Outcomes are tricky with alternative treatment
Know their impact before applying them
Through the ages, dozens of substances have been used to treat chronic wounds. Even now, some clinicians opt for old-time remedies whose effectiveness and safety are unproven in controlled clinical studies. In a review of alternative topical therapies used in wound care, Cecilia Rund, RN, CETN, a clinical nurse consultant with Smith & Nephew’s Wound Care Division in Baltimore, uncovered some interesting — and disturbing — results associated with topical wound treatments.1 Here are some of the treatments she found, along with the problems they cause.Honey
Hundreds of ancient Egyptian written records mention the use of honey to treat wounds, Rund says. Honey is composed of glucose, fructose, water, amino acids, and a number of other chemicals, including inhibine, an enzyme that breaks down into hydrogen peroxide (a disinfectant) and gluconolactone (a mild antibiotic). When honey is heated, another ingredient, propolis, provides an antimicrobial effect. Honey, Rund says, is therefore a natural antimicrobial agent.
Rund reports that in 1992, investigators tested the antimicrobial effect of honey in vitro by applying it to colonies of several different pathogens. In most cases, unprocessed honey inhibited the growth of all of the strains of bacteria used in the experiment.
Advocates of honey claim it helps debride wounds, reduces edema and maceration, and promotes granulation tissue formation and epithelialization.
Despite its potential as a wound-healing agent, however, honey raises some concerns, Rund says. Unprocessed raw honey is not sterile, for one thing. In addition, bees may carry pesticides and other contaminants that could find their way into the finished product. And as with all of the alternative topicals, controlled clinical studies have been sparse and insufficient to allow for sound conclusions.
Dilantin (phenytoin)
After the introduction of phenytoin as an antiseizure medication in the late 1930s, physicians noted that about one in five patients who took the drug developed gingival hyperplasia. Their curiosity about whether phenytoin could promote tissue growth in nonhealing wounds led to its limited use as a topical treatment. In one recent controlled trial, Rund says, 75 patients with chronic skin ulcers were treated with either topical phenytoin or saline dressings. The investigators reported a greater reduction in wound area and an earlier appearance of healthy granulation tissue in the phenytoin group than in the control group.
After treatment, half of the phenytoin group had negative tissue cultures, compared with only 7% of the control group. Complete wound healing occurred in 73% of the phenytoin group, compared with 28.5% of the control group.
Still, Rund stresses the need for additional controlled studies on phenytoin before it can be recommended as a topical wound-healing agent.
Aloe vera
Extracted from the interior of aloe vera plant leaves, aloe vera gel is thought to have moisturizing and therapeutic properties. Written evidence of aloe vera use on wounds has been found on Egyptian papyrus scrolls dating back more than 2,000 years, and it was mentioned in the Bible, Rund says.
An examination of one variety of aloe vera gel revealed that it comprised glucose, uric acid, salicylic acid, creatinine, alkaline phosphate, cholesterol, triglycerides, lactate, calcium, magnesium, zinc, sodium, potassium, and chloride.
Results of clinical trials in which aloe vera was used to treat wounds have been mixed, Rund says. Some investigators reported accelerated wound healing without scarring, while others noted significant wound healing delays among patients treated with aloe vera. The disparity of the results makes further research imperative, she says.
Antacids
Antacids cause a definite drying affect when applied to the skin, and they appear to absorb some of the drainage from open wounds, creating a somewhat dry surface, says Rund. The practice of using antacids around wounds has occurred primarily in ostomy care, where dry surfaces are needed to attach ostomy appliances, Rund explains. However, she adds, there is no pharmacologic indication for the application of antacids in open wounds. In addition, the drying effect of these agents makes them of questionable value at time when moist wound healing is the standard of care.
Gentian violet
Gentian violet is a dye used to stain tissue and mark skin. At one time it was used in wound treatment because of its astringent affect and, possibly, a degree of antimicrobial activity. However, Rund says that the chemical has been found to be carcinogenic when used in open wound tissue and on mucous membranes, and therefore it should never be used as a topical treatment.
A slew of other substances have undergone scrutiny as topical treatments for open wounds. Some of them are still in use, even though little hard evidence is available to support their efficacy or safety. These include animal fats and vegetable oils, benzoyl peroxide, betadine and sugar mixtures, gauzes impregnated with scarlet red, petrolatum, insulin, mercurochrome, steroids, and vinegar, Rund says.
Rund insists that health care providers "cease the indiscriminate use of topicals" based on a few positive anecdotal reports. Some of these alternatives may indeed be found to provide benefits to wound patients. But until there is a firm basis of scientific evidence, the use of an unproved remedy may not only be ineffective, it may be dangerous.
Reference
1. Rund CR. "Alternative Topical Therapies for Wound Care." In: Krasner
D, Kane D. Chronic Wound Care. 2nd ed. Wayne, Penn: Health Management
Publications; 1997:219-226.
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