Written by: Helen Roden, RN, TV CNS Heart of England NHS Foundation Trust, Birmingham & Linda Redfern, RN, TVN Heart of England NHS Foundation Trust, Birmingham
Activon Tulle was selected to manage a chronic, non healing leg ulcer (Fig.1). Prior to this case study, honey was not included on the trust’s formulary. Product evaluation in an acute trust is notoriously challenging. Trials can be thwarted when patients move between wards, sites or are discharged home to the community setting. In addition, patients may present with a chronic wound that is not a priority in terms of their overall medical management and not expected to progress due to poor healing potential. When a patient presents with such a wound, why look for an alternative product? Control of symptoms and patient comfort are sometimes the primary considerations for the TVN. Here, a product was needed to achieve both.
Patient presented with multiple co-morbid factors and poor healing potential.
- Venous disease
- Renal failure requiring dialysis
- Poor nutrition; physically emaciated
- A heavily colonised wound; “multiple micro organisms”
- Wound had increased in size from 7x7cm to 21x15cm
- Symptoms of malodour, increase in exudate and bleeding at the wound bed
- Presence of slough and necrotic tissue
- Extremely painful at dressing change.
Previous treatment methods had included sharp debridement, Quadrafoam, Alginate, Silver Sulfadiazine (SSD), and Hydrogel.
The wound was 70% granulation tissue, 20% slough, 10% necrosis with a moderate malodorous exudate. Tendons were exposed.
Fig 2: Bright red friable granulation, bled easily, exposed tendons present, pain score 4.
Following holistic patient and full wound assessment, a dressing was required which would:
- Be antimicrobial: active against a wide range of wound pathogens
- Treat critical colonisation
- Remove slough and necrosis by autolysis
- Maintain a moist but not wet wound environment
- Act as an anti-inflammatory, reducing inflammation associated with chronic wounds
- Maintain comfort at dressing changes unlike current treatment
- Reduce malodour thus improving quality of life
- Stimulate healing, although this was not the main objective1.
Daily dressing changes using Activon Tulle® were initiated. The wound was irrigated with normal saline to remove previous dressing debris. Barrier film was applied to peri-wound skin to prevent maceration from wound exudate.
Activon Tulle® 10cm x 10cm (fig. 3) was applied in its folded state in order to provide a higher concentration of honey and meet the needs of the wound. An absorbent pad secured with a bandage was then applied.
Noticeable improvement was observed as early as the first dressing change:
- The patient’s pain decreased significantly particularly at dressing change
- Necrotic tissue had softened and areas were easily removed
- Granulation tissue did not appear as friable. It did not bleed, indicating symptoms of critical colonisation were improving
- The amount of exudate increased as expected when honey is used. It did not however, cause maceration of the surrounding tissues.
Product choice was based on holistic and detailed wound assessment. In the presence of multiple co morbid factors, practitioners should question whether to actively debride2. Full investigation into the aetiology of the leg ulcer should also be a priority. However, use of debriding agents was justified; the wound was debriding autolytically and tendons were exposed.
Sulfadiazine cream (applied daily for 2-3 weeks) was discontinued when signs of critical colonisation remained unchanged. There is growing concern associated with prolonged Silver use in addition; the wound was becoming wetter, requiring increased frequency of change. This did not fit with the objective to optimise comfort. Formulary alternatives included a high dose silver (Acticoat Absorbent) or Iodine based product (Iodoflex). The former was considered unsuitable due to the pain associated with the wound and Iodine was contraindicated due to risk of toxicity as a result of renal failure3.
The patient undoubtedly had a poor prognosis which impacted upon his potential to heal. However, the management of symptoms associated with the wound were effectively managed with Activon Tulle®. This should not be undervalued.
A longer evaluation period was planned however, the patient died. We do not have permission to publish further photographic evidence. Nevertheless this single patient case study highlighted the therapeutic benefits of honey in wound care. Symptoms of malodour and pain concerned the patient, distressing him and his family. Application of Honey in the form of Activon Tulle® significantly reduced both.
The patient outcome does not detract from this valuable case study which confirmed there is role for honey on the trust formulary. Activon Tulle® provided a non toxic, alternative to other antimicrobials and met the challenging symptoms associated with the wound. It is not always possible to heal a chronic wound but this should not be considered the sole measure of success. This case study therefore contributes to the wealth of evidence supporting honey as an effective, modern wound management product.
1. Cooper R (2005) The antimicrobial activity of honey. In White R, Cooper R, Molan P, eds. Honey: A modern wound management product. Wounds UK, Aberdeen: chap 2
2. Debridement: Controlling the Necrotic/Cellular Burden Ayello, Elizabeth; Cuddigan, Janet E. Advances in Skin & Wound Care: March 2004 - Volume17 - Issue 2 - pp 66-75
3. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. Wounds UK, Aberdeen, 2010