New Treatments

HYPERBARIC OXYGEN

There have been no controlled trials comparing the use of hyperbaric oxygen therapy

Table 2.6 Properties, and indications of available dressings

Flat Flat

Type wound wound Cavity of Necrosis/ Gangre- Low High with low with high without dressing slough nous Infection exudate exudate exudate exudates sinus

Dry +

+ + +

Enzymatic +

debrider

Films

+ +

Foams

+ + +

+

Hydrogels +

+ +

Hydrocolloids

+ +

+

Alginates

+ + Alginate

Alginate Alginate

rope

rope rope

Table 2.7 Advantages and disadvantages of available types of dressings

Cavity with sinus tract

Table 2.7 Advantages and disadvantages of available types of dressings

Type of

dressing

Advantages

Disadvantages

Traditional dressings (gauze and absorbent cellulose)

Films

Foams

Hydrogels

Hydrocolloids

Cheap and widely available. Appropriate for gangrenous lesions

Semi-permeable. Form bacterial barrier. Durable. Require changing every 4-5 days. Cheap

Appropriate for ulcers with high production of exudates. Provide thermal insulation. Easily conformable. May be used to fill cavities without sinus tracts

Effective, versatile and easy to apply. Very selective, with no damage to surrounding skin. Safe process, using the body's own defense mechanisms. Promote autolysis and healing. Decrease risk of infection. Useful in removing slough from wounds. May be used to fill cavities with sinus tracts

Safe and selective, using the body's own defense mechanisms. Good for necrotic lesions, with light to moderate exudates. May be used to fill cavities without sinus tracts. Can be easily used with a shoe. Adhesive surface prevents slippage. Do not require daily dressing changes. Cost-effective

Adhere to the wound bed and may cause bleeding on removal. Provide little protection against bacterial contamination

Useful on flat or superficial wounds only. Some patients are allergic to the adhesive in the dressing

Variability in absorbency of different foams. Limited published data

Effect difficult to quantify. Not as effective and rapid as surgical debridement. Not appropriate for neuro-ischemic ulcers, which produce minimal exudates. Wound must be monitored closely for signs of infection

Their occlusive and opaque nature prevents daily observation of the wound. Wound must be monitored closely for signs of infection. May promote anaerobic growth and mask a secondary infection

(continued overleaf)

Table 2.7 (continued)

Type of dressing

Advantages

Disadvantages

Alginates

Enzymatic debriders

Medicated dressings

Useful as absorbents of exudates. Good for infected ulcers. Some products have hemostatic properties

Good for any wound with a large amount of necrotic debris, and for eschar formation. Promote autolysis and fast healing. Decrease maceration of the skin, and risk of infection

Not appropriate for neuro-ischemic ulcers, which produce minimal exudates. Some researchers think they may traumatize the wound bed and predispose to infections. May dry out and form a plug within the wound bed. Requires painstaking removal with the use of large amounts of saline

Costly. Must be applied carefully only to the necrotic tissue. May require a specific secondary dressing. Irritation and discomfort may occur

Data based on animal models and cell cultures only in the treatment of neuropathic ulcers. At the present time it is only used to treat patients with severe foot infections which have not responded to other treatments. Hyperbaric oxygen is particularly effective in patients with foot ischemia.

FACTORS ACCELERATING WOUND HEALING

Platelet-Derived Growth Factor-^

Platelet-derived growth factor-^ (PDGF-P, becaplermin, Regranex®, Janssen-Cilag) has been developed as a topical, effective and safe therapy for the treatment of diabetic foot ulcers and has also been found to be effective and safe as local therapy for the treatment of non-infected diabetic foot ulcers. It is applied as a gel on the ulcer surface once daily by the patient, while the ulcer is debrided on a weekly basis. A dose of 100 ^g/g has been demonstrated to be the most effective. Compared to standard treatment, more ulcers treated with becaplermin heal completely and in a shorter time. The maximum time required to achieve has been reported as 20 weeks.

Dermagraf®

Dermagraf® (Smith & Nephew) is a bio-engineered 'human dermis' designed to replace the patient's own damaged dermis. It is applied to the ulcerated area on a weekly basis. Preliminary results show that it is an effective and safe treatment. According to a controlled trial, 50% of diabetic foot ulcers healed within 8 weeks when treated with Dermagraf, compared to 8% of ulcers treated with standard methods. Dermagraf should be stored at -70 °C and must be thawed, rinsed and cut to the size of the ulcer prior to implantation. As with becaplermin, the presence of infection is a contraindication to its use.

Graftskin

Graftskin (Apligraf®, Novartis) consists of an epidermal layer formed by human ker-atinocytes and a dermal layer, composed of human fibroblasts derived from neonatal foreskin in a bovine collagen matrix. Studies have shown that treatment with Apligraf resulted in a higher percentage of diabetic foot ulcers healing completely and in a shorter time (56% of the ulcers healed in 65 days), compared to placebo (39% of the ulcers healed in 90 days). Apligraf has been shown to be safe and, in addition, its use was found to lead to a reduction in the incidence of osteomyelitis and amputations.

Granulocyte-Colony Stimulating Factor (GCSF)

Subcutaneous administration of GCSF once daily for 1 week in patients with infected foot ulcers resulted in a faster resolution of the infection, earlier eradication of bacterial pathogens isolated from wound swabs, shorter duration of i.v. antibiotic administration and shorter duration of hospital stay in a double-blind placebo-controlled study. Larger controlled studies are needed to evaluate the efficacy and safety of GCSF in the treatment of the infected foot ulcers.

Hyaff®

Hyaff® (Convatec, Bristol-Myers-Squ-ibb) is a semi-synthetic ester of hyaluronic acid. Serum or wound exudates, when in contact with Hyaff, form a moist environment which promotes granulation and healing. So far it has been used in the treatment of neuropathic ulcers with promising results.

Keywords: Classification of foot ulcers; Meggitt-Wagner classification of foot ulcers; 'The University of Texas classification system for diabetic foot wounds'; neuro-ischemic ulcers, characteristics; isch-emic ulcers, characteristics; neuropathic ulcers, characteristics; prevention of foot ulcers; risk category for foot ulcers; education in foot care; insoles; limited joint mobility; methods for offloading pressure on the foot; total-contact cast; manufactured casts; removable cast walkers; scotch-cast boot; therapeutic footwear; heel-free shoes; half shoes; shoe terms; hyperbaric oxygen; platelet-derived growth factor-^; Dermagraf®; Graftskin; Apligraf®; granu-locyte-colony stimulating factor; Hyaff®; dressings; dressings, advantages and disadvantages

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