MAY 2011

CLINICAL MANAGEMENT extra Wound Bed Preparation and Complementary and

CME CATEGORY 1 ANCC 1 Credit 2.8 Contact Hours

Karen Laforet, MClSc, BA, RN, IIWCC & Associate Director of Nursing & Calea Home Care & Mississauga, Ontario, Canada & Associate Professor & School of Physical Therapy & University of Western Ontario, London, Ontario, Canada Gail M. Woodbury, PhD, MSc, BScPT, BSc & Assistant Professor & School of Physical Therapy & Adjunct Associate Professor & Department of and Biostatistics & University of Western Ontario, London, Ontario, Canada R. Gary Sibbald, BSc, MD, MEd, FRCPC (Med Derm), MACP, FAAD, MAPWCA & Professor Public and Medicine & University of Toronto & Toronto, Ontario, Canada & Director of Toronto Regional Wound Clinics & Director of the International Interprofessional Wound Care Course & University of Toronto & President of the World Union of Wound Healing Societies

Ms Laforet has disclosed that she is a consultant/advisor to Hollister Wound Care; is/was a member of the speaker’s bureau for 3M-Canada; and is/was a stock shareholder for 3M United States. Dr Woodbury has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity. Dr Sibbald has disclosed that he is/was a recipient of grant/research funding from 3M, BSN Medical, Coloplast, Gaymar, KCI, Johnson & Johnson (Systagenix), and Mo¨ lnlycke; is/was a consultant/advisor to 3M, BSN Medical, Coloplast, Covidien, Gaymar, KCI, Johnson & Johnson (Systagenix), Mo¨ lnlycke, and the Registered Nurses Association of Ontario; is/was a member of the speaker’s bureau for 3M, BSN Medical, Coloplast, Gaymar, KCI, Johnson & Johnson (Systagenix), and Mo¨ lnlycke. The authors disclose they will discuss off-label uses for complementary alternative medicine regarding Aloe vera gel; Calendula officinalis (Marigold); Essential oils: Chamomile, Lavender, Ti Tree/Tea Tree; Honey (propolis); Hypericum (St. John’s Wort); and Quercus alba (white oak bark).

All staff, including spouses/partners (if any), in a position to control the content of this CME activity have disclosed that they have no financial relationships with, or financial interests in, any commercial companies pertaining to this educational activity.

To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least 14 of the 19 questions correctly.

This continuing educational activity will expire for physicians on May 31, 2012.

PURPOSE: To enhance the learner’s competence in counseling patients about complementary and alternative medicine (CAM) modalities for wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to: 1. Use knowledge of CAM theory and treatment modalities in educating patients. 2. Apply CAM treatment information to patient scenarios related to wound care.

ADVANCES IN SKIN & WOUND CARE & VOL. 24 NO. 5 226 WWW.WOUNDCAREJOURNAL.COM Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. ABSTRACT pret how their unique role challenges current evidence-based practice. Burgeoning patient interest in medicinal herbs makes it important for healthcare professionals to increase their awareness and CAM BACKGROUND knowledge. This review article provides data on the most When treating patients, the authors of this article and their commonly used topical plant extracts in North American wound clinical teams often will introduce the therapeutic double bind care practice. to empower the patient’s preconceived preference for local KEYWORDS: wound bed preparation, wound bed, complementary wound care. This technique consists of having a trial of the and alternative medicine, complementary medicine, alternative patient’s chosen local wound care for 4 weeks. If the wound medicine has the ability to heal, it will be 30% smaller by week 4, if 1 ADV SKIN WOUND CARE 2011;24:226-36; quiz 237-8. complete healing is expected by week 12. If the wound has not decreased in size, the other proposed treatment (usually a traditional treatment and not an alternative therapy) out- INTRODUCTION lined at the first visit and written in the chart is implemented. Interest in complementary and alternative medicine (CAM) The patient may even sign an informal consent to indicate this continues to growVboth for the public who are seeking ways is a negotiated contract where the healthcare practitioner to improve or maintain health and for healthcare professionals has accepted the patient’s viewpoint first and only com- who are part of a patient’s circle of care. The public’s interest mitted to another option if the preset benchmarks have not in CAM requires healthcare professionals to become aware of been met. This is a way of addressing patient-centered con- CAM’s health benefits and potential risks to provide safe and cerns but also gaining therapeutic experience with potentially efficacious care. useful complementary therapies that are not part of current For fear of disapproval, patients are often reluctant to re- wound care formularies. Toxic therapies with a greater poten- veal to their healthcare practitioner that they use alternative tial to cause harm should not be used with the therapeutic medicines. It is therefore important to establish a comfortable double-bind methodology. environment for patients to disclose their complementary and Another method to garner therapeutic trust is to proactively alternative medicine options. seek out information from the client on initial assessment and The authors will discuss the responsible use of Aloe vera gel, during each client visit using a simplified questionnaire, ‘‘ask, Calendula officinalis (marigold), essential oils (chamomile, lav- advise, assist, arrange,’’ or the 4-A method2 (Table 1). The 4-A ender, ti tree), honey, Hypericum (St John’s wort), and Quercus method takes approximately 1 to 3 minutes to complete. The alba (white oak bark) based on the literature. A CAM wound bed healthcare practitioner’s willingness to address the individual preparation (WBP) paradigm is presented as an attempt to patient’s needs provides a forum to discuss safety concerns, in- develop an integrated approach for healthcare practitioners crease their knowledge of safe alternatives, and agree on local to follow. treatment options. By reading this article, healthcare practitioners will be better From a Western culture perspective, many of the comple- able to distinguish how various complementary therapies mentary and alternative medicine concepts are new. In a clinical may augment conventional wound care treatment and inter- situation where a healthcare provider is asked for an opinion

Table 1. CAM USAGEa

Ask About CAM use: ‘‘Have you used any form of CAM in the last 6 months’’ (or since you last visited the healthcare practitioner)? Assist Provide intervention if CAM use is contraindicated or toxic to treatment plan. Advise on safer options. Refer to known and respected sites and information sources. Advise Regarding importance of safe choices for CAM, work with your physician to integrate therapies for maximum benefit. Arrange Follow up if necessary. Refer to appropriate information sources. aModified from ‘‘Integrating Smoking Cessation Into Daily Nursing Practice; RNAO Best Practice Guidelines.’’2 Used with permission from RNAO.

WWW.WOUNDCAREJOURNAL.COM 227 ADVANCES IN SKIN & WOUND CARE & MAY 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. prior to a potential therapeutic trial, here are some online new immigrants locate in North America, traditional medical resources to consider: practices are retained and shared with friends and coworkers. & perform PubMed (http://www.ncbi.nlm.nih.gov/sites/entrez?db= The social media, Internet sites, and social and work-related pubmed) search for clinical inquiries, such as ‘‘studies with CAM networks are all information sources disseminating CAM use. agent X AND wound healing.’’ See Figure 1 and Table 2 for summaries of CAM information.38–52 & check Wikipedia free encyclopedia (http://www.wikipedia. org) for an overview of the substance in lay terminology and WHAT IS COMPLEMENTARY AND see sidebar ‘‘Resources for Additional CAM Information.’’ ALTERNATIVE MEDICINE? & use keyword phrase that includes the name of the CAM Complementary and alternative medicine is an umbrella term agent ‘‘AND toxicity’’ when using Internet search engines. used to describe healthcare-related therapies, practices, and In a more detailed search from a Western evidence-based products that are not considered part of conventional medicine. approach, clinicians would Complementary or integrative medicine describes treatments & search the literature, used in conjunction with conventional medicine. Alternative & select articles, medicine refers to therapies that are used in place of conventional & critically appraise the evidence, medicine.3 Healthcare professionals need to be aware that not all & interpret the results, and forms of CAM are practiced by regulated professionals. For & consider benefits and risk for applicability to practice. example, , herbology, and traditional Chinese For many of these topics, there are few or no studies to medicine are not currently regulated in most communities. analyze. Practice is based on expert opinion of potential ther- , massage therapy, , , and apeutic actions, and caution is recommended to avoid agents are often regulated by professional associations or with significant toxicities. The authors had difficulty following state/provincial health acts. this process for potential therapies to be included in this review. How often are the general public and healthcare professionals CHALLENGES FOR CAM RESEARCH using some form of CAM? The answer varies by sex, age, race, Evidence-based healthcare involves the synthesis of best evi- and ethnicity; however, it is estimated that up to 89% of pa- dence for a particular clinical problem. One of the challenges tients and more than half of all healthcare practitioners are using when seeking to validate CAM therapies within the evidence- some form of CAM.3–7 The demographics of individuals ac- based model is the denial of its core componentsVthat is, CAM cessing CAM include all age groups, cultures, and socioeconomic treatment based on individual signs and symptoms. For example, groups. These demographic characteristics have evolved from when a traditional Chinese medicine practitioner diagnoses a the 1993 study of Eisenberg et al8 that identified those most likely patient with , the diagnosis will be that the patient to use CAM were nonblack, college educated, and between the has ‘‘wind heat in the lungs’’ orVmore specificallyVdeficient ages of 25 and 49 years with middle-class incomes. lung (pronounced ‘‘chee’’) and deficient lung yin.The Complementary and alternative therapies, especially herbal patient’s treatment is then based on his/her particular signs and treatments, are often perceived as natural and safer than phar- symptoms. Although this patient may be diagnosed with maceutical products.3 Despite the widespread healthcare pro- deficient lung Qi and deficient lung yin, another patient may fessional’s acceptance of evidence-based medicine principles, the present with a completely different set of signs and symptoms general public seems to have a mistrust of conventional medi- but have the same diagnosis of deficient lung Qi and deficient cine, also referred to as allopathic medicine, with lung yin.4 Both patients may not receive similar treatments, even & the rise in chronic disease states, though they have the same diagnosis. This example demon- & superinfections such as methicillin-resistant Staphylococcus strates the different theoretical framework of the CAM mode. aureus (MRSA)/vancomycin-resistant Enterococcus, Complementary alternative medicine cannot be researched & medical error with nosocomial injuries and deaths, using the current scientific evidence-based healthcare model. & pharmaceutical tampering, and & treatment complications.3,4 HOW DOES THIS INFORMATION In addition, access to herbal, dietary, and homeopathic prod- TRANSLATE TO THE MANAGEMENT ucts is easy compared with prescription . Herbal OF CHRONIC WOUNDS? products are located over the counter at local drug stores, health Approximately 10 years ago, a group of wound specialist health- food stores, grocery stores, discount super marts, and shops care practitioners developed the concept of WBP to address the carrying country-specific traditional foods and supplements. As need for a more holistic approach to chronic wound care

ADVANCES IN SKIN & WOUND CARE & VOL. 24 NO. 5 228 WWW.WOUNDCAREJOURNAL.COM Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. management.9 This approach emphasizes treating the cause and treatments and incorporated them within a modified WBP patient-centered concerns before addressing local wound care. algorithm (Figure 1). This addition to the WBP approach has the The components of local wound care include debridement, benefit of connecting the recommendations to the original WBP infection and inflammation control, moisture balance, and finally model, along with the best practice guidelines and evidence. the edge effect for healable wounds when all other components are correct and the wound is stalled (Figure 1). Within this TREAT THE CAUSE paradigm, patient-centered concerns are 1 of 3 key cornerstones The common belief within all complementary and alternative of care: If people feel better, they function better, and their methods is that a body in balance is able to heal itself. When wounds are more likely to heal. Since its introduction in 2000, the a body is out of balance, signs and symptoms of disease develop. WBP model is now considered a criterion standard for evidence- At the risk of oversimplifying the philosophies of various based wound care management.9 Within the context of this traditional medicines, chronic disease states are signs that the model, the authors have reviewed the commonly used CAM body is out of balanceVwithin itself, its local environment, and

Figure 1. WOUND BED PARADIGM FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE

*Traditional Chinese Medicine, **Ayurvedic Therapies

WWW.WOUNDCAREJOURNAL.COM 229 ADVANCES IN SKIN & WOUND CARE & MAY 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 2. CAM SYSTEMS

Acupuncture Insertion of fine needles into certain points along the body’s meridian ( pathways) rebalancing the flow of Qi or the body’s life force Allopathic medicine Allopathy, term coined by C.F.S. Hahnemann to designate the biologically based approach that focuses on treating specific symptoms rather than considering the whole patient. Also referred to as conventional medicine38 Aromatherapy Therapeutic use of plant-derived essential oils to stimulate the healing mechanisms of the body and the mind39 of India.40 The Tri- theory (individual’s body-mind constitution) is one of the cornerstones used to understand an individual’s health Chelation therapy Cleansing of arteries using EDTA intravenously plus dietary supplements and lifestyle changes to remove heavy metals from the body41 Improves nerve function through spinal alignment with focus on subluxation42 Energy work encompasses a number of different techniques using practitioner intent and energy to stimulate the body’s energy pathways; examples: Qi Gong, health kinesiology, Brain Gym, vibrational therapy Herbal therapy Therapeutic use of phytochemicals (plant extracts) for the treatment of disease or to maintain a condition of improved health. In North America, choice of herb or phytomedicine is self-selected. In other countries, it is usually prescribed by physicians43 Homeopathy Symptoms are considered a signal of how the body is adapting or attempting to survive. Remedies (prescriptions) are individualized to the person using ‘‘law of similars’’ (comparable to immunizations or treatments)44 Hydrotherapy Water in its 3 formsVsolid, liquid, and vaporVis used to revitalize, maintain, and restore health. Treatments include saunas, steam baths, foot baths, sitz baths, and cold and hot water compresses45 Magnetic therapy Static or pulsed magnetic therapy applied to activate the body’s natural electromagnetic impulses to assist healing. Based on premise the human body is composed of electromagnetic frequencies46 Massage therapy A professional and therapeutic healing technique that involves the manipulation of superficial and deeper layers of muscle and connective tissue to enhance the function and promote relaxation. Regulated in most developed countries47 Naturopathy Blends modern scientific knowledge with traditional and natural forms of medicine. Based on a philosophy to stimulate the healing power of the body and treat the underlying cause of disease. Treatments are chosen based on the individual patientVchosen from natural and traditional modalities: lifestyle, botanical medicine, clinical nutrition, hydrotherapy, homeopathy, traditional Chinese medicine/acupuncture48 Nutritional Individually selected nutrients and food supplements depending on age, activities, and state of health. supplementation Supplements selected to work synergistically and individually for prevention and treatment of disease Orthomolecular therapy uses natural substancesVvitamins, minerals, amino acids, trace elements, and fatty acidsVto correct imbalance or deficiencies and restore the optimum environment of the body49 Reflexology Uses therapeutic pressure on the foot’s reflex points to enhance the body’s natural healing mechanism and balance body function50 Traditional Chinese Includes , acupuncture, Qi Gong (energy exercise), meridian massage, , and so on. medicine (TCM) The theory is based on balance of yin and yang: yin is material, called the blood or liquid, and yang is function, called the Qi (chi). The person’s Qi must be in balance with the universe’s Qi. Diagnosis and treatment is holistic51 Traditional medicine Traditional medicine refers to the knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures, used in the maintenance of health and in the prevention, diagnosis, improvement, or treatment of physical and mental illness. When adopted outside its traditional culture, traditional medicine is often called complementary and alternative medicine52

ADVANCES IN SKIN & WOUND CARE & VOL. 24 NO. 5 230 WWW.WOUNDCAREJOURNAL.COM Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. the universe. Restoring balance is the main focus of all natural The extracts are natural volatile oils with chemical and medicinal healing methods for traditional Chinese medicine, homeopathy, properties. Today, there are more than 150 different essential naturopathy, ayurveda, and local traditional medicines. A person oils. The chemistry of essential oils is not clearly understoodV with a wound who seeks treatment from a CAM practitioner will each oil may contain at least 100 different chemical components. be assessed and treated holistically. A multicomponent treatment What is known is that essential oils work in the body in 3 ways: is aimed at restoring balance and may include herbs (eg, ginseng, pharmacologically, physiologically, and psychologically. Ginkgo), homeopathic remedies, dietary changes, water therapy, Pharmacologically, the essential oil’s chemical components energy work, exercises, and so on, with the intent to treat the interact with the body’s chemistry. A crossover study was com- whole person. In addition, they may receive symptomatic treat- pleted in a long-term-care facility to investigate the effective- ment. Although the ‘‘cause’’ is treated differently, both models ness of Lavandula angustifolia (lavender) versus current focus on the whole person rather than treat only the clinical signs. standard of care in treating agitated behaviors of people with dementia in Hong Kong. The mean agitation score was de- ADDRESS PATIENT-CENTERED CONCERNS creased up to 70% in the lavender group versus the control Pain and decreased quality of life are a big concern for persons group (P<.001).13 with chronic wounds. As mentioned previously, people who Physiologically, certain oils have an affinity for particular seek CAM are looking for safer alternatives. Pain parts of the body. For example, spice oils tend to benefit the has risks and possible adverse effects; thus, many people digestive system, and leaf oils, such as marjoram, tend to act endure their pain rather than deal with adverse effects, such as as a tonic and antispasmodic. a ‘‘foggy’’ brain that interferes with abilities such as driving The psychological effects of essential oils are stimulated by a car, constipation, or sleep disturbances. The introduction of the olfactory center of the brain occurring slowly over minutes the World Health Organization’s (WHO’s) Pain Ladder10 has to hours. A number of essential oils are effective in providing not completely overcome the subjective nature of pain that an analgesic, calming, and healing effect. Lavender, marjoram, remains a challenge for conventional medicine. Factors that in- and chamomile are well known for their analgesic and adap- crease pain include fear, anxiety, negative attitude, and certain togenic (balancing) effects. The most effective essential oil stimulatory substances, such as coffee or caffeine, which may treatments are via vaporization (diffusers or aerosol), adminis- increase sensitivity to pain. tered by the patient or accompanied by massage (away from the A number of alternative therapies can help reduce or elimi- site of injury) by a professional aromatherapist or massage nate pain when the exact cause is unknown, or the cause is known therapist. but cannot be removed. Acupuncture, aromatherapy, energy work, and plant extracts have all been shown to be effective ENERGY WORK modalities for managing pain. Each of these provides an alter- Energy work encompasses a number of different techniques nate signal or stimulus as outlined in the gate control theory of where a practitioner uses his/her intent and energy to stim- Melzack and Wall,11 decreasing dosage and frequency of anal- ulate the body’s energy pathways. Some energy techniques gesic medications in some patients. Careful monitoring is recom- are influenced by a particular faith or understanding. Many mended when patients are receiving these supportive therapies. people may use energy work in conjunction with other forms Acupuncture is used to rebalance the flow of Qi (pronounced of CAM. Examples of energy work include Qi Gong, health chee)Vthe body’s life force. Fine needles are inserted along kinesiology, Brain Gym, Tong Ren therapy, and vibrational ther- the body’s energy pathways (meridians) to harmonize physi- apy. There is some research showing efficacy for therapeutic cally, mentally, and spiritually. The WHO recognizes the ef- touch, , and to assist healing. fectiveness of acupuncture for a number of disorders, including chronic pain.12 Qualified acupuncturists include physical ther- PLANT EXTRACTS apists, traditional Chinese medicine practitioners, and other Capsicum, commonly known as cayenne, has demonstrated healthcare practitioners. It is important to advise patients to efficacy as a topical analgesic for the reduction of pain in arthri- check credentials to ensure the person is qualified and has re- tis and postoperative and neuropathic pain14 and as an anti- ceived training from a reputable school. They also need to ensure spasmodic for muscle spasms. It can be used as an adjunct along that appropriate aseptic technique is followed, that is, use of with systemic pain management. The analgesic effects are not disposable needles, wearing gloves, and proper hand washing. well understood; however, the most commonly accepted hypo- Aromatherapy is the therapeutic application of the aromatic thesis identifies that capsicum destroys substance P, interfering essences of certain plants, trees, roots, fruits, flowers, and spices. with prostaglandin pathways and oxygen radical transfers.15–17

WWW.WOUNDCAREJOURNAL.COM 231 ADVANCES IN SKIN & WOUND CARE & MAY 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Studies have shown promising results for the treatment of neu- properties of honey are thought to result from the debriding ropathic pain using topical preparations.18 properties of the enzyme catalase, absorption of edema due to Capsicum should be used externally and applied locally only its hygroscopic properties, ability to promote granulation and to the intact skin area intended for treatment and is not to be epithelialization from the wound edges, and its antimicrobial directly applied to broken skin, mucous membranes, or eyes. properties.25 Some patients, however, have been reported to Capsicum produces a local burning, and by the gate control experience contact dermatitis from honey use. theory, it is this effect that relieves pain. It can cause In a large, randomized controlled trial of venous ulcers com- unpleasant burning or stinging for some individuals, and paring honey or usual treatment along with compression, both rapid-onset allergic sensitization is rarely seen. The recom- groups healed at the same rate, yet more adverse effects occurred mended strengths for ointment or cream are 0.02% to 0.05% in the honey-treated group.26 In general, honey is useful for capsaicinoids in an emulsion base. The duration of adminis- increased superficial bacterial burden, especially when accom- tration is for only 2 days in 1 location. Application locations panied by a hard eschar for autolytic debridement. It is not use- must rotate, with 14 days’ rest, before applying in the same ful in venous ulcers without increased bacterial burden or with location to avoid local nerve damage or hyperemia.17 soft slough. When honey becomes diluted with wound exudate, Turmeric (Curcuma longa), also known as curcumin, has it may become odiferous and even promote bacterial growth been held sacred and used for centuries in ayurvedic medicine if not changed at appropriate time intervals (depending on level for inflammatory conditions.19 During India’s Vedic period of exudate). Patients need to be cautioned to use only medically (c. 1500–500 BCE), the orange-yellow rhizome of turmeric was approved honey dressings. Local or store-bought honey may called the ‘‘herb of the sun’’ and was regarded as the most contain bacteria and other contaminants. outstanding healing herb.20 Turmeric is composed of 3 main Aloe vera (Aloe) is used orally and topically to treat a wide curcuminoids that interact with a number of molecules in- variety of health-related concerns. Only the leaf gel is indicated volved in inflammation including leukotriene inhibition.16 In topically. The dried leaf latex, taken from the outside edges a short-term study investigating the antirheumatic activity of of the plant, is used solely for oral preparations. The leaf gel turmeric, the effects were comparable with those of a nonster- has a hydrogel effect useful for autolytic debridement with a oidal anti-inflammatory analgesic.21 Another study focusing on composition of up to 99% water with more than 75 other con- postoperative inflammation demonstrated that turmeric pro- stituents, including A, C, and E and potentially some of duced a better anti-inflammatory response than in a the B group, enzymes, polysaccharides, amino acids, sugars, and small group of male patients following hernia operations.22 In minerals. Researchers have identified 5 proposed primary North America, turmeric is generally taken orally; however, mechanisms to explain the therapeutic effects of Aloe: ayurvedic practitioners blend the powder into a paste or lotion 1. Salicylate compounds block prostaglandin release. for the treatment of superficial wounds, external inflammation, 2. The molecular structure contains acetylated mannose– and . If used externally, the paste or lotion should be polysaccharide immunomodulating and anti-inflammatory applied only to intact skin. agents. 3. Magnesium lactate () inhibits histadine- LOCAL WOUND CARE decarboxlyaseVan enzyme that controls conversion of hista- mine in mast cells. Debridement 4. Carboxy-peptidase enzyme specifically inactivates Honey has been used topically for centuries to accelerate bradykininVa proinflammatory agent. wound healing along with other topical agents; it is not a 5. Acemannan (polysaccharide) activates macrophages and substitute for antimicrobials. It has been reported to be helpful tissue growth factor and inhibits thromboxane A2.27 in treating , pressure ulcers, and infected wounds.23 In The effectiveness of Aloe on wound healing is limited and vitro, it has been shown to have antibacterial and antifungal contradictory.28–30 The topical clinical use of Aloe gel is rec- activity to organisms commonly infecting surgical wounds.23 ommended as a hydrogel formation in direct contact with the In a randomized controlled trial, honey-impregnated gauze wound. Carriers (base components used to ‘‘carry’’ the active was compared with a polyurethane film for partial-thickness plant ingredients) include poultices, compresses, ointments, burns. The honey-treated wounds healed statistically earlier or gels. Whenever possible, the pure gel is recommended to (mean, 10.8 vs 15.3 days) and with equal complications, such minimize the risk of local burning or stinging on application or as infection, overgranulation, and contracture, compared with allergic contact dermatitis secondary to other components.31 the polyurethane film–treated wounds.24 The wound-healing If using pure gel (95% gel extract), apply as one would using

ADVANCES IN SKIN & WOUND CARE & VOL. 24 NO. 5 232 WWW.WOUNDCAREJOURNAL.COM Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. a hydrogel product. Because of the high water content, daily it was used by Australian aborigines as an antiseptic to prevent dressing changes are recommended. Secondary dressing choices wound infection. Colonists used the leaves of this tree to make would be similar to what is currently used for hydrogels. See tea, resulting in the name tea tree. They also used the leaves to Table 3 for more information on topical products. flavor beer. The primary uses of TTO is as an antimicrobial- antibacterial (attacks cell membranes), antifungal, and antiviral, Infection Control as well as anti-inflammatory (interferes with interleukin [IL] 1B In addition to honey, common topical herbal antimicrobials and IL-10 and prostaglandin E2).32 Studies have demonstrated include ti tree oil and Calendula. that high levels of TTO-terpenoids induce neutrophil and mono- The essential oil of ti-tree oil ([TTO], tea tree oil, Melaleuca cyte activity. Tea tree oil is effective against MRSA. An in vitro alternifolia) is well known for its antimicrobial activity. Originally, study of both mupirocin-susceptible and mupirocin-resistant

Table 3. CAM TOPICAL PRODUCTS

Local Wound Care: Topical Products Proposed Mechanisms of Action as Listed Moisture in Categories Debridement Antibacterial Anti-inflammatory Balance Comment

Aloe vera gel XXX X& Antipruritic (Aloaceae family) & Pure extract contains 95% Aloe gel & Commercial products may contain alcohol & Contact allergic dermatitis occasionally occurs Calendula officinalis XX & Used for stalled chronic (marigold) wounds & Triterpenes are a main anti-inflammatory (anti-infective component) & Contact allergic dermatitis may occur Essential oils: XX & Not to be used on leg ulcers chamomile, due to sensitization lavender, ti tree/tea & Contact allergic dermatitis tree & May cross-react with ragweed group of plants Honey (propolis) X X X & May cross-react with balsam of Peru & May become allergen with increased topical use Hypericum XX & Not to be used on large (St John_s wort) wounds (may cause increase in thyroid-stimulating hormone) Quercus alba (white X & Cross-reaction in patients oak bark) allergic to aspirin & Use caution in individuals with renal/hepatic dysfunction, pregnancy

WWW.WOUNDCAREJOURNAL.COM 233 ADVANCES IN SKIN & WOUND CARE & MAY 2011 Copyright @ 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. strains of MRSA was tested. All samples tested were susceptible In addition, it has demonstrated antistaphylococcal activity.37 to TTO.33 In general, this product is safe to use. A small per- Because of the salicylate content, it is not recommended to centage of the population will experience allergic contact be used for large wounds because dermatitis may occur. dermatitis. A number of reactions may be minimized or pre- vented when low concentrations are used. (When inappropriate Moisture Balance undiluted TTO was used, 6% of the study population developed Wounds require cellular growth to fill the skin defect. Cells require skin reactions.) It is recommended that diluted and well- a moist aqueous environment and do not do well with dessication formulated products be used32: 3% to 5% dilution (7–15 drops or the presence of excess wound fluid. Optimal moisture balance per 30-mL fluid), as a compress for packing or applying 3 to 5 dressings include the absorbancy of foams and calcium alginates drops neat of TTO onto the alginate or mixed in a hydrogel and the donation of moisture with a hydrogel. Many of the alter- before wound application. native medicines do not provide this moisture balance property Calendula (C officinalis, pot marigold) is sometimes con- except for those in a hydrogel type of preparation. fused with Tagetes species of marigolds, the common garden plant. Calendula’s active components include terpenoids (anti- Wound Edge inflammatory agents), carotenoids, polysaccharides (antibacterial After all other components of WBP have been implemented, and agents), and flavonol glycosides. The Commission E (Germany) if the wound is stalled, agents discussed in the Calendula and reports localized anti-inflammatory and wound healing action aromatherapy sections can be applied around the edge of the with topical application.17 Calendula’s anti-inflammatory effects wound. When a healable chronic wound is ‘‘stuck,’’ consider in some cases exceed the effects of indomethacin.34 Tests also dividing the wound into 2 equal halves and use 2 options for local demonstrate that ointments containing Calendula activate tissue wound careValways using the WBP paradigm as a guide. As regeneration and epithelial tissue development.35 Calendula- discussed previously, using the therapeutic double-bind techni- infused ointments in a beeswax base is preferred and may be que, if the wound is not 30% smaller by week 4 with either applied directly to the wound base, onto the primary dressing, treatment, it will not heal by week 12. This is a visual tool to assist around the wound edge, and the periwound. the healthcare practitioner and the patient to find an optimal Hypericum (St John’s wort) is well known for its use in treating topical treatment. Always remember: The cause of the wound depression, and it has a history of topical use for wounds, must be treated. Whether complementary alternative or conven- abrasions, and superficial burns. Constituents of Hypericum also tional methods are used, if the cause is not addressed, the wound offer therapeutic effects: amentoflavone and hypericin have anti- will not close. A painful wound is a signal to the patient and to the inflammatory effects, whereas hyperforin inhibits the growth of healthcare practitioner that something is wrong. Treating patient- gram-positive bacteria.36 In a randomized, double-blind clinical centered concerns as well as optimizing the initial components of study, the healing of 144 women post–cesarean delivery using local wound careVdebridement, moisture balance, infection, and Hypericum demonstrated improved wound healing on day 10 inflammatory controlVcan go a long way to improving the lives and decreased scar formation on day 40 using the Vancouver of persons with chronic wounds. Scar scale.36 Hypericum is an astringent (coagulates ) and when prepared for external application is typically prepared by SUMMARY extracting the flower with olive oil or grape seed oil and mixed in Complementary alternative medicine provides an additional tool an ointment for clinical use. The oily Hypericum preparation is kit for optimal WBP for persons with wounds. This therapeutic thought to provide the anti-inflammatory action. Hypericum option is often accessed by patients, leaving many healthcare (usually seen with oral preparations) has been used for oc- professionals ill-equipped to answer questions regarding safety or casional skin irritation and photosensitivity. It is recommended efficacy. Each clinician requires a basic knowledge of potential that Hypericum be used on small wounds only to minimize risk benefits and risks of these agents, as the clinician is a key member of absorption. in the therapeutic relationship and circle of care. Clinicians need to Quercus alba (white oak bark) has historically been used for be willing to participate in therapeutic double-bind strategies, its astringent action. Oak decoctions or tinctures are made by when appropriate, and to counsel patients about true concerns first mashing and then boiling the oak bark in water to extract regarding the safety and efficacy of alternative therapies. oil. The chemistry of white oak bark (Q alba) includes ter- It is important to again note that the authors do not recommend pinoids (anti-inflammatory agents), tannins, quercitol (astrin- the topical wound care use of any potentially toxic herbs or gent, hyperosmotic agent), and B12. Oak bark may be common topical irritants/allergens, including oil of clove, comfrey, useful in treating patients with inflammatory skin diseases. Echinacea, garlic, goldenseal, horsebaum, or marshmallow.

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