Moist Wound Healing With Limited Resources

Dear Readers:      How would you dress a wound if you were in a setting without “modern” wound care? A MEDLINE search found evidence of moist wound healing (MWH) alternatives from countries with limited resources that reduce pain, healing time, or costs of care when compared to gauze or other alternatives. Though more sufficient randomized controlled trials (RCTs) are needed, this evidence merits consideration. Moist wound healing alternatives explored in controlled clinical studies include banana leaves,¹ boiled potato peels,¹ honey,² plastic food wrap,³ or amniotic membranes.² Practitioners in settings with reimbursement challenges or limited access to “modern” dressings may wish to test this evidence for MWH alternatives that improve both patient comfort and healing time in their own settings. The discovery of MWH has stimulated wound care innovation for more than 200 years.⁴ This Evidence Corner highlights the innovative contributions of clinical practitioners who have responded to challenging resource limitations by deriving their own evidence-based MWH modalities to improve patient outcomes.      Laura Bolton, PhD, FAPWCA      Adjunct Associate Professor      Department of Surgery, UMDNJ      WOUNDS Editorial Advisory Board Member and Department Editor

Banana Leaf Dressing or Vaseline Gauze?

     Reference: Gore MA, Akolekar D. Banana leaf dressing for skin graft donor areas. Burns. 2003;29(5):483–486.      Rationale: Petroleum jelly or Vaseline® impregnated gauze (VG) is the most commonly used dressing for skin graft donor sites, but it often adheres to wounds causing patients significant pain and anxiety. Banana leaves are large, economical, nonadherent, and plentiful as a wound dressing option.      Objective: Conduct a controlled trial to compare efficacy of banana leaf dressings (BLD) with VG dressing for use on skin graft donor sites.      Methods: A prospective, controlled, same-patient controlled study at a Malaysian Hospital compared split-thickness skin graft donor site healing, ease of use, and pain using BLD or VG. Similar fresh donor site areas on each of the 30 patients were dressed with a BLD or VG and left in place for up to 8 days after surgery. The BLD consisted of a banana leaf pasted to bandage cloth with flour paste that was dried for 24 hours, rolled, packed into a paper bag, and autoclaved. Patients were blinded to the dressing on each site until the first dressing change, when a 0–10 visual analogue scale (VAS) was used to record patient-reported pain before and during dressing change. The VAS was also used to record clinicians’ ratings of ease of dressing removal. Qualified professionals recorded the day when BLD- and VG-dressed skin graft donor site areas were completely epithelized.      Results: Donor site areas dressed with BLD epithelized completely in a mean of 8.67 days compared to 11.73 days in VG-dressed areas. Patients reported less pain with the BLD (1.1) in place than VG (9.47), and on BLD removal (0.97) than VG (6.9). Ease of BLD dressing removal was rated 1.1 compared to 9.53 with VG. All differences were statistically significant (P Honey on Burn Wounds      Reference: Wijesinghe M, Weatherall M, Perrin K, Beasley R. Honey in the treatment of burns: a systematic review and meta-analysis of its efficacy. N Z Med J. 2009;122(1295):47–60.      Rationale: Despite a long tradition of honey use in treating burns and other wounds, it is not well recognized as mainstream medical care.      Objective: Conduct a systematic review and meta-analysis of RCTs that compared the efficacy of honey with another burn wound dressing.      Methods: MEDLINE, EMBASE, CINAHL, and Cochrane databases were searched through February 2007 for the key words “honey” or “burns.” Relevant derivative references were examined. RCT quality was assessed using the maximum 5-point Jadad score based on adequacy of randomization, blinding, and follow-up. Non-burn, preclinical, or non-randomized studies were excluded. The primary outcome was the percent of subjects with burn wounds dressed with honey or with silver sulfadiazine whose wounds healed at 15 days post burn. Secondary outcomes were the percentage of burns healed at 21 days, converting to sterile swabs at 7 days, and presence of contractures or hypergranulation tissue. Studies meeting homogeneity requirements were tested for inverse-variance-weighted odds ratios for efficacy differences. Publication bias was absent based on Forest plots.      Results: Of 55 studies on honey, eight RCTs—each with Jadad score 1—on 624 subjects with either partial-thickness or superficial Clinical Perspective      While there is a need for more studies of a higher quality; banana leaf, boiled potato peel, and honey are emerging in regions with limited resources as alternatives or additions to gauze dressings to improve wound healing or pain outcomes. In addition to the work described above, Gore et al¹ reported similar comfort and healing results for banana leaf dressings and boiled potato peels, although banana leaves cost less. Honey was reported as an equally safe and effective alternative to povidone iodine as a dressing for Wagner Grade II diabetic foot ulcers⁵ and supported faster partial-thickness burn healing than boiled potato peels⁶ or fresh amniotic membrane.⁷      Using days to epithelization as a valid, reliable healing outcome for acute wounds, the RCTs described and cited above generate hypotheses for further research or testing in practice: A) partial-thickness burn healing may be faster with less pain using a banana leaf or honey than potato peels or amniotic membrane, and B) split-thickness skin graft donor sites may heal faster with less pain if dressed with banana peels compared to petrolatum-impregnated gauze.      This research reinforces earlier findings that petrolatum gauze is not MWH.4 Water vapor transmission rate through the dressing 1 day after application (WVTR) of less than 35 g/m2/h provides MWH healing benefits in most acute and chronic wounds.⁴ If one is unable to measure WVTR then patient pain, difficult dressing removal, or wound reinjury will alert practitioners to provide a moister (lower WVTR) environment. Higher WVTR dressings, such as impregnated gauze, can provide MWH if heroically re-moistened every 4 hours⁸ or during the early, highly exuding phase of wound repair, but might delay healing in most chronic or acute wounds,^4,9 and increase pain⁹ or the incidence of clinical infections¹⁰ compared to hydrocolloid, film, or foam dressings.      For patients’ sake, it is time to stop calling impregnated gauze “MWH” and using it as a “MWH” control in otherwise well-conducted RCTs. ERRATUM: In the January article by Solway et al, (Microbial Cellulose Wound Dressing in the Treatment of Skin Tears in the Frail Elderly), the photo used in “A” should have been in “C” and vice versa (Figure 1, page 18). The editors sincerely regret and apologize for the error.