Caring for chronic wounds can be complicated

Feet imprint from a patient suffering from diabetic neuropathy, which is affecting the areas that are darker.

We have all sustained an abrasion or a cut at some point. The first signal is usually pain, and perhaps blood.

If it’s a small wound, we clean the affected area, put on a plaster and wait for the body to orchestrate a complex cascade of events designed to heal itself.

If you’re young and healthy, life goes on as the healing process takes place.

But there’s a segment of people whose wounds do not heal within a reasonable time frame.

Worse yet, they don’t even know they have a wound because their ability to feel pain or temperature changes is reduced.

This group suffers from diabetic neuropathy, a type of nerve damage that affects the legs and feet caused by high blood sugar (glucose).

The damage can result in loss of foot sensation and changes in the sweat-producing glands, increasing the risk of being unaware of foot calluses or cracks, injury or risk of infection.

Symptoms of neuropathy include tingling, numbness, burning or pain.

The 2015 National Health and Morbidity Survey (NHMS) revealed that 17.5% of Malaysian adults have diabetes, and almost half of them are undiagnosed.

When diabetics have a wound, it can lead to ulcers and amputations.

Common ulcer types include venous ulcers and arterial ulcers, which can both lead to open sores caused by poor blood circulation to the leg.

Ulcers can also result from standing too long, which causes blood to pool in the lower extremities.

Pressure ulcers or injuries occur due to the pressure applied on certain points of the body due to prolonged immobilisation, e.g. in stroke patients or babies in incubators.

Ulcers can also be caused by acute wounds (burns, surgery or trauma), which can turn chronic if not healed within the stipulated time.

According to Hospital Kuala Lumpur Wound Care Unit head Dr Harikrishna KR Nair, foot ulcers are the most common among diabetics and make up 70% of wound cases.

“Most of the time, the wound doesn’t heal due to multiple factors. We look at the whole patient and not the hole in the patient.

“A general assessment tells you if the patient is diabetic and if it is not controlled, and if he’s got complications from diabetes such as neuropathy (nerve damage), vasculopathy (decreased blood supply, especially at the foot), or immunopathy – these are all immunocompromised conditions.

“When you wear slippers or put your leg on the sand, we can see the indentation where the high pressure areas are – that’s when we start getting neuropathy concerns,” he says.

The Wound Care Unit started in 2013 with 2,500 patients, but that has now skyrocketed to 12,000-plus patients today.

And the numbers are increasing every year, which is worrying.

Increased infection

In January 2019, the Journal of Wound Care published a study that was performed on diabetic foot ulcer patients at the unit.

The objective was to determine the frequency and risk factors for diabetic foot infection, and to identify factors associated with delayed wound healing of diabetic foot ulcers.

Results showed that of the 340 patients (216 male and 124 female) patients who attended the clinic (average age of 58), 41.5% presented with infection in ulcers that had an average cross-section of 21.5cm.

Further analysis revealed that Chinese patients were most likely to develop infections, with the average healing time being three months.

The study concluded that large ulcer sizes, along with poor blood sugar and blood pressure control, were common risk factors for both ulcers and infections.

Feet imprint from a patient suffering from diabetic neuropathy, which is affecting the areas that are darker.
Some studies show that wounds close completely within a month with topical continuous oxygen therapy, says Dr Harikrishna.
— SAM THAM/The Star

“The infection rates are very high in Asia, unlike in Europe and the United States.

“A big thing here is biofilm infection (communities of microorganisms that attach to each other and to surfaces, e.g. by bacterial adherence).

“That means there is a layer of film on top of the wound, and if you don’t remove it, antibiotics cannot get in.

“So there is decreased oxygenation (hypoxia) and decreased blood supply (ischaemia),” explains Dr Harikrishna, who is also the president of the Malaysian Society of Wound Care Professionals.

There are different methods used to treat wounds. Traditionally, honey was the remedy, with medical grade honey now available on the market.

Conservative treatment consists of using oxide films and changing the dressing two or three times a week, as opposed to daily changing.

There is also maggot debridement therapy – a type of biotherapy using live, sterile fly larvae or maggots to remove dead cells and reduce bacterial contamination of the wound and stimulate healing.

Adjunct or supportive therapies include the use of micro-current, monochromatic infrared and hyperbaric oxygen, among others.

Says Dr Harikrishna: “Good wound care will be done after completing our assessment where we cleanse, debride, deslough, put on a dressing and offload the pressure (on your feet) with a walker or proper footwear.

“Then (we help you) control your weight and blood sugar level.

“The healing time depends on the patient’s wound. No one method is best, but oxygen and blood supply are important.

“If it’s critical ischaemia and there are a lot of blocks, then we have to go in and do a foot bypass or put a stent, depending on the condition of blood vessels.”

Using oxygen to heal

Oxygen works in all phases of wound healing.

Dr Harikrishna says: “In diabetic foot ulcers, 60% of them are anaerobic, i.e. there is no oxygen.

“These germs thrive without oxygen, so the body comes up with a molecule called the reactive oxygen species or ROS, that kills off these germs and fights infection.

“Now there is also topical continuous oxygen therapy, where you have a battery-operated device with a generator inside.

“It takes in 98% of oxygen from the air, enriches it and makes it 100%.

“The device connects to the oxygen delivery system (ODS), which continuously shoots oxygen straight to the wound 24 hours a day so that your wound has extra oxygen to speed up healing.

“It helps stop the bleeding, repair tissue, reduce inflammation, kill germs and change the anaerobic environment to an aerobic environment.

“However, because of increased blood supply, the wounds might be more ‘wet’ the first week, but a proper occlusive dressing will keep it in place.

Feet imprint from a patient suffering from diabetic neuropathy, which is affecting the areas that are darker.
Only healthcare personnel like doctors, assistant medical officers and nurses are qualified to dress wounds. — Love on Wheels

"In the second week, the wound starts to heal. If you’re not diabetic, a normal wound might take three weeks to heal.

“If you put oxygen directly on the wound, it will heal within a month if you’re diabetic – just an extra week longer than normal people, which is good.”

According to Dr Harikrishna, international guidelines say that 50% of the wound size (length, width and depth or volumetric assessment) has to be reduced

within a month, so that it can close within 12 weeks.

“In some studies we have done with this therapy, wounds close completely within a month!” he says.

This newer oxygen therapy is recommended for those who have a hypoxic component to the wound.

If the wound is necrotic and infected, it has to be debrided and the infection has to be cleared first before topical continuous oxygen therapy can be applied.

If the limb turns black and is wet, it has to be amputated. Dry gangrene can cause a limb to fall off by itself (autoamputation).

The therapy is available in most public and private hospitals, and patients are taught how to use the device. The one-time use ODS costs about RM180.

“In terms of advance wound management, it cuts down financial cost and burden for the patient and health system.

“If you look at the cost of purchasing this product in comparison to healing time, the longer it takes to heal, the more it costs the patient,” he says.

While oxygen therapy is used in many aesthetic centres, Dr Harikrishna points out that the topical continuous oxygen therapy is a medical treatment to be administered on a wound.

“You cannot put it on your face, because skin has dead tissue on top and the oxygen cannot be absorbed.

“In a wound, the epidermis of the skin is gone, so when you shoot oxygen on it, it goes in because of the change in partial pressure.

“The pressure goes from high level outside to lower level inside, so there is a movement in.

“Additional oxygen doesn’t cause any problem. Here, we’re giving oxygen only to the wound, so it’s pretty safe,” he says.

Qualified to dress wounds

Dr Harikrishna warns patients from going to unlicensed or non-qualified personnel to seek treatment.

“There are a lot of people out there without proper certifications, who supposedly open wound care centres or profess to be diabetic foot specialists.

“They have even appeared on television saying they are wound care specialists because the programme host did not check their credentials!

“Also, with the use of social media, most things need to be verified.

“The only people who can do wound dressing are doctors, assistant medical officers or nurses, he says, cautioning that patients should not even change their dressings themselves.

For diabetics, the specialist advises them not to go barefoot.

He says: “Because you cannot feel, you only find out something is wrong when there’s a fetid odour coming from the feet.

“That’s why a diabetic must check his feet between the toes and the soles for cracks, fissures, wounds, ulcers every night before he sleeps.

“Either his wife or himself (by using a mirror) must check.

“Make sure the lighting and his eyesight are good because he might also have diabetic retinopathy (damage to the blood vessels in the eye).

“And because we have such a high diabetic rate, chances are his wife also has diabetes with retinopathy, so both can‘t see! In that case, ask the son or someone else to check.”Feet imprint from a patient suffering from diabetic neuropathy, which is affecting the areas that are darker.

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