Innovative Wound Care

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I do want to differ with fisherdvm in one respect . . . Do NOT cleanse wounds with H2O2. It is caustic and kills healing cells. No cleaning agent has ever been shown to have significant improvement in wound healing over simple water. (The exception, with H202, is the mouth. Oral surgeons still recommend rinsing with 1/2 strength peroxide there, although I have never searched the literature to see if this is actually supported by good data.)
 
Do they make finger cots for toes? Finger cots are latex "fingers" that are meant to be slipped over an injured/bandaged finger to keep it dry and protected. You have to use tape or something at the top (I sometimes make do with a hair elastic) to seal water out. I don't think they are large enough for a big toe but they might make something similar for toes. For an injury like yours it would have to go on over gauze or other padding. I'm still cringing just thinking about that!
Hope you heal soon!

An unlubricated condom could be used to keep the big toe dry.
 
The wound care "innovation" of the decade? Petrolateum. Why? Topical antibiotics like neosporin, bacitracin are making headlines as the allergens of the year with incidences like 1 to 2%. They are found in polysporin and triple antibiotics. Double blinded studies have shown petroleum jelly is a better wound healing stimulant than the over the counter antibiotic products. While bacitracin and neosporin are the most commonly recommended wound care products by ER physicians, they are rapidly falling out of favor due to the high rate of allergic contact dermatitis. My preference for wound dressing in the day of MRSA is bactroban (mucopuricin), or one of its relatives.

A quote from medscape:

Antimicrobial Preservatives and Antimicrobials
There is a consumer tendency to seek out a product's active ingredients when purchasing a new product, while deeming the inactive ingredients to be superfluous information. Often, these inactive ingredients contain known sensitizing antimicrobial preservatives. The preservatives are ubiquitous in medical creams and ointments, lotions, make-up, and shampoos, for example, as they are added to extend the shelf-life of these products. Companies are permitted to change the ingredients of their products, without completely redesigning the label. While the ingredient list may change, many persons do not realize that a similar label could contain alternate ingredients. This necessitates careful instruction on label reading. Although many product labels do not list inactive ingredients, companies are still under disclosure mandates. One exception to this is products not regulated by the U.S. Food and Drug Administration (FDA), such as herbal remedies. Allergies to these can be seen in patients with chronic skin diseases, who subsequently use these medications or in more sensitive infrequent users. Two of the most common antimicrobial allergens are notoriously seen in several over-the-counter products, namely first aid kits. A common misconception is that over-the-counter is synonymous with benign or inert, but with each medication there is an inherent risk and benefit ratio that should be evaluated since many contain potential allergens.

Neomycin is a topical antibiotic found in the ointments used daily for minor cuts and abrasions (Neosporin, polysporin) and in medicated eye and ear drops. In fact, people who have had frequent otitis externa are more likely to have a sensitivity reaction to neomycin (Van Ginkel, Bruintjes, & Huizing, 1995). These patients can then develop systemic dermatitis if treated with an aminoglycoside antibiotic, such as gentamicin, which stimulates the immune system through cross reactivity.
Bacitracin, an antibiotic, is added to medications and eye drops similarly to neomycin. Actually, it is often combined with neomycin and other antibiotics in first aid products. Due to the increasing exposure to this antibiotic ointment, bacitracin has landed near the top of the list for common allergens in the United States. There have been reports that 2% of patients who use bacitracin postoperatively have a reaction but, more importantly, there have also been several reports of anaphylaxis (Gette, Marks, & Maloney, 1992; Jacob & James, 2004).
Thimerosal, an organic mercurial compound, is used as a preservative in vaccinations (tetanus) and cosmetics. Like many other preservatives, it is found in a wide variety of otic and ophthalmic solutions, including contact lens solutions and cleansers. Patients with thimerosal allergies can have an acute hypersensitivity reaction to vaccinations. The Public Health Agency in Canada has recommended that these patients receive their vaccinations in an environment with resuscitation capabilities (Canada Communicable Disease Report, 2003). Additionally, the FDA has put forth the discontinuation or minimalization of use in U.S. vaccines (FDA, 2005).

Methylchloroisothiazolinone/Methylisothiazolinone (MCI/MI) is a preservative that is commonly used in cosmetics, shampoo, and bubble bath, but also has a utility as a pesticide. The last decade has seen a replacement of solvent-based paints with more ecologically friendly paints such as water-based paints. These new paints need more preservatives than their predecessors, and MCI has quickly taken its place as the most common preservative in water-based paints (Reinhard et al., 2001). This has led to more and more patients presenting with an airborne contact dermatitis from the MCI in the paint. These patients present with a rash on their air-exposed skin and respiratory symptoms (Bohn, Niederer, Brehm, & Bircher, 2000).

Parabens are some of the most widely used preservatives found in consumables (mayonnaise, frozen dairy products, jellies) to leave-on products (eye shadow, sunscreen, lotions). Parabens are found in rectal and l creams, as well as injectable and topical anesthetics. Notably, while parabens are the most prevalent preservative in all topical therapeutic preparations, they are the least sensitizing overall. In the allergic individual however, the allergic response can be smoldering, dramatic, and systemic (DermNet.com, 2005a). This underscores the importance for patients with an allergy to inform all of their health care providers to assure avoidance.

An allergy to formaldehyde-releasing preservatives and formaldehyde is very common due to its widespread use. Of course, this goes hand-in-hand with the difficulty of avoidance. For example, cigarettes are preserved with a formaldehyde resin, so patients are at risk for exposure by smoking or second-hand smoke (Schaller, Triebig, & Beyer, 1989). The current guideline is for formaldehyde content to be less than 0.2% for leave-on products; however, 5% is permissible in nail polish as a hardener (International Programme on Chemical Safety, 2002). Cosmetics, home cleaners, baby wipes, deodorants, and shampoos are important sources for exposure. Wrinkle-free clothing is treated with a formaldehyde textile resin, and dry cleaning is a process using formaldehyde (Rietschel & Fowler, 1995). Patients with allergies to formaldehyde commonly present with trouser dermatitis, which is a dermatitis between the thighs or behind the knees due to friction between clothes and skin (DermNet.com, 2005b)."
 
I respect TSM's opinion. Many astringents, topical antibacterials, and hydrogen peroxide can slow or impair epithelization (http://books.google.com/books?id=Cn...=book_result&resnum=4&ct=result#PRA1-PA223,M1)

I use hydrogen peroxide on cleansing of primary closure of wounds of the face and scalp almost exclusively over the last 6 years - averaging over 30 closures (10 are larger closures, 20 are biopsies) a week - and it is great for removing crust, dried blood, and debris off the sutures. The bubbling action removes dry serum, soften up keratin debris, and helps to lift off the crusts. About 1/4 of the wounds are on the face, nose, ears... etc - so they are in cosmetically critical areas. The cleaner the stiches, the less chance of wound infection.

Sterile saline is a better cleaning agent, but is harder to find in an inexpensive form. My preference is a can of pressurized saline spray, under the Equate brand, or other common brands, at Walmart and Target. Target always carry it. Cost about 2 us dollars, and has about 16 oz.

If I were to use hydrogen peroxide on an open wound, I would stop when the wound is clean (bright red and clean of crust and debris). Then an occlusive bandage and petroleum jelly or a prescription antibiotic ointment would follow to let the wound epithelized. The bandage is changed daily. How to know when to stop hydrogen peroxide? When the wound is bright red from healthy granulation tissue.

From the stand point of harm to a healing wound, I think hydrogen peroxide is probably one of the gentlest of the debridement aid. Surgical debridement with a scalpel blade and cleansing with normal saline is preferable, but most patients are not capable of doing it themselves. Wet to dry dressing works well for wound debridement, but some folks can't handle the pain of ripping the dry gauze off. It is done by applying a semiwet sterile gauze to the wound with sterile isotonic saline, it is left to dry in open air. When dried, the serum and dead material will adhere to the gauze like glue, and you would yank it off quickly. It can be painful, but offers good debridement and cleaning of the wound.
 
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White petroleum vs. bacitracin for postoperative wound care. (adapted from the Journal of the American Medical Association 1996;276:972-7). Is an article advocating the use of sterile petroleum jelly instead of topical antibiotics.
 
On the topic of hydrogen peroxide, there are some evidence that reactive oxygen molecules can stimulate angiogenesis, but perhaps at a lower concentration than household hydrogen peroxide:

Scientists Identify a New Role for Oxygen in Wound Healing

Home > News > Article
COLUMBUS, Ohio – Ohio State University medical researchers have demonstrated that reactive oxygen species at appropriate levels can support the healing of wounds, and specifically that wounds can generate their own low concentration of hydrogen peroxide, which has a role in healing.
A recent Ohio State study showed that at the site of injury, cells of wound tissue convert oxygen to reactive oxygen species, triggering oxidation-reduction, or redox driven mechanisms. Excess levels of reactive oxygen species, such as during chronic inflammation, may impair healing, but low levels offer healing benefits.

The observation that the redox state of the wound tissue may influence healing outcomes could lead to consideration of a novel redox-based principle for wound therapy, said Chandan Sen, lead author of a paper detailing the findings and professor and vice chair of the department of surgery at Ohio State.

The research paper is available in the online version of Molecular Therapy, the journal of the American Society of Gene Therapy.

A key characteristic of problem wounds is that they are hypoxic, or suffer from poor oxygenation, meaning too little oxygen is available to initiate the reactive oxygen-dependent healing processes.

“Proper oxygenation of a wound is a fundamental pre-requisite,” said Sen, also deputy director of the Davis Heart and Lung Research Institute at Ohio State and chief editor of the international journal Antioxidants and Redox Signaling.

Under conditions of sufficient oxygenation, wound-related cells generate small amounts of reactive oxygen products, including hydrogen peroxide, which, at correct levels, acts as a chemical messenger to support healing. The hydrogen peroxide in question is not the typical household strength 3 percent solution, but a lower concentration of the compound that at a molecular level sends a message needed to trigger angiogenesis, or the formation of new blood vessels, the scientists found.

Their study provides the first direct evidence that low levels of hydrogen peroxide are enzymatically generated by the body as a wound heals in healthy tissue.

Problem wounds, however, may suffer from conditions that limit hydrogen peroxide production at the wound site. These conditions cause improper oxygenation and compromised immune function, or stem from genetic defects or chronic conditions such as diabetes that compromise the enzyme NADPH oxidase, a cellular mechanism behind the ability to kill bacteria. In these and similar cases in which the body can’t be counted on to heal itself, appropriate delivery of reactive oxygen species could provide a new basis for therapeutic exploration, the scientists said.

“We’re saying that the body makes hydrogen peroxide at very minute dosages that act as a signal for repair,” Sen said. “An excess of hydrogen peroxide can be damaging, but if we can find an innovative approach to deliver low levels of hydrogen peroxide into wounds that are difficult to heal, that could be helpful.

“Basic science studies have identified hydrogen peroxide as a trigger that drives redox signaling. Redox-based strategies to heal problem wounds may be applicable to a large number of people suffering from chronic wounds, such as diabetics, the immune-challenged and those suffering from chronic granulomatous disease,” he added.

To mirror those conditions, Sen and colleagues designed a study to compare wounds in mice with compromised health – specifically, mice deficient in MCP-1, a protein known for its involvement in recruitment of immune cells to wounds and in the formation of blood vessels, and others deficient in p47phox, a member of NADPH oxidase family – to wounds in mice with normal health to monitor molecular activity under varying conditions. In mice with built-in deficiencies whose wounds were not healing, the topical application of low-dose hydrogen peroxide identical to the concentration that occurred naturally in healthy mice corrected abnormal wound closures, the study reports.

Scientists determined that one key role of hydrogen peroxide in wound healing is to induce vascular endothelial growth factor in wound-related cells, a gene believed to be the most efficient signal to stimulate blood vessel formation in wounds.

Using a viral gene delivery approach involving catalase, an enzyme that rapidly decomposes hydrogen peroxide, scientists also showed that forced decomposition of hydrogen peroxide generated by the wound tissue results in impaired healing. Sen said these observations underscore the significance of hydrogen peroxide, generated by wound cells, in deciding healing outcomes.

Sen said the study sets a new paradigm supporting the role of reactive oxygen species – generated from oxygen – as a signal for repair in the healing process. He added that these new findings also underscore the critical need to ensure that wounds are appropriately oxygenated.

A strong solution of hydrogen peroxide has been historically used clinically to disinfect wounds. While such an approach may be effective in disinfecting, hydrogen peroxide at that strength may hurt newborn regenerating tissue. The study showed that too much hydrogen peroxide can be damaging to a wound.

“Our observation that dermal wound healing is subject to redox control represents an important step toward redox-based therapies in the clinic,” Sen said. “The solution to problem wounds lies in an interdisciplinary multifactorial approach. To enable that solution, all facets of a problem wound need to be mechanistically understood. The redox control aspect represents a new facet.”

A grant from the National Institute of General Medical Sciences of the National Institutes of Health supported this work.

Sen co-authored the study with Sashwati Roy, Savita Khanna and Koshore Nallu, all with the OSU Laboratory of Molecular Medicine, and Thomas K. Hunt of the University of California at San Francisco Department of Surgery.


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An unlubricated condom could be used to keep the big toe dry.

Maybe the injury site wasn't clear in my original post. Look at the bottom of your foot. The injuiry is to the big toe from the front of the ball of the foot to the first joint and encompasses the entire bottom of the toe in that area. The wound penetrates the fascia at the toe joint. I don't think it is possible to use the foot and keep it dry using anything that would slip over the toe.

Now, if it were further forward on the toe where the condom or cot could be sealed posteriorly I can see how they would work.
 
A podiatrist should recommend a metatarsal support to relieve the pressure on the wound. As your great toe and the inside of the ball of the foot bear up to 80% of your body weight while walking - a "rocker" shoe might be prescribed to relieve the pressure on the wound so it can heal. In addition, a cushion might need to be cut to lift the foot away from any bulky bandage material you might use.

While many wound care experts don't recommend hydrogen peroxide, or betadine - the location of your wound (moist, damp, and prone to exudate) might warrant the use of such mixture as a cleansing agent. At least at first, until the wound granulate - and is ready to heal in with epithelium. This area is known for mixed infection - pseudomonas, staph, and fungus.

I would not take this wound lightly. We might laugh at the contribution of podiatrist in medicine, and some even call them "quacks".... But I hold most of them in high regard. If you don't take good care of it, infection of the bone, or worse might occur.

Leave it to the expert, and let scubaboard opinions to minor issues.
 
Take - a - picture
 
I'm happy in one way; nothing has been posted I hadn't known about; honey and granulated sugar excepted :) But, my knowledge was only part of the purpose of this thread.

The main purpose was to air some of the field first aid methods and update others. One example is the idea of alcohol or H2O2 to clean wounds. Very old school.

One of the things that surprised me was people's willingness to use Super Glue and similar things to cover a wound rather than just close it. It seems to me that putting something like that on this size wound would be traumatic in itself and would not only delay healing, but could possibly increase the possiblility of infection.

One lesson that hasn't been mentioned is Tetanus. Even if you don't have tetanus in your area be sure you do keep your shots up to date for travel.
 
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