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Wound Care

Wound healing is important not only for the local repair but also for its beneficial effect to systemic physiological processes. When wounds become chronic, individuals are susceptible to generalized inflammatory cascades that can affect many organs and even lead to death. Skin is the most commonly injured tissue, and its proper repair is important for reestablishment of its barrier function.

Per a prescription order, a formulation can be compounded to contain the proper combination of active ingredients, in the most appropriate base, to treat a specific type of wound. We customize medications to meet each individual’s specific needs.

For example, the choice of cream, ointment, or gel can be clinically significant. Each time a wound needs to be cleaned, there is the potential for disruption of new tissue growth. Gels, which are more water soluble than creams or ointments, may be preferable for wound use because a gel can be rinsed from the wound by irrigation. Another useful dosage form is the “polyox bandage” – which can be puffed onto a wound and will adhere even if exudate is present. A polyox bandage can be compounded to contain the active ingredient(s) of your choice.

Topical Pracaxi Oil Base for Scar and Wound TherapyThe objective of a case series by Banov et al. was to evaluate the utility of fatty acids found in pracaxi oil for wound and scar therapy. Initially, 21 patients with various surgical, traumatic, or burn wounds and scars were enrolled. A topical anhydrous silicone base containing pracaxi oil was applied alone, or was compounded to include one or more additional medications tailored to the specific needs of each patient, such as 1% pentoxifylline, 1% caffeine, 1% tranilast, or 2% mupirocin. Patients were advised to apply the compounded topical medication to new or existing scar or wound areas by lightly massaging the compound into and around the scar or wound. The recommended application frequency was two to four times daily based on the attributes of the scar or wound. The mean duration of application of the compounded topical anhydrous base containing pracaxi oil was 11 days and ranged from 48 hours to 3 weeks based on the size and severity of the wound or scar.

The study found that the application of a compounded anhydrous silicone base containing pracaxi oil alone or in combination with other active substances led to considerable improvements in wound healing and scar attributes and is a potentially useful option in the treatment of burns or surgical, or traumatic wounds and scars.

Dermatol Ther (Heidelb). 2014 Dec;4(2):259-69.

Case series: the effectiveness of Fatty acids from pracaxi oil in a topical silicone base for scar and wound therapy.

Click here to access the PubMed abstract of this article.

Topical Sildenafil: Potential Benefits for Wound HealingA clinical study evaluated the effects of topical sildenafil on Pressure ulcer (PrU)-related healing in human subjects. Enrolled patients were randomly allocated to receive topical sildenafil (10%) ointment or placebo daily. Wound healing was assessed visually and photographically by the change in wound score according to two-digit Stirling scale. Decreases in grades of the PrUs were significantly higher in sildenafil group compared with placebo group. In addition, surface areas of ulcers in sildenafil group were significantly reduced compared to the control group at day 14 of intervention. It appears that these effects may be mediated by improvement of microvascular reperfusion in the skin and soft tissue.

Int Wound J. 2015 Feb;12(1):111-7.

Sildenafil in the treatment of pressure ulcer: a randomised clinical trial

Click here to access the abstract of this article.

Bosn J Basic Med Sci. 2014 Aug; 14(3): 125–131.

Effect of topically applied sildenafil citrate on wound healing: experimental study

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EGCG for Wound Healing and Scar PreventionEGCG (the polyphenols in green tea) may potentially accelerate the wound-healing process and prevent scarring. This potential benefit is particularly exciting for people with conditions such as diabetes, which inhibits the wound-healing process.

Green Tea Linked To Skin Cell Rejuvenation.

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Occlusive, Water-Soluble Gel for Wound ManagementPolyethylene Glycol (PEG) based occlusive, water-soluble gels specifically formulated for wound management promote a moist environment allowing for optimal healing. These gels contain organic Meadowsweet Extract with phenolic glycosides and flavonoids that potentially provide germicidal, anti-inflammatory and healing properties along with the ability to deliver Active Pharmaceutical Ingredients (APIs) topically to sensitive wound sites.

Benefits:

  • Adherent
  • Occlusive
  • Water-washable allowing for easy cleaning and debridement
  • Maintains a moist wound site

Ideal for:

  • Wounds
  • Diabetic skin ulcers, insufficiency (stasis) ulcers, stage I-IV pressure ulcers
  • First and second degree burns
  • Post-surgical incisions
  • Cuts & Abrasions
  • Dermatological applications where a water-washable base would be of benefit

A moist wound environment allows the possibility of increased macrophage and fibroblast activity, re-epithelialization and the production of collagen, and decreased pain. Water washable bases are very important in wound care since wounds need to be cleaned/debrided on a regular basis. Ointments that are not water soluble can disrupt the healing process when the wound is cleaned.

NOTE: Polyethylene glycol (PEG) based vehicles should not be used where absorption of large quantities of polyethylene glycol is possible, such as on extensive burn areas and large surface areas, particularly in patients with moderate or severe renal impairment.

Topical Insulin Accelerates Re-epithelializationInsulin, when topically applied to wounds, accelerates re-epithelialization and stimulates maturation of the healing tissue, and has significant potential for the treatment of chronic wounds in which re-epithelialization is impaired. Because of its long history of safe use in humans for decades, insulin may prove to be a powerful therapy without major adverse effects.

The study strongly suggests that insulin improves wound healing through an integrated effect not only on re-epithelialization but also on the underlying granulation tissue. Compared with other growth factors used to promote wound repair, insulin treatment is likely to be much less expensive and more readily available. When choosing a concentration of insulin for wound therapy, it is important to determine a dose that does alter blood glucose levels in vivo.

BMC Cell Biology200910:1

Cell and molecular mechanisms of keratinocyte function stimulated by insulin during wound healing

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Topical Phenytoin to Promote Wound HealingA systematic review of fourteen randomized controlled trials provided moderate evidence to support the use of phenytoin for the treatment of leg ulcers, leprosy wounds, chronic wounds and diabetic foot ulcers.

Br J Dermatol. 2007 Nov;157(5):997-1004.

The clinical effect of topical phenytoin on wound healing: a systematic review.

Click here to access the PubMed abstract of this article.

A randomized control study in India evaluated the effect of topical phenytoin on healing in diabetic foot ulcers. One hundred patients with grade I/II diabetic foot ulcers were randomly divided into two equal groups with the study group treated with topical phenytoin dressings and the control group receiving normal saline wound dressings. Discharge and slough from wound reduced significantly by day 14 in phenytoin group and within 21 days in control group. Mean duration of hospital stay in phenytoin group was 20 days, whereas in control group, it was 26 days.

J Clin Diagn Res. 2013 Oct; 7(10): 2238–2240.

Topical Phenytoin Application in Grade I and II Diabetic Foot Ulcers: A Prospective Study

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Decubitus Ulcers; Venous Stasis and Diabetic Ulcers; Traumatic Wounds; Skin Autograft Donor Sites; and BurnsPhenytoin has been used topically to speed the healing of decubitus ulcers, pressure sores, venous stasis and diabetic ulcers, traumatic wounds, skin autograft donor sites, and burns. Ketoprofen may be used to control inflammation and pain, lidocaine provides topical anesthesia, and pentoxifylline may improve microcirculation at the wound margins and promote healing of the injured area. Misoprostol, a prostaglandin analog, is often included in wound care formulations to promote healing. Debridement of necrotic eschar with 40% urea paste may also speed healing. Medications which improve capillary blood flow can be added to a compounded medication to enhance circulation at the wound margins and promote healing of the injured area.
Topical Phenytoin for Wound HealingThe stimulatory effect of orally administered phenytoin on gingival tissue prompted its assessment in wound healing. Phenytoin may promote wound healing by a number of mechanisms, including stimulation of fibroblast proliferation, facilitation of collagen deposition, glucocorticoid antagonism, and antibacterial activity. Phenytoin has been used topically in the healing of pressure sores, venous stasis and diabetic ulcers, traumatic wounds, skin autograft donor sites, and burns.

Rhodes et al compared the healing of stage II decubitus ulcers with topically applied phenytoin and two other standard topical treatment procedures in 47 patients in a long-term care setting. Ulcers were examined for the presence of healthy granulation tissue, reduction in surface dimensions, and time to healing. Topical phenytoin therapy resulted in a shorter time to complete healing and formation of granulation tissue when compared with DuoDerm dressings or triple antibiotic ointment applications. The mean time to healing in the phenytoin group was 35.3 +/- 14.3 days compared with 51.8 +/- 19.6 and 53.8 +/- 8.5 days for the DuoDerm and triple antibiotic ointment groups, respectively. Healthy granulation tissue in the phenytoin group appeared within 2 to 7 days in all subjects, compared to 6 to 21 days in the standard treatment groups. The phenytoin-treated group showed no detectable serum phenytoin concentrations.

Anstead et al. described a patient with a massive grade IV pressure ulcer that was unresponsive to conventional treatment, yet responded rapidly to treatment with topical phenytoin. Song and Cheng reported phenytoin improved wound breaking strength in normal and radiation-impaired wounds. The results of their study indicated that topical phenytoin accelerated normal and irradiation-impaired wound healing by increasing the number of wound macrophages and improving the macrophage function. Pendse et al evaluated the effectiveness of topical phenytoin in healing chronic skin ulcers in a controlled trial of 75 inpatients. At the end of the fourth week, 29 of 40 phenytoin-treated ulcers had healed completely versus 10 of 35 controls. They concluded: “topical phenytoin appears to be an effective, inexpensive, and widely available therapeutic agent in wound healing.”

The effectiveness of topical phenytoin as a wound healing agent was compared with that of OpSite and a conventional topical antibiotic dressing (Soframycin) in a controlled study of 60 patients with partial-thickness skin autograft donor sites on the lower extremities. Mean pain scores were lower and mean time to complete healing (complete epithelialization) was best in the phenytoin-treated group (6.2 +/- 1.6 days). Topical phenytoin compared very favorably with, and in some aspects was superior to, occlusive dressings.

The efficacy of topical phenytoin in the treatment of diabetic foot ulcers was evaluated in a controlled inpatient study. Fifty patients were treated with topical phenytoin, and 50 patients received dry sterile occlusive dressings. Both groups improved, but the ulcers treated with topical phenytoin healed more rapidly. Mean time to complete healing was 21 days with phenytoin and 45 days with control.

No study reported any significant adverse effects secondary to topical phenytoin therapy.

Ann Pharmacother 2001 Jun;35(6):675-81

Topical phenytoin treatment of stage II decubitus ulcers in the elderly.

Click here to access the PubMed abstract of this article.

Biochem Pharmacol 1999 May 15;57(10):1085-94

Role of phenytoin in wound healing–a wound pharmacology perspective.

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Ann Pharmacother 1996 Jul-Aug;30(7-8):768-75

Phenytoin in wound healing.

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Int J Dermatol 1993 Mar;32(3):214-7

Topical phenytoin in wound healing.

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Chung Hua I Hsueh Tsa Chih 1997 Jan;77(1):54-7

[The effect of systemic and local irradiation on wound macrophages and the repair promoting action of phenytoin sodium]

Click here to access the PubMed abstract of this article.

Diabetes Care 1991 Oct;14(10):909-11

Topical phenytoin in diabetic foot ulcers.

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Benzoyl Peroxide for Treatment of Decubitus UlcersBenzoyl peroxide is a powerful oxidizing agent with broad spectrum germicidal activity and good liposolubility. Therefore, it may represent a good agent for prevention of wound infection in areas with high density of sebaceous glands. Topical treatment of pressure sore with 20% benzoyl peroxide in O/W emulsion yielded very satisfactory results. In another study, 10% benzoyl peroxide gel was used prophylactically once a day for 7 days before surgery. The researchers concluded that topical benzoyl peroxide is an efficacious, harmless, and inexpensive agent for prevention of wound infections in seborrheic regions.

Med Cutan Ibero Lat Am 1988;16(5):427-9

[Benzoyl peroxide in the treatment of decubitus ulcers].

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J Dermatol Surg Oncol 1994 Aug;20(8):538-40

Utility of topical benzoyl peroxide for prevention of surgical skin wound infection.

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Miscellaneous

Arch Dermatol. 2001 Oct;137(10):1288-90

Debridement of necrotic eschar with 40% urea paste speeds healing of residual limbs and avoids further surgery.

PMID: 11594851 No Abstract Available.

Odor from malignant cutaneous wounds, ulcerated tumors, some pressure ulcers, and fungating tumors can cause great distress and embarrassment for patients. Topical metronidazole is one medication that has been used to eliminate this odor, greatly improving the patient’s quality of life. Exudate and associated cellulitis may also decrease significantly with appropriate topical therapy.

Ostomy Wound Manage 1997 Jan-Feb;43(1):56-60, 62, 64-6

Malignant Cutaneous Wounds: a Management Protocol

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Numerous topical preparations containing cholestyramine or sucralfate (creams, adhesive pastes, enemas, suppositories) have been used for their protectant properties or for treatment of a variety of dermatologic and mucosal problems, including oral and esophageal ulcers, peristomal and perineal excoriation, decubitus ulcers, and radiation-induced rectal and vaginal ulcerations, and second and third degree burns.

Ann Pharmacother 1996 Sep;30(9):954-6

Cholestyramine ointment to treat buttocks rash and anal excoriation in an infant.

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Dis Colon Rectum 1987 Feb;30(2):106-7

Cholestyramine ointment in the treatment of perianal skin irritation following ileoanal anastomosis.

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Clin Exp Dermatol. 2000 Nov;25(8):584-8

Topical sucralfate in the management of peristomal skin disease: an open study.

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Burns. 2001 Aug;27(5):465-9

Topical use of sucralfate cream in second and third degree burns.

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