suggested that the perceived benefits of topical placental extracts may be due to multiple effects on
angiogenesis, collagen synthesis, and epithelial cell
proliferation. It is noteworthy that patients with venous ulcers did not receive compression bandaging,
because it is not available in India. Another observation
is that malignant changes in trophic wounds are rare in
India.
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NONHEALING WOUNDS
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