MAKING PROGRESS WITH STALLED WOUNDS
Active Leptospermum Honey and Negative
Pressure Wound Therapy for Nonhealing
Postsurgical Wounds
Edna F. Ganacias-Acuna, MD
Medical Director, Wound Care & Hyperbaric Clinic
Methodist Dallas Medical Center, Dallas, Texas
he use of negative pressure wound therapy (NPWT,
T
V.A.C. Therapy®, KCI, San Antonio, TX) has grown
rapidly over recent years. The modality creates a healingfriendly environment by promoting the growth of granulation tissue and removing exudate and infectious material.
While the evidence base supporting this treatment grows,
certain issues specific to NPWT require attention. According to the manufacturer’s specifications and in order to
maximize the benefits of NPWT, all devitalized tissue (including eschar and hardened slough) should be removed
as thoroughly as possible before NPWT application. This
may require sharp or surgical debridement. If the patient
is not a candidate for sharp debridement, an alternative debridement approach (ie, autolytic, enzymatic, or mechanical) must be implemented.1 Also, once NPWT is initiated,
malodor upon dressing removal must be addressed. Malodor with occlusion has been well documented2-6 and may
be related to bacteria7 and/or alterations in the skin, including altered epidermal lipids, DNA synthesis, epidermal cell
turnover, pH, epidermal morphology, sweat glands, and
stresses to the Langerhans cells.8 The combination of an occlusive dressing, necrotic tissue, and decreased dressing
change frequency increases the potential for malodor. An
odor filter, a standard piece of equipment on the various
NPWT systems, is designed to control odor within the exudate receptacle but not at the wound site.
The following case report describes the use of active Leptospermum honey (ALH) paste (MEDIHONEY®, Derma Sciences, Inc., Princeton, NJ) in combination with NPWT to
determine if this approach would help resolve debridement
and odor concerns and provide a synergistic therapeutic effect. The components and properties of ALH, a medical grade
honey, help prepare the wound bed: high osmolarity helps
draw fluid from the wound and underlying tissue, aiding in
debridement of slough and devitalized tissue9,10 and physiochemical and antimicrobial characteristics11-13 have been reported to reduce or eliminate malodor14 via several
mechanisms. First, bacteria preferentially metabolize glucose
Figure 1. May 20, 2009: wound area = 307.50 cm2; volume = 1076.25 cm3. Tissue: 75% viable, 25% nonviable.
Exudate was copious. After sharp debridement, ALH
paste and NPWT were initiated.
in the honey instead of the amino acids present in tissue and
serum, resulting in the formation of lactic acid (as opposed
to ammonia, sulfur, and amines). Second, the antimicrobial
action of honey reduces the presence of bacteria — and subsequently their associated ability to cause odor — in the
wound bed.13 This particular type of honey, unlike all other
honeys, does not lose its antimicrobial activity in the presence
of wound fluid.11,12
Case Report
Thirty-two-year-old Mr. Q had undergone extensive abdominal surgery and a hernia repair with mesh that was left
open to heal by secondary intention. The mesh had become
infected, requiring subsequent re-exploration of the abdomen
and removal of the infected mesh. Mr. Q was discharged to
home receiving NPWT to bridge the abdominal wall margins
Making Progress With Stalled Wounds is made possible through the support Derma Sciences, Inc., Princeton, NJ. The opinions and statements of the clinicians contained
herein are specific to the respective authors and are not necessarily those of Derma Sciences, Inc., OWM, or HMP Communications. This article was not subject to the
Ostomy Wound Management peer-review process.
10
OSTOMY WOUND MANAGEMENT MARCH 2010
www.o-wm.com
MAKING PROGRESS WITH STALLED WOUNDS
wound was 100% filled with granulation tissue, a split-thickness
skin graft was used to achieve complete closure (see Figure 3).
The use of ALH paste used in combination with NPWT dressings was associated with rapid reduction in slough, malodor, and
exudate. Granulation tissue formation improved. These outcomes enabled the application of a split-thickness skin graft for
complete closure with no evidence of subsequent infection. n
References
Figure 2. July 1, 2009: wound area = 146.10 cm2; volume
= 131.49 cm3. Tissue: 90% viable, 10%.nonviable. Exudate was moderate. At 6 weeks, necrotic tissue in the
base of the wound was completely debrided and the
wound bed was filling with granulation tissue.
Figure 3. August 17, 2009: Twelve days earlier, the patient
underwent successful surgical closure with split-thickness skin grafting.
Andros G, Armstrong DG, Attinger CE et al. Consensus statement on
negative pressure wound therapy (V.A.C. Therapy) for the management
of diabetic foot wounds. Ostomy Wound Manage. 2006;52(6 suppl):1–
32.
2. Hinman CD, Maibach HI. Effect of air exposure and occlusion on experimental human skin wounds. Nature. 1963;200:377–378.
3. Valenta AL. Using the vacuum dressing alternative for difficult wounds.
Am J Nurs. 1994;94(4):44–45.
4. Aly R, Shirley C, Cunico B, Maibach HI. Effect of prolonged occlusion
on the microbial flora, pH, carbon dioxide and transepidermal water loss
on human skin. J Invest Dermatol. 1978;71(6):378–381.
5. Marples RR, Kligman AM, Growth of bacteria under adhesive tapes.
Arch Dermatol. 1969;99(1):107–110.
6. Kumar P. Limited access dressing. Wounds, 2008;20(2):49–59.
7. Finegold SM. Pathogenic anaerobes. Arch Intern Med.
1982;142(11):1988–1992.
8. Zhai H, Maibach HI. Effect of occulsion and semi-occlusion on experimental
skin
wound
healing:
a
reevaluation.
Wounds.
2007;19(10):270–276.
9. Gethin G, Cowman S. Manuka honey vs. hydrogel — a prospective,
open label, multicentre, randomised controlled trial to compare
desloughing efficacy and healing outcomes in venous ulcers. J Clini
Nurs. 2008;18(3):466–474.
10. White RJ, Molan P. A summary of published clinical research on
honey in wound management. In: Cooper R, Molan P (eds). A Modern
Wound Management Product. Aberdeen, UK: UK Publishers;
2005:130–142.
11. Cooper RA, Jenkins L. A comparison between medical grade honey and
table honeys in relation to antimicrobial efficacy. Wounds.
2009;21(2):29–36.
12. Cooper RA, Jenkins L, Rowlands R. The influence of catalase on the
antibacterial activity of honey. Poster presented at the Symposium on
Advanced Wound Care. San Diego, CA. April 2008.
13. Blair SE, Cokcetin NN, Harry EJ, Carter DA, et al. The unusual antibacterial activity of medical-grade Leptospermum honey: antibacterial
spectrum, resistance, and transcriptome analysis. Eur J Clin Microbiol
Infect Dis. 2009;28:1199–1208.
14. Moore S. Squamous cell carcinoma of the head and neck: using active
Leptospermum honey for wound management and odor control. Poster
presented at the South Central Region Wound, Ostomy, Continence
Nursing Conference. Edmond, OK. September 2008.
and prepare the wound bed for surgical closure.
After several weeks of NPWT at home, exudate and malodor increased and healing stalled. Mr. Q was referred to the
wound care clinic for evaluation. A large amount of necrotic
slough tissue was noted in the base of the wound (see Figure
1), along with a large amount of foul-smelling exudate. Sharp
debridement was performed. To facilitate continued autolytic
debridement, ALH was initiated with the NPWT dressings. A
thin layer (the thickness of a dime) of ALH paste was applied
to the surface of the wound before the NPWT foam dressing
was applied. The dressing was changed three times per week.
Over 10 weeks, the wound remained slough- and malodorfree, exudate decreased, and healthy granulation tissue was filling the wound; no infection was noted (see Figure 2). Once the
12
OSTOMY WOUND MANAGEMENT MARCH 2010
www.o-wm.com