Innovative Wound Care

[ArcticDiver]

You could wear a dry suit...

If I had not been in the tropics and sans dry suit that would have been an option once the initial swelling subsided and allowed me to fin with minimal pain. Unfortunately...........

 

[fisherdvm]

Glad to hear that your wound is doing fine. It is hard to make an internet assessment of a wound's severity, so I assumed a worst case scenario as you described "down to the fascia" - which means "holy sh.." in my book. If it is healing well, it likely is a "degloving" injury of the upper layer of the skin, or what we call the stratum corneum. The ball of the foot has about 1/4 inch of this protective rubbery stuff. Ripping it off will cause some bleeding, but not excessive. This probably explain why it healed well.

But, for anyone else with the same type of wound, even if it is as mild as yours - I would not hesitate to say again - get a professional opinion. And in this case, I would say it is going to be a podiatrist, or orthopedic surgeon. MD's can oversell themselves in complex wounds - and only a few have had exposure to treating difficult wounds of the feet. Even in the area of dermatology, only a few have had exposure to a wound care clinic.

 

[fisherdvm]

Thank you TSM and DocV for always keeping me up to date. I am well aware of peroxide slowing down epithelization, and osteoblast migration - but I find that its debridement and antibacterial mechanism outweights its disadvantages in the cleansing of primary closures (where you have good blood supply and quick healing). I also think it still has a place in secondary intention healing where a physician's input is not available in contaminated wounds or in a wound known for complication from bacteria, yeast and fungi.

In a nonsterile setting where a physician is not supervising the treatment of a wound - like in wilderness medicine - I think throwing away the hydrogen peroxide based on some in-vitro study might be a little excessive. I think enough in vivo studies has been done by thousands if not millions of people to show that it worked. Unfortunately never double blinded. The debridement of adherent dryblood, serum and fibrin by a bottle of hydrogen peroxide would require 10 times the quantity of sterile saline, and pressure injection with a syringe or lavage pump.

I am sure in a wound care clinic - it will impair wound healing if multiple antibacterial agents are used. But when a patient without access to physician is left with only bacitracin, neosporin, and OTC meds - I am not ready to throw away an old time remedy that has been used in every specialty of medicine for several decades.

Sometimes, we throw the baby out with the bath water, and I hate to see this agent lose its place in medicine. Especially home medicine or wilderness medicine - where we will never be able to perform a double blinded study - as we will always have access to the best antibiotic, gallons of sterile saline, and surgical debridement - and no physician are willing to subject themselves to an inferior agent.

In a similar type of argument, I always like to keep a wound covered, and moist (but bacteria free). But in a different setting - such as wilderness medicine - without resources, letting an eschar form might prevent infection.

And in certain locations, bandages aggravate the conditions, rather than help - such as paronychia or infection of the nail. Bandaging simply trap moisture allowing the causative agents (yeast and bacteria) to grow, and make things worse. And astringents play a good role in chronic paronychia, but not in other wounds. Whereas in most wound, if one can assure sterilily, bandages are best. Places which I don't use bandages more than 2 or 3 days are on the face. Occlusion of the sweat glands and sebaceous glands of the face tends to aggravate follicular health, and increase the risk of folliculitis or acne like eruption.

But one is perfectly correct in saying that hydrogen peroxide is not an agent of choice for wound irrigation.

 

[fisherdvm]

Here is a good article summarizing the risks and benefits of hydrogen peroxide in wound care:

Antiseptics on Wounds: An Area of Controversy
from Wounds

Hydrogen Peroxide
A three-percent solution of hydrogen peroxide is commonly used as a wound antiseptic. The three-percent solution demonstrates in-vitro broad-spectrum efficacy. Its greatest activity is towards Gram-positive bacteria, but the presence of catalase in these bacteria makes dilutions below three percent less effective.[1] In a similar fashion, catalases present in tissues can render hydrogen peroxide even less bactericidal in vivo.[6] Although hydrogen peroxide is very commonly used, surprisingly few studies have been conducted to examine its effect on the wound healing process and its efficacy as a wound antiseptic (Table 3).

Animal and human studies have shown hydrogen peroxide to have no negative effect on wound healing. Lineaweaver, et al.,[29] did not find retardation of reepithelization in a rat model after irrigation of the wound with three-percent hydrogen peroxide. However, at the in-vitro component of the same study, he found minimal bactericidal effect of hydrogen peroxide. Gruber, et al.,[52] found acceleration of reepithelization in a rat model and in a clinical trial. However, bullae were formed on or about the day of healing in most of the patients, suggesting possibly that hydrogen peroxide should not be used in newly formed epithelium.

In another study by Tur, et al.,[80] hydrogen peroxide was found to significantly increase the blood flow in ischemic ulcers in a guinea pig model. The increased blood flow may be due to new vessel formation through activation of metalloproteinases. Interestingly, the blood flow was increased even in places distant to the local application of hydrogen peroxide. No explanation was given for this finding. However, the authors found no difference in the wound-healing rate. This may be due to the limited sensitivity of the method they used to evaluate the clinical response (visual determination of the non-necrotic area).

In a clinical study evaluating the effectiveness of hydrogen peroxide on reducing the infection rate of appendectomy wounds, no toxic effects were found, but it was found to be ineffective.[81] Similarly, in another clinical study in human blister wounds contaminated with Staphylococcus aureus, hydrogen peroxide was found not to retard the healing but neither did it decrease bacterial load.[82]

In conclusion, hydrogen peroxide appears not to negatively influence wound healing, but it is also ineffective in reducing the bacterial count. However, it may be useful as a chemical debriding agent. The American Medical Association concluded that the effervescence of hydrogen peroxide might provide some mechanical benefit in loosening debris and necrotic tissue of the wound.[13]

 

[ArcticDiver]

Glad to hear that your wound is doing fine. It is hard to make an internet assessment of a wound's severity, so I assumed a worst case scenario as you described "down to the fascia" - which means "holy sh.." in my book. If it is healing well, it likely is a "degloving" injury of the upper layer of the skin, or what we call the stratum corneum. The ball of the foot has about 1/4 inch of this protective rubbery stuff. Ripping it off will cause some bleeding, but not excessive. This probably explain why it healed well.

But, for anyone else with the same type of wound, even if it is as mild as yours - I would not hesitate to say again - get a professional opinion. And in this case, I would say it is going to be a podiatrist, or orthopedic surgeon. MD's can oversell themselves in complex wounds - and only a few have had exposure to treating difficult wounds of the feet. Even in the area of dermatology, only a few have had exposure to a wound care clinic.

Whoa; since when does the statement that a wound is healing well become a synonym for the wound being mild? Also, please don't put words in my mouth, or in my post, as the case may be. I said it was healing well; not that it was healed.

I think I addressed the idea of getting further assistance in an earlier post. In fact most of the people I know and associate with would have self-treated in this situation. Most would have been wise enough not to cover the wound with Super Glue, Duct Tape, or to further traumatize the tissue with alcohol or H2O2.

One of the main ideas in this post, as I stated earlier, was to allow people to give voice to their favorite wound treatments and for others to be able to read them for consideration when they are wounded.

 

[fisherdvm]

References for:
Antiseptics on Wounds: An Area of Controversy

[Wounds 15(5):149-166, 2003. © 2003 Health Management Publications, Inc.]

1. McDonnell G, Russell AD. Antiseptics and disinfectants: Activity, action and resistance. Clinical Microbiology Reviews 1999;12(1):147-79.
3. Niedner R. Cytotoxicity and sensitization of povidone iodine and other frequently used anti-infective agents. Dermatology 1997;195(Suppl 2):89-92.
6. Brown CD, Zitelli JA. A review of topical agents for wounds and methods of wounding. J Dermatol Surg Oncol 1993;19:732-7.
13. Rodeheaver GT. Wound cleansing, wound irrigation, wound disinfection. In: Krasner D, Kane D. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, Second Edition. Wayne, PA: Health Management Publications, Inc., 1997:97-108.
29. Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg 1985;120(3):267-70.
52. Gruber RP, Vistnes L, Pardoe R. The effect of commonly used antiseptics on wound healing. Plast Reconstr Surg 1975;55(4):472-6.
80. Tur E, Bolton L, Constantine BE. Topical hydrogen peroxide treatment of ischemic ulcers in the guinea pig: Blood recruitment in multiple skin sites. JAAD 1995;33(2:1):217-21.
81. Lau WY, Wong SH. Randomised, prospective trial of topical hydrogen peroxide in appendectomy wound infection. Am J Surg 1981;142:393-7.
82. Leyden JJ, Bartelt NM. Comparison of topical antibiotic ointments, a wound protectant and antiseptics in the treatment of human blister wounds contaminated with Staphylococcus aureus. J Fam Pract 1987;24(6):601-4.

 

[fisherdvm]

Also, please don't put words in my mouth, or in my post, as the case may be. I said it was healing well; not that it was healed.

I am not putting words in your mouth, just glad to hear wound is doing well.

most of the people I know and associate with would have self-treated in this situation. Most would have been wise enough not to cover the wound with Super Glue, Duct Tape, or to further traumatize the tissue with alcohol or H2O2.

Most physicians I know would not diagnose or prognose over the phone, on a video cam, or on the internet. I don't think anyone here suggested that the wound is "mild". It is your column, you can tell us as much as you want or as little as you want.

If you are implying it is "unwise" to use hydrogen peroxide, that is fine. Conventional wisdom, apparently, has been replaced by new wisdom. The whole objective analysis of this area is not yet complete.

I was not prognosing, diagnosing, arguing with anyone about the severity of your wound. Only can do that in my office. So, you can tell us as little, or as much as you want on your wound. The topic of discussion is still on wound care - which is the heading of your topic.

But if you want to split your discussion into the treatment of your wound, perhaps we'll have to start a different thread? If you object to my commenting about your wound, that is fine too.

 

[fisherdvm]

Back to hydrogen peroxide. Based on this excellent review I quoted, it appears to accelerate angiogenesis, and granulation.

On whether it affects epithelization, it is not completely clear. Might not, or might. Bullae formation on newly epithelized skin does not necessary mean damaging living epithelium. It might just be desquamating or removing the dead layer or stratum corneum (which we expect it to do).

Based on this review article, I find it might actually be helpful to use hydrogen peroxide to debride a fresh wound, until granulation tissue appears. Then to stop, and let epithelization take place.

Such argument against using hydrogen peroxide on a freshwound might be a little premature. As epithelization in a second intention healing wound does not take place until well into 6 or 7 days later, when granulation tissue appear.

In the case of primary closure of wound - I only have evidence from my clinical practice - which it does not negatively impact wound healing, scar formation, or cosmetic effect of primary closure. If anything, I find it impossible to keep wounds of the scalp clean without using hydrogen peroxide.

I stand behind my original proposal in the use of hydrogen peroxide in early wound of the skin.

 

[fisherdvm]

On the subject of innovative and "state of the art" wound care. I think it is a waste of money, and a waste of time.

I've cared for wound that has been treated with $700 a tube regranex, and failed. The same with the very expensive "Dermagraft" - human skin substitute. By focusing on the basics - support stocking, debridement, and microbial control - one should not need these new technologies.

My complaint is not the science, it is the application in less than ideal wounds. One has to look at the reason why a wound is not healing, and not simply relying on several thousand dollars worth of expensive drugs, or "artificial human skin".

If a 50 cent bottle of hydrogen peroxide can stimulate granulation tissue, why bothers with Regranex. If you can get healthy granulation tissue, why do you need "Dermagraft". There is plenty of autologous skin on most peoples shoulder and belly - why would you want to put some baby's foreskin on your wound? I harvest small to large amount of skin from the same patient's shoulder above the clavicle, and do full thickness skin graft on chronic wounds with adequate granulation tissue. Half of the time it takes, half of the time it doesn't (not completely). It is alot cheaper than Dermagraft (it is your own skin). And no risk of unknown virus or pathogen is introduced. When it doesn't take - the skin graft - tremendous granulation tissue is stimulated, and the wound heals on its own within a short time.

Innovative is not necessary good. Sometime old fashioned is still the way to go.

 

[vladimir]

But, for anyone else with the same type of wound, even if it is as mild as yours - I would not hesitate to say again - get a professional opinion.

I don't think anyone here suggested that the wound is "mild".

You can see where ArcticDiver got that impression though.

Welcome back, Doctor Fisher.