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Honey has been used for centuries to heal wounds. When antibiotics came on the scene in the 1940’s, honey lost in popularity as an agent of healing. Now, as concern has mounted regarding the proliferation of antibiotic-resistant organisms (AROs), scientists have begun to re-examine some of the known time-proven remedies for care of wounds. Honey is one of these old remedies that is being studied with fresh eyes.

How is honey used in wound management?

When applied to burns, honey is known to soothe the discomfort associated with burns and to help burns heal more quickly. Honey has also been shown to:

•  Improve healing
•  Reduce healing time
•  Reduce scar formation

Honey, in particular Manuka honey, has been shown to be useful against some strains of resistant bacteria. Manuka comes from a plant by the same name which is native to New Zealand.

How does honey help in healing?

Honey has been shown to stimulate human monocytes (a type of white blood cell that are responsible for phagocytosis of foreign substances) to produce inflammatory cytokines. Cytokines are secreted by immune cells in response to pathogens, and signal immune cells to increase their response to pathogens.

Honey is also a potent antibacterial agent for several reasons:

• Honey has a high sugar content (creating an osmotic efffect)
• Honey has a low moisture content 
• Honey creates an acidic environment
• Honey contains hydrogen peroxide

How much honey should be used?

The amount of honey necessary to adequately treat a wound is a subject of controversy, with few studies agreeing on how much honey should be applied, or even how often and by what method it should be applied.

Using honey on diabetic ulcers

Although few studies have been conducted specifically on the use of honey in the management of diabetic ulcers, those that are available have been favourable to the use of honey. Honey has been reported as being more effective than conventional treatment in more than 100 case reports for treatment of chronic wounds. In one particular study, honey was effective when several other treatments had failed in a diabetic foot ulcer colonized with Pseudomonas, vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). The wound is reported to have healed slowly, and it was theorized that the way in which honey is processed may have removed some of its beneficial components, including some of its antibacterial ability.

Problems with using honey for wound care

There have been no reports of allergic reactions to honey itself, but some individuals may be sensitive to pollen or bee proteins in honey. Also, when honey is used in copious amounts, tissue may become dehydrated. This is easily remedied by the application of saline packs. Few patients have reported discomfort severe enough that a honey application could not be tolerated, but some patients did report transient stinging

Due to the composition of honey, directly applying honey to wounds may not be effective because the honey may be squeezed out the sides of the dressing. In addition, wounds that are heavily exudative may wash away the applied honey from the wound bed. For this reason, dressings impregnated with honey are now being manufactured in a sterile form. Such dressings are prepared to be able to handle large amounts of exudate so that the honey in the dressings stays in direct contact with the wound being treated. Dressings should be changed when saturated.

See how honey recently helped save a man’s leg read more.

Wound care management is undergoing rapid changes in which new information becomes available constantly. As a health care professional, the amount of new information can be overwhelming. At WoundEducators.com, we are committed to providing you with the latest, most up-to-date evidence-based knowledge available.

If you are interested in becoming a certified wound care specialist, visit WoundEducators.com to learn how easy it is to take your career to the next level.

Sources:

Anderson, J., Hanson, D., Hunter, S., Langemo, D. & Thompson, P. (2009). Use of honey

            for wound healing. Advances in Skin and Wound Care. Retrieved March 6, 2009

            from www.woundcarejournal.com.

Betts, J.A. & Molan, P.C. (2008). Using honey to heal diabetic foot ulcers. Retrieved

            March 6, 2009 from www.woundcarejournal.com.

The jobless rate in the United States has now surpassed 8%. Every industry, including health care, must tighten their purse strings in order to remain viable in today’s tough economic climate. Part of this strategy may be the retention of employees that can offer organizations the most value for their money. How can you ensure that you won’t become one of the “statistics”? Making yourself indispensable to the organization you work for is one way you can ensure that you remain employed when others around you are losing their jobs.  Consider the following key points to increasing your personal value:

1. Education is key- Employers are always impressed by credentials, and educating yourself is never wrong. Not only do you increase your knowledge level, but also your career flexibility and options. Education can open up new avenues to you (and your employer). Your employer will appreciate your dedication to your career that pursuing further education shows, and you will appreciate the commensurate pay raises!
   
2. Become certified- This is one step further than continuing education. Becoming certified in a specialty area such as wound care shows that you are committed to excellence. Certification, because of the necessary requirements to uphold your certification, also tells your employer that you will remain current in the field. Certification is usually optional, and this tells your employer that you are someone who values both themselves and their career and says that you are willing to go that extra mile to bring something special to the table.
   
3. Discover your niche- Becoming certified elevates you above the crowd. The practitioner who is certified will be sought after and will be indispensable to their employer. Due to the rapid changes in wound care management that are taking place, as well as changes in the law regarding wound care, employers will value someone who has the most current and up-to-date knowledge in regards to management, liability, and standards of care.
   
4. Build relationships- Use the knowledge you gain from becoming a wound care specialist to build your relationships and network with others who will recognize your value as a certified professional. Offer to use your knowledge to assist and teach others and you will be remembered. This will ensure that you always have options should your current job ever evaporate. You will gain a world of confidence from becoming a certified specialist in wound care, and this will help you to make and maintain valuable and lucrative relationships that will serve you well.
   
5. Be the best that you can be- It may sound like a cliché, but by becoming one of the “elite” in wound care management you can help to ensure positive outcomes for your patients while using your knowledge to lower the overall costs associated with wound care.  Your employer will appreciate your understanding of new treatment modalities that can help to defray costs, making you an invaluable member of any organization, especially in today’s world of cost containment.

Perhaps the most important thing that you can do to increase your job security is to love what you do. People who are passionate about their career stand out, and are generally happier than their colleagues who view their jobs as just that-a job. Educating yourself has so many positives and no downside. Becoming wound care certified will allow you to have greater control over your career and will afford you more choices.

WoundEducators.com is dedicated to assisting health care practitioners to achieve excellence and satisfaction within a growing field that shows no signs of slowing. In fact, the need for certified wound consultants will keep growing due to new standards in wound care management. Do yourself a favour and consider becoming a certified wound care specialist. In doing so, you will help prove your value to your employer and ensure that your career remains safe.

What is Hydrofera Blue?

Hydrofera Blue is a product which is made of a polyvinyl alcohol sponge impregnated with Methylene Blue and Gentian Violet, substances which have been in use for over 50 years and are proven to provide broad-spectrum bacteriostatic protection.

What types of wounds can Hydrofera Blue be used on?

Hydrofera Blue is highly absorptive and is effective against numerous bacteria, including MRSA and VRE. It can be used on a variety of wounds, including:

Ÿ  Pressure ulcers

Ÿ  Venous stasis ulcers

Ÿ  Radiation burns*

Ÿ  Orthopedic wounds

Ÿ  Arterial ulcers

Ÿ  Donor sites

Ÿ  Lacerations/abrasions

Ÿ  Post-op incisions

*Hydrofera Blue is not indicated for the treatment of third-degree burns.

Advantages of Hydrofera Blue

Hydrofera Blue dressings are highly absorptive and can be used on wounds which are draining heavily. They are also very durable and can be compressed to 1/10^th their normal size. They are quite soft and unlikely to damage or irritate healthy tissue. Hydrofera Blue is biocompatible and is highly resistant to chemicals.

How to use Hydrofera Blue dressings

The dressing should be wet with sterile normal saline or sterile water. Squeeze the dressing and leave some fluid in for drier wounds; for heavily exudating wounds, squeeze the dressing until it is almost dry. Position the dressing so that it is in contact with the wound. Hydrofera Blue may be used as a packing or as a wound cover, overlapping the edges of the wound by at least 1 inch.

It is important to make sure that the dressing does not completely dry out. The dressing should be changed every one to three days, or when the area of dressing over the wound becomes saturated. Also, if the dressing turns white, this indicates that it has used all its antimicrobial substance, and the dressing should be changed.

Cover Dressings

Because it is so important to ensure that the Hydrofera Blue dressing does not dry out, care should be taken to choose an appropriate cover dressing:

If the wound bed is dry, a cover dressing which prevents the wicking away of moisture should be chosen. Good examples of appropriate cover dressings may include hydrocolloids, adhesive foams, film dressings, or composite dressings.

If the wound bed is draining heavily, a dressing which will absorb this excess moisture should be chosen. ABD pads, foam dressings and composites may be used to serve this purpose. When the outer dressings are soaked, they should be removed, but the Hydrofera Blue dressing may be left in place until it changes color to white, at which time it should be changed.

Hydrofera Blue is a good multi-purpose dressing that can be used to treat a variety of wounds and is effective against a variety of microbes, including VRE and MRSA. The main components, Gentian Violet and Methylene Blue, have been used for many years and have proven to be safe. A major advantage of the dressing is its ability to handle large amounts of exudate, its durability, and its ability to conform to virtually any wound bed size or shape.

If you are interested in learning more about wound care management, or are ready to take the next step in becoming a certified wound care specialist, please contact us for more information. Woundeducators.com is dedicated to bringing you the most current information in wound care available.

Chronic wounds often require that more than one agent be used to treat the wound, depending on the stage of wound healing. You might often hear the term “bacterial load” to denote the amount of bacteria present in and on a wound. Bacterial load can have a deleterious effect on wound healing. All chronic wounds are believed to be contaminated to some degree with bacteria.  Depending on the amount of bacteria present, wounds may be classified as:

• Contaminated
• Colonized
• Critically colonized
• Infected

The first two categories, contamination and colonization, are not treated routinely with antibiotics. Wounds that are critically colonized should be treated, or they may progress to the infected stage. Wounds in the infected stage usually show all the classic signs and symptoms of infection; that is, erythema, edema, increased odour and pain, a rise in white blood cell count and a rise in temperature.  It is important to note that an infection may be clinically “silent” or unapparent.  Individuals who are immunocompromised or who have inadequate perfusion to the involved area are not only at greater risk for infection but also less likely to exhibit the classic signs of infection (Myers, Betsy, 2008).

What is Polyhexamethylene Biguanide?

PHMB is a commonly used antiseptic, and can be found in such substances as perioperative cleaning products, contact lens cleaning solutions, swimming pool cleaners, and the like. In-vivo and in-vitro studies have shown the safety and effectiveness of PHMB. PHMB interacts with the surface of the bacteria, and then is transferred to the bacteria’s inner cytoplasm and the cytoplasm membrane and eventually causes cell death.

There are several products commercially available which contain PHMB:

• Kerlix AMD99
• Excilon AMD99
• Telfa AMD99
• Xcell AE Cellulose Wound Dressing

Such products are intended for use on partial-and-full thickness wounds. Advantages of these dressings are that  they:

• absorb wound exudate
• support autolytic debridement of non-viable tissue
• provide a moist wound bed
• reduce pain

In addition, PHMB has been shown to be effective against MRSA, Enterococcus faecalis, Candida albicans, Eschirichia coli, and Bacillus subtilis.

Polyhexamethylene biguanide (PHMB) has been studied in recent literature and no evidence of resistance to PHMB has been observed.

Cost-Effectiveness of PHMD

Estimated costs associated with treating chronic wounds are estimated to be around $40,000.00, including the costs of supplies and services. Any delay in wound healing, such as occurs when wounds become infected, will increase the cost associated with care. Studies have shown that the cost of PHMD is similar to that of other advanced dressings.

“Currently, PHMB does not have a history of resistance or cytotoxicity, has demonstrated promotion of healing, and may play a new and important role as an antimicrobial agent in dressings” (Cavorsi, Lee, & Mulder, 2007).

Polyhexamethylene biguanide is one of a series of wound care treatments we are happy to present you with at WoundEducators.com. If you are interested in taking the next step and becoming wound care certified, please contact us.

Iodine has long been in use as an antibacterial agent and a skin disinfectant. It was discovered in 1811, and gained widespread popularity during the American Civil War, where it was used liberally to treat the wounds of soldiers. In its original form, iodine caused pain and irritation when applied to wounds, it has been shown to impair the function of cells involved in wound healing, and it also had the unfortunate side effect of skin discoloration.

Since the late 1940’s, newer, safer, and less painful formulations of iodine in the form of iodophors have come into use. These products release sustained low levels of iodine, which bind to proteins, fatty acids, and nucleotides. These products have a broad spectrum of activity against bacteria, mycobacterium, fungi, and protozoa.

Cadexomer Iodine

Cadexomer iodine is a slow release antimicrobial which has the capability to absorb excess wound exudate while maintaining a sustained level of iodine in the wound bed. Cadexomer iodine is available both as a dressing and as an ointment. In studies it has been shown to be effective in reducing counts of MRSA (methicillin-resistant staphylococcus aureus) and Pseudomonas aeruginosa. It is estimated that 1 gram of Cadexomer iodine can absorb as much as 7 ml of fluid. The iodine is slowly released as the iodine is absorbed, which helps to reduce the bacterial load while simultaneously debriding the wound. It requires moisture to be activated.  Unlike povidone iodine dressings which release iodine immediately upon application, the sustained release of iodine from cadexomer iodine dressings does not cause cytotoxic effects.

Potential Contraindications

Studies have shown that cadexomer iodine is effective in healing chronic ulcers; however, one of the serious potential side effects of using iodine for the treatment of wounds is that there is the potential for the absorption of iodine. For this reason, thyroid function should be monitored in patients who use this therapy for extended periods of time. In addition, iodine can interact negatively with lithium, and should be used with caution in patients who are on lithium concurrently. Iodine should not be used at the same time as mercurial antiseptics, such as mercurochrome.

Given the growing concern over the rise of antibiotic-resistant organisms, cadexomer iodine is an effective alternative for the treatment of chronic wounds. Reports of resistance to iodine are scarce, despite the fact that iodine has been in use for over 150 years. Cadexomer iodine can be safely used on most patients (providing they are not sensitive to iodine itself) and provides good coverage of bacteria, mycobacterium, fungi, and protozoa, as well as being effective against MRSA.

Woundeducators.com strives to bring you the most current knowledge in the field of wound care management. Interested in achieving wound care certification in this growing field? Please contact us for further information or if we can answer any questions in regards to how you can enhance your career in this exciting and rapidly-expanding field.

The use of silver in wound care has a long history. A recent resurgence in interest in silver dressings as antiseptic agents has come about, largely due to an increase in antimicrobial-resistant organisms such as MRSA (methicillin-resistant staphylococcus aureus).

What is silver’s mechanism of action?

Silver is effective as an antimicrobial because it binds to and destroys bacteria cells at multiple sites. This ability to bind to several sites is the main reason why bacterial resistance to silver is rare, making silver an attractive option. 

When the silver cation binds to proteins in the bacteria, the following can result:

• The protein structure is altered, causing structural and functional changes in the cell
• The bacterial cell wall can rupture, causing its contents to leak out, leading to cell death
• The bacteria is prevented from carrying out functions necessary for its survival, such as respiration and taking in nutrients, leading to cell death

Antibiotics usually only have one method of killing bacteria (i.e. preventing replication) while silver has several methods of killing bacteria.

What types of silver dressings are available?

Silver dressings are commercially available in several forms. The main difference in these dressings is in how much silver they contain and how quickly they release the silver cation. At present silver dressings are found in the following forms:

• Films
• Foams
• Alginates 
• Hydrogels
• Hydrocolloids

The form in which you choose to deliver silver to the wound will depend on the type of wound, where it is located, and the amount of drainage present.

When should I use silver?

Dressings containing silver may be appropriate for short-term use on wounds that are critically colonized or infected.  You should be cautious about using silver for wounds that show signs of cellulitis or a systemic infection, wounds that are colonized with fungus, in clients with interstitial nephritis or leucopoenia, and when signs of possible side effects are present, such as erythema multiforme. Silver should not be used solely to treat an infection, but as an adjunct to help decrease the number of bacteria on the surface of a wound. Keep in mind that using more silver is not necessarily better, as silver has been found to be cytotoxic to fibroblasts and single layers of epithelial cells in vitro as well and retards wound epithelialization in vivo.  Use dressings with the least amount of silver necessary to “get the job done”.

Note that there are two substances that should not be used in conjunction with silver:
Saline- Saline will react with the silver cation to form silver chloride crystals, consequently decreasing the amount of silver released. This is important to know, as many times saline is used as a cleansing agent during dressing changes.
Papain-urea deriding ointment- The ointment will be deactivated by the silver, thus rendering it useless as a debriding agent.

In addition, silver dressings must be removed if a patient is to undergo an MRI. They should be discontinued once wound bioburden is controlled and wound healing progresses. Silver dressings should also be discontinued, and alternate treatments initiated, if no improvements in wound status are noted after 1 or 2 weeks of use.

Silver is making a comeback as a treatment option to help decrease bacterial loads in wounds. Although it has many advantages, silver also has its drawbacks. Woundeducators.com strives to bring you the latest in wound care treatment to keep you informed in today’s competitive and changing world. If you are interested in learning more about this topic, or others like it, or are interested in obtaining wound care certification, contact us today.

A burn may be defined as damage to the skin caused by heat or chemicals. Effective management of burns is dependent on both the depth and the severity of the burn. Burns can be extremely challenging because the wound environment is constantly changing.

Burn Severity

Severity of a burn takes several factors into account, such as the patient’s age, burn depth, the size of the burn, and its location.

Age
The old and the very young have a higher mortality rate from burns than do older children and younger adults.

Burn Depth
Depth of a burn is determined by how much of the skin is destroyed:

• Superficial burn- confined to the outer epidermal layer
• Partial thickness burn- involves the epidermal layer and a portion of the inner dermis
• Full-thickness burn-both layers are destroyed
• Subdermal burn- involves destruction of both layers and extends down into the tissue below, and may include damage to tendons, muscle, fat, and bone.

It is important to note that burn depth is not static, but may change over time.

Burn Size
The size of a burn has traditionally been determined by The Rule of Nine, which divides body segments into areas of 9%. For example, a burn to an entire leg is awarded 9%; the anterior trunk is given 18%.

Burn Location
The location of a burn may also determine severity. For example, burns sustained to the face and neck may compromise the patient’s airway. Burns to the perineum are very prone to infection. Therefore, the location of a burn sometimes determines severity.

Burn Management

Superficial burns- Superficial burns are most often caused by sunburn and usually require no treatment beyond a moisturizing cream. These burns heal themselves within a week and cause no permanent visible damage to the skin, although repeated damage to the skin from sunburn can increase the risk of developing skin cancer.

Partial-thickness burn- Partial-thickness burns can be divided into two different categories, superficial partial-thickness and deep partial-thickness. They are treated differently.

Superficial partial-thickness burns involve leakage of large amounts of plasma and large blister formation. Resulting wounds are pink, moist, and very painful. Pain is the most severe in these types of burns because nerve endings are exposed. Healing generally occurs in one to two weeks and scarring is not common. Risk of infection is also low because blood supply is adequate in these types of burns.
Blisters should not be allowed to remain intact for longer than two days, as these blisters are a source of potential infection. Loose skin and large blisters should be cleansed and debrided. Daily wound cleansing can be accomplished with a non-cytotoxic wound cleanser and the wounds may be covered with a contact layer such as a petrolatum-impregnated gauze, reinforced with dry gauze. If no exudate is present, the dressing does not need to be changed; if exudate is present, the dressing should be removed and the wound cleansed and redressed. Alternately, skin substitutes may be used. Skin substitutes protect the wound bed and provide moist wound healing.

Deep partial-thickness burnsmay take months to heal as reepithelialization is slow. These wounds will appear white and dry. Blood flow is often compromised, and these wounds are prone to infection and may convert to a full-thickness injury. The presence of sensation to touch helps in differentiating these injuries from full-thickness burns. Treatment of these burns focuses on removing eschar and using topical antibiotics during the process of debridement. These wounds may also require surgical closure (excision and grafting). Agents containing silver, either as an ointment or as an impregnated membrane dressing are frequently used. If cream is used, it must be removed and reapplied daily. Impregnated dressings decrease the need for frequent dressing changes. Dry gauze dressings should be used over the cream or silver dressing.

Full-thickness burnsinitially appear white and waxy, or may appear leathery brown or black if the burn produces char. These burns are painless. Treatment is similar for full-thickness and deep partial-thickness burns. Early surgical debridement and wound closure with skin grafting or skin substitutes is the most common treatment method.

Subdermal burns often cause such severe damage that amputation is frequently necessary.

Burns require constant assessment and treatment to avoid complications such as scarring, infection, disfigurement, and loss of function. Woundeducators.com strives to bring you the most up-to-date and comprehensive information currently available to recognize, classify, and treat such injuries. If you are interested in obtaining wound care certification, please contact us for more information. 

Over the past few weeks we have discussed venous insufficiency ulcers and arterial insufficiency ulcers and ways to differentiate between the two.  Now it’s time to test your knowledge.  See if you can answer the questions to this short quiz. 

Check back next week when we will be discussing burn wound injuries.

Don’t miss the December CWCA application deadline!

Upcoming CWCA Exam Periods:
February 7-21, 2009
Materials deadline:  December 19th
Later registration:  December 20th - January 9th

Venous ulcers can be debilitating, painful, and challenging to treat for healthcare professionals. It is reported that between 10 and 35% of the population has some form of venous disease and that 80 to 95% of leg ulcers are a result of chronic venous disease (Kline & Sieggreen, 2004).

What is chronic venous insufficiency?
Chronic venous insufficiency can be defined as venous hypertension of the deep and superficial veins, and may be complicated by incompetent venous valves causing reflux, or backward flow of blood.

The following steps are believed to occur in the development of venous ulcers:

1. A blood clot (thrombosis) develops, which may occur months or years before the ulcer develops
2. Valves become incompetent following the thrombosis, despite the vein recanalizing
3. Valves in the distal segment of the vein become exposed to increasing pressure (venous hypertension); valve function in the proximal vein is compromised
4. Pressure increases until perforating veins and capillaries are involved
5. Once capillaries are involved, the skin follows suit, and the stage is set for the development of venous ulcers

Appearance of venous ulcers
Venous ulcers may vary in size from very small to extremely large. Borders may appear irregular and are not usually as well-defined as arterial ulcers. Venous ulcers often weep, and drainage may be moderate to heavy. The skin surrounding the ulcer may be edematous. The patient may have edema whether or not an ulcer is present, and this may cause weeping of fluid through the skin. This may cause itching of the skin, which the patient may not be able to resist scratching, leading to further damage to the skin. Venous ulcers may cause pain, especially upon weight-bearing.

Treatment of venous ulcers
The mainstay of treatment for venous insufficiency is external compression to improve blood flow and decrease edema. Compression must be a lifelong treatment once venous insufficiency is diagnosed, not just for the duration of ulcer treatment.

Compression stockings should be fitted properly to provide 30 to 40 mm Hg pressure. Knee-high stockings are sufficient, as it is the distal skin and subcutaneous tissues that are involved in venous insufficiency; some patients may prefer thigh-high stockings. Higher stockings are acceptable, but patients should ensure that they fit well and do not roll down, as this may compress tissue behind the knee.

Compression stockings should be worn during daytime hours when the patient is upright. At night, during sleep, the legs are elevated and stockings do not need to be worn.

Dressings to treat venous ulcers should have the capability of absorbing the large amount of drainage these ulcers may produce. If necrotic tissue is present, dressings that stimulate autolytic debridement can be used. Infection should be treated if present, but antibiotics should not be given empirically.

In the presence of these wounds, it should be mentioned that arterial insufficiency may also be present at the same time. Patients who have wounds that do not heal despite proper and aggressive treatment should be evaluated for underlying arterial insufficiency.

Wound Care Certification
The past two weeks we have covered both arterial and venous ulcers, from pathogenesis to symptoms and treatment. If you have found these articles interesting, perhaps you are interested in taking the next step to becoming a certified wound care specialist. At wound educators.com, we are dedicated to providing the most current and up-to-date information on wound care, and assisting healthcare professionals to realize their ambitions. For more information on becoming certified in wound care management, visit our web site at www.woundeducators.com.