Cristina Quinteiro
Cristina Quinteiro, Nurse, Santa Casa da Misericórdia Health Unit of Montemor-o-Velho, Portugal  

Introduction

Aging is associated with an increased likelihood of co-morbidity and other factors that are known to delay wound healing (Gosain and DiPetro, 2004; Bonifant and Holloway, 2019). Additionally, aging itself is a risk factor for chronicity as a consequence of changes in the epidermis and dermis. The dermo-epidermal junction becomes flattened, and elasticity of the skin reduces due to morphological changes in collagen and elastin, which predispose the tissue to shear and friction forces (Gosain and DiPetro, 2004; Bonifant and Holloway, 2019). Moreover, the microcirculation and lymphatic drainage of the dermis is decreased with age, and this affects its ability to adapt to injury and clear the wound of pathogens thus inhibiting wound contraction (Gosain and DiPetro, 2004). Older patients, frequently described in the literature as aged 65 years or above, often have multiple comorbidities, such as poor circulation, poor nutritional and hydration status, and the presence of diseases such as diabetes that affect general health (Leung et al, 2018; Wilkinson and Hardman, 2020). These comorbidities can negatively influence the wound healing trajectory, making vigilance during wound management crucial in this older population (Gosain and DiPetro, 2004; Bonifant and Holloway, 2019). Conventional therapies can be unsuccessful in this patient group, with wounds becoming non-healing. Globally, chronicity presents a major healthcare and economic burden, raising the need for emerging alternative treatments (Sen, 2019; Wilkinson and Hardman, 2020).


Honey has been used since ancient Egyptian times, but its use declined with the discovery of antibiotics (Nair et al, 2020; Smaropoulos and Cremers, 2020a;2021). With the advent of antibiotic resistance, however, honey regained some popularity (Nair et al, 2020; Smaropoulos and Cremers, 2020a,2021). Medical grade honey (MGH) has both antimicrobial and pro-healing activities and can safely be used in wound care (Combarros-Fuertes, 2020; Hermanns et al, 2020; Nair et al, 2020; Smaropoulos and Cremers, 2020a;b;2021). The low pH, high osmolarity, and release of low amounts of hydrogen peroxide, in addition to the presence of several antimicrobial molecules make MGH a strong antimicrobial agent (Combarros-Fuertes, 2020; Nair et al, 2020; Pleeging et al, 2020; Smaropoulos and Cremers, 2020a;b). Since the antimicrobial activity is based on these multiple mechanisms, MGH is effective against a broad range of microorganisms, including antibiotic resistant strains, with no resistance towards MGH reported (Cremers et al, 2020; Nair et al, 2020; Pleeging et al, 2020). In addition, topical application of MGH forms a physical barrier to the environment, preventing new pathogens from invading (Smaropoulos and Cremers, 2019; Smaropoulos and Cremers, 2020a;2021). MGH has anti-inflammatory and anti-oxidative properties and enhances healing by providing a moist wound environment and stimulating debridement, angiogenesis and reepithelialisation (Molan, 2002; Mandal and Mandal, 2011; Smaropoulos and Cremers, 2019; Smaropoulos and Cremers, 2020b).

MGH has been used safely and effectively in a wide variety of wounds, such as traumatic injuries, burns, pressure ulcers, lacerations, diabetic foot ulcers, and full and partial-thickness wounds, even in the presence of infection with multi-resistant bacteria or biofilms and in complex, older patients (Combarros-Fuertes et al, 2020; Nairs et al, 2020; Pleeging et al, 2020; Smaropoulos and Cremers, 2020a;2021) and in older patients (Zeleníkováa and Vyhlídalováb, 2019). Recently, a systematic review of 30 randomized controlled studies concluded that honey decreased healing time and was cost-effective (Yilmaz and Aygin, 2020).

This article will now detail the successful use of MGH to achieve wound closure in an older patient with two leg ulcers, despite the presence of multiple barriers to healing, including advanced age and multiple co-morbidities.

 

Methods

Patient information

A 91-year-old female presented to the Santa Casa da Misericórdia Health Unit of Montemor-o-Velho for consultation. The patient, who lived with her daughter, son-in-law and grand-daughters, had difficulties walking and used crutches to aid mobility. Despite this, she fell at home, and obtained two wounds to her right lower leg. The patient had several known barriers to wound healing, in addition to advanced age, including a history of heart and kidney failure, stroke, diabetes, venous insufficiency of the lower limbs, right hip prosthesis, and lumbar hernia surgery. She was taking 12 medications to manage these conditions.

Assessment

Upon consultation, the dimensions of the wound on the medial side of the leg were 6.0cm x 5.5cm, while the wound on the posterior side was 3.0cm x 5.0cm. Both wounds were superficial and had irregular edges. Signs of inflammation were present, including redness, heat, pain, and local oedema. It was decided to treat the wounds with honey-based wound care products from L-Mesitran (Theo Manufacturing B.V., Maastricht, the Netherlands) based on previous successful outcomes in similar patients.

For the first five days, L-Mesitran Ointment (containing 48% MGH, hypoallergenic lanolin, vitamin C, vitamin E, zinc oxide and essential oils) was used in combination with L-Mesitran Tulle (tulle impregnated with L-Mesitran Soft containing 40% MGH, propylene glycol, PEG4000, and vitamins C and E) on both wounds. This was followed by L-Mesitran Soft in combination with L-Mesitran Tulle for the remaining period, to ensure full contact was made with the wound bed and to promote debridement. Owing to the presence of venous insufficiency in the lower limbs, compression hosiery was also applied.

Treatment

For the first three weeks following injury and before starting L-Mesitran treatment, the patient was treated with several other wound care products both in another health institution and at home. In the first week post-injury, the patient consulted her local health care centre. The wounds were disinfected with saline, and povidone iodine dermal solution and iodine ointment applied. The wound was then covered with Vaseline. This is not considered best practice, but unfortunately is still often used. Povidone iodine is an antiseptic but does not aid healing since it can dry out the wound bed and is cytotoxic to fragile new tissue growth, limiting tissue repair. As no progress was made, the general practitioner prescribed Clavamox 500mg (amoxicillin and clavulanate) for eight days and daily nurse-led wound care for one week. Although not best practice, antibiotic therapy is often prescribed by general practitioners. The wounds still failed to progress, with the wound beds covered in a dense yellowish fibrin layer. The family decided to change the treatment regimen and manage at home. Saline washing, dermal povidone iodine, povidone ointment and Bepanthen Plus cream were subsequently used on alternating days for one week.

During this three-week period, signs of inflammation remained, including redness, heat, pain, and local oedema in the leg and the foot of the right lower limb. Following three weeks of unsuccessful treatment, the patient was referred to the hospital for consultation. it was decided to treat the wounds topically with L-Mesitran monotherapy, based on previous successes in similar types of lesions and patients. The wound areas were cleaned using normal saline solution. The medial wound was treated with L-Mesitran Ointment in combination with L-Mesitran Tulle for five days and the posterior wound for nine days. Thereafter, L-Mesitran Soft in combination with L-Mesitran Tulle was used until complete wound closure occurred. Simple sterile gauze was used as a secondary dressing, fixed with adhesive tape and compression hosiery was applied to manage venous insufficiency. Wounds were treated on an outpatient basis, and strict wound care guidelines were provided to the caregiver. The patient was appointed for weekly consultation. The patient’s family cared for her and there were no issues with adherence to wound care treatment.

 

Results and discussion

While several commonly used regimens were ineffective for weeks, a clear wound progression was observed after the first days of L-Mesitran treatment. Although previous treatments were suboptimal, this is often a problem when patients are treated by clinicians lacking current wound care knowledge, or are cared for by family and friends. It is advisable to seek specialist input in any case where a wound has failed to progress two weeks post injury. This particularly applies to patients with known barriers to healing, such as co-morbidities and advanced age, as described in this case. Treatment often focuses on antiseptic properties to clean the wound; however, these products typically do not promote healing. Examples of such antimicrobial treatments include povidone iodine, antibiotics, and silver dressings. Other treatments only keep wounds moist and do not have antimicrobial activity, such as Vaseline and Bepanthen, as used in this case. However, this is not considered best practice and monotherapy with a product such as MGH that cleans the wound while stimulating healing is preferable.

The wound healing progression in time during L-Mesitran treatment
Figure 1. The wound healing progression in time during L-Mesitran treatment
​Upon consultation on Day 0 (Figure 1), the wounds were covered with yellow fibrin, and the medial wound measured 6.0cm x 5.5cm and the posterior wound 3.0cm x 5.0cm (Figure 1; day 0). L-Mesitran is known to promote healing by multiple mechanisms. MGH creates a moist wound environment which aids faster healing, compared to dry and wet wounds that may obstruct the healing process through desiccation and maceration, respectively (Smaropolous and Cremers, 2020b;2021). The osmotic activity together with the low pH stimulate autolytic debridement, which is clearly depicted in the presented case (Figure 1; day 5). At this timepoint, the yellow fibrin layer has been debrided. The wounds had decreased in size to 4.8cm x 3.7cm (medial) and 3.5cm x 3.0cm (posterior). After nine days of L-Mesitran treatment, the wound healing further progressed, and wounds became more superficial (Figure 1; day 9). MGH is known to stimulate angiogenesis (Smaropolous and Cremers, 2020b;2021), which can be observed as a more red and vital colour of the wound tissue (Figure 1; day 9). These new blood vessels deliver oxygen and nutrients to the wound bed. In addition, the external topically applied MGH also provides important nutrients to the wound, which further stimulates cell proliferation and cell migration. These processes are visualised by the formation of granulation tissue in the wound bed and by the reepithelialisation occurring from the edges of the wound. The patient confirmed that she did not experience any pain or discomfort during treatment. On day 17, the wounds were completely healed (Figure 1; day 17). Although this paper describes only one case, similar enhanced wound progression has been observed in other patients treated with MGH (Zeleníkováa and Vyhlídalováb, 2019; Yilmaz and Aygin, 2020). Adjuvant therapies may focus on stimulation of blood flow by using compression therapy or optimize other factors that influence healing, including nutritional and hydration status, and medication. These may also have influenced the healing trajectory.


Conclusion

Older people with wounds and multiple barriers to healing present a management challenge. In these patients, healing should not be taken for granted, and early, effective treatment initiated to avoid the development of chronicity which is costly for both the healthcare system and patient. Treatment modalities that can optimise the wound healing environment and remove local barriers to healing can help to achieve timely wound closure. L-Mesitran is an MGH-based wound care product that possesses antimicrobial activity and a wide range of pro-healing properties. Moreover, recent literature concluded that honey decreased healing time and was cost-effective (Zeleníkováa and Vyhlídalováb,2019; Yilmaz and Aygin, 2020). The case presented here demonstrates the use of MGH in achieving wound closure in a previously non-healing patient.

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