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344Rev Esc Enferm USP

2010; 44(2):344-9www.ee.usp.br/reeusp/

Use of collagen and aloe vera in

ischemic wound treatment: study caseOliveira SHS, Soares MJGO, Rocha PS


ischemic wound treatment: study case

USO DE COBERTURA COM COLGENO E ALOE VERA NO TRATAMENTO DEFERIDA ISQUMICA: ESTUDO DE CASO

EL USO DE COLGENO Y ALOE VERA EN EL TRATAMIENTO DE LA HERIDAISQUMICA: ESTUDIO DE CASO

1 PhD in Nursing in Health Promotion, Federal University of Cear. Professor at the Health Technical School at the Federal University of Paraba. Joo Pessoa,PB, Brazil. [email protected] 2 PhD in Nursing, Federal University of Cear. Professor at the Federal University of Paraba, Medical-Surgical Nursingand Administration Department. Joo Pessoa, PB, Brazil. [email protected] 3 Master student in Education, Universidade Lusfona do Porto, Portugal.

Professor at the Faculdade Integrada de Patos. Patos, PB, Brazil. [email protected]

ORIGINA

LARTICLE

Received: 06/27/2008Approved: 04/22/2009

Portuguese / English:www.scielo.br/reeusp

RESUMOO presente estudo relata o caso clnico deum paciente diabtico e hipertenso, porta-dor de ferida isqumica, tratado com cober-tura no convencional, base deAloe verae colgeno. Faz parte de um projeto de pes-quisa experimental, coordenado por profes-sores e enfermeiros que atuam em projetospara o desenvolvimento de novas tecnolo-gias para o tratamento de feridas. O caso emtela foi selecionado dentre os dos demaispacientes acompanhados. A coleta de dadosfoi efetuada atravs da anamnese e examefsico do paciente, utilizando-se um instru-

mento com dados relativos s condies dopaciente e da leso, bem como atravs doregistro fotogrfico da leso. Os curativosforam realizados diariamente e, ao final deaproximadamente dez semanas, observou-se a total cicatrizao da leso. No foramobservados desconfortos ou complicaesdecorrentes do uso do produto, concluindo-se que o mesmo apresentou boa tolerabili-dade e eficcia teraputica para este caso emparticular.

DESCRITORESCicatrizao de feridas.Teraputica.

Aloe.Colgeno.Doena crnica.Ferimentos e leses.

Simone Helena dos Santos Oliveira1,Maria Julia Guimares Oliveira Soares2, Pascalle de Sousa Rocha3

ABSTRACTThe present study is a clinical case reportof a patient with diabetes and hyperten-sion, with an ischemic wound, treated witha non-conventionalAloe vera and collagenplastering. This study is part of an experi-mental research project, coordinated byprofessors and nurses that work togetherto discover new ways for wound treatment.This case was chosen among many patients.Data was collected through anamneses andphysical examination of the patients con-dition, the wound, and pictures were taken.The plastering was applied every day, and

by the end of ten weeks, total healing wasobtained. There was no discomfort or anyother implication as a result of using thecompound. In conclusion, the compoundwas well accepted and efficient in this par-ticular case.

KEY WORDSWound healing.Therapeutics.

Aloe.Collagen.Chronic disease.Wounds and injuries

RESUMENEste estudio reporta el caso clnico de unpaciente hipertenso, diabtico, con unaherida isqumica tratada con apsitos noconvencionales deAloe vera y colgeno, yforma parte de un proyecto de investiga-cin experimental coordinado por profeso-res y enfermeros que trabajan en proyec-tos de desarrollo de nuevas tecnologaspara el tratamiento de heridas. El caso dereferencia fue elegido entre muchos pa-cientes en seguimiento. Los datos fueronobtenidos por la anamnesis y el examen f-sico del paciente, utilizndose un instru-

mento con datos relativos a las condicio-nes del paciente y de la lesin, as como unregistro fotogrfico de la lesin. Las cura-ciones se realizaron diariamente, al cabo deaproximadamente diez semanas se obtuvola curacin total. No se observ incomodi-dad o cualquier otra complicacin deriva-da de la utilizacin del producto, por lo quese concluye en que el tratamiento demos-tr una buena tolerabilidad y eficacia tera-putica para este caso particular.

DESCRIPTORESCicatrizacin de heridas.Teraputica.Aloe.Colgeno.Enfermedad crnica.Heridas y traumatismos.

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INTRODUCTION

Chronic wounds can be defined as those that do not spon-taneously heal within three months and which frequentlydevelop into an infectious situation. They can be consideredcomplex wounds, especially when associated with systemicpathologies that impede the healing process(1).

Leg ulcers are among chronic wounds. These are veryfrequently observed in medical practice and require exten-sive financial resources for their management. Leg ulcersare characterized by limited or irregular loss of dermis orepidermis and can reach the subcutaneous and underlyingtissues. It affects the extremities of inferior limbs and itscauses are commonly related to problems in the arterial orvenous vascular system(2).

The most common cases of leg ulcers occur betweenthe ages of 30 and 80. They occur due to functional alter-

ations that cause not only gradual reduction of renewal ofthe epidermis (30% to 50%) but also a diminishing of gradualskin repair and injuries and collagen deposits(3).

It is estimated that from 80% to 85% ofcases of leg ulcers are caused by chronicvenous insufficiency(2) and 5% to 20% accruefrom ischemia due to arterial insufficiency,usually due to the progression of atheroscle-rosis. Clinical disorders, which usually accom-pany this condition, are diabetes mellitus(DM) and systemic arterial hypertension(SAH)(4).

Feet are particularly vulnerable to circu-latory and neurological damage and the leastinjury might cause ulcers and infections.These are more common and develop morerapidly in the presence of DM(5). Simply controlling glucoselevels, though essential, does not necessarily ensure theselesions will heal. They often develop into necrosis and in-fectious situations that may even lead to amputation(1).

Ulcers are usually located in the instep of a foot and aresmall (1.5cm2), though healing is reached in 60% to 80% ofthe patients(6-7). The average time these lesions take to healwith medical treatment is ten weeks, with chance of re-

lapse between 13% and 44% after the first year and 60%after two years(7-8).

Given its chronic nature and probability of relapse overshorter or longer periods of time, these ulcers can havepsychosocial repercussions for patients as they requirechanges in lifestyle, prolong the time individuals need tobe away from family life, and alter individuals self-image,which affects individuals at different levels of intensity, andlimits daily activities. For health care facilities, it increasesexpenses with supplies and specialized care.

Considering these implications, high-tech dressings havebeen developed and applied to enable better means of

healing, and their use is associated with critical and con-tinuous assessments and to a therapy based in a holisticperspective(9). From this perspective, experimental studiesbased on medicinal herbs and other elements that act onthe healing process are being developed and include re-search addressing the use ofAloe vera and collagen.

Aloe vera has been used in traditional medicine to cureseveral ailments such as skin diseases, injuries caused byirradiation, eye diseases, intestinal disorders and viral dis-eases. It presents healing, anti-inflammatory, and skin pro-tection, in addition to bactericidal and laxative propertiesand detoxifying agents.Aloe is frequently used on skin le-sions due, mainly, to its emollient and soothing power. Inaddition to the vitamins C, E, complex B and folic acid, itcontains minerals, essential amino acids and polysaccha-rides that stimulate tissue growth and cell regeneration(10).

The application of a rectalAloe-based ointment to treathemorrhoids and anal fissures showed effective results,

which according to patients, presented no side effects. Itsuse has been recommended as an additional therapy totreat these diseases, not only due to its effective action but

also because it is an easily produced, cheapand easily accessible product(11). Its use in thetreatment of psoriasis, acne and dermatitisimproved lesions in 47.7% and healed lesionsin 45.5% of the studied patients(10).

Collagen is the most abundant protein inanimals. The biomaterials created from col-lagen are alternative therapies with severalapplications in the medical and dentistry

fields, since they present great biocompatibil-ity and the ability to promote wound heal-ing. In the biomedical field, it has been usedto repair abdominal walls, tendons, liga-

ments, and wounds, among other issues(12-13).

Studies evaluating the application of new biomaterials andseveral medical-hospital products are relevant for the treat-ment of wounds because they seek ways to expedite the heal-ing process, minimize the discomfort of patients, facilitate thecare delivered by the nursing and multiprofessional teams andreduce hospitalization and healthcare costs.

From that perspective, this study reports the clinical case

of a diabetic and hypertensive patient, who carries an is-chemic wound, treated with non-conventional Aloe veraand collagen-based dressing.

METHOD

This case report is part of an experimental researchproject entitled: Assessment of the Therapeutic Efficacyof VERHAGAZE(a), coordinated by professors from the

Studies [...] of newbiomaterials [...] are

relevant for thetreatment of woundsbecause they seek

ways to expedite thehealing process,

minimize the discomfortof patients...

(a) MBM Farmacutica Ltda.

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Departments of Chemistry, Medical-Surgical Nursing andAdministration, and the Health Technical School at theParaba Federal University, carried out jointly with nursesfrom the Lauro Wanderley University Hospital, who workwith projects addressing new technologies to treatwounds.

The implementation of this product in human beingswas initiated after the project was approved by CEP (ap-proved on March 9, 2006, N 0002-06) and authorized bythe National Health Surveillance Agency (ANVISA). It wascarried out in the outpatient unit of a public hospital inJoo Pessoa, PB, Brazil.

The dressing was composed of sterile gauze for topicaluse, with extract ofAloe vera in gel (1.5ml), collagen (2.0g),glycerin (5.3ml) and paraben preservatives (0.1g) includedin its composition.

Patients were selected according to the following crite-

ria: older than 21 years of age; consenting to participate inthe study through a free and informed consent form (Reso-lution n 196/96 of the National Health Council(14)), and sys-tematically attending the health service to change the dress-ings. Patients were first informed of the studys objectives,their right to withdraw at any time, and their confidential-ity was ensured. The studied case was selected among theremaining follow-up patients.

Data collection was carried out on a daily basis throughthe application of an instrument containing the followingvariables: identification data (age, gender, occupation, ad-mission, specialty, diagnosis); conditions inherent to the

patient (smoking, alcoholism, nutritional conditions, mo-bility, history of current disease, previous treatments, medi-cation); assessment of lesion (type, location, microbial con-tent, exudate, edges, adjacent skin, pain, measurement)with a blank space for additional notes if necessary.

Physical assessment and anamnesis were first collected,then the therapeutic course was chosen according to thisassessment. The aspects previously described were consid-ered in evaluating the lesions. Pain was evaluated accord-ing to the patients reports, the intensity of which was clas-sified as low, moderate or intense, and as continuous, in-termittent, nocturnal, when walking, when one is touchedor at rest.

Other items such as sensitivity to the formula compo-nents, increased pain and lesions dimensions, bleeding,infection and development of necrosis or increased area ofnecrosis were aspects systematically observed as potentialadverse reactions to the product. These items were evalu-ated based on the observation of the lesions characteris-tics and symptoms reported by patients. All observations

were recorded daily in the instrument after the dressingwas applied. During this procedure, weekly photographicrecords were taken to permit visualization and follow-upof the case by the members of the research group duringmonthly meetings. Due to the difficulty in standardizing alinear measurement of the lesion among professionals who

applied the dressings, the researchers decided to follow thedevelopment of the studied case, that is, the reduction ofthe lesions dimensions, through photographic records,since this is one way to evaluate wounds.

The lesion was cleaned with warm saline solution at0.9% using a 20cc syringe and a 40x12 needle to irrigatethe area, aiming to achieve 8 to 15 psi. The perilesionalarea was cleaned and dried with gauze and then the dress-ing was applied on the moist wound, which was coveredwith a dry gauze, wrapping the foot with a crepe bandage,fixed with tape.

CASE REPORT

D.C.M, 52 years old, male, driver, resident in Santa Rita,PB, Brazil, is a diabetic and hypertensive patient taking Fu-rosemide 40mg twice a day and hidrocloritiazida 25mgtwice a day, sought out the outpatient clinic and reporteda traumatic injury that had not healed for four months. Thepatient did not report any previous injury with a difficulthealing process. The physical assessment indicated a goodgeneral condition, consciousness, lucid, active, well-nour-ished, normal colored, walking unaided, with a lesion onthe left foots instep; wound bed with granulation tissueand tendon exposed; a small amount of odorless sero-he-

matic exudation; slightly swollen and well-defined edgesadhered to the bed and small areas with fibrin; adjacentskin with slightly ischemic areas, cold to palpation; regularand filiform posterior tibial pulse; preserved peripheralperfusion; with edema in the affected limb. Intermittentpain, intense to the touch (during irrigation with saline at0.9%) and moderate when walking (changes upon admis-sion on June 12, 2006).

The first assessment was on June 12, 2006, whichshowed that the injury was caused by a mechanical traumaculminating in an ischemic ulcer (Figure 1). The adoptedtreatment was cleaning the lesion with jets of saline solu-

tion at 0.9% followed by the application of the dressing (Fig-ure 2). A similar procedure was used in the following dress-ings. In addition to care directly related to the affected areasuch as rest, hygiene, protection against new trauma, rec-ommendations were given concerning the need to followthe prescribed diet, and systematic use of medication tocontrol glucose levels and high blood pressure as funda-mental elements for treatment success.

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Figure 1 - Left foot instep. First assessment (June 12, 2006) Figure 2 - First application of Aloe vera and collagen-based

dressing (June 12, 2006)

On June 26, the bed wound presented granulation tis-

sue covering the tendons, with only one tendon with smallexposed area; yellow secretion in small quantity and odor-less; edges with fibrin in contraction and epithelialization;the patient reported slight pain during the lesion cleans-ing. To the patients and the groups satisfaction, only 16days after the dressing was applied, satisfactory develop-ment was observed. The patient was asked whether he hadfollowed the recommendations concerning care of the af-fected area and control of the underlying conditions; heanswered yes. Recommendations were reinforced anddoubts were clarified whenever necessary.

On July17, the lesion presented granulation tissue to-

tally covering the wound bed; slight serous exudate, regu-lar edges in progressive contraction, shiny perilesion with-out cutaneous maceration. At this point, the patient nolonger reported any pain. The fact the product kept thelesion moistened and did not cause cutaneous maceration,and also kept the perilesional skin shiny caught the atten-tion of the researchers because it demonstrated theproducts moisturizing action.

On July 31, the presence of epithelial tissue covering much

of the wound bed, forming a yellow crust on the edges andabsent exudation, was observed. The patient did not reportany pain. On August 7, the newly formed epithelium was cov-ering almost the whole wound surface and a yellow crust cov-ered the edges. However, it did not interfere in the healingprocess, and re-epithelization and diminished extension ofwound was observed. On August 14, the granulation tissuewas almost imperceptible due to the formation of clear pinkepithelium. The crusts autolytic debridement gradually pro-gressed, without causing discomfort to the patient (Figure 3).

The treatment with the product finally ceased on August22; it lasted two months and 11 days (Figure 4). The formation

of a scar with an area that corresponded to approximately of the lesion area at the beginning of the treatment was ob-served, evidencing a quite satisfactory contraction process andnewly formed tissue. Although the healing process was com-plete, recommendations concerning care for the scar to pre-vent new trauma and the importance of self-care related toSAH and DM was reinforced in order to minimize vascular com-plications that might lead to the emergence of new lesions.

Figure 3 - Assessment on August 14, 2006 Figure 4- Scar on August 22, 2006

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Progressive improvements were observed during thetreatment considering that appropriate moistening wasmaintained from the beginning to the end of the treat-ment. Neither maceration on the edges or on adjacentskin was observed. The wound diminished in size, withedge contraction, and progressive formation of granula-

tion tissue and epithelial granulation at each assessmentwere evidenced. The lesion completely healed after ap-proximately ten weeks of treatment, evidencing the effi-cacy of the dressing in regard to tissue repair over theperiod indicated by the literature (15-16) in patients withappropriate follow-up.

No complication was observed during the applicationof the product. On the contrary, the intense pain manifestedduring the irrigation in the cleansing process progressivelylessened until it completely ceased, even before healing wascomplete. The product was efficient in the treatment ofthe studied case and did not cause any complication or dis-

comfort to the patient. It is important to note that the suc-cess of the treatment is also a result of the patients com-pliance with recommendations concerning the underlyingconditions (SAH and DM) and care of the injury.

FINAL CONSIDERATIONS

This study showed the experimental results of the ap-plication of a non-conventional Aloe vera and collagen-based dressing on an ischemic lesion in a patient with sys-temic arterial pressure and diabetes mellitus. The complexhealing process in patients with these conditions requiresspecial care related to glucose control, blood pressure lev-

els, nutrition and rest, and direct care of the lesion, involv-

ing the choice of dressings that facilitates an ideal environ-ment to promote lesion epithelization. Hence, this studyled the group of researchers to reflect on the importanceof treating a patient with a lesion in a holistic way and alsoof seeking alternative treatments through studies investi-gating responses to new dressings.

Although the application of this product presented suc-cessful results, this studys findings are not sufficient toconfirm its efficacy, nor even to make generalizations. Onlythe analysis of an experimental study with a larger samplecan provide further explanations of the use of this producton this type and other types of lesions, as well as its effectson the healing process and potential discomfort, sensitiv-ity and adverse reactions of patients, though no complica-tion or discomfort was identified in the studied case.

Despite the studys relative limitation due to the diffi-culty in standardizing the procedure of taking linear mea-surements of the lesion, the photographic record was a sat-isfactory resource to evaluate the development of the lesionin response to the products application, showing full heal-ing within the expected period of treatment of a patient withappropriate follow-up by qualified professionals.

Contributing to the cure of lesions through the testingofAloe vera and collagen reaffirms the significant role ofnursing in the development of new alternatives for the treat-ment of wounds, and moreover, it strengthens the gratify-ing feeling of delivering integral nursing care, contributingto the self-esteem of patients with lesions. Humanized andquality nursing care is undoubtedly a factor of great rel-evance to be considered since it positively influences the

personal and social life of these patients.

REFERENCES

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12. Costa OR, Veinsten FJ. Utilizacin de colgeno en grnulos en

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Correspondence addressed to: Pascalle de Sousa RochaRua Ruy Tavares Costa, 274 - Bairro AltiplanoCEP 58046100 - Joo Pessoa, PB, Brazil

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