A Clinical Minute: Is It Time to Rethink Your Wound Care Modalities in Complex Wound Management?

  Complex patients with multiple comorbidities are becoming increasingly more common; consequently, so are complex wounds. The main challenges associated with complex wounds include the need for multiple modalities, limitations of advanced therapies (eg, access, compliance, cost), and underlying disease concerns (eg, diabetes, vascular disease). In my wound care clinic patient population, where 80% of the patients have diabetes, these complex patients are the norm.   In these clinical situations, wound management needs to be approached through multiple avenues with wound care modalities working in concert. Wound management goals include promoting autolytic debridement, achieving moisture balance, and supporting wound healing. MEDIHONEY® (Derma Sciences, Inc, Princeton, NJ) can play a key role in achieving these goals through its two key mechanisms of action: 1) low pH (3.2–4.5), which may help modulate the alkaline pH common in chronic wounds,^1,2 and 2) high osmolarity to increase wound bed fluid and promote autolytic removal of nonviable tissue.^2-5

  The following two cases illustrate the role of MEDIHONEY® in the care of challenging diabetic foot wounds.

Case Reports

  Case 1. An 80-year-old man had a complicated diabetic foot infection (Wagner Grade 4) post first ray resection. Initially, the wound measured 2.5 cm x 8 cm x 1.5 cm with exposed bone and cautery artifact. The wound was treated with negative pressure wound therapy; however, the patient was unable to comply with treatment due to cognitive problems. On day 40, we switched to MEDIHONEY® gel covered with a secondary foam dressing (see Figure 1). One week later, a substantial increase in granulation tissue was noted, and 2 weeks later granulation tissue appeared over the bone (see Figure 2). Five weeks later, the bone was covered and the wound was closing, with complete closure achieved at 8 weeks after starting MEDIHONEY® (see Figure 3).

  Case 2. A 32-year-old female patient had three ulcerations on her left lateral foot, right heel, and right hallux amputation site that were present for about 2 months. Her diabetes was poorly controlled (HbA1c = 12.1%), and she had retinopathy, neuropathy, and early kidney disease. We ruled out osseous infection and applied MEDIHONEY® Alginate dressing to the left lateral foot wound. Initially, the wound measured 7.5 cm x 4.2 cm x 0.7 cm (see Figure 4). By week 3 of treatment, the wound decreased in size, and on week 4, TCC-EZ® and XTRASORB® (Derma Sciences Inc., Princeton, NJ) dressings were added to the wound management armamentarium (see Figure 5). By promoting autolytic debridement, MEDIHONEY® can lead to an increase in wound fluid; adding a secondary dressing designed for fluid absorption is recommended to avoid maceration. After 6 weeks of treatment, granulation tissue covered the majority of the wound bed and any soft slough present was easily removed by surgical debridement. The callus decreased, and no maceration was noted. Within 3 months of treatment with MEDIHONEY®, and within 8 weeks of combination treatment with TCC-EZ®, the wound healed (see Figure 6).

  These two cases illustrate how basic wound management strategies including optimal dressing selection, offloading, and debridement can actively contribute to wound healing. In combination with offloading and debridement, MEDIHONEY’s mechanism of action actively contributes to support wound healing. MEDIHONEY® works well with a variety of dressings including alginates to manage exuding wounds and gels to donate moisture to drier wounds.

  In summary, despite the complexity of wounds and underlying disease concerns, these wounds successfully progressed to closure. Complex wounds may not need complex solutions — simply include MEDIHONEY® as one of your wound management modalities.

  For more cases demonstrating the use of MEDIHONEY® in diabetic lower extremity ulcers, visit the MEDIHONEY® Power Webinar series at www.dermasciences.com/elearning-portal/ for a 30-minute case review by Dr. Dimitrios Lintzeris.

A Clinical Minute is made possible through the support of Derma Sciences, Inc, Princeton, NJ. The opinions and statements provided in A Clinical Minute are specific to the respective authors and not necessarily those of OWM or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.

1. Gethin G. Influence of Manuka honey on surface pH, MMP-2, MMP-9 and wound size of chronic wounds. European Wound Management Association Conference. Lisbon, Portugal, May 2008.

2. Milne SD, Connolly P. The influence of different dressings on the pH of the wound environment. J Wound Care. 2014;23(2):53–57.

3. Gethin G, Cowman S. Manuka honey vs. hydrogel — a prospective, openlabel, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. J Clin Nurs. 2008;18(3):466-474.

4. Acton C, Dunwoody G. The use of medical grade honey in clinical practice. Br J Nurs. 2008;17(20):S38–S44.

5. Chaiken N. Pressure ulceration and the use of active Leptospermum honey for debridement and healing. Ostomy Wound Manage. 2010;56(5):12–14.