Advanced Wound Care

Kevin Foster, MD, MBA, FACS

Medical Director, Director of Surgical Research, Program Director of the General Surgery Residency Training Program at Maricopa Integrated Health System

Karen Richey, RN, BSN

Manager of Burn, Surgery and Trauma Research

Britni Ferguson, PA-C

Arizona Burn Center

The Arizona Burn Center at Maricopa Medical Center – Phoenix, Arizona

MEDIHONEY Wound GelThe Use of MEDIHONEY Wound Gel in the Non-operative Management of a Deep Partial Thickness Flame Burn to the Face.

MediHoney®

Advanced Wound Care PREPARE

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Active Leptospermum Honey pH: 3.5–4.5

Neutral

The low pH of Medihoney® helps to lower the pH within the wound environment,6,7 which has been shown to have wound healing benefits.8

Wound bed

Dermis

Subcutis

MEDIHONEY®’s high osmotic potential draws additional fluid from the deeper tissue to the wound surface, aiding the body’s natural processes to cleanse debris and necrotic tissue from the wound.9

IntroductionFacial burns, especially deep partial thickness burns present unique challenges to the burn care team. No other anatomic area is as cosmetically and visually important as the face. Excision and grafting of face burns uniformly lead to outcomes that are suboptimal1 both in terms of tissue elasticity and post healing appearance. Additionally, suboptimal outcomes can negatively impact the patient’s psychological state2 and ability to overcome the trauma of the original injury. Therefore, techniques to conservatively manage burns of the face are very important.We describe the use of medical grade honey gel (MEDIHONEY®) in the successful management of a deep partial thickness face burn in a young female patient where surgery was not the preferred intervention.The use of honey for healing goes back thousands of years, to ancient Egypt and Greece. Honey has unique methods of action which prepare the wound bed to heal and assists in autolytic debridement.3-5 These methods of action include pH modulation and a high osmotic effect. Honey has a low pH (3.5-4.5) which helps to reduce the pH of the wound environment, contributing to a more acidic environment conducive to healing.6-8 The high osmotic effect, created by the high sugar content of honey, promotes an increase flow of fluid from deeper tissues to the wound surface to help soften and liquefy non-viable tissue.3-5

MEDIHONEY® is a medical grade honey derived from the Leptospermum species of the tea tree bush with properties that are beneficial throughout the phases of the healing process. The honey is gamma irradiated for sterility and is available in several dressing formats which enable easy and efficient application in burn care. This paper provides the results of the use of MEDIHONEY® Gel on a critical, deep partial thickness burn to the face. MEDIHONEY® is indicated for partial thickness burns. Please see the package insert for complete product information and directions for use.

Key Mechanisms of Action

High Osmolarity Low pH Level

MediHoney®

Advanced Wound Care PREPAREClinical History and Background The patient was a 21 year old female who suffered burns to 50% of her total body surface area. The injury occurred on October 16, 2013 and was the result of a house explosion. It was believed that the patient detonated a natural gas leak when lighting a candle. Upon admission and assessment of her injuries, the patient was put into a temporary medically induced coma (a high dose of analgesia and anxiolytic) with aggressive surgical debridement performed to her hands and bilateral extremities the following day. The burns suffered to her face were believed to be a deep dermal burn and the initial treatment included Sulfamylon applied to the ears and nose and Silvadene to the face. On Day 2 (10-18-2013) after admission, the current management to the face was not debriding or breaking down the eschar adequately and the decision was made to change to MEDIHONEY® Wound Gel. The MEDIHONEY® Wound Gel was impregnated into Xeroform® gauze and applied to cover the entire face including eyelids and ears. After application, a gauze wrap and a burn net was applied on top to keep dressings in place. The dressings were changed daily as per facility protocol. No other therapy or care modality was added to this daily routine for the patient’s face.

The first images taken where on Day 5 (10-21-2013) denoting the extent of trauma and facial eschar present. This image was taken after the dressings were removed and the area was cleansed to assess the tissue. Daily dressing changes involved cleansing with soap and water and a wash-cloth, or Norsen® Debrider spatula, to gently lift off the softened or liquefied eschar, and then reapplying the MEDIHONEY® Wound Gel impregnated dressing. During the next seven days, softening of the eschar with complete debridement in various facial areas was noted by staff.

Images on Day 12 (10-28-2013) depict this wound improvement, including a reduction in non-viable tissue and healthy granulation tissue formation. No surgical intervention was performed and the staff continued the daily MEDIHONEY® dressing changes.Continued advancement in granulation tissue formation and complete epithelialization in various areas were noted on Day 19 (11-04-2013). It was observed that the patient’s cheek, nose and chin area were healing faster than the tissue on the patient’s forehead. To accommodate this, treatment for the forehead was changed from MEDIHONEY® Wound Gel impregnated onto Xeroform® to the MEDIHONEY® HCS dressing.

Without any surgical or other intervention than MEDIHONEY® GEL and the MEDIHONEY® HCS dressings, the image on Day 58 (12-16-13) shows the patient’s face was nearly healed 2 months after the initial burn injury. The patient was discharged to an acute rehab facility a month after this image was taken (1-10-2013).

Discussion and ConclusionDeep partial thickness burns present a dilemma to the burn surgeon especially when they impact the face. The outcome with the use of MEDIHONEY® on this deep partial thickness face burn is compelling. The patient demonstrated excellent healing outcomes and post healing appearance. Using this one product from the acute burn phase through to healing enabled a simple plan of care for the staff. Most importantly, the patient was able to avoid potentially multiple surgeries and an uncertain cosmetic outcome. As of this publication, the patient is under a plan of care to reduce the isolated areas of redness and for continual improvement in cosmetic appearance. We hope to update this case in the future.

Overall, the result of this case was encouraging and suggests that incorporating MEDIHONEY® into a burn care regimen for face burns and deep partial thickness burns may be very beneficial.

Day 5 (10-21-13)

Day 58 (12-16-13)

Day 19 (11-04-13) Day 12 (10-28-13)

8.5 Months

Post Initial Injury (6-27-14)

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Derma Sciences, Inc.104 Shorting RoadToronto, Ontario M1S 3S4 i Canada

Manufacturer:

Availability of these products might vary from a given country or region to another, as a result of specific local regulatory approval or clearance requirements for sale in such country or region.n Non contractual document. The manufacturer reserves the right, without prior notice, to modify the products in order to improve their quality.n Warning: Applicable laws restrict these products to sale by or on the order of a physician.n Consult product labels and inserts for any indication, contraindications, hazards, warnings, precautions, and instructions for use.

Additional information for EMEA Customers only: Products mentioned in this document are CE class I devices. All the medical devices mentioned on this document are CE marked according to European council directive 93/42/EEC on medical devices and its relatives, unless specifically identified as “NOT CE MARKED”.

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MediHoney®

Advanced Wound Care PREPARE

Integra New Zealand

Timeline Summary of MEDIHONEY® Treatment

First images taken showing 100% facial eschar present. This is day 3 of the Medihoney® treatment. Images were taken post cleansing and prior to redressing with MEDIHONEY® Wound Gel.

• MEDIHONEY® Wound Gel; full face and ear coverage

• Impregnated onto Xeroform® gauze

Significant autolytic debridement to soften and liquify the facial eschar. Wound healing in progress with appropriate formation of granulation tissue.

Chin, cheeks and nose have re-epithelialized and closed. Forehead has healthy appearing granulation tissue with re-epithelialization beginning to appear at the edges.

• Protocol modified to MEDIHONEY® HCS sheet dressing for the forehead area

Face nearly healed 2 months after initiating MEDIHONEY® treatment. No surgical intervention was performed. Images show epithelium working to close from outside in.

Accident Occurred: 21 year old female suffered burns to her body and face as the result of a gas explosion in her home.

Decision was made to switch to a daily treatment of MEDIHONEY® Wound Gel due to the lack of progress of the current topical intervention of Sulfamylon and Silvadene to breakdown the facial eschar.

Day 1

Day 2

Day 5

Day 12

Day 19

Day 58