Successful Management of Complex Pediatric and Neonatal Wounds With Methylene Blue and Gentian Violet Foam Dressings

Vita Boyar, MD

Disclosures

Wounds. 2021;33(10):253-259. 

In This Article

Results

Eight cases (100%) demonstrated successful debridement, antibacterial coverage, exudate absorption, decreased wound edge thickness, and appropriate wound bed preparation for successful healing using MB/GV foam dressings. Six wounds (75%) were observed to heal completely, and 2 wounds were healing well when patients were transferred to a different facility and lost to follow-up.

Negative pressure wound therapy was considered for but not used in 3 wounds (cases 5, 7, and 8). Reasons for not using NPWT were as follows: challenging location in all 3 cases, and in 2, both involving pressure injuries, concerns existed for osteomyelitis, which precluded NPWT use. The MB/GV PVA foam was chosen because of the capillary wicking action of this dressing. A clean wound bed was achieved in all cases.

Additional wound care products were administered in 4 cases. Case 3 received hydrolyzed collagen powder (Hycol; Sanara MedTech Inc) because the wound had a slow healing trajectory. Case 4 received medical grade active Leptospermum honey (MediHoney; Integra Lifesciences), which the author's clinic typically uses in extravasation wounds. In case 8, hydrolyzed collagen powder followed by dehydrated amniotic membrane was used owing to the significant depth of the wound. Case 5 achieved complete slough removal and beginning of granulation tissue formation with the MB/GV PVA dressing alone. Thereafter, hydrolyzed collagen was added to complete closure. No side effects attributable to MB/GV foam dressings were noted. The Table describes the demographics and outcomes of all 8 cases. All cases are described in greater detail herein.

Neonatal Cases

Case 1: Giant Omphalocele. The patient was a 55-day-old infant, born at 33 weeks gestational age, with an almost fully epithelialized giant omphalocele, congenital cardiac defects, persistent pulmonary hypertension, and respiratory insufficiency. Omphalocele is a congenital abdominal wall defect in which an infant's intestine or other abdominal organs remain outside the body, secondary to failure to return to the intestinal cavity through the umbilical opening (Figure 1A).

Figure 1.

Case 1: newborn with a giant omphalocele (A) at initial presentation. (B) Areas of skin breakdown. (C) Two days after initial treatment with methylene blue and gentian violet foam covered by gauze dressing, decreased moisture was observed.

In this patient, skin breakdown, slough, and bacterial colonization with methicillin-susceptible Staphylococcus aureus developed on a portion of the omphalocele. The intestines were covered only by a thin layer of amniotic tissue. A sclerotic agent, silver sulfadiazine cream, was used to dry the amnion and epithelialize the omphalocele. Areas of skin breakdown presented with slough, constant thin exudate, and occasional bleeding (Figure 1B). The etiology was likely positional friction and shear against bed linens. Previous treatments were ineffective, including usage of skin polymer, silver foam, and gauze over the course of more than 10 days. Management was changed to MB/GV PVA foam, slightly moistened with normal saline, and covered with Kerlix gauze (Cardinal Health). The dressing was changed every 2 to 3 days. Decreased moisture was observed after the first change on day 2 (Figure 1C). Slough was minimized after 2 dressing changes. Exudate was manageable, and the wound was kept dry and further maceration was prevented. The wound completely healed within 10 days.

Case 2: Giant Omphalocele. The patient was 76-days-old, born at 36 weeks gestational age, with multiple comorbidities and giant omphalocele with an outer skin breakdown accompanied by constant oozing and maceration. Thin slough was observed. As in case 1, MB/GV PVA foam was applied (Figure 2A). Slough was removed after 2 dressing changes (4 days), and new granulation growth occurred within 1 week (Figure 2B), with complete epithelialization achieved by day 16.

Figure 2.

Case 2: giant omphalocele in a newborn. (A) Methylene blue and gentian violet foam saturated with exudate. (B) Clean and healing wound area, granulation, and epithelization are seen at day 8.

Case 3: Neonatal Peripheral Intravenous Catheter Extravasation. A 10-day-old patient was born at 33 weeks gestational age, with intrauterine growth retardation and sustained stage 4 extravasation. The wound required debridement because slough was prevalent (Figure 3A). Collagenase was covered by MB/GV PVA foam, and an outer silicone dressing was applied (Figure 3B). In addition, collagenase was applied daily. Noticeable improvement was seen by day 4 (Figure 3C), augmented by gentle mechanical monofilament debridement. The wound bed was clean by day 6. Methylene blue and gentian violet PVA foam was used to enhance debridement and reduce the antibacterial burden. Once the wound bed was clean, the proliferative stage was enhanced with hydrolyzed collagen powder, which was applied to the wound bed every 3 to 4 days and covered by a small piece of a perforated contact layer (Mepitel; Mölnlycke Health Care). The MB/GV foam was continued for 3 more days, after which management was transitioned to collagen covered by a secondary dressing. The wound healed completely by 3 weeks (Figure 3D).

Figure 3.

Case 3: intrauterine growth retardation and sustained stage 4 extravasation in a newborn. (A) Wound bed covered with slough. (B) Methylene blue and gentian violet dressing cut to shape on the wound. (C) Noticeable decrease in slough with islands of granulation tissue seen on day 4. (D) Healed wound.

Case 4: Neonatal Peripheral Intravenous Catheter Extravasation. This 20-day-old preterm patient was born at 29 weeks gestational age with peripheral intravenous extravasation. The wound was very irregular, with thickened edges and significant slough, and was slow to heal. A piece of foam dressing was cut to shape and applied to the wound. This foam dressing was changed every 2 days. The wound bed was clean after 3 changes. Methylene blue and gentian violet foam was continued for 3 more days, after which management was transitioned to medical-grade honey as per the unit's secondary dressing protocol. The wound healed within 2 weeks.

Case 5: Dehisced Colonized Surgicalabdominal Wound. An 8-day-old infant was admitted for nonbilious vomiting, abdominal distention, lethargy, failure to gain weight, and failure to pass stool for the prior 3 days. Radiographic examination raised suspicion for low intestinal obstruction, specifically Hirschsprung disease. Biopsy was positive for the lack of nerve cells (ganglions) in a large segment of the bowel. Part of the bowel was poorly developed and resected; temporary mucous fistula and an ostomy were created to allow growth before definitive surgery. Three days after surgery, the middle area of the original incision dehisced. This dehiscence was particularly challenging because it was between the stoma and mucous fistula (Figure 4). Initially, the surgical team managed the wound using hydrofiber (Aquacel; ConvaTec). However, the wound remained open with increasing slough and thickening edges. Swabs revealed the wound to be colonized with gram-positive bacteria. At that point, management was changed to MB/GV PU foam, which was cut to shape. An ostomy appliance was also placed over the stoma. Within 1 week, the edges were flatter, slough was removed, and the dehisced area was contracting with growing granulation tissue. Hydrolyzed Collagen (Hycol) was added twice, with the second application 3 days after the first, to complete epithelialization.

Figure 4.

Case 5: slough covering dehisced area.

Case 6: Peristomal Irritant Dermatitis. A 2-month-old infant developed peristomal dermatitis secondary to increased effluent and skin irritation from the appliance. Colostomy was originally performed as a result of intestinal malrotation and volvulus, requiring significant intestinal resection. Feeding intolerance was noted prior to admission, possibly due to the introduction of a new formula; this increased stoma output. Various treatments had been tried for 1 week, including crusting, skin polymer, zinc cream, and powder. An oversized MB/GV PVA ostomy dressing was placed around the stoma. A colostomy barrier ring and colostomy bag were placed on top of that dressing. The dressing successfully retained moisture, which allowed an increased interval between appliance changes (range, 8 hours–36 hours to 48 hours) and facilitated skin healing.

Pediatric Cases

Case 7: Sacral Pressure Injury. A 14-year-old male with Stevens-Johnson syndrome, systemic bacterial infection, shock, respiratory failure requiring intubation, and kidney failure was admitted. He continued to deteriorate and was placed on extracorporeal membrane oxygenation. The patient's hemodynamic status was very labile, interfering with effective repositioning. Multiple pressure injuries developed, including a stage 4 sacral injury with possible underlying osteomyelitis. This sacral wound required significant enzymatic and autolytic debridement and had copious exudate and thickened edges. Sharp and mechanical debridement were not considered as viable options because the patient was initially on heparin and disseminated intravascular coagulation with thrombocytopenia had also devel0ped. The use of MB/GV PVA foam provided strong wicking, enhanced exudate absorption, and debridement. After 1 week, the wound bed was cleaner. After 10 days, the edges were flatter and granulation tissue had begun to develop. The foam dressing was continued to maintain a healthy wound bed. The patient was transferred to a rehabilitation facility after 3 weeks.

Case 8: Sacral Pressure Injury. A 15-year-old male was admitted for respiratory failure, coming from a long-term rehabilitation facility. He had a history of cerebral palsy, non-mobility, and neurodevelopmental delay. On admission, a stage 4 sacral pressure injury was found. Wound infection was of concern because of the presence of slough, strong odor, tissue friability, periwound erythema, and rolled edges. Culture from the wound, tracheal secretions, and urine grew Escherichia coli. Systemic antibiotics were administered. Previous wound treatments had been attempted at the long-term rehabilitation facility, including silver-based packing, with no improvement (Figure 5A). Management was changed to collagenase covered with MB/GV PVA foam for 1 week (Figure 5B). The dressing was changed every 2 days as it was difficult to keep the wound clean of fecal matter. Mechanical debridement with monofilament pad was done with every change. After 8 days, the wound bed was clean. Management was changed to hydrolyzed collagen powder covered by MB/GV PU foam and eventually dehydrated amniotic membrane. A repeat wound culture on day 5 was negative. The patient was transferred to a rehabilitation facility and lost to final follow-up, but the wound was healing well prior to transfer (Figure 5C).

Figure 5.

Case 8: a sacral pressure injury in a 15-year-old male. (A) Initial pressure injury on presentation. (B) On day 7, there was decreased central slough area and increased peripheral granulation tissue. (C) Healing wound before patient transfer to a rehabilitation facility.

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