Editor’s note: This is our first installment of “online only” features focusing on wound care around the world. These articles are intended to detail innovative and resourceful ways that clinicians are helping to heal patients’ wounds in all corners of the globe, and practices are likely to differ from those in the most advanced regions.
INTRODUCTION
Diabetes mellitus–related wounds are serious complications of the increasing prevalence of diabetes, resulting in long hospital stays, high costs, and an increased need for rehabilitation, home care, and the use of social services. Appropriate management is mandatory to prevent further complications and even death.1,2
Electrical stimulation (ES) has long been recommended as a treatment for wound healing. It mimics the natural “current of injury” that occurs in the injured skin and enhances the healing process by stimulating the growth of granulating tissues with an additional bactericidal effect.3–6 Electrical stimulation has also been reported as directional cues in cell movements and wound healing, which activate signaling pathways similar to those reported for chemotaxis.7 The usual principle is to conduct the current through electrode pads in direct contact with the human body. The method has not been widely used because of the potential adverse effects to the surrounding tissue from the electrodes. As a result of this contact, an increased risk of infection and pain to the patient has been reported. However, the literature has examined the positive effect of the method on chronic ulcers, especially in the field of diabetic pathology.8,9
Wireless microcurrent stimulation (WMCS) is a new method of ES. The WMCS device (Wetling EU ApS, Fredensborg, Denmark) produces and transfers negatively charged electrons to the wound area, which has been positively grounded to the bed, using available oxygen in the air as a medium transfer. The patient is connected to the device through a neutral electrode applied to the wrist of the patient. A control box permits the adjustment of the current (1.54.5 μΑ) and treatment duration.
To the authors’ knowledge, there are a small number of centers worldwide that are using WMCS as a method of choice for wound therapy. Two relative announcements have been reported internationally.10,11 The authors have already used WMCS technology for a number of cases. In this article, the authors report for the first time 2 cases of diabetes-related complications (acute and chronic wound) that were successfully treated using WMCS technology. Thus, although reported results are limited, the authors suggest that a combination of WMCS treatment with standard wound care procedures may help promote and accelerate the healing process of both acute and chronic wounds.
CASE REPORTS
Case 1
A 70-year-old man presented to the Wound Medical Care Service Centre in Jakarta, Indonesia, with a difficult-to-heal chronic diabetic ulcer, at the lower right leg (Figure 1A). The patient underwent a foot amputation at the tarsal level a year earlier because of a serious diabetic ulcer that had reached the bone, causing osteomyelitis. After the amputation, the ulcer remained unhealed, and the wound size was enlarged; however, the patient had a normal blood glucose level, well-controlled diet, and stable blood pressure. The authors initiated treatment with the WMCS device, using 1.5-μA current for an hour every day. Standard wound care (cleaning with normal saline and necrotomy depending on the necessity) was administered before the WMCS therapy. A hydrocolloid dressing was used after each therapy.
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Figure 1: CASE 1. PHOTOGRAPHS ILLUSTRATE THE ULCER PRIOR TO (A) AND FOLLOWING TREATMENT (B AND C). A, DAY 0; B, DAY 10; C, DAY 45
After a series of 45 treatments, the patient’s wound was completely healed (Figure 1B, C). The authors note that the number of treatments varies, depending on the severity of the wound and the underlying disease itself. Typically, the WMCS is used once daily for 1 hour each session. It is expected that the number of treatments is increased when a complicated and severe wound is to be treated. For acute wounds, as in case 2 in the following section, clinicians may observe healing after only 4 treatments.
Case 2
A 47-year-old woman with known type 2 diabetes (A1c ∼13%) presented with cellulitis of the left hand following a recent skin injury due to neuropathy—a complication of her diabetes (Figure 2A). The patient had undergone surgery 2 weeks prior to her visit to the authors’ clinic. The surgeon had removed the necrotic tissue and made skin incisions to drain the wound site. Despite routine wound care in the general hospital, there was no significant improvement, and the healing process stalled. Her blood glucose level was controlled using insulin and oral antidiabetic medication.
Figure 2: CASE 2. PHOTOGRAPHS ILLUSTRATE THE ULCER PRIOR TO (A) AND FOLLOWING TREATMENT (B, C, AND D). A, DAY 0, BEFORE THE INITIATION OF THE THERAPIES, FRONT AND LATERAL VIEWS; B, DAY 5 (AFTER 3 THERAPIES), FRONT AND LATERAL VIEWS; C, DAY 7 (AFTER 4 THERAPIES); D, THREE WEEKS AFTER THE LAST TREATMENT
The patient subsequently began receiving wound care treatment at the Wound Medical Care Service Centre. The wound was cleaned using normal saline, and dead tissue was debrided to provide an optimal environment for the healing process. Each WMCS treatment was applied for an hour every other day, using a 1.5-μA microcurrent. After each session, the wound was covered with moist, sterilized gauze. The patient was not given antibiotics during the treatment course because she had finished a single course of antibiotics after the surgical procedure, with no results. In addition, no topical antibacterial agents were administered during the course of treatment.
After a series of 4 therapy sessions, the wounds were healed, and the swelling was significantly reduced (Figure 2B–D). The blood glucose level was also easier to control, possibly because the source of infection had been managed. The patient reported no discomfort during treatment, and there was no incidence of new infection during the courses of treatment. Figure 2D was taken 3 weeks after the last treatment, showing the latest condition of the hand with a satisfying result.
DISCUSSION
To the authors’ knowledge, this is the first study that suggests the potential efficacy of WMCS technology in the treatment of diabetes-related wounds. An optimal current of injury that came from the wounded tissue combined with the stimulation from WMCS promoted a positive wound healing result in the authors’ experience. The wounds were treated using a combination of standard wound care and WMCS technology. With prior cleansing using normal saline, the ES by WMCS using 1.5 μA for an hour in each session indicated a promising result. The authors hypothesized that the potential gradient in the wounds was maintained high, and the healing process was still occurring, probably due to the moist environment in the wounded tissue.
The treatment for these patients was noninvasive with minimal risk of infection. Neither patient reported any adverse effect from the treatment. The authors suggest that WMCS technology may be effective in promoting the healing process in diabetic patients with acute or chronic wounds. The ES method by WMCS technology should be studied further for its potential to promote wound healing in patients with type 2 diabetes.
REFERENCES
1. Lipsky BA, Berendt AR, Deery HG, et al.. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004; 39: 885–910.
2. Sen SK, Gordillo GM, Roy S, et al.. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen 2009; 17: 763–71.
3. Kloth LC. Electrical stimulation for wound healing: a review of evidence from in vitro studies, animal experiments, and clinical trials. Int J Low Extrem Wounds 2005; 4: 23–44.
4. McCaig CD, Rajnicek AM, Song B, Zhao M. Controlling cell behavior electrically: current views and future potential. Physiol Rev 2005; 85: 943–78.
5. Sussman physical therapy: electrical stimulation for wound healing, chapter 16. In: Sussman C, Bates-Jensen B, eds. Wound Care Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, MD: Aspen Publishers; 1998: 357–89.
6. Cutting KF. Electrical stimulation in the treatment of chronic wounds. Wounds 2006; 2: 3–11.
7. Zhao M, Song B, Pu J, et al.. Electrical signals control wound healing through phosphatidylinositol-3-OH kinase-γ and PTEN. Nature 2006; 442: 457–60.
8. Houghton PE, Kincaid CB, Lovell M, et al.. Effect of electrical stimulation on chronic leg ulcer size and appearance. Phys Ther 2012; 83: 17–28.
9. Baker LL, Chambers R, DeMuth SK, Villar F. Effects of electrical stimulation on wound healing in patients with diabetic ulcers. Diabetes Care 1997; 20: 405
10. Wirsing P, Habrom A. Can WMCS (Wireless
Microcurrent Stimulation) improve the treatment of chronic wounds? Poster 149 presented at the EWMA Conference, Vienna, Austria, May 23-25, 2012.
11. Blatti M, Friedli S, Zehnder T. Use of a new method of electrostimulation for hard-to-heal wounds. Poster 244 presented at EWMA Conference, Vienna, Austria, May 23-25, 2012.
