Nanocrystalline Silver as a Single Treatment

for Decubitus Ulcer: A Case Report

Vidya H. D. Ayuningtyas

, Suci Prawitasari

, Aunur Rofiq

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Brawijaya / dr. Saiful Anwar Regional

General Hospital, Malang, Indonesia

Keywords: Nanocrystalline Silver, Decubitus Ulcer, PUSH Scale.

Abstract: The prevalence of decubitus ulcer is very high, especially in inpatient ward and intensive care unit. Adequate

treatment for the wound and prevention measures for decubitus ulcer complication are all mandatory to reduce

the health burden and cost. Previous studies already showed the positive effects of nanocrystalline silver (nAg)

in ulcer healing progress. The purpose of this study is to evaluate the effect of using nAg dressing towards

decubitus ulcer severity. A 31 years old female diagnosed with grade III decubitus ulcer sized 4.7 x 2.7 cm2

was treated with debridement and nAg dressing which regularly changed every week for 4 weeks. Clinical

improvement was evaluated using photography images and Pressure Ulcer Scale for Healing (PUSH) tool.

The evaluation results showed that there was 57% reduction in overall ulcer size in just 4 weeks treatment.

The value of PUSH scale was also found lower down from 14 at the beginning into 10 at the end of the study.

This report highlights the antibacterial effect of nAg dressing as the most potential benefitting factor of the

decubitus ulcer healing. No side effect found during the application of nAg dressing in this patient.

1 INTRODUCTION

Decubitus ulcer or widely known as pressure ulcer,

bedsore, and pressure injury is a localized injury of

the skin and underneath structures due to a

combination of pressure and shear force.1 The

prevalence of decubitus ulcer, range widely from

0.4% at the lowest in acute ward up to almost 24% in

chronic ward. In concordance, the high prevalence of

decubitus ulcer is always followed by the increase of

health cost and burden, which strongly correlated

with the incidence of complications and prolonged

hospital sta .(Norman, 2016).

The failure of healing process as a result of

ischemia, prolonged pressure and trauma is the major

pathogenesis of decubitus ulcer. (Powers,2012)

Bacteria plays a huge role in delaying the wound

healing and thus need to be eradicated by using

multiple kinds of antiseptic or antibiotic. However,

both antiseptic and antibiotic have a flaw as a therapy;

antiseptic may be toxic for the cells and antibiotic has

been known to cause resistance when used

improperly (Dabiri,2016).

Silver, in its pure-active form, has been known to

have antiseptic, antimicrobial, anti-inflammation and

broad-spectrum antibiotic effect without inducing

toxic reaction (Fong, 2006). Though very beneficial,

pure silver is very easy to deactivate thus need

repeated application to achieve the treatment dose

(Argirova,2011). Nanocrystalline technology in nAg-

impregnated dressing provide wider contact area with

the active components while also give better

absorbance of silver ion on the woundbed thus

increasing its efficacy. We reported a 31 years old

woman diagnose with grade III decubitus ulcer

treated with nAg dressing.

2 CASE

A 31 years old female consulted to dermatology

and venereology department of dr. Saiful Anwar

Regional General Hospital by cardiovascular

department for wound on the buttock. The wound has

been recognized since 5 weeks before consulted.

Patient never knew the size and appearance of the

wound but felt mild pain and itch on the wound area

(VAS for the pain is 3). There was no tingling

sensation on the surrounding area of the wound.

History of fever was denied. Patient was once

admitted to dr. Saiful Anwar Regional General

Hospital for 12 days for post-partum cardiomyopathy

Ayuningtyas, V., Prawitasari, S. and Roﬁq, A.

Nanocrystalline Silver as a Single Treatment for Decubitus Ulcer: A Case Report.

DOI: 10.5220/0008158003850388

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 385-388

ISBN: 978-989-758-494-7

385

about 6 weeks before consulted. During first

admission, the wound was never treated and patient

never received education for mobilisation. After

discharged, patient stayed in bed almost all the time

and only went to the bathroom 2-3 times a day.

Patient stopped wearing diaper since 4 weeks before

consultation and started wearing diaper again two

days before consulted. The diaper was changed 1-2

times a day. History of fecal/urine inconsistency was

denied. Patient never treat the wound and only

consume medication for her heart disease which

consist of furosemide 20 mg once a day, captopril 3 x

25 mg, bisoprolol 5 mg once a day, diazepam 2 mg

once a day, laxadin once a day, NAC 3 x 200 mg, and

cefixime 2 x 100 mg.

General physical examination was normal.

Dermatological examination revealed single

erythematous-based ulcer with irregular border

localized on sacral region. The ulcer sized 5 x 3.5 cm,

covered with yellowish crust and necrotic tissue with

minimal clear exudate. The surrounding skin was

hyperpigmented and no edema. Gram examination

revealed polymorphonuclear cells and gram-negative

coccus. Laboratory examination showed renal

azothemia with ureum level 74,5 mg/dL and

creatinine level 1,01 mg/dL, hyperuricemia 11,0

mg/dl, increase of procalcitonin level 30,53 ng/ml,

hyponatremia 129 mmol/L and hypoalbuminemia

3,04 g/dl. Blood count and blood sugar level was

within normal limit.

Patient was diagnosed with grade III decubitus

ulcer and treated with nAg dressing for 4 weeks in

outpatient ward dermatology and venereology

department of dr. Saiful Anwar Regional General

Hospital. Clinical improvement was evaluated using

photography images and PUSH scale. The evaluation

results showed reduced of ulcer size of about 7.25

cm2 (57% reduction) by the end of the evaluation on

the fourth week (Figure 1). PUSH scale was also

found lower down from 14 at the beginning into 10 at

the end of the study (Table 1).

Figure 1. The weekly improvement of decubitus ulcer. The ulcer length and width were reduced significantly in each week

of evaluation, counting for about 35% reduction in the first week, from 12.69 cm

(4.7 x 2.7 cm) (a) into 8.2 cm

(4.1 x 2.0

cm) (b). The reduction continued as the lesion shrinked into 4.48 cm

(3.2 x 1.4 cm) on the third week (c). Though by the

fourth week the ulcer was sli htly enlarged, measured 5.44 cm

(3.4 x 1.6 cm) (d), this result did not change the grade of the

ulcer severity. Overall reduction within four weeks was about 57%.

Table 1. Pressure Ulcer Scale for Healing Record

Pressure Ulcer Healing Record

Week 0 1 3 4

Length x Width 12.69 cm

(9) 8.2 cm

(8) 4.48 cm

(7) 5.44 cm

(7)

Exudate Moderate (2) Moderate (2) Minimal (1) Minimal

(1)

Tissue Type Slough (3) Slough (3) Granulation

(2)

Granulation

(2)

TOTAL 14 13 10 10

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

386

Table 2: The results of Schirmer test.

Week II III IV

Schirmer test Different > 50% Different > 50% Different <25%

3 DISCUSSION

The National Pressure Ulcer Advisory Panel

(NPUAP) has classified decubitus ulcer into four

grades. First grade decubitus ulcer defined as solely a

non-blanchable erythematous lesion located on bone-

prominence areas. Second grade decubitus ulcer

identified as loss of some part of dermis layer thus the

lesion appears as a shallow, pink-based ulcer, without

slough. Decubitus ulcer categorized into grade three

when the damage affect all layer of the skin thus

exposing subcutaneous fat, but not bone and/or

muscle. Decubitus ulcer grade four defined as an

ulcer accompanied by an exposure of bone and

muscle while also having slough, necrotic tissue and

scar (EPUAP, 2009). This patient was diagnosed with

decubitus ulcer grade three.

The major factor of the pathogenesis of decubitus

ulcer is prolonged inflammation. Within the

environment of chronic ulcer there is an imbalance of

biochemical and molecular components which

mostly caused by bacterial colonization and infection.

Bacterial infection will induce an increase of matrix

metalloproteinase and inflammatory cytokines,

decrease of matrix metalloproteinase inhibitor level

and growth factors. All of the aforementioned

mechanisms lead to delayed healing process and

chronic ulcer development (Fong, 2006.)

The ideal topical therapy needs to fulfil several

criteria such as having antibacterial activity, low

resistance level, low evaporation level, prevent

dehydration, low side effect, can control the pain,

easy to use and having low toxic risk. Silver has a

nature as an antiseptic, antimicrobial, anti-

inflammation and a broad-spectrum antibiotic agent.

The active form of silver, such as Ag+ and Ag0, has

many potent antimicrobial effects that can destroy

microbes through cellular respiration blockade

mechanism and disturb the function of bacterial cell

membrane. The free silver kations bind the protein of

the tissue, altering the structure of bacterial cell

membrane and cause cell death. The silver kations

also able to cause DNA and RNA denaturation thus

hindering cell replication (Fong, 2006) .

The benefit of using wound dressing comprised of

optimal control of moisture, temperature, fluid

permeability, and pH of the wound while also

minimalize the infection, prevent the wound from

excessive trauma and reduce the pain.7 In terms of

silver ion, dressing helps to release the ion gradually,

compensating the nature of silver ion that easily

bound to sodium.

The structure of nAg dressing consists of three

layers with silver-embedded mesh enclosed by two

layers made from rayon/polyester. The

nanocrystalline technology is a modern technology

providing reactive small silver particles thus able to

cover larger area of the wound. The silver kations are

released subsequently and continuously, relieving the

bad odour and exudate, reducing the risk of bacterial

colonization and preventing the wound from

secondary infection (Fong, 2006).

Several studies, either in vivo, in vitro and clinical

test in human support the benefits of using nAg

dressing as a new regiment for chronic wound

treatment. Compared to the other types of topical

silver, e.g. nitrate silver, silver sulfadiazine and

mafenide acetate, nAg has an ability not only to kill

bacteria faster but also effective for broader spectrum

of bacteria, than the others (Wright, 1998;

Thomas,2003).

In vivo study showed that nAg dressing

effectively improve granulation and reduce the

biomolecular inflammatory components10. Clinical

test in human is still very scarce and have low quality

of study. However, several researchers proved that

nAg dressing is correlated with lower pain scale,

reduced volume of the exudate, reduced infection of

the wound and lessen the health cost (Fong, 2006;

Tredget, 1998;Voight,2001). Even now, there is yet

in vivo study that explain the toxicity of nAg towards

keratinocytes and fibroblasts. Nevertheless, in vitro

study has proven that the toxicity level of nAg is very

low. (Fraser,2004)No incidence of resistance ever

reported (Fong, 2006).

Patient was given nanocrystalline dressing

treatment as patient was diagnosed with grade three

decubitus ulcer with high prone to sepsis, indicating

the urgent need of the patient of an adequate and

effective antibacterial agent to prevent new focal

infection development and other severe

complications. Other than dressing, patient and

paramedics also received education of reposition

technique, maximum degree of bed elevation and the

importance of changing the diaper regularly.

During follow up, we found a significant

improvement, showed as decrease of PUSH scale

from 13 at the beginning to 10 at the end of the study.

Nanocrystalline Silver as a Single Treatment for Decubitus Ulcer: A Case Report

387

The ulcer size also found reduced from 12.69 cm2

into 5.44 cm2. These results consentient with

previous studies mentioning the role of topical silver

in re-epithelialization, skin granulation, and

vascularization acceleration thus improving the ulcer

healing. (Demling, 2002; Wright, 2002) No side

effect ever reported during this study.

4 CONCLUSIONS

A 31 years old woman was diagnosed with decubitus

ulcer grade 3 based on history taking and physical

examination. Patient received treatment with nAg

dressing for four weeks. The wound was evaluated

once a week. From the weekly evaluation we found a

significant reduction of ulcer length and width. The

PUSH scale also found 3 points decrease by the end

of the evaluation.

REFERENCES

Argirova, M., & Hadjiiski, O., 2011. Application of the

nanocrystalline silver in treatment of burn wounds in

children. In Skin Grafts-Indications, Applications and

Current Research. InTech.

Dabiri, G., Damstetter, E., & Phillips, T.,2016. Choosing a

wound dressing based on common wound

characteristics. Advances in wound care, 5(1), pp. 32-

41.

Demling, R. H., & DeSanti, M. L., 2002. The rate of re-

epithelialization across meshed skin grafts is increased

with exposure to silver. Burns, 28(3), pp. 264-266.

EPUAP N, NPUAP N., 2009. Prevention and treatment of

pressure ulcers: quick reference guide. Washington DC.

Fraser, J. F., Cuttle, L., Kempf, M., & Kimble, R. M., 2004.

Cytotoxicity of topical antimicrobial agents used in

burn wounds in Australasia. ANZ journal of surgery,

74(3),pp. 139-142.

Fong, J., & Wood, F., 2006. Nanocrystalline silver

dressings in wound management: a review.

international Journal of Nanomedicine, 1(4), pp. 441.

Norman, G., Dumville, J. C., Moore, Z. E., Tanner, J.,

Christie, J., & Goto, S., 2016. Antibiotics and

antiseptics for pressure ulcers. The Cochrane Library.

Powers, J.G., Odo, L., Phillips, T.J., 2012. Decubitus

(Pressure) Ulcers in Fitzpatrick's Dermatology in

General Medicine Eight Edition. Goldsmith. L, Katz. S,

Gilchrest. B, Paller. A, Leffel. D, Wolff. K, editors.

New York: McGraw Hill.

Thomas, S., & McCubbin, P., 2003. An in vitro analysis of

the antimicrobial properties of 10 silver-containing

dressings. Journal of wound care, 12(8), pp. 305-308.

Tredget, E. E., Shankowsky, H. A., Groeneveld, A., &

Burrell, R., 1998. A matched-pair, randomized study

evaluating the efficacy and safety of Acticoat silver-

coated dressing for the treatment of burn wounds.

Journal of Burn Care & Rehabilitation, 19(6), pp. 531-

537.

Ülkür, E., Oncul, O., Karagoz, H., Yeniz, E., & Çeliköz, B.,

2005. Comparison of silver-coated dressing

(Acticoat™), chlorhexidine acetate 0.5%(Bactigrass®),

and fusidic acid 2%(Fucidin®) for topical antibacterial

effect in methicillin-resistant Staphylococci-

contaminated, full-skin thickness rat burn wounds.

Burns, 31(7), pp.874-877.

Voigt, D. W., & Paul, C. N., 2001. The use of Acticoat as

silver impregnated telfa dressings in a regional burn and

wound care center: the clinicians view. WOUNDS-A

COMPENDIUM OF CLINICAL RESEARCH AND

PRACTICE, 13(2), pp. 11-20.

Westby, M. J., Dumville, J. C., Soares, M. O., Stubbs, N.,

& Norman, G., 2017. Dressings and topical agents for

treating pressure ulcers. The Cochrane Library,

6:Cd011947.

Wright, J. B., Lam, K., & Burrell, R. E., 1998. Wound

management in an era of increasing bacterial antibiotic

resistance: a role for topical silver treatment. American

journal of infection control, 26(6), pp. 572-577.

Wright, J. B., Lam, K., Buret, A. G., Olson, M. E., &

Burrell, R. E., 2002. Early healing events in a porcine

model of contaminated wounds: effects of

nanocrystalline silver on matrix metalloproteinases,

cell apoptosis, and healing. Wound Repair and

Regeneration, 10(3), pp. 141-151.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

388