Topical phenytoin treatment of stage II decubitus ulcers in the elderly

Phenytoin-loaded bioactive nanoparticles for the treatment of diabetic pressure ulcers: formulation and in vitro/in vivo evaluation

Drug repurposing offers the chance to explore the full potential of existing drugs while reducing drug development time and costs. For instance, the anticonvulsant drug phenytoin (PHT) has been investigated for its wound healing properties. However, its poor solubility and variability of doses used topically limit its use. Hence, the aim of this study was to improve the properties and wound healing efficacy of PHT for the treatment of diabetic bedsores. PHT was encapsulated, using a modified ionic gelation method, in either positively or negatively charged chitosan-alginate nanoparticles (NPs), which possess previously demonstrated wound healing potential. These NPs were characterized by transmission electron microscopy, differential scanning calorimetry, and Fourier-transform infrared spectroscopy. PHT-loaded NPs were evaluated in vivo for their pressure ulcers' healing potential using diabetic rats. The prepared NPs, especially the positively charged particles, exhibited superior wound healing efficacy compared to PHT suspension, with respect to healing rates, granulation tissue formation, tissue maturation, and collagen content. The positively charged NPs resulted in a 56.54% wound closure at day 7, compared to 37% for PHT suspension. Moreover, skin treated with these NPs showed a mature dermis structure with skin appendages, which were absent in all other groups, in addition to the highest collagen content of 63.65%. In conclusion, the use of a bioactive carrier enhanced the healing properties of PHT and allowed the use of relatively low doses of the drug. Our findings suggest that the prepared NPs offer an effective antibiotic-free delivery system for diabetic wound healing applications.

Eliminating non-healing wounds: a review

Non-healing cutaneous wounds, including pressure, diabetic and venous ulcers, are wounds where the skin and underlying tissues die due to ischemia, infection, metabolic conditions, immunosuppression or radiation. Some can be eliminated with relatively straightforward techniques, although they may continue to grow in diameter and depth, becoming increasingly painful and never heal. Others respond more slowly or poorly to treatment, while others are recalcitrant to treatments. This review examines the etiology of non-healing wounds and different wound management treatments. In addition, it examines the efficacy of platelet-rich plasma in promoting wound healing and its potential mechanisms of action. It is concluded that platelet-rich plasma alone, but more effectively when combined with another technique(s), has the greatest potential for promoting complete wound healing. However, further studies are required to determine whether the efficacy of wound healing induced by each of these techniques is enhanced by applying the techniques simultaneously.

Outcomes of topical phenytoin in the management of traumatic wounds

INTRODUCTION

Regular dressing of traumatic wounds is of paramount importance for healing. Phenytoin, an anticonvulsant, is thought to promote wound healing through multiple mechanisms, including fibroblast proliferation, granulation tissue formation, antibacterial activity, and pain alleviation.

AIM

To assess the effect of topical phenytoin on traumatic wound healing in terms of granulation tissue formation, pain alleviation, and time taken for wound healing.

METHODOLOGY

Fifty patients with traumatic wounds were divided into equal and comparable groups. After cleaning the wound, phenytoin dressing was done in the study group and saline dressing in the control group. Thereafter, regular dressings of the wounds were done, and healing was assessed on day 14 and day 21.

RESULTS

On day 14, the wound surface area, percentage of granulation tissue, VAS score amongst cases was 39.4 ± 29.75 cm², 82.12 ± 9.71%, 4.52 ± 1.08, and that of controls was and 51.28 ± 25.33 cm², 62.72 ± 9.01%, 6.52 ± 1.22, respectively. On day 21, the wound surface area, percentage of granulation tissue, VAS score amongst cases were 29.4 ± 29.88 cm², 92 ± 4.46%, 2.8 ± 0.94, and that of controls were 38.92 ± 23.24 cm², 78.56 ± 8.19%, and 4.88 ± 1.17, respectively. The time taken for wound healing was 21.76 ± 5.28 days amongst cases and 31.64 ± 8.31 days amongst controls. Staphylococcus aureus was the commonest organism isolated in both the groups. On day 14,18(72%), wounds in the study group showed negative culture, whereas, in the control group, it was negative in 12 (48%) patients. The rate of granulation tissue formation was higher in cases when compared to controls amongst smokers and diabetics. The difference in all these parameters between the groups was statistically significant (P-value <0.05).

DISCUSSION AND CONCLUSION

We observed a considerable increase in granulation tissue formation, pain alleviation, and reduction in time taken for wound healing. Topical phenytoin is a safe, effective, readily available, and frugal agent that can accelerate wound healing through its multimodal action, thus reducing patient morbidity and economic burden.

MESH TERMS

Phenytoin, Wound healing, Topical, Ulcer, Anticonvulsant, Granulation Tissue, Saline dressing.

Role of Phenytoin in Diabetic Foot Ulcers

Of the complications of diabetes mellitus, foot ulcers are the most dreaded complications, as they can progress at an alarming rate and can be very difficult to treat. Various modalities have been described in the treatment of diabetic foot ulcers. One such modality of phenytoin therapy uses the disadvantage of the drug, that is, gingival hyperplasia to the advantage of wound healing. We hereby report a case of diabetic foot ulcer managed with injection phenytoin sprayed topically over the wound.

Biosynthesis, Characterization, and Wound-Healing Activity of Phenytoin-Loaded Copper Nanoparticles

Wound-healing is a very complex and evolutionary process that involves a great variety of dynamic steps. Although different pharmaceutical agents have been developed to hasten the wound-healing process, the existing agents are still far from optimal. The present work aimed to prepare and evaluate the wound-healing efficacy of phenytoin-loaded copper nanoparticles (PHT-loaded CuNPs). CuNPs were biosynthesized using licorice aqueous extract. The prepared CuNPs were loaded with PHT by adsorption, characterized, and evaluated for wound-healing efficiency. Results showed that both plain and PHT-loaded CuNPs were monodisperse and exhibited a cubic and hexagonal morphology. The mechanism by which PHT was adsorbed on the surface of CuNPs was best fit by the Langmuir model with a maximum loaded monolayer capacity of 181 mg/g. The kinetic study revealed that the adsorption reaction followed the pseudo-second order while the thermodynamic parameters indicated that the adsorption process was physical in nature and endothermic, and occurred spontaneously. Moreover, the in vivo wound-healing activity of PHT-loaded CuNP impregnated hydroxypropylmethyl cellulose (HPMC) gel was carried out using an excisional wound model in rats. Data showed that PHT-loaded CuNPs accelerated epidermal regeneration and stimulated granulation and tissue formation in treated rats compared to controls. Additionally, quantitative real-time polymerase chain reaction (RT-PCR) analysis showed that lesions treated with PHT-loaded CuNPs were associated with a marked increase in the expression of dermal procollagen type I and a decrease in the expression of the inflammatory JAK3 compared to control samples. In conclusion, PHT-loaded CuNPs are a promising platform for effective and rapid wound-healing.

Dressings and topical agents for treating pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality.

SEARCH METHODS

In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision.

AUTHORS' CONCLUSIONS

A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.

Topical phenytoin for treating pressure ulcers

BACKGROUND

Pressure ulcers are common in clinical practice and pose a significant health problem worldwide. Apart from causing suffering to patients, they also result in longer hospital stays and increase the cost of health care. A variety of methods are used for treating pressure ulcers, including pressure relief, patient repositioning, biophysical strategies, nutritional supplementation, debridement, topical negative pressure, and local treatments including dressings, ointments and creams such as bacitracin, silver sulphadiazine, neomycin, and phenytoin. Phenytoin is a drug more commonly used in the treatment of epilepsy, but may play an important role in accelerating ulcer healing.

OBJECTIVES

To assess the effects of topical phenytoin on the rate of healing of pressure ulcers of any grade, in any care setting.

SEARCH METHODS

In September 2016, we searched the following electronic databases to identify relevant randomized clinical trials: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library); Ovid MEDLINE; Ovid Embase; and EBSCO CINAHL Plus. We handsearched conference proceedings from the European Pressure Ulcer Advisory Panel, European Wound Management Association and the Tissue Viability Society for all available years. We searched the references of the retrieved trials to identify further relevant trials. We also searched clinical trials registries to identify ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) addressing the effects (both benefits and harms) of topical phenytoin on the healing of pressure ulcers of any grade compared with placebo or alternative treatments or no therapy, irrespective of blinding, language, and publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted information on participants, interventions, methods and results and assessed risk of bias using Cochrane methodological procedures. For dichotomous variables, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables, we calculated the mean difference with 95% CI. We rated the quality of the evidence by using Grading of Recommendations, Assessment, Development and Evaluation approach (GRADE).

MAIN RESULTS

Three small RCTs met our inclusion criteria and included a total of 148 participants. These compared three treatments with topical phenytoin: hydrocolloid dressings, triple antibiotic ointment and simple dressings. In the three RCTs, 79% of participants had grade II ulcers, and 21% of participants had grade I ulcers; no participants had grade III or IV ulcers. Two RCTs had a high risk of bias overall and the other RCT was at unclear risk of bias due to poor reporting. Two RCTs had three intervention arms and the other had two intervention arms.Two studies compared topical phenytoin with hydrocolloid dressing (84 participants analysed). The available data suggest that hydrocolloid dressings may improve ulcer healing compared to topical phenytoin (39.3% ulcers healed for phenytoin versus 71.4% ulcers healed for hydrocolloid dressings (RR 0.55, 95% CI 0.33 to 0.92; 56 participants, 1 study; low quality evidence). We downgraded the evidence twice: once due to serious limitations (high risk of bias) and once due to the small sample size and small number of events. Two studies compared topical phenytoin with simple dressings (81 participants analysed). From the available data, we are uncertain whether topical phenytoin improves ulcer healing compared to simple dressings (39.3% ulcers healed for phenytoin versus 29.6% ulcers healed for the simple dressing (RR 1.33, 95% CI 0.63 to 2.78; 55 participants, 1 study; very low quality evidence). This evidence was downgraded once due to serious limitations (high risk of bias) and twice due to the low number of outcome events and resulting wide CI which included the possibility of both increased healing and reduced healing. We therefore considered it to be insufficient to determine the effect of topical phenytoin on ulcer healing. One study compared topical phenytoin with triple antibiotic ointment, however, none of the outcomes of interest to this review were reported. No adverse drug reactions or interactions were detected in any of the three RCTs. Minimal pain was reported in all groups in one trial that compared topical phenytoin with hydrocolloid dressings and triple antibiotic ointment.

AUTHORS' CONCLUSIONS

This review has considered the available evidence and the result shows that it is uncertain whether topical phenytoin improves ulcer healing for patients with grade I and II pressure ulcers. No adverse events were reported from three small trials and minimal pain was reported in one trial. Therefore, further rigorous, adequately powered RCTs examining the effects of topical phenytoin for treating pressure ulcers, and to report on adverse events, quality of life and costs are necessary.

Antibiotics and antiseptics for pressure ulcers

BACKGROUND

Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. A range of treatments with antimicrobial properties, including impregnated dressings, are widely used in the treatment of pressure ulcers. A clear and current overview is required to facilitate decision making regarding use of antiseptic or antibiotic therapies in the treatment of pressure ulcers. This review is one of a suite of Cochrane reviews investigating the use of antiseptics and antibiotics in different types of wounds. It also forms part of a suite of reviews investigating the use of different types of dressings and topical treatments in the treatment of pressure ulcers.

OBJECTIVES

To assess the effects of systemic and topical antibiotics, and topical antiseptics on the healing of infected and uninfected pressure ulcers being treated in any clinical setting.

SEARCH METHODS

In October 2015 we searched: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid EMBASE, and EBSCO CINAHL Plus. We also searched three clinical trials registries and the references of included studies and relevant systematic reviews. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials which enrolled adults with pressure ulcers of stage II or above were included in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included 12 trials (576 participants); 11 had two arms and one had three arms. All assessed topical agents, none looked at systemic antibiotics. The included trials assessed the following antimicrobial agents: povidone iodine, cadexomer iodine, gentian violet, lysozyme, silver dressings, honey, pine resin, polyhexanide, silver sulfadiazine, and nitrofurazone with ethoxy-diaminoacridine. Comparators included a range of other dressings and ointments without antimicrobial properties and alternative antimicrobials. Each comparison had only one trial, participant numbers were low and follow-up times short. The evidence varied from moderate to very low quality.Six trials reported the primary outcome of wound healing. All except one compared an antiseptic with a non-antimicrobial comparator. There was some moderate and low quality evidence that fewer ulcers may heal in the short term when treated with povidone iodine compared with non-antimicrobial alternatives (protease-modulating dressings (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.98) and hydrogel (RR 0.64, 95% CI 0.43 to 0.97)); and no clear difference between povidone iodine and a third non-antimicrobial treatment (hydrocolloid) (low quality evidence). Pine resin salve may heal more pressure ulcers than hydrocolloid (RR 2.83, 95% CI 1.14 to 7.05) (low quality evidence). There is no clear difference between cadexomer iodine and standard care, and between honey a combined antiseptic and antibiotic treatment (very low quality evidence).Six trials reported adverse events (primary safety outcome). Four reported no adverse events; there was very low quality evidence from one showing no clear evidence of a difference between cadexomer iodine and standard care; in one trial it was not clear whether data were appropriately reported.There was limited reporting of secondary outcomes. The five trials that reported change in wound size as a continuous outcome did not report any clear evidence favouring any particular antiseptic/anti-microbial treatments. For bacterial resistance, one trial found some evidence of more MRSA eradication in participants with ulcer treated with a polyhexanide dressing compared with a polyhexanide swab (RR 1.48, 95% CI 1.02 to 2.13); patients in the dressing group also reported less pain (MD -2.03, 95% CI -2.66 to -1.40). There was no clear evidence of a difference between interventions in infection resolution in three other comparisons. Evidence for secondary outcomes varied from moderate to very low quality; where no GRADE assessment was possible we identified substantial limitations which an assessment would have taken into account.

AUTHORS' CONCLUSIONS

The relative effects of systemic and topical antimicrobial treatments on pressure ulcers are not clear. Where differences in wound healing were found, these sometimes favoured the comparator treatment without antimicrobial properties. The trials are small, clinically heterogenous, generally of short duration, and at high or unclear risk of bias. The quality of the evidence ranges from moderate to very low; evidence on all comparisons was subject to some limitations.

A Comparative Study of Honey and Phenytoin Dressings for Chronic Wounds

Chronic wounds are a common problem faced by health care professionals, both in the community and in the hospital setting. The aim of this study was to evaluate the use of honey and phenytoin with respect to the process of wound healing, eradication of infection, pain relief and hospital stay. The study included 150 patients, 3 groups of 50 each (group A, honey dressing; group B, phenytoin dressing; group C, saline dressing). The appearance of granulation tissue was faster with significant wound area reduction after 3 weeks in groups A and B compared to group C. Eradication of infection was evident earlier in the honey- and phenytoin-treated groups along with significant pain relief as compared to that of group C. The outcomes of the use of honey and phenytoin as wound dressings are beneficial and comparable. Honey provides quicker pain relief and removes malodour more effectively.

Re-evaluation of the first phenytoin paste healing effects on oral biopsy ulcers

BACKGROUND

Until now, several formulations of topical phenytoin have been used to promote wound healing.

AIM

This study was aimed at re-evaluating the effects of a newly formulated phenytoin mucoadhesive paste on wound healing after oral biopsy.

SUBJECTS AND METHODS

In a double-blind clinical trial, 35 consecutive patients with oral lichenoid or lichen planus lesions were randomized into two groups. After incisional biopsy, patients applied simple, or 1% phenytoin paste at least three times a day (after each meal), for 4 days. They were evaluated every other day for size of wound closure, severity of pain, and diameter of the inflammatory halo. This study was approved by Medical Ethics committee of Shahid Beheshti University of Medical Sciences, Tehran, Iran. Statistical analysis was performed using Mann-Whitney U test and Ordinal Logistic Regression.

RESULTS

Of 35 patients, 17 (10 [10/17, 59%]) men, 7 (7/17, 41%) women, mean age: 40 (4.11) were in phenytoin group, and 18 (9 [9/9, 50%]) men, 9 (9/9, 50%) women, mean age: 43.1 (5.15) were in placebo group. There were no significant differences between both study groups in terms of age and sex (male/female ratio) (P = 0.76, P = 0.88). As all biopsies were done by means of punch number 8, the incisions were of 10 mm length. After second and third appointments, it was observed that patients in the treatment group showed quicker wound closure and less pain compared to control group significantly (P < 0.05). Although not significant, patients treated with phenytoin paste had smaller inflammatory halo than controls.

CONCLUSION

Applying 1% phenytoin mucoadhesive paste on oral biopsy incisions resulted in accelerated wound healing and decrease in pain.

Effects of topical phenytoin on nasal wound healing after mechanical trauma: An experimental study

OBJECTIVES/HYPOTHESIS

Impaired postoperative wound healing is the second most common morbidity after synechia formation in endoscopic sinus surgery. The aim of this experimental study was to investigate the potential effects of topical phenytoin on wound healing after nasal mucosal trauma in rats.

STUDY DESIGN

An experimental study at the Inonu University Faculty of Medicine.

METHODS

Twenty-four rats were randomized into three groups: 1) phenytoin group (n = 8), 2) control group (n = 8), and 3) vehicle group (n = 8). After damaging the right nasal cavity, in the phenytoin group, 1% topical phenytoin cream was applied for 7 days. The rats in the control group did not receive any treatment. The vehicle group was treated with daily topical cold cream for 1 week. The rats were sacrificed at the end, and the nasal cavities were excised. Tissue edema and inflammatory cell infiltration were compared among the groups. Additionally, proliferating cell nuclear antigen (PCNA) and cluster of differentiation 31 (CD31) immunoexpression levels were evaluated. Furthermore, in biochemical analysis, the tissue levels of vascular endothelial growth factor and (EGF) of the groups were investigated.

RESULTS

In the phenytoin group, tissue edema and inflammatory cell infiltration were significantly decreased, and PCNA and CD31 immunoexpression levels were more prominent (P < .001) and the tissue EGF levels were significantly higher (P < .01).

CONCLUSIONS

Topical phenytoin treatment may alter the nasal wound healing after mechanical trauma. The potential beneficial effects of topical phenytoin on nasal mucosa should be investigated by further experimental and human trials.

LEVEL OF EVIDENCE

NA.

Topical Phenytoin Application in Grade I and II Diabetic Foot Ulcers: A Prospective Study

BACKGROUND

India is fast becoming world diabetes capital. Diabetic foot infections are major problems among innumerable complications associated with diabetes.

MATERIAL AND METHODS

A randomized control study was conducted to evaluate the effect of topical phenytoin on healing in diabetic foot ulcers. One hundred patients with grade I/ II diabetic foot ulcers were randomly divided into two equal groups. Patients subjected to topical phenytoin dressing were classified under study and those who underwent normal salinewound dressings were classified as control. Both the groups were compared in terms of discharge, slough, wound area reduction and duration of hospital stay.

RESULTS

Discharge and slough from wound reduced significantly by day 14 in phenytoin group and within 21 days in control group. Mean duration of hospital stay in phenytoin group was 20 days, whereas in control group, it was 26 days. This difference was statistically significant (p value <0.005,df 1).

CONCLUSION

Hence, Phenytoin proved to be useful as a topical agent in promoting healing and in controlling infections in diabetic foot ulcers.

Which medical devices and/or local drug should be curatively used, as of 2012, for PU patients? How can granulation and epidermidalization be promoted? Developing French guidelines for clinical practice

INTRODUCTION

Management of a patient with pressure ulcer sore(s) must associate local and general treatment.

OBJECTIVES

To determine which medical devices other than supports and which treatments may be used for pressure sore healing (granulation tissue and epithelization/epidermidalization) as of 2012.

METHODS

Systematic review of the literature querying the databases: PASCAL Biomed, PubMed, and Cochrane library from 2000 through 2010.

RESULTS

Data in the literature on granulation tissue and epithelisation/epidermidalization in pressure sore healing are poor. The level of evidence regarding the relative effectiveness of one modern dressing compared to another has remained low. However, the study data on the interest of hydrocolloid dressing compared with impregnated gases are more significant.

DISCUSSION

Studies with heterogeneous results and populations have shown low power. Meta-analyses are difficult due to the wide range of therapeutic aims. Further clinical studies with adequate methodology are needed prior to elaboration of more specific recommendations.

CONCLUSION

The use of hydrocolloid dressing may be recommended to improve granulation tissue development and epithelization/epidermidalization in pressure sore (Level B).

The effect of topical phenytoin on healing in diabetic foot ulcers: a randomized controlled trial

AIM

The aim of the study was to evaluate the effect of topical phenytoin on healing in diabetic foot ulcers. A randomized, controlled, double-blind, clinical trial was conducted.

METHODS

A phenytoin dressing and a control dressing were manufactured. Individuals who were ≥ 18 years of age with peripheral neuropathy, an ankle brachial pressure index > 0.5 and a diabetic foot ulcer ≥ 4 weeks' duration were independently randomized to the phenytoin group (31 participants) or the control group (34 participants). Participants with renal disease, ankle brachial pressure index < 0.5, necrosis or osteomyelitis were excluded. Subjects received standard wound care and dressing application. Primary endpoint analysis (diabetic foot ulcer closed or not at 16 weeks) was calculated by survival analysis.

RESULTS

Participants (n = 65, 52 with Type 2 diabetes) were treated for a maximum of 16 weeks. Sixty per cent of the diabetic foot ulcers closed overall (18 in the phenytoin group, 20 in the control group) with no statistically significant differences in complete healing or in diabetic foot ulcer area over time between the two groups. At 24-weeks follow-up, one diabetic foot ulcer had recurred.

CONCLUSIONS

There were no differences in diabetic foot ulcer closure rates or in diabetic foot ulcer area over time between the two groups. This study does not support the use of phenytoin in the treatment of diabetic foot ulcers.

Evaluation of wound healing effect of topical phenytoin on excisional wound in albino rats

OBJECTIVES

Wound healing is a significant healthcare problem in today's medical practice. Despite extensive treatment modalities that are supposed to hasten the wound healing process, the outcomes of existing methods are far from optimal. One such agent that has been tried previously and found controversial in wound healing is phenytoin. In this study, the wound-healing efficacy of phenytoin was investigated in albino rats.

MATERIALS AND METHODS

20 male Wistar albino rats were subjected to excisional wounds measuring 500 mm(2) on the back and then randomized to two groups (n = 10): Control group (A) and treatment group (B). The control group received no drug treatment till the end of the study. 1% Phenytoin cream was applied to the wounds of rats in the group B and continued till the 16(th) day of the study. The areas of wounds were measured on the Days 4, 8, 12, and 16 of the experiment. The percentages of the healing wounds were calculated by Walker formula after measurement of the wound area. The total number of days required for complete epithelization of wounds was noted in each group.

RESULTS

Statistically significant reduction (P < 0.05) in average wound area was seen in Group B (P value=0.0017, 0.0001, 0.0001, 0.0001), respectively, on Days 4, 8, 12, and 16 of the experiment in comparison to Group A. The average number of days required for complete epithelization of wound area was less in Group B as compared to Group A (P=0.0120). The difference was statically significant

CONCLUSION

In the present study, topical phenytoin accelerated healing of excisional wound in albino rats.

The use of topical phenytoin for healing of chronic venous ulcerations

BACKGROUND

Many topical agents have been used for promotion of healing of chronic venous ulcers. One such agent that has been tried is phenytoin. The effect of phenytoin on cutaneous healing has been suggested. This study was designed to evaluate the efficacy of topical phenytoin in healing of venous ulcerations.

METHODS

One hundred and four patients with chronic venous ulcers were recruited in this study. They were divided into study group and control group. The study group was 54 patients while control group was 50 patients. Patients in the study group were subjected to dressing of their ulcers with topical phenytoin once daily while patients in the control group were subjected to dressing with normal saline. All patients were followed up for eight weeks and assessed for their ulcer status and recorded as: complete healing, partial healing, no improvement or worsening of the condition.

RESULTS

By the end of the eight weeks, complete healing was evident in 35/54 of the patients (64.8%) in the study group and 26/50 of the patients (52%) in the control group. It was statistically significant (p = .04). The rate of reduction in the mean surface area of the ulcers was faster in the study group than control group. Minor side effects were reported among 4 patients (7.4%) of the study group in the form of burning sensation.

CONCLUSION

Topical phenytoin can be used to enhance healing of chronic venous ulcers in conjunction with the established treatment. It has favorable results and tolerable local side effects.

Two percent topical phenytoin sodium solution in treating pyoderma gangrenosum: a cohort study

Oral phenytoin is an extensively used medicine for the treatment of convulsive disorders. Topical phenytoin has also been used for various types of ulcers. To determine the effectiveness of 2% topical phenytoin sodium solution in treating recalcitrant pyoderma gangrenosum. Six patients with treatment-resistant pyoderma gangrenosum who attended to Dermatology Unit/Ward were taken to the study and applied topical 2% phenytoin sodium solution to the wounds alone with other systemic therapy. Response to the treatment was assessed weekly. Three patients had idiopathic PG and other three had secondary diseases. At the end of the 4th week four patients showed complete resolution of the ulcers whereas other two patients showed the partial resolution. No adverse effects were noted. Phenytoin sodium 2% solution is beneficial for pyoderma gangrenosum (PG) with various etiologies. It enhanced the healing of the ulcer especially when the patient has treatment resistant disease.

Assessment of the effect of phenytoin on cutaneous healing from excision of melanocytic nevi on the face and on the back

BACKGROUND

Topical phenytoin is a powerful skin wounds healing and it may be useful in clinical practice. The purpose of this study was to evaluate the effect of topical phenytoin 0.5%, by comparing it with cream (control) in wounds resulting from excision of two melanocytic nevi in the same patient. Our purpose was also to assess if phenytoin had better therapeutic and cosmetic outcomes when compared with cream (control).

METHODS

This study evaluated 100 patients with skin wounds from excision of melanocytic nevi. 50 patients with lesions on the face and 50 patients with lesions on the back, totalizing 200 lesions excised with modified punch. The resulting superficial skin wounds had the same diameter and depth, and second intention healing followed.Patients were followed for 60 days. Student's t-test, Mann Whitney nonparametric test, analysis of variance, LSD test, Shapiro-Wilks test and Fisher test were used to analyze the results, depending on the nature of the variables being studied.

RESULTS

Phenytoin showed better therapeutic and cosmetic results, by healing faster, with more intense epithelization in wounds in comparison with cream (control). Phenytoin showed a statistically significant difference regarding the following parameters (p < 0.05): wounded area and healing time. Phenytoin application resulted in a smaller area and a shorter healing time. Also the intensity of exudates, bleeding, and the epithelization were more intense in phenytoin-treated wounds. Regarding the shape and thickness of the scar, injuries treated with phenytoin had round and flat shaped scars in most of the cases. Considering patient's gender and phototype, female patients presented smaller wounds and scar areas; and phototype I had the largest scar areas. Contact eczema was an adverse reaction in 7 injuries located on the back caused by cream (control) and hypoallergenic tape.

CONCLUSIONS

Phenytoin showed better therapeutic and cosmetic results compared with cream (control). Phenytoin is a low cost drug, which accelerates skin wounds healing in human patients.

TRIAL REGISTRATION

ISRCTN96539803.

Update on Pressure Ulcer Management and Deep Tissue Injury

Objective:

To review recent literature regarding therapeutic management of pressure ulcers and to discuss the potential implications of the newly recognized entity, deep tissue injury (DTI).

Data Sources:

A MEDLINE search was conducted of pressure ulcer therapy published between January 2001 and October 2009. Key search terms included pressure ulcers, deep tissue injury, nutrition, antibiotics, and therapy.

Study Selection and Data Extraction:

Comparative clinical trials involving pharmacologic agents in the treatment of pressure ulcers and DTI were evaluated. Included trials were those with defined interventions and outcome parameters for wound healing.

Data Synthesis:

Pressure ulcers remain an important issue in the care of elderly and immobilized patients. DTI has been recently added by the National Pressure Ulcer Advisory Panel as a separate category in the staging of pressure ulcers. There is currently a lack of consensus on how to identify and treat DTI. but preventive measures typically employed in the management of all pressure ulcers have been recommended. Recent studies on topical phenytoin, silver preparations, and growth factors report benefit in the management of pressure ulcers. However, studies evaluating these treatment approaches often lack the sample size necessary to adequately support recommendations.

Conclusions:

Determining the extent of tissue damage in DTI is currently not possible. Therefore, management recommendations focus on limiting extension of the ulcer stage through preventive strategies. Routine use of topical phenytoin, silver preparations, or growth factors in therapy of pressure ulcers cannot be recommended until more data from rigorously designed studies are available.

The impact of topical phenytoin on recalcitrant neuropathic diabetic foot ulceration

OBJECTIVE

To study the impact of topical phenytoin on the healing of recalcitrant neuropathic diabetic foot ulcers in patients with no clinical evidence of ischaemia or infection, and to evaluate its antibacterial effect.

METHOD

Thirty-two patients were enrolled into the study. Topical phenytoin in the form of 2% aerosol powder was applied once daily in addition to the patient's usual treatment (weekly sharp debridement, offloading and use of a gauze dressing) for eight weeks. The primary outcome was change in ulcer area over time, measured by grid tracing. Secondary outcomes were the ability of topical phenytoin to eradicate bacterial isolates, and the occurrence of adverse events.

RESULTS

Topical phenytoin significantly improved healing of recalcitrant neuropathic diabetic foot ulcers. Baseline wound area was 319.3 + 340.4 mm2, reducing to 286.1 + 341.1 mm2 and 269.1 + 341.2 mm2 after four and eight weeks respectively. However, the overall reduction in ulcer size was only 18.3% + 27.5% and 25.7% + 38.6 % respectively. Topical phenytoin therapy over eight weeks did not eradicate any of the bacterial wound isolates (Staphylococcus spp., Proteus spp. or Pseudomonas spp.). Of the 32 patients evaluated, only eight (25%) achieved more than 50% reduction in ulcer size after eight weeks of treatment.

CONCLUSION

Topical phenytoin can enhance wound healing in recalcitrant neuropathic diabetic foot ulcers, although only one-quarter of patients achieved more than 50% reduction in ulcer size after eight weeks of therapy. Further research is needed to characterise those patients who will satisfactorily respond to such therapy.

The clinical effect of topical phenytoin on wound healing: a systematic review

BACKGROUND

Oral phenytoin was first introduced as an antiseizure medication in 1937. Over 60 years investigators have shown an interest in how topical phenytoin may be used to promote wound healing in a variety of chronic wounds.

OBJECTIVES

Systematically to identify, summarize and critically appraise the clinical evidence available on the effects of topical phenytoin on wound healing.

METHODS

Systematic searches were carried out in PubMed (1963-2005), Medline (1966-2005) and Cinahl (1982-2005) for the years listed and in the Cochrane Library and the University of York NHS Centre for Reviews and Dissemination. The search terms used the following key words alone and in combination: phenytoin, wounds and injuries, wound healing, and wound care. Secondary hand searching was also carried out using relevant journal articles and reference lists, historical books, conference proceedings and theses in the area of wound healing. Papers were included if they described randomized controlled trials (RCTs) on humans and if the primary aim was wound closure, with a secondary aim of measuring wound healing over time. The methodological quality of the papers in this systematic review was assessed using the van Tulder method and in addition best-evidence synthesis was carried out. The magnitude of the effect of phenytoin therapy in the studies included in the systematic review was investigated in four of the 14 trials.

RESULTS

Fourteen RCTs were included in the systematic review. Two papers were of high and 12 papers of low to moderate methodological quality. Most papers failed to describe randomization, treatment allocation and blinding techniques adequately. There was moderate evidence presented to support the use of phenytoin for the treatment of leg ulcers, leprosy wounds, chronic wounds and diabetic foot ulcers. There was a positive percentage treatment effect in favour of the phenytoin-treated group in one study investigating diabetic foot wounds and one study on chronic wounds. There was limited evidence for the use of phenytoin on burns and war wounds.

CONCLUSIONS

Overall it would appear that studies investigating the effect of topical phenytoin on wound healing are of moderate methodological quality, and these suggest that there may be a positive effect on wound healing in a variety of wounds.

Topical phenytoin solution for treating pressure ulcers: a prospective, randomized, double-blind clinical trial

STUDY DESIGN

Prospective, randomized, double-blind clinical trial.

OBJECTIVES

To evaluate the efficacy of topical phenytoin solution in treating pressure ulcers among patients with spinal cord disorders and to evaluate the systemic absorption of topical phenytoin.

SETTING

Physical Medicine and Rehabilitation Unit, Christian Medical College, Vellore, India.

METHODS

Twenty-eight patients with stage 2 pressure ulcers were randomized to receive either phenytoin solution (5 mg/ml) or normal saline dressing on their ulcers once daily for 15 days. Efficacy of the treatment was determined by assessing the reduction in Pressure Ulcer Scores for Healing (PUSH 3.0), ulcer volume and ulcer size as on day 16. Serum phenytoin concentrations were estimated to determine the systemic absorption of topical phenytoin.

RESULTS

Statistically insignificant but marginally higher reduction in PUSH 3.0 scores and ulcer size were seen with topical phenytoin treatment. Systemic absorption of topical phenytoin was negligible. No adverse drug events were detected during the study.

CONCLUSIONS

Phenytoin solution is a safe topical agent that accelerates healing of pressure ulcers. However, its efficacy is only slightly more than normal saline treatment.

Efficacy and Tolerability of Hyaluronan (ialuset??) in the Treatment of Pressure Ulcers

BACKGROUND

Pressure ulcers are complex chronic wounds and a frequent cause of morbidity in elderly subjects in hospitals and nursing homes. Local treatment is based on the use of dressings that protect the wound and provide a favourable environment for healing to occur. ialuset, a treatment based on hyaluronan (hyaluronic acid), is already available on the market and known to be an effective treatment for venous leg ulcers. However, no clinical trials of hyaluronan as a treatment option for pressure ulcers have been reported as yet.

METHODS

The purpose of this review was to investigate the efficacy and tolerability of ialuset in the treatment of pressure ulcers. To this end, this article reports data from 21 predominantly elderly patients with National Pressure Ulcer Advisory Panel grade II, III or IV pressure ulcers treated with ialuset cream or gauze pads over a 3-week period in ten hospitals in France.

RESULTS

A significant median decrease of 4cm2 in the surface area of treated wounds was observed after 3 weeks of ialuset use (p < 0.05 vs baseline). A >or=50% reduction in pressure ulcer surface area was seen in 65.0% of patients (95% CI 44.8, 84.3). Nine patients (45%) showed a >or=50% increase in epithelial surface compared with the initial lesion. Patient-reported pain appeared to decrease during the 3-week treatment period, although this decrease did not quite reach statistical significance (p = 0.07). Additionally, a significant decrease in the mean percentage of fibrous tissue in the wound was observed (p = 0.02), as was a non-significant increase in granulation tissue (p = 0.1). General efficacy was considered as good or very good for nearly all patients on review of the data (19/20 patients as assessed by clinicians). Overall tolerability was also considered good or very good in 12/15 assessments by patients at day 21.

CONCLUSION

These preliminary findings suggest that ialuset is a promising option in the treatment of pressure ulcers; however, further investigation in the form of large, randomised clinical trials is required before firm conclusions can be drawn regarding the efficacy and tolerability of this treatment in this context.

Antiepileptic drug use and the occurrence of pressure ulcers among bedridden institutionalized elderly patients: a retrospective chart review

BACKGROUND

Phenytoin (PH) is indicated primarily for the control of grand mal and psychomotor seizures. However, topical PH has been used for the treatment of various types of ulcers, including pressure ulcers.

OBJECTIVE

The aim of this study was to investigate the possibility of a relationship between the use of oral PH and the prevalence of pressure ulcers among bedridden institutionalized elderly patients.

METHODS

This retrospective chart review was conducted in a state-run urban geriatric medical center in Israel and involved long-term bedridden institutionalized patients who were receiving chronic antiepileptic medication during the 7-year period between January 1996 and December 2003. The prevalence of pressure ulcers in patients who received treatment with PH alone or in combination with other antiepileptic drugs was compared with that in patients who received antiepileptic agents other than PH.

RESULTS

The study analyzed data from the medical charts of 153 patients, 72 of whom received PH alone or in combination with other antiepileptic drugs, and 81 of whom received antiepileptic agents other than PH. Patients' mean (SD) age was 78.5 (7.2) years; 106 (69.3%) were women. All patients were totally dependent with respect to activities of daily living (mean Katz score, 2.0 [2.0]) and had severe cognitive decline (mean Mini-Mental State Examination score, 3.5 [3.3]). Pressure ulcers occurred in 9.7% of PH recipients and 27.2% of non-PH recipients (P = 0.006; chi2 = 7.55). In PH recipients, 85.7% of pressure ulcers were of mild to moderate severity (stage I or II), compared with 59.1% of ulcers in non-PH recipients; the difference between groups was not statistically significant. Four (18.2%) non-PH recipients and no PH recipients had stage IV pressure ulcers. In the PH group, 71.4% of patients had a pressure ulcer in only 1 anatomic location, compared with 22.7% of the non-PH group (P = 0.023; chi2 = 5.13); 28.6% of PH recipients and 63.6% of non-PH recipients had pressure ulcers in 2 or 3 anatomic locations; and 3 (13.6%) non-PH recipients and no PH recipients had pressure ulcers in > or = 4 areas.

CONCLUSIONS

In the long-term bedridden institutionalized patients studied, those who received PH had lower rates of pressure ulcers, as well as less severe ulcers. PH may be a useful anticonvulsive agent in frail elderly patients, who are at risk for the development of pressure ulcers.

Phenytoin-induced lymphocytic chemotaxis, angiogenesis and accelerated healing of decubitus ulcer in a patient with stroke

We studied the effect of topically applied phenytoin on the healing of a decubitus ulcer in the sacral region of an immobile patient with stroke. Another similar, but smaller, ulcer was treated with conventional treatment only and served as a control. The ulcers were measured once a week and biopsies were taken from the margins before, 1 week and 2 weeks after commencing treatment with phenytoin. Clinically, phenytoin substantially accelerated the rate of healing. Microscopic examination of the biopsies showed increased lymphocytic infiltration of the phenytoin-treated lesion. Anti-CD31 immunohistochemistry revealed dense CD31+ lymphocytic infiltration and increased angiogenesis only in the phenytoin-treated lesion. Our findings suggest that phenytoin enhances wound healing by stimulating lymphocytic chemotaxis and up-regulation of angiogenesis.