As the wound healing process has been better elucidated, the practice of wound care has evolved. However, the fundamental principles of great wound care have not changed considerably over time. The process begins with an assessment of the whole patient.
Any underlying medical conditions that impair wound healing should be treated. These include systemic infection, hyperglycemia, inadequate nutritional status, poor circulation, a deficient immune system, and also the absence of someone dedicated to caring for the wound. Once patient factors have been adequately addressed, attention should be turned to the wound itself.
The majority of chronic wounds encountered in hospitalized patients can be categorized into four kinds of ulcers: pressure, diabetic, venous and ischemic. In addition, chronically infected wounds can occur in the setting of underlying osteomyelitis or a foreign body. With respect to local wound care, the principles are usually the same: eradicate infection, debride necrotic tissue, remove any nonessential foreign material, maximize arterial inflow and venous outflow, and maintain the wound moist and clean.
Topical pharmacologic wound care can help achieve these goals to a certain extent. In broad terms, agents commonly utilized in local wound care may be grouped into 3 categories: antimicrobial agents, enzymatic agents and growth factors.
Topical antimicrobials are moderately effective in treating infected wounds. They provide the benefit of delivering a high therapeutic dose of the drug to a local region with minimal systemic side effects, particularly in wounds with relatively underperfused tissues. They are not, however, a substitute for systemic antimicrobial therapy when indicated.
The goal of topical antimicrobial therapy would be to diminish the burden of bacteria to a level that is manageable by the host immune cells. In fact, sub-infection levels of bacteria have been shown to accelerate wound healing and granulation by promoting the infiltration of neutrophils, monocytes and increased collagen deposition.
There are a variety of commercially obtainable topical antimicrobials. Silver sulfadiazine is utilized in superficial soft tissue infections. Its effectiveness against Pseudomonas makes it a favored choice in burn treatment. Two other commonly used antibiotic agents are Bacitracin and Neosporin. These petroleum-based ointments are useful more for superficial infections. In addition, they may be utilized on surgical incisions, particularly of the face, to minimize bacterial load and provide a moist wound environment to promote epithelialization.
The role of povidone-iodine in topical wound care is somewhat controversial. A number of animal studies demonstrate no adverse affect on wound tensile strength or reepithelialization rates. On the other hand, several human in vitro and in vivo studies have shown that Betadine inhibits fibroblast proliferation, kerotinocyte growth and migration, and hampers the phagocytic effect of monocytes and granulocytes.
Any admixture of blood, pus or fat has been proven to diminish the antimicrobial effect of Betadine. Given this data, numerous plastic surgeons don't use Betadine as a topical antimicrobial, although it is still commonly utilized in the operating room as a prepping agent. Other specialties that treat wounds still use Betadine because of the lack of convincing clinical trials and a long history of its use.
In addition to appropriate antimicrobial therapy, the wound must be properly debrided of any devitalized tissue. Necrotic tissue can serve as a culture medium for further bacterial proliferation, and its presence will impede the healing procedure. Sharp debridement is the simplest, most effective means of eliminating nonviable tissue. Enzymatic debriding agents are an adjunct to surgical debridement. As with antimicrobial agents, there is a spectrum of enzymatic agents that is commercially obtainable.
Maybe the realm with the greatest therapeutic potential in the pharmacologic treatment of wounds is the use of growth factors. A variety of growth factors and chemotactic agents have been discovered since the 1970s, and numerous have been probed for feasible clinical applications. Platelet-derived growth factor (PDGF) is present in acute surgical wounds, nevertheless not in chronic, nonhealing wounds.
In several randomized controlled trials, topical application of PDGF increased wound tensile strength and accelerated the healing process overall. Recombinant PDGF is currently the only cytokine approved for use in chronic wounds, specifically in neuropathic diabetic foot ulcers. It's obtainable commercially as beclapermin; however the extremely high price makes its use prohibitive in numerous centers.
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