Effect of honey dressing in the management of diabetic foot ulcers: A meta-analysis

A meta-analysis study to assess the effect of honey dressing (HD) in the management of diabetic foot ulcer (DFU). A comprehensive literature examination till January 2023 was implemented and 1794 linked studies were appraised. The picked studies contained 882 subjects with DFUs were in the picked studies' baseline, 424 of them were using HD, and 458 were using a control. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of HD in the management of DFUs after DFU by the dichotomous and continuous styles and a fixed or random model. The HD applied to DFUs caused a significantly higher wound healing rate (OR, 2.06; 95% CI, 1.45-2.93, P < .001) and lower wound healing time (MD, −10.42; 95% CI, −16.27- −4.58, P < .001) compared with the control. The HD applied to DFUs caused a significantly higher wound healing rate and lower wound healing time compared with the control. Although precautions should be taken when commerce with the consequences since most of the picked studies for this meta-analysis was with low sample sizes.     

Management of negative pressure wound therapy in the treatment of diabetic foot ulcers

Diabetic foot (DF) is a common complication of diabetes and the first cause of hospital admission in diabetic patients. In recent years several guidelines have been proposed to reinforce the the management of DF with a notable increase in diabetes knowledge and an overall reduction of amputations. Significant improvements have been reached in the treatment of diabetic foot ulcers (DFUs) and nowadays clinicians have several advanced medications to apply for the best local therapy. Among these, negative pressure wound therapy (NPWT) is a useful adjunct in the management of chronic and complex wounds to promote healing and wound bed preparation for surgical procedures such as skin grafts and flap surgery. NPWT has shown remarkable results although its mechanisms of action are not completely understood. In this paper, we offer a complete overview of this medication and its implication in the clinical setting. We have examined literature related to NPWT concerning human, animal and in vitro studies, and we have summarized why, when and how we can use NPWT to treat DFUs. Further we have associated our clinical experience to scientific evidence in the field of diabetic foot to identify a defined strategy that could guide clinician in the use of NPWT approaching to DFUs.     

A comparison of diabetic foot ulcer outcomes using negative pressure wound therapy versus historical standard of care

Diabetic foot ulcers (DFUs) are a leading cause of morbidity and hospitalisation among patients with diabetes. We analysed claims data for Medicare part B diabetic foot ulcer patients treated with Negative Pressure Wound Therapy at home (N = 1135) and diabetic foot ulcer patients from a published meta-analysis of randomised controlled wet-to-moist therapy. The expected costs of care for the two treatments were also compared. A significantly greater proportion of wounds treated with NPWT achieved a successful treatment endpoint compared with wet-to-moist therapy at both 12 weeks (39.5% versus 23.9%; P < 0.001) and 20 weeks (46.3% versus 32.8%; P < 0.001). NPWT-treated patients reached a successful wound treatment endpoint more rapidly, and the benefit was apparent in all wound sizes. Expected 20-week treatment costs for NPWT were similar to those for wet-to-moist therapy if one nursing visit per day for the latter is assumed but 42% less if two nursing visits per day are made. Thus, NPWT may improve the proportion of DFUs that attain a successful wound treatment endpoint and decrease resource utilisation by a given health care system compared with standard wet-to-moist therapy.     

A prospective randomised comparative parallel study of amniotic membrane wound graft in the management of diabetic foot ulcers

Our purpose was to compare healing characteristics of diabetic foot ulcers treated with dehydrated human amniotic membrane allografts (EpiFix®, MiMedx, Kennesaw, GA) versus standard of care. An IRB‐approved, prospective, randomised, single‐centre clinical trial was performed. Included were patients with a diabetic foot ulcer of at least 4‐week duration without infection having adequate arterial perfusion. Patients were randomised to receive standard care alone or standard care with the addition of EpiFix. Wound size reduction and rates of complete healing after 4 and 6 weeks were evaluated. In the standard care group (n = 12) and the EpiFix group (n = 13) wounds reduced in size by a mean of 32·0% ± 47·3% versus 97·1% ± 7·0% (P < 0·001) after 4 weeks, whereas at 6 weeks wounds were reduced by ?1·8% ± 70·3% versus 98·4% ± 5·8% (P < 0·001), standard care versus EpiFix, respectively. After 4 and 6 weeks of treatment the overall healing rate with application of EpiFix was shown to be 77% and 92%, respectively, whereas standard care healed 0% and 8% of the wounds (P < 0·001), respectively. Patients treated with EpiFix achieved superior healing rates over standard treatment alone. These results show that using EpiFix in addition to standard care is efficacious for wound healing.     

Relationship between maceration and wound healing on diabetic foot ulcers in Indonesia: a prospective study

The aim of this study was to clarify the relationship between maceration and wound healing. A prospective longitudinal design was used in this study. The wound condition determined the type of dressings used and the dressing change frequency. A total of 62 participants with diabetic foot ulcers (70 wounds) were divided into two groups: non‐macerated (n = 52) and macerated wounds (n = 18). Each group was evaluated weekly using the Bates–Jensen Wound Assessment Tool, with follow‐ups until week 4. The Mann–Whitney U test showed that the changes in the wound area in week 1 were faster in the non‐macerated group than the macerated group (P = 0·02). The Pearson correlation analysis showed a moderate correlation between maceration and wound healing from enrolment until week 4 (P = 0·002). After week 4, the Kaplan–Meier analysis showed that the non‐macerated wounds healed significantly faster than the macerated wounds (log‐rank test = 19·378, P = 0·000). The Cox regression analysis confirmed that maceration was a significant and independent predictor of wound healing in this study (adjusted hazard ratio, 0·324; 95% CI, 0·131–0·799; P = 0·014). The results of this study demonstrated that there is a relationship between maceration and wound healing. Changes in the wound area can help predict the healing of wounds with maceration in clinical settings.     

胫骨横向搬移治疗糖尿病足溃疡

目的:探讨采用Ilizarov技术行胫骨横向搬移术治疗糖尿病足溃疡的临床疗效。方法 :自2013年7月至2017年3月,采用Ilizarov胫骨横向搬移术治疗20例糖尿病足溃疡患者,男14例,女6例;年龄46～61(51.6±6.8)岁。Wagner分级:3级5例,4级15例。手术前后观察并记录截肢平面、溃疡愈合情况、创面愈合时间、VAS疼痛评分、患足皮温,CTA观察血管再通及血管网重建情况。结果:20例患者均进行了随访,时间12～58个月,平均22.4个月,所有患者足部溃疡顺利愈合,时间6～18(13.2±3.7)周,坏死及截肢平面没有上移,患足疼痛明显缓解,VAS评分由术前的5.6±0.8降低至术后1年的0.9±0.4,差异有统计学意义(t=-26.55,P0.05);患足皮温由治疗前的(27.9±1.1)℃提高至术后1年的(30.9±1.1)℃(t=-5.98,P0.05)。CTA可见术前闭塞的血管再通,微血管数量明显增加,足部血管网重建。结论:Ilizarov胫骨横向搬移术能促进足部血管的再生、微血管网的再通或重建,从而改善糖尿病足患者的血液循环,促进溃疡的愈合,适合以微血管病变为主的糖尿病足患者。对于主干大动脉严重狭窄或闭塞的患者应当慎重或配合介入等血管再通技术联合应用。     

Effect of ultrasound-supported wound debridement in subjects with diabetic foot ulcers: A meta-analysis

A meta-analysis study to assess the effect of ultrasound-supported wound debridement (USSD) in subjects with diabetic foot ulcer (DFU). A comprehensive literature examination till January 2023 was implemented and 1873 linked studies were appraised. The picked studies contained 577 subjects with DFUs in the studies' baseline, 282 of them were using USSD, 204 were using standard care, and 91 were using a placebo. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to calculate the consequence of USSD in subjects with DFUs by the dichotomous styles and a fixed or random effect model. The USSD applied to DFU caused a significantly higher wound healing rate compared with the standard care (OR, 3.08; 95% CI, 1.94–4.88, P < .001) with no heterogeneity (I² = 0%) and the placebo (OR, 7.61; 95% CI, 3.11–18.63, P = .02) with no heterogeneity (I² = 0%). The USSD applied to DFUs caused a significantly higher wound healing rate compared with the standard care and the placebo. Though precautions should be taken when commerce with the consequences as all of the picked studies for this meta-analysis was with low sample sizes.     

Safety,efficacy and pitfalls of fibrocyte application in the treatment of diabetic foot ulcer

Fibrocytes are unique bone marrow‐derived cells with great potential in wound healing. Hence, the aim of this study was to determine the safety and efficacy of the applied circulating fibrocytes in the treatment of non healing diabetic foot ulcers. Peripheral blood mononuclear cells were isolated by centrifugation through Ficoll–Paque method. After 3 days, the non adherent cells were removed by a single, gentle aspiration. Adherent cells were cultured in the same medium for 10 days. The cells were characterised using mouse anti‐human‐CD45‐fluorescein isothiocyanate (FITC) and mouse anti‐human–collagen I, and also characterised by immunofluorescence microscopy using the above mentioned antibodies. Sterility measures were applied for clinical evaluation. Based on the literature review, cell transplantation generally requires at least 3 × 10⁶ cells regarding efficacy measures. As fibrocytes are non proliferating cells, 350 ml patient's blood is required to prepare patient‐specific serum before cell isolation and culture, and 85 ml patient's blood is needed for cell isolation and differentiation on cell transplantation applications. In our survey, no diabetic patient was inclined to be donor of such blood volume, mainly because of their pre‐assumption that they are anaemic. It is concluded that fibrocytes do not seem to be candidate cells for cell therapy in the treatment of diabetic foot ulcers because of the rarity of this cell population in circulation.     

Management of diabetic foot ulcers and the challenging points: An endocrine view

Diabetic foot ulcers (DFU) are one of the most challenging complications of diabetes. Up to one-third of patients with diabetes mellitus (DM) may suffer from DFUs during their life. DFU is one of the leading causes of morbidity in patients with DM. The treatment period is challenging, and the recurrence rate of DFUs is high. Hence, establishing prevention strategies is the most important point to be emphasized. A multidisciplinary approach is necessary in the prevention and treatment of DFUs. Patients at risk should be identified, and prevention measures should be taken based on the risk category. Once a DFU is formed, the appropriate classification and evidence-based treatment interventions should be executed. Glycemic control, diagnosis and treatment of vascular disease, local wound care, diagnosis, and treatment of infection should be addressed along with the proper evaluation and management of general health status.     

Clinical validation of an artificial intelligence-enabled wound imaging mobile application in diabetic foot ulcers

There is a lifetime risk of 15% to 25% of development of diabetic foot ulcers (DFUs) in patients with diabetes mellitus. DFUs need to be followed up on and assessed for development of complications and/or resolution, which was traditionally performed using manual measurement. Our study aims to compare the intra- and inter-rater reliability of an artificial intelligence-enabled wound imaging mobile application (CARES4WOUNDS [C4W] system, Tetsuyu, Singapore) with traditional measurement. This is a prospective cross-sectional study on 28 patients with DFUs from June 2020 to January 2021. The main wound parameters assessed were length and width. For traditional manual measurement, area was calculated by overlaying traced wound on graphical paper. Intra- and inter-rater reliability was analysed using intra-class correlation statistics. A value of <0.5, 0.5–0.75, 0.75–0.9, and >0.9 indicates poor, moderate, good, and excellent reliability, respectively. Seventy-five wound episodes from 28 patients were collected and a total of 547 wound images were analysed in this study. The median wound area during the first clinic consultation and all wound episodes was 3.75 cm² (interquartile range [IQR] 1.40–16.50) and 3.10 cm² (IQR 0.60–14.84), respectively. There is excellent intra-rater reliability of C4W on three different image captures of the same wound (intra-rater reliability ranging 0.933–0.994). There is also excellent inter-rater reliability between three C4W devices for length (0.947), width (0.923), and area (0.965). Good inter-rater reliability for length, width, and area (range 0.825–0.934) was obtained between wound nurse measurement and each of the C4W devices. In conclusion, we obtained good inter-rater and intra-rater reliability of C4W measurements against traditional wound measurement. The C4W is a useful adjunct in monitoring DFU wound progress.     

Use of a Nanoflex powder dressing for wound management following debridement for necrotising fasciitis in the diabetic foot

This paper discusses the application of Nanoflex powder dressing for management of complex soft tissue wounds. A case report is presented detailing the management of a 43‐year‐old Native American woman with diabetes mellitus who required serial debridements for necrotising fasciitis. Following debridement, the patient was left with a large dorsal foot wound and was transitioned through multiple advanced wound healing modalities. Negative pressure wound therapy (NPWT) was initially utilised in the early postoperative setting to control drainage and to promote granulation tissue; the patient was subsequently transitioned to a Nanoflex powder dressing on postoperative day 4. She reported a decrease in pain associated with dressing changes when transitioned from NPWT to the use of Nanoflex powder dressing. We hypothesise that this pain reduction is the result of a light cooling effect of the exudate‐controlling dressing and subsequent reduction in inflammation as well as the total contact nature of the dressing. Nanoflex powder dressings are a recently developed advanced wound healing modality with promise in the management of complex soft tissue wounds, both as a primary wound dressing as well as a delivery platform for analgesics, antimicrobials and pro‐angiogenic compounds.     

The efficacy of topical royal jelly on healing of diabetic foot ulcers: a double‐blind placebo‐controlled clinical trial

Foot ulcers are major sources of morbidity in individuals with diabetes mellitus. As royal jelly (RJ, a worker honey bee product) contains enzymatic, antibacterial and vasodilative properties, it can potentially help in healing of diabetic foot ulcers (DFUs). This study aimed to evaluate the efficacy of topical RJ on healing of DFUs. Diabetic patients with foot ulcers who were referred to us at Khorshid Hospital, Isfahan, Iran, were managed by offloading, infection control, vascular improvement and debridement (if required). Then, all ulcers were randomly selected to receive either 5% sterile topical RJ or placebo on their total surface area. Patients were followed for 3 months or until complete healing. Twenty‐five patients (6 females and 19 males) and a total of 64 ulcers were included and randomly allocated to case or control group (32 per group). Four ulcers were excluded and 60 ulcers included in the final analysis. Healing parameters including depth, length and width reduction rate, duration of complete healing and incidence of complete healing did not show any significant difference (P = 0·69, 0·95, 0·7, 0·74 and 0·6, respectively) between groups. We did not observe any side effect of topical RJ application. This study could not confirm any significant superiority of 5% topical RJ over placebo for the treatment of DFUs.     

Efficacy and cost‐effectiveness of octenidine wound gel in the treatment of chronic venous leg ulcers in comparison to modern wound dressings

The aim of this study was to determine the efficacy, safety and cost‐effectiveness of an octenidine‐based wound gel in the treatment of chronic venous leg ulcers. For this purpose, 49 wounds were treated with either modern wound‐phase‐adapted dressings alone (treatment arm 1; n = 17), octenidine wound gel plus modern wound‐phase‐adapted dressings (treatment arm 2; n = 17) or octenidine wound gel alone (treatment arm 3; n = 15). During the study period of 42 days with dressing changes every 3–5 days, wound healing characteristics and treatment costs of different dressings were analysed. Wound size reduction was significantly better (P = 0·028) in both octenidine wound gel treatment arms compared to modern dressings alone with total reductions of 14·6%, 64·1% and 96·2% in treatment arms 1–3. Early wound healing was merely observed under octenidine wound gel treatment (n = 9), whereby lowest treatment costs were generated by octenidine wound gel alone (€20·34/dressing change). As a result, the octenidine wound gel is cost‐effective and well suitable for the treatment of chronic venous leg ulcers, considering both safety and promotion of wound healing.     

A wearable wound moisture sensor as an indicator for wound dressing change: an observational study of wound moisture and status

Wound moisture is known to be a key parameter to ensure optimum healing conditions in wound care. This study tests the moisture content of wounds in normal practice in order to observe the moisture condition of the wound at the point of dressing change. This study is also the first large‐scale observational study that investigates wound moisture status at dressing change. The WoundSense sensor is a commercially available moisture sensor which sits directly on the wound in order to find the moisture status of the wound without disturbing or removing the dressing. The results show that of the 588 dressing changes recorded, 44·9% were made when the moisture reading was in the optimum moisture zone. Of the 30 patients recruited for this study, 11 patients had an optimum moisture reading for at least 50% of the measurements before dressing change. These results suggest that a large number of unnecessary dressing changes are being made. This is a significant finding of the study as it suggests that the protocols currently followed can be modified to allow fewer dressing changes and less disturbance of the healing wound bed.     

Quality of life in patients with diabetic foot ulcers: validation of the Cardiff Wound Impact Schedule in a Canadian population

The purpose of this study was to evaluate and validate the Cardiff Wound Impact Schedule (CWIS), a disease‐specific quality‐of‐life measure, in a diabetic foot ulcer (DFU) population. Patients with DFUs have restrictions as part of their treatment and rehabilitation, which can affect health‐related quality of life (HRQoL). Because of the high number of comorbidities experienced in diabetes, a disease‐specific quality‐of‐life measure is needed to best assess the affect of a foot ulcer on HRQoL. Patients with DFUs completed the CWIS and a World Health Organization generic quality‐of‐life questionnaire. Validity was assessed by comparing domains of the questionnaires. Patients were categorised using the University of Texas wound classification system. Mean CWIS scores were compared between categories to assess the questionnaire's ability to differentiate wound severity. Patients with open ulcers scored significantly lower on the CWIS than those with healed ulcers. Correlations between questionnaire domains were as follows: Social Life with Social Functioning (r = 0·641, P < 0·001); Well‐Being with General Health (r = 0·533, P < 0·01); Physical Symptoms and Daily Living with Physical Functioning (r = 0·631, P < 0·01) and Health‐Related Quality of Life with Vitality (r = 0·425, P < 0·01). However, there was no significant difference in mean CWIS scores between categories of wound severity. We have demonstrated the ability of the CWIS in assessing HRQoL in a DFU population and its ability to differentiate between healed and non healed states.     

Current scenario of traditional medicines in management of diabetic foot ulcers: A review

Diabetic foot infections and diabetic foot ulcers (DFU) cause significant suffering and are often recurring. DFU have three important pathogenic factors, namely, microangiopathy causing local tissue anoxia, neuropathy making the foot prone to injuries from trivial trauma, and local tissue hyperglycaemia favouring infection and delaying the wound healing. DFU have been the leading cause for non-traumatic amputations of part or whole of the limb. Western medicines focus mainly on euglycaemia, antimicrobials, debridement and wound cover with grafts, and off-loading techniques. Advances in euglycaemic control, foot care and footwear, systemic antimicrobial therapy, and overall health care access and delivery, have resulted in an overall decrease in amputations. However, the process of wound care after adequate debridement remains a major cost burden globally, especially in developing nations. This process revolves around two basic concerns regarding control/eradication of local infection and promotion of faster healing in a chronic DFU without recurrence. Wound modulation with various dressings and techniques are often a costly affair. Some aspects of the topical therapy with modern/Western medicines are frequently not addressed. Cost of and compliance to these therapies are important as both the wounds and their treatment are “chronic.” Naturally occurring agents/medications from traditional medicine systems have been used frequently in different cultures and nations, though without adequate clinical base/relevance. Traditional Chinese medicine involves restoring yin-yang balance, regulating the ‘chi’, and promoting local blood circulation. Traditional medicines from India have been emphasizing on ‘naturally’ available products to control wound infection and promote all the aspects of wound healing. There is one more group of chemicals which are not pharmaceutical agents but can create acidic milieu in the wound to satisfy the above-mentioned basic concerns. Various natural and plant derived products (e.g., honey, aloe vera, oils, and calendula) and maggots are also used for wound healing purposes. We believe that patients with a chronic wound are so tired physically, emotionally, and financially that they usually accept native traditional medicine which has the same cultural base, belief, and faith. Many of these products have never been tested in accordance to “evidence-based medicine.” There are usually case reports and experience-based reports about these products. Recently, there have been some trials (in vitro and in vivo) to verify the claims of usage of traditional medicines in management of DFU. Such studies show that these natural products enhance the healing process by controlling infection, stimulating granulation tissue, antimicrobial action, promoting fibroblastic activity and collagen deposition, etc. In this review, we attempt to study and analyse the available literature on results of topical traditional medicines, which are usually advocated in the management of DFU. An integrated and ‘holistic’ approach of both modern and traditional medicine may be more acceptable to the patient, cost effective, and easy to administer and monitor. This may also nevertheless lead to further improvement in quality of life and decrease in the rates of amputations for DFU.     

A cost‐effectiveness analysis of optimal care for diabetic foot ulcers in Australia

In addition to affecting quality of life, diabetic foot ulcers (DFUs) impose an economic burden on both patients and the health system. This study developed a Markov model to analyse the cost‐effectiveness of implementing optimal care in comparison with the continuation of usual care for diabetic patients at high risk of DFUs in the Australian setting. The model results demonstrated overall 5‐year cost savings (AUD 9100·11 for those aged 35–54, $9391·60 for those aged 55–74 and $12 394·97 for those aged 75 or older) and improved health benefits measured in quality‐adjusted life years (QALYs) (0·13 QALYs, 0·13 QALYs and 0·16 QALYs, respectively) for high‐risk patients receiving optimal care for DFUs compared with usual care. Total cost savings for Australia were estimated at AUD 2·7 billion over 5 years. Probabilistic sensitivity analysis showed that optimal care always had a higher probability of costing less and generating more health benefits. This study provides important evidence to inform Australian policy decisions on the efficient use of health resources and supports the implementation of evidence‐based optimal care in Australia. Furthermore, this information is of great importance for comparable developed countries that could reap similar benefits from investing in these well‐known evidence‐based strategies.     

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients

To compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.