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A Comprehensive Review of Topical Odor-Controlling Treatment Options for Chronic Wounds

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A Comprehensive Review of Topical Odor-Controlling Treatment Options for Chronic Wounds Wound Care J Wound Ostomy Continence Nurs. 2016;43(6):598-609. Published by Lippincott Williams & Wilkins A Comprehensive Review of Topical Odor-Controlling 3 Treatment Options for Chronic Wounds Alma Akhmetova ¿ Timur Saliev ¿ Iain U. Allan ¿ Matthew J. Illsley ¿ Talgat Nurgozhin ¿ Sergey Mikhalovsky ABSTRACT The process of wound healing is often accompanied by bacterial infection or critical colonization, resulting in protracted infl ammation, delayed reepithelization, and production of pungent odors. The malodor produced by these wounds may lower health-related quality of life and produce psychological discomfort and social isolation. Current management focuses on reducing bacterial activity within the wound site and absorbing malodorous gases. For example, charcoal-based materials have been incorporated into dressing for direct adsorption of the responsible gases. In addition, multiple topical agents, including silver, iodine, honey, sugar, and essential oils, have been suggested for incorporation into dressings in an attempt to control the underlying bacterial infection. This review describes options for controlling malodor in chronic wounds, the benefi ts and drawbacks of each topical agent, and their mode of action. We also discuss the use of subjective odor evaluation techniques to assess the effi cacy of odor-controlling therapies. The perspectives of employing novel biomaterials and technologies for wound odor management are also presented. KEY WORDS: Chronic wound , Control , Dressing , Infection , Malodor , Odor , Therapy . INTRODUCTION evidence concerning the effi cacy of various interventions de- signed to reduce malodor produced by some chronic wounds Common clinical manifestations associated with wounds in- remains sparse. 5 clude pain, itch, odor, bleeding, and production of exudate; Unpleasant odor is often found in chronic wounds, and however, malodor is recognized as one of most distressful especially those that have not closed following 3 months of aspects of some wounds. 1 Malodor from a wound has been treatment. 6 , 7 However, our knowledge regarding the epide- shown to produce psychological discomfort and embarrass- miology and pathogenesis of malodorous wounds remains ment among patients and clinicians caring for these patients. 2 limited. Several reports have examined the associations be- It has also been shown to increase social isolation. 3–5 While tween wound type, duration of treatment, degree of infl am- some researchers have addressed this bothersome symptom, mation, level of bacterial contamination, and development of malodor. 8 , 9 Howell-Jones and colleagues 10 evaluated fi ndings Alma Akhmetova, BSc, Laboratory of Experimental and Clinical Pharmacology from 95 microbiology laboratories; they found that 41% of and Pharmacy, National Laboratory Astana, Nazarbayev University, Astana, Kazakhstan. swabs from venous leg ulcers were associated with an unpleas- ant odor. Foot ulcers occur in approximately 15% of persons Timur Saliev, MD, PhD, Laboratory of Translational Medicine and Life 11 Sciences Technologies, National Laboratory Astana, Nazarbayev University, with diabetes mellitus. Diabetes mellitus, symptomatic bac- Astana, Kazakhstan. terial wound infection, vascular diseases, and necrosis of tis- 8-11 Iain U. Allan, PhD, School of Biomaterials and Biomolecular Sciences, sues may trigger and prolong infl ammation, thus impeding University of Brighton, Brighton, United Kingdom. the healing process; these sequelae increases the risk for devel- Matthew J. Illsley, PhD, School of Biomaterials and Biomolecular Sciences, opment of wound malodor. 11-15 University of Brighton, Brighton, United Kingdom. Th e fetid odor associated with some wounds is attributable Talgat Nurgozhin, MD, PhD, Laboratory of Experimental and Clinical to a combination of factors such as necrotic tissues and bacte- Pharmacology and Pharmacy, National Laboratory Astana, Nazarbayev ria. 8,16 It has been shown that both anaerobic and aerobic bacte- University, Astana, Kazakhstan. ria contribute to the release of unpleasant odors from wounds; Sergey Mikhalovsky, PhD, School of Biomaterials and Biomolecular although anaerobic bacteria are considered the major producer Sciences, University of Brighton, Brighton, United Kingdom; and School of 17 Engineering, Nazarbayev University, Astana, Kazakhstan. of malodor. Bacteria responsible for odor include the an- aerobes: Bacteroides, Clostridium sp, 17 Prevotella sp, Porphyro- This is an open-access article distributed under the terms of the Creative 17 Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY- monas sp, Fusobacterium nucleatum , beta-hemolytic Strepto- NC-ND), where it is permissible to download and share the work provided it is cocci , 18 and aerobes: Proteus sp,19 Klebsiella sp, Pseudomonas sp, properly cited. The work cannot be changed in any way or used commercially. methicillin-resistant Staphylococci . 19 Bacterially produced mal- The authors declare no confl icts of interest. odorous molecules encompass a range of volatile metabolites Correspondence: Timur Saliev, MD, PhD, Centre for Life Sciences, such as cadaverine, putrescine, sulfur, 8 and short-chain fatty Nazarbayev University, Unit 9, 53 Kabanbay batyr Ave, Astana 010000, acids including n -butyric, n -valeric, n -caproic, n -haptonic, and Kazakhstan ( [email protected] ). caprylic acids. 20 Putrescine and cadaverine have an intense ac- DOI: 10.1097/WON.0000000000000273 rid smell 21 ; they tend to linger and can cause vomiting. 22 598 JWOCN ¿ November/December 2016 ¿ Volume 43 ¿ Nu mber 6 www.jwonline.com Copyright © 2016 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited. JWOCN ¿ Volume 43 ¿ Nu mber 6 Akhmetova et al 599 No widely used classifi cation system for characterizing odors Study Quality Assessment Tools (National Heart, Lung, and produced by wounds exists; patients and clinicians often de- Blood Institute, Bethesda, Maryland, https:// www.nhlbi.nih.gov/ scribed these unpleasant smells as foul, putrid, sweet, acrid, pun- health-pro/guidelines/in-develop/cardiovascular-risk-reduction/ gent, and off ensive. 1 , 14 Nevertheless, it has been observed that tools ), which was adapted for purposes of this review. specifi c species of bacteria produce specifi c types of odor. For 23 example, Shirasu and colleagues used gas chromatography– Techniques for Assessing Wound Odor mass spectrometry to evaluate wound odor and demonstrated A recent online survey found low overall satisfaction of odor that dimethyl trisulfi de from exudate was a common source management and the need to develop more eff ective strate- of “sulfury” odor emitted from wounds. Dimethyl trisulfi de gies and guidelines in this fi eld. 1 Th e majority of the conduct- is a known end product of Pseudomonas aeruginosa . Refer to ed studies included in this review used subjective analysis to Table 1 for a summary of the range of malodors associated with determine presence of wound odor. In most cases, only the chemical compounds frequently found in the beds of chronic 19 presence and intensity of odor were recorded; few studies eval- wounds with bacterial colonization or infection. uated the effi cacy of its control. Table 2 summarizes the scal- Odor is frequently used as an indicator of bacterial coloniza- 24 ing systems used in questionnaire studies for identifi cation of tion in the wound bed. Colonization is typically accompanied 2,13,21,29,32,33,87,98,127 25 intensity of wound odor. Most of the scales by formation of a biofi lm. Bacterial biofi lms are more prevalent distinguished odor intensity as low, medium, or strong. An in chronic wounds than in acute wounds. For example, James 26 “Overall Evaluation Scale” was usually used to measure the and associates demonstrated that 60% of chronic wounds eff ectiveness of a dressing to control odor rather than odor contained biofi lms as compared to 6% of acute wounds. Bio- intensity. 29 Th e scales changed statistically before and follow- fi lms are communities of bacterial species living within a exo- 30 31 25 ing treatment using either paired t test, the Friedman test, polysaccharide shield (EPS). Th e EPS acts as a barrier for both the Spearman test, 32 or Mann-Whitney U test, 33 supporting antibiotics and innate cells of the host’s immune system, thus their responsiveness to intervention. Nevertheless, statistical preventing eff ective wound healing and odor management. analysis was not always possible due to diff erences in respons- Th e purpose of this article is to summarize studies focus- es reported by health care providers versus patients. 21 We hy- ing on odor control in the management of chronic wounds pothesize that odor perception may be aff ected by various fac- therapies. In comparison with other systematic reviews on tors, including reduced sensitivity, and recommend additional malodorous wounds such as the work conducted by da Costa 28 research on this topic. Santos and colleagues, this article synthesizes fi ndings from Some researchers have attempted to develop more objective all available studies that included odor reduction in diff erent instruments tecÚiques for objectively measuring wound odor, types of chronic wounds and it summarizes potential therapies but none has gained widespread acceptance in clinical prac- for preventing or controlling wound-associated odors. tice. 34 , 35 Th omas and colleagues 19 proposed a novel method
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