Monika, Varechová is Nurse and Head of Wound Care Team, Department of LDN Město Albrechtice, SZZ Krnov, Czech Republic.

INTRODUCTION


Palliative care provides holistic, person-centred care by managing symptoms, preventing suffering by treating pain and other problems, and providing physical, psychosocial and spiritual support (Chaplin, 2004; Grocott and Gray, 2010; Dale and Emmons, 2014). Palliative wound care should focus upon relieving wound-related suffering and improving the quality of life of patients and their families when facing life-threatening illness (Grocott and Gray, 2010; Dale and Emmons, 2014). Patients requiring palliative wound care can present with any type of wound, particularly those common in older people, such as venous leg ulcers (VLUs), pressure ulcers, diabetic foot ulcers and malignant wounds (Chaplin, 2004; Agale, 2013).
 
Aging affects skin properties such as the thickness and elasticity of the skin and can affect wound repair processes (Farage et al, 2013; Sgonc and Gruber, 2013). In addition, aging is associated with comorbidities that can also compromise healing, such as diabetes, atherosclerosis, heart failure, blood pressure problems, venous insufficiency, and immune system problems (Jaul et al, 2018). Because of these comorbidities, older people have a greater risk of developing chronic non-healing wounds (Sgonc and Gruber, 2013).

A chronic leg ulcer is defined as a defect in the skin below the level of the knee persisting for more than six weeks, showing no tendency to heal after three months of appropriate treatment or is still not fully healed at 12 months (Agale, 2013). Approximately one per cent of the adult population suffer from leg ulcers, and the incidence of active leg ulceration increases with age; the prevalence increases from 3.6% among those aged 65 years and above to 5% in those aged over 80 years (Agale, 2013).

 
The majority of leg ulcers are venous (45–60%) in origin, with 10–20% caused by arterial disease, 15–25% as a result of underlying diabetic pathology or a combination of these well-known etiological factors (10–15%). Less frequently, underlying disorders may exist, such as malignancy; vasculitis; hematological, infectious and metabolic diseases, and chemical and physical anomalies (Mekkes et al, 2003). Treatment of leg ulcers often involves a multidisciplinary approach to diagnose the underlying problem(s) and often is a long-term and costly process that can last for months or even years (Frykberg and Banks, 2015).

In an aging population there is an increased prevalence of cancer, diabetes and other chronic morbidities, coupled with an increased prevalence of wounds, inevitably leading to an increased need for palliative wound care. In palliative patients, the healing of chronic wounds may not be possible, so improving quality of life through symptom management is often the goal of wound care, focusing on addressing specific problems, including infection, pain, wound odour, exudate, and quality of life (Mekkes et al, 2003; Kelechi et al, 2017).
 

Medical grade honey (MGH)


Medical grade honey (MGH) may be a promising therapy for palliative patients with chronic wounds as it has broad-spectrum antimicrobial activity to prevent infection, and is known to create a moist wound environment that promotes healing (Smaropolous and Cremers, 2019; Nair et al, 2020; Pleeging et al, 2020). MGH also has strong osmotic activity that stimulates the outflow of wound exudate, and creates a switch in the microenvironment of the wound through its low pH and anti-inflammatory and anti-oxidative activities (Smaropolous and Cremers, 2020a,b,c). Angiogenesis is stimulated and MGH is an important nutrient source for newly formed granulation and epithelial tissue (Smaropolous and Cremers, 2019; 2020a).

Here, we present the case of a complex, older palliative patient with bilateral chronic leg ulcers and multiple comorbidities who was successfully treated with MGH.

Case report

Patient information


A 79-year-old male was admitted with large bilateral VLUs for evaluation by the wound care specialist. The patient had large cell lung cancer for which he was receiving palliative care and multiple comorbidities associated with older age, including venous insufficiency, phlebitis and thrombophlebitis of the lower legs, and hypoalbuminemia. Upon consultation, both wounds were heavily colonized, and a strong malodour was quickly penetrating the room. The patient stated that the odour negatively impacted on his quality of life and social interaction with other people, e.g. he had trouble traveling by public transport because of it. The patient also reported persistent wound-related pain and the score on the visual analogue scale for pain was between two and four for a long period (a score of 0 indicates no pain and 10 being the highest level imaginable). The patient received analgesics three times a day and additional analgesics when required for wound-related pain. In addition to this, regular medications such as vitamins, diuretics, anti-thrombotics and vasoprotectives were administered to the patient from the beginning of hospitalization to optimize the medical management of underlying conditions. Comprehensive nursing care was also given that focused on pain control, rehabilitation, self-care and self-sufficiency, and nutritional status and hydration to optimize factors that promote wound healing and to improve patient’s general health and quality of life.

Wound care treatment


The leg ulcers had previously been treated for approximately three years on an outpatient basis without success. During this period, home care was provided and treatment was changed several times. The patient’s overall health presented several barriers to healing, and in addition, patient compliance may not have been optimal with some elements of the treatment, such as regularly wearing compression.

Following presentation, the wounds were monitored daily and cleaned with saline solution and gauze. In order to eliminate colonization of the wounds, mechanical debridement with a saline-wetted gauze was performed and wounds were subsequently treated with a hydrogel and zinc paste for the first week. At the time of treatment, this was the first-line technique used for wound debridement. Retrospectively and following the use of MGH-based wound care products, L-Mesitran (Theo Manufacturing BV, Maastricht, the Netherlands) is now used at this stage for its ability to stimulate autolytic debridement (Nair et al, 2020; Pleeging et al, 2020; Smaropolous and Cremers, 2020c).

From the second week onwards, the wounds were treated with L-Mesitran Net (a sterile, open-weave mesh dressing containing 20% medical grade honey [MGH]) in combination with L-Mesitran Ointment (containing 48% MGH, hypoallergenic lanolin, vitamin C, vitamin E, zinc oxide and essential oils). Both products contain MGH, which possesses wide-spectrum antimicrobial activity and promotes wound healing. L-Mesitran wound dressings were changed twice a week. After the wounds became more superficial, wound treatment was changed to L-Mesitran Soft (containing 40% MGH, propylene glycol, PEG4000, and vitamin C and E), a gel that was applied topically 2–3 times a week. Compression therapy was also used to treat the underlying aetiology.

Results and discussion


Upon presentation the wounds were heavily covered with slough (Figure 1, day 0).
Figure 1. Day 0.

For the first week, the wounds were treated with zinc paste and hydrogel and mechanical debridement was performed to remove the sloughy tissue. These treatments resulted in a decrease of slough (Figure 2, day 8).
Figure 2. Day 8.

From day 8, treatment with L-Mesitran Net in combination with L-Mesitran Ointment was started. L-Mesitran has antimicrobial activity and promotes autolytic debridement, which resulted in cleaning of the wound (Figure 3, day 14).
Figure 3. Day 14.

Compared to the initial presentation of the wounds, by day 14 of treatment they looked more vital and the malodour was completely absent. Wound odour is produced by bacteria metabolizing serum, tissue proteins, and dead cells that result in the formation of amino acids and an unpleasant smell attributed to the release of ammonia, amines, and sulphur compounds (Yapucu Gunes and Eser, 2007; Alam et al, 2014). The glucose in MGH acts as an alternative substrate for these bacteria and is converted into odourless lactic acid (Yapucu Gunes and Eser, 2007; Alam et al, 2014; Nair et al, 2020). This decrease in malodour is notable after a couple of days of MGH treatment (Nair et al, 2020; Pleeging et al, 2020).

By day 53 of treatment, both wounds had halved in size (Figure 4, day 53).
Figure 4. Day 53.
 
MGH enhances cell proliferation and migration, noted in the new granulation tissue and epithelialization seen around the edges of the wound. Red vascularized tissue is also present. MGH is known to promote angiogenesis, which is important for supplying oxygen and nutrients from the body to the wound bed. As the wounds were more superficial, treatment was changed to L-Mesitran Soft at day 81 of treatment. Wound progression was further improved (Figure 5, day 95) and the wounds became even smaller and more superficial.
Figure 5. Day 95.
 
After 123 days (Figure 6), the wounds were completely healed without any complications.
Figure 6. Day 123.

Despite the potential for chronic wounds to impact on pain sensitization, the patient was able to reduce analgesia during the treatment as healing occurred. No pain or any other negative side effects from the treatment were observed and confirmed by the patient. The dressing changes were pain free and the presence of MGH prevented the incorporation of the dressing into the wound bed and subsequent re-opening of freshly formed granulation tissue (Nair et al, 2020; Smaropolous and Cremers, 2020b). Moreover, the state of well-being and quality of life was strongly improved as the wound progressed towards healing. The patient, who had had the wounds for three years, found the progress very encouraging. He stated a preference for L-Mesitran products as he was convinced by the activity and by seeing the clear progression himself.

MGH locally affects most aspects of wound healing and therefore can serve as a powerful and local wound care treatment, however systemic factors may still play a role and should be part of the overall wound care treatment. In this case, optimizing other systemic factors, such as nutrition and hydratation status also contributed to the positive outcome.

Conclusion


The presented case report evidently shows that the use of L-Mesitran products as part of a holistic management approach switched the chronic leg ulcers from stagnation into healing despite the complex nature of the wounds in this palliative patient. The L-Mesitran products were easy to use and cost effective and did not result in any pain or discomfort. The patient‘s quality of life was improved through symptom control, including the elimination of odour and pain. As the patient was terminally ill, healing was considered unlikely, so achieving it was unexpected. The patient and treating physicians were extremely satisfied with the outcome, leading to the conclusion that L-Mesitran products may be worth considering in similarly complex palliative patients with chronic wounds.

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