Use of Chitosan-Based Dressings for the Management of a Chronic Lower Limb Ulcer

A Case Report

Madhukar Kulkarni, MS; Sanjay Deshpande, MS; Sumedh Lokapure, MD

Disclosures

Wounds. 2022;34(2):e13-e16. 

In This Article

Abstract and Introduction

Abstract

Introduction: Nonhealing ulcers are difficult to manage because they deviate from the normal wound healing process. The standard treatment with saline dressings is not efficient in treating patients with such wounds; advanced wound care dressings are needed. Chitosan-based advanced wound dressings are gaining popularity because of their unique characteristics, such as absorbency, conformability, and pain alleviation at the wound bed. A case of an ulcer that developed after cellulitis and healed with application of a chitosan-based dressing is presented.

Case Report: An 81-year-old female with hypertension was admitted to the hospital with a high-grade fever, generalized weakness, anorexia, and right lower limb pain with redness. Venous insufficiency in the right lower limb in the form of early insufficiency at the right saphenofemoral and saphenopopliteal junctions along with right leg varicosities was evident on color Doppler ultrasound. A diagnosis of cellulitis was made; the patient was treated with antibiotics and discharged from the hospital. The cellulitis progressed, and an incision and drainage of the right leg was performed on the second admission. The patient was admitted twice more, and the wound was surgically debrided twice and antibiotics were administered. During this period, the patient was treated with saline dressing changes for almost 4 weeks. Because the wound was nonhealing and infected during the fourth hospital admission, chitosan-based dressings were used. Daily dressing changes for 10 days resulted in 100% granulation tissue. Later, the patient underwent skin grafting and was eventually discharged.

Conclusions: The use of chitosan-based dressings resulted in progression to complete granulation, along with the management of exudate, pain, and Pseudomonas infection. The results of this case suggest patients with nonhealing ulcers may benefit from early use of advanced wound care dressings.

Introduction

Chronic ulcers are arrested in the inflammatory phase and generally do not proceed to the proliferative stage, resulting in delayed wound healing.[1] The serious complications of ulcers include septicemia, bone and joint infections, and gangrene. Management of the ulcer depends on ulcer severity and involves removal of dead tissue, administration of antibiotics in cases of clinical infection, and use of pain medications to relieve discomfort.[2] In patients with poor blood circulation or who are affected by blood disorders, treatment of ulcers can be prolonged in comparison with those who are not afflicted (normal population), and application of various methods may be necessary to improve circulation before ulcers can be treated.[3]

Cellulitis, which is a cause of leg ulceration, is an acute skin infection involving the dermis and subcutaneous tissues.[4] Patients with comorbid conditions such as diabetes, immunodeficiency, or impaired circulation are at increased risk of cellulitis. Moreover, in patients older than 65 years, cellulitis of the lower extremity is likely to lead to thrombophlebitis.[4] Cellulitis is usually managed with antibiotics; lack of treatment or delayed treatment places patients at risk of potentially serious problems such as sepsis, kidney damage, or the formation of leg ulcers.[5] The complications of cellulitis can be serious and can include extensive tissue damage, which may lead to gangrene. The infection can also spread to the blood, bones, lymphatic system, heart, or nervous system, resulting in amputation, shock, or death.

Treatment of ulcers depends on the type of ulcer. Arterial ulcers require primary treatment to restore blood circulation to the affected area in addition to the administration of antibiotics to mitigate symptoms. Venous ulcers—the most common type of leg ulcer—can take months to heal fully. Management of these ulcers focuses on improving blood flow to the affected area; antibiotics are administered only in cases of clinical infections.[2] Chronic ulcers are typically heavily exudative, and the exudate contains inflammatory proteases and cytokines that are capable of attacking surrounding healthy skin if the exudate is not removed efficiently from the wound surface.[2]

A moist wound environment is essential in all phases of wound healing. It accelerates the reepithelialization process and collagen synthesis. It also facilitates the action of growth factors as well as keratinocyte and fibroblast proliferation, and it promotes angiogenesis.[2]

Necrotic tissue in chronic wounds can impair healing and impede keratinocyte migration over the wound bed. Debridement, or the removal of nonviable wound tissue, is essential to good wound bed preparation. Debridement can be performed using surgical, autolytic, enzymatic, biologic, or mechanical methods.[6] As the bacterial load increases to the point of critical colonization on wounds, healing becomes impaired as the result of local infection.[7] Infection may spread into surrounding tissues, resulting in deep infection, which may progress to systemic infection.[6] Addressing local wound infection using cleansing agents and topical antimicrobial agents can improve healing.

Various techniques are used in managing chronic wounds, such as wound dressings, negative pressure wound therapy, adjuvant wound therapies, and advanced dressing methods.[8] The 3 broadest categories of wound dressings include those that facilitate autolytic debridement, adjust moisture levels at the wound bed, and control the bacterial load.[9] The advanced wound care dressings are alginates, foams, hydrocolloids and hydrogels, iodine and silver-based preparations, and oxidized regenerated cellulose.[8]

Other advanced technologies currently in development involve the use of chitosan, which is a highly biocompatible and biodegradable polymer obtained from the shells of crustaceans. For over a decade, chitosan-based dressings have advanced the development of wound care dressings. They are particularly useful in wound management because of their nontoxic bacteriostatic and fungistatic properties.[10] These dressings have been successfully used to manage wounds of varying sizes and etiology, including chronic ulcers, diabetic foot ulcers, pressure ulcers, vascular ulcers, chronically infected wounds, traumatic wounds, postoperative wounds, and leg ulcers, as well as complex conditions such as epidermolysis bullosa.[11–14] One such dressing is MaxioCel (Axio Biosolutions Private Limited), which was developed using 100% chitosan. The dressing also has the advantage of transforming into a cohesive gel matrix on contact with the wound exudate.

This case report describes the effective use of a bioactive microfiber dressing following unsuccessful attempts to use conventional methods to achieve wound healing of a chronic right lower limb ulcer that developed after cellulitis. The patient described in the case provided informed consent to publish this report.

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