The Use of Activon (Manuka Honey) on Foot Ulcerations following a Chemical Burn Injury in a Patient with Peripheral Diabetic Sensory Neuropathy.

A 54 year old male with Diabetes Mellitus, Type 2, was cleaning drains in his garden with Caustic Soda (sodium hydroxide) while only wearing trainer-style shoes.  Some caustic soda inadvertently spilled onto the top of his shoes soaking through to the skin on the dorsum of both feet. It wasn’t until the following day that the gentleman noticed that his skin had painless red patches across the dorsum of his foot and toes, corresponding to where he had spilt Caustic Soda.

Over the next three days the patient noticed the top of his socks becoming moist.  On removing his sock he could see the skin on the dorsum of his foot was starting to break down.  Four days after injury he presented to his practice nurse where foot ulceration, caused by direct contact of caustic soda (an alkali) on the skin, was diagnosed. 

The nurse dressed the patient’s wounds with Inadine, Lyofoam and crepe bandage and the patient was advised to rest.

One week later the patient was referred to the Diabetes Specialist Podiatrist by the practice Nurse when no significant reduction in the size of the wounds or the amount of slough present could be seen.

Podiatry Intervention

During Assessment by the Podiatrist:

-  it was confirmed that the patient had Diabetes Peripheral Sensory Neuropathy (loss of sensation to a 10g monofilament) but his feet were not completely insensate and indeed the patient complained of discomfort from the wound site after application of Iodine dressings.  

-  the patient had a history of sub-optimal blood glucose control

-  on examination the dorsum of the left foot was red and hot with dense, viscous slough covering the wound beds.  With erythema marked around the ulcer sites. (See photos A & B)

-  it was found the patient had a good lower-limb arterial supply.

-  he was wearing slippers as he was unable to wear shoes due to his feet being bandaged.

Management:

Wound Care:

-  the wounds were cleansed with sterile saline then Activon (100% medical-grade Manuka honey) was applied as the primary treatment. 

N.B: Activon was chosen as the primary treatment for it’s antimicrobial, anti-inflammatory properties and for it’s ability to assist in autolytic debridement. It also would promote a moist wound environment. 

-  a secondary low-adherent, absorbent dressing was applied over the Activon and held in place with cotton bandage and Comfifast

Pressure Relief:

-  the patient was issued with an extra-depth, Velcro-fastening shoe which accommodated the dressing and allowed him to mobilise with minimal trauma to the wound sites.

Metabolic Control:

-  the patient was referred to the Diabetes Specialist Nurse who discussed and agreed with the patient ways to achieve improved blood glucose control.

Shared Care:

- following liaison between the Podiatrist and the patient’s General Practice the patient returned to the Practice Nurse two days later and then seen once to twice weekly by the nurse for another two-and-a-half  weeks where the same dressing regime – using Activon as the primary treatment - was used until the Podiatry Department reviewed the patient 19 days later.

Podiatry Review (19 days later – See Photos C & D)

• the patient detailed that he had felt slight ‘tingling’ initially but no pain on application of the At subsequent dressing changes carried out by the nurse there was no tingling & no pain.  This was in contrast to the feeling of discomfort he had felt on each application of Inadine dressings.

• it was found that the Activon had effectively removed most of the slough tissue from the left dorsum and the wounds had significantly reduced in size.  All wounds in the right foot had epithelialised.  There was no erythema present.

• two weeks later, with continual use of Activon, all ulcer sites had fully epithelialised.

Conclusion

Management of Diabetic Foot Ulceration involves a number of components of care.   In this case the use of Activon proved an effective treatment in debriding devitalised tissue and progressing ulceration to complete epithelialisation in a Diabetic Patient with sensory loss.