Friday, March 19, 2010

MANAGEMENT OF HYPERGRANULATION : BETWEEN ALBOTHYL AND SILVER NITRATE

Ns. Triyana Ety Ruswati, SKep
Indonesian Enterosthomal Therapy Nurse Program 2008

CASE :

Albothyl has been used for the management of hypergranulation tissue. It is readily available for use in Indonesia. You are concerned thet new ETNs are unsure how to use it. You write a 1500 word paper on hypergranulation tissue both in wounds and or around stomas and how to manage this. Albothyl.
At INETNA meeting you give a 15 minute power point presentation on the use of albothyl and alternative substances or methods for treating hypergranulation. You develop a poster either on the use of this product or on the use of silver nitrate.

MANAGEMENT OF HYPERGRANULATION : BETWEEN ALBOTHYL AND SILVER NITRATE

A. Introduction

Hypergranulation often occurs in wound treatment, and a difficult condition to deal with. Hypergranulation tissue usually presents in wounds healing by secondary intention and is clinically recognized by its friable red appearance. Its presence in a wound inhibits epithelialisation.

Hypergranulation is also known as overgranulation, exuberant granulation, proud flesh, hypertrophic granulation and hyperplasia of granulation tissue. When faced with a wound of any origin, the nurse should conduct a holistic assessment. The aim of care is to facilitate wound healing with the best possible cosmetic result.

Hystorically the treatment of hypergranulation tissue consisted of destruction of the hypergranulation tissue by cautery, curettage, silver nitrate, steroid preparation or application of pressure (Semchyshyn, 2005).

In Indonesia the using of albothyl for treat hypergranulation is very common, but there is no evidence reported about the benefit of using albothyl. Albothyl is the most available medication in many hospitals than any agents, so the nurse often using albothyl rather than other such as silver nitrate.

B. Definition

Granulation tissue is a transitional replacement for normal dermis, which eventually matures into a scar during the remodeling phase of healing. It is characterized from unwounded dermis by its extremely dense network of blood vessels and capillaries, elevated cellular density of fibroblast and macrophages and randomly organized collagen fiber (Ovington & Schultz, 2004).
In some cases, it is possible for the granulation tissue to continue forming within the wound even after it has drawn level with the surrounding healthy skin. This is known as hypergranulation, overgranulation, exuberant granulation tissue, proud flesh, hyperplasia of granulation and hypertrophic granulation (Dealey, 1999).

Hypergranulation tissue can form in chronic wounds, around stoma site and around the tube of gastrostomy or jejenustomy.

C. Characteristic

Hypergranulation tissue can be classed as healthy and unhealthy. Unhealthy tissue presents as either a dark or a pale bluish/ purple uneven mass rising above the level of the surrounding skin (Harris & Rolstad, 1994). It may be dehydrated with a dull surface and its bleed easily. It is also quite friable and easy to break.
The presence of such tissue as well as increasing the patient’s risk of infection, prevent or slow epithelial migration across the wound and thus delay wound healing (Dealey, 1999).

Hypergranulation can occur in some malignant tumours. Biopsy of the tissue is essential if malignancy is suspected or if hypergranulation tissue repeteadly recurs following removal. Hypergranulation tissue only needs to be removed if epithelialisation is retarded and healing is impended because the skin surface will restored during the remodeling or the maturation stage of healing (Blackley, 2004).

D. Aetiology

The exact aetiology for hypergranulation is not known, but there are many factors contribute for the formation hypergranulation such as :

1. Malodour and exudates are also common as infection is usually instrumental in
the formation of unhealthy hypergranulation tissue
2. Bacterial bioburden
3. Continued minor trauma or friction from mobility
4. Increased moisture level from drainage and bleeding
5. Imbalance between collagen synthesis and degradation

Other possible explanation is the overgrowth of fibroblast and endothelial cells. These highly vascular lesions resemble pyogenic granuloma on histological analysis. The presence of this tissue results in the inhibition of fibroblast proliferation and prevents wound healing (Semchyshyn, 2005).

E. Management of hypergranulation

With time, hypergranulation may resolve itself but most clinicians feel the need to remove it. Clinical judgement is required for the management of each individual patient. Although there is very little in the literature regarding the management of hypergranulation tissue, the fact that there are numerous treatments used by various wound clinicians demonstrated that is presence is recognized as a clinical problem (Harris& Rolstad, 1994).

There are many treatment options for hypergranulation but little research to support their use or to suggest which is the most effective. There is no consensus as to the correct treatment for this condition.

Because granulation tissue is very delicate, it can sometimes be removed by wiping with a cotton swab or gauze sponge. Excess tissue may also be excised.
Treatment consists of destruction of hypergranulation tissue by cautery, shave excision, silver nitrate, application of pressure, aluminium chloride or curettage (Semchyshyn, 2005).

Carville (1998) state that the removal of hypergranulation tissue can be achieved using :

1. Surgical or conservative shape wound debridement
2. Pressure application using foam dressing and either compression bandaging or
firm fixation tape
3. Dressings impregnated with hypertonic saline
4. Caustic agents such as silver nitrate and copper sulphate (may cause discomfort
and necrosis)
5. Topical corticosteroids

Polyurethane foams are often used in the treatment of overgranulation tissue. It is assumed that the pressure of the foam on the granulation tissue reduces the oedema and flattens the overgranulation tissue. When foam dressings were advocated for use in overgranulation tissue it was suggested that two pieces of foam were applied to increase the pressure on the tissue.

F. Albothyl alias phenol methyl aldehyde

Albothyl consist of policresulen (condensation product of metacresolsulfonic acid and methanol). Its indicate for local haemostatic, cleansing and tissue regeneration in burns, wounds, chronic inflammatory processes, decubitus lesion, crural ulcers, condyloma acuminate and stomatitis aphthosa. Policresulen solution is one of the method for burning wound, it can help fall off the bad tissue.

Because of the effect of burning wound by policresulen, the albothyl used widely in many area such as gynecology and dermatology. But there are no literature or study shows that albothyl can use to treat hypergranulation tissue. May be it used by evidence and experiment in treating hypergranulation in Indonesia. Albothyl is widely use to treat hypergranulation in Indonesia but not supported by research or study about the effectiveness of albothyl. The use of albothyl not quite understood because of the lack information about it.

Even albothyl can help fall off the bad tissue, the adverse reaction is partial irritation (burning or pain) and local irritation. Many patient state that the albothyl is painfull. The albothyl should used partially and can not use two drugs in the same part and time.

G. Silver nitrate (AgNO3)

Silver nitrat is a chemical compound with chemical formula AgNO3. Silver nitrate has been used as an antiseptic. Fused silver nitrat, shape into stick, was traditionally called lunar caustic and used as a cauterizing agent. It can also used in wound management to diminish overgranulation tissue in healing wounds such as ulcers and sinuses.

A typical applicator of silver nitrate (pencil shape) composed of 75 % silver nitrate with 25 % potassium nitrate (other literature said 95 % silver nitrate and 5 % potassium nitrate). As the silver nitrate contacts with water (in the blood) the compound goes into solution forming nitric acid. The acid subsequently is responsible for the cautery effect. This chemical effect will oxidize organic matter, coagulate tissue and destroy bacteria causing the excess tissue to slough off.
Silver nitrate is inexpensive, easily available and application requires minimal technical skill. In practice the silver nitrate pencil is usually only rubbed onto the affected area, not held in place for a given period of time. Silver nitrate should only be used to treat areas less than the size of a thumbnail as a general rule (Rollins, 2000).

The silver nitrate pencil is usually not considered first-line therapy for hypergranulation and it tends to be reversed for more stubborn area of granulation (Griffiths et al, 2001).The use of silver nitrate is directly reduces fibroblast proliferation and not recommended for prolonged or excessive use (Dealey, 1999).

Topical administration of silver nitrate to granulation tissue has produced good results in practice (Borkowski, 2005). Silver nitrate can be applied once or twice a day; the treatment is normally applied every one to four days, until the tissue has completelyslough. It may be necessary to apply silver nitrate on more than one occasion because of reccurence (Borkowski, 2005).
Chemical burns have been reported with silver nitrate, and more likely to occur with longer application times. A topical barrier preparation such as petroleum jelly or white soft paraffin should be applied to protect the normal skin surrounding the area of hypergranulation (Griffiths et al, 2001).

H. Other method that available in many hospital in Indonesia

1. Foam

A popular treatment option is the use of polyurethane foam applied directly to the hypergranulation tissue with light pressure. This provides a non-traumatic treatment option in the absence of clear evidence to support the alternative methods (Cameron & Newton, 2004).
Harris and Rolstad (1994) reported the findings of a small clinical trial of a polyurethane foam to treat hypergranulation. A prospective non controlled correlation study was undertaken with 10 patient with 12 wound using polyurethane foam dressing to reduce hypergranulation tissue. The result demonstrated a significant decrease in height of 2 mm of granulation tissue from baseline to measurements taken two weeks later (p<0.01)

SOURCES :
href="http://www.bahmon.org.uk/">http://www.bahmon.org.uk/
Hanif J, Tasca RA, Frosh A, Ghufoor K, Stirling R (2003). Silver nitrate : histological effects of cautery on epithelial surface with varying contact times.
Harris A, Rolstad BS (1994). Hypergranulation tissue : a non-traumatic method of management. Ostomy wound manage 40 (5) : 20
Rollins H (2000). Hypergranulation tissue at gastrostomy site. Wound care (3) : 127
Semchyshyn N (2005), Surgical complication. E-Medicine. (http://www.emedicine.com/derm/topic829.htm)

2 comments:

Maggie said...

Dear Ns Triyana

Many thanks for posting this article. This is what i have been looking for. My father is a PEG tube user for 9 months and has been suffering with over granulation ever since on his stomach skin. Doctor in Singapore has recommended to use silver nitrate but it seems we have difficulty in finding where to buy this item for "cauter-ing" the granulation. The pharmacy nor hospital are not selling those. One of doctors in Jakata recommend using albothyl and it has been very effective in reducing the overgranulation. But when we reconfirm with doctor in singapore, they dont recommend using this as this medicine is generally used for stop bleeding.

What's your general view about it. Is there any "major"side effect if we occasionally albothyl to reduce the granulation? Any suggestion where to buy the silver nitrate stick?

many thanks
Mag

Doddy Lukito said...

I would also appreciate if could get update about this matter as well.
Thank you.

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