Innovative new treatments are set to transform care for people with chronic wounds, as Mark Greener discovers

Chronic wounds are unpleasant, distressing and disabling. And they’re common. Some 200,000 people in the UK live with chronic wounds, such as leg, pressure and diabetic ulcers.

Essentially wounds that don’t heal within six weeks to four months, chronic wounds can cause excruciating pain, anxiety and depression, and the offensive smell can lead to social isolation. Severe ulcers can expose muscle, bone, tendons and joints, and even end in amputation. In fact, recent figures suggest that there is an amputation every 75 minutes in England due to diabetes alone.

However, new treatments may offer people with chronic wounds renewed hope. Many of these treatments are, at first sight, unexpected, as they use sound, electricity and the contents of the average kitchen cupboard to aid healing.

A common problem

During a meeting of the European Wound Management Association (EWMA) in London earlier this year, researchers from Dublin reported that about one person in every 27 (3.7 per cent) had at least one wound. Surgical wounds accounted for about two-fifths of these (42.7 per cent). Almost one in five people had leg ulcers (18.9 per cent), one in 10 had pressure ulcers (10.3 per cent) and one in 20 had diabetic foot ulcers (5.2 per cent).

Two-thirds (67.6 per cent) of wound patients had one wound, but one patient had 11. And almost one in 12 (8.5 per cent) of the patients had chronic wounds that persisted for more than five years.

Another study presented at the EWMA, from Birmingham and Solihull, included 452 patients with chronic wounds. Of these, 2.9 per cent had multiple wounds, with leg ulcers being the most common and accounting for a quarter (26 per cent) of chronic wounds. The same proportion of wounds persisted for at least 12 months.

Shocking advances

Over the years, several treatments for chronic wounds have reached the market, including simple dressings, skin substitutes and breathing pure oxygen. But as the figures above suggest, none are very effective. However, recent innovations seem set to transform the care of people with chronic wounds.

Ultrasound, for example, images babies in the womb and allows doctors to examine tissues that x-rays can’t reveal. But now, new research published in the Journal of Investigative Dermatology in July has found that ultrasound transmits a vibration through the skin that stimulates cells in wounds, which accelerates healing.

“Skin ulcers are excruciatingly painful for patients and, in many cases, can only be resolved by amputation of the limb,” says lead author Dr Mark Bass, from the University of Sheffield. “Using ultrasound wakes up the cells and stimulates a normal healing process. Because it is just speeding up the normal processes, the treatment doesn’t carry the risk of side effects that are often associated with drug treatments.”

In studies of old mice with diabetes, ultrasound reduced healing times by 30 per cent, restoring the speed of recovery to that seen in young, healthy animals. Ultrasound also recruited fibroblasts – a cell important in healing – into the wound. Clinical studies are needed and researchers believe that “refining the treatment” could improve the benefits.

Nevertheless, Dr Bass notes that “because ultrasound is relatively risk free, we could expect to see it in broad clinical use within three or four years.” Another new approach uses electricity to accelerate wound healing. Researchers from the University of Manchester created two halfcentimetre, harmless wounds on each upper arm of 40 volunteers.

The wounds on one arm, acting as the control, healed normally. The other wounds were treated with electrical pulses over two weeks, which stimulated the formation of new blood vessels. This, in turn, increased blood flow to the wound and resulted in faster healing.

“This research has shown the effectiveness of electrical stimulation in wound healing, and therefore we believe this technology has the potential to be applied to any situation where faster wound healing is particularly desirable, such as following human or veterinary surgical wounds, accidental or military trauma and in sports injuries,” remarks principal investigator Dr Ardeshir Bayat.

Maggots and spices

For centuries, traditional healers used maggots to clean wounds and, for several years, doctors have used larvae of the common green-bottle fly to treat chronic wounds. It sounds unpleasant, but they remove dead tissue, disinfect the wound and accelerate healing. Indeed, research published in Antimicrobial Agents and Chemotherapy in May reported that maggots produce at least 47 proteins that attack many bacteria in wounds.

New wound dressings and adhesive bandages could contain synthetic versions of these proteins. Traditional healers have also used honey to aid wound healing for millennia and several modern wound care products now contain medicalgrade honey, which counters infections and reduces inflammation. However, honey isn’t the only mainstay of the kitchen cupboard that helps wounds heal.

Certain bacteria can form communities called biofilms that are often surrounded by a ‘wall’ of proteins, sugars and other chemicals. These often form on chronic wounds, making it tough for antibiotics to reach the bacteria. However, researchers have found a new way to package antimicrobial compounds from peppermint and cinnamaldehyde – the chemical responsible for the flavour and aroma of cinnamon – in tiny capsules that kill biofilms and actively promote healing.

The new material, reported in ACS Nano in June, could become a topical antibacterial and disinfectant. The researchers packaged both peppermint oil and cinnamaldehyde into nanoparticles of silicon dioxide – sand’s main constituent.

The average size was just 150 nanometres – that’s about the same size as the distance your nails grow in two-and-a-half minutes – and they could get about 660 of the silica nanoparticles across the diameter of an average human hair. The microcapsules were effective against four types of bacteria, including one that was antibiotic resistant, and promoted growth of fibroblasts.

Reducing the burden

A quarter of people with diabetes develop skin ulcers, particularly foot ulcers that, in some cases, lead to amputations. Indeed, the number of diabetes-related amputations is at an “all-time record high”, according to a new analysis by Diabetes UK. The high glucose levels in the blood of people with diabetes can damage the nerves carrying messages from the feet to the brain.

Therefore people with diabetes may not realise when they tread on something sharp, develop a blister due to tight shoes or if a bath is too hot, and so are less likely to protect small wounds. In addition, their skin may not heal as well as those without the disease and, as a result, damage can worsen quickly, developing into ulcers. According to Diabetes UK, the average number of diabetes-related amputations in England was 7,042 a year between 2011 and 2014.

This compared to 6,677 annually between 2010 and 2013. The charity says that good diabetes management and foot care would potentially avoid up to 80 per cent of these amputations. “The number of diabetes-related amputations is now at an all-time high of 135 per week in the UK, but many of these amputations could be prevented with better care and support,” says Libby Dowling, Diabetes UK clinical advisor.

So what should pharmacy assistants look for? “The danger signs of a diabetic wound include a foot that’s red, warm or swollen; a break in the skin; any discharge or oozing, or feeling unwell,” Libby told Training Matters.

“If a person with diabetes presents any of these symptoms to their pharmacy team, they should be referred to their GP, foot protection team or A&E if out of hours, straight away. This is because these signs suggest an infection, which, if not treated immediately, can lead to an amputation.”

In addition, pharmacy assistants can suggest that people with chronic wounds should see their GP or practice nurse. As mentioned above, there are numerous new treatments on the horizon and, as NHS Direct notes, wearing compression stockings, losing weight and good skincare can all help protect against venous leg ulcers.Compression stockings, for example, squeeze the legs, which improves circulation.

Most compression stockings are tightest at the ankle and gradually become looser up the leg. This encourages blood to flow upwards, back towards the heart. Users should wear the stockings at all times when they are out of bed.

Certainly, there is a need to educate and inform people with chronic wounds. For example, researchers from Bradford interviewed 50 patients at high risk of pressure ulcers. The researchers told the EWMA that a quarter (24 per cent) of patients did not know what a pressure ulcer was, despite receiving information about prevention.

About half (52 per cent) correctly recognised that pressure ulcers could occur at several sites around the body. However, only 18 per cent knew that they should tell a healthcare professional if their skin was sore. What’s more, only 58 per cent of patients were aware that nurses had told them that they were at risk of developing a pressure ulcer, while 24 per cent realised that poor mobility was a risk factor and understood the importance of repositioning.

Researchers re-interviewed nine patients the following day and found that understanding had improved, which underscores the fact that education can make a difference. Pharmacy assistants can therefore suggest sources of additional information and support, including nurses, GPs and NHS Direct. Diabetes UK has also published a guide to foot care.

It’s worth making an effort to educate and inform patients and carers. The advances in management are welcome and exciting. But when it comes to chronic wounds, prevention really is better than cure.

Diabetes-related amputations are now at an all-time high of 135 per week in the UK, but many of these amputations could be prevented with better care and support