Fighting diabetic foot ulcer by combination therapy, including larva therapy, Medi honey ointment, and silver alginate dressings: A case report

Abstract

Introduction and importance

Diabetic foot ulcers (DFUs) are a common complication of diabetes and can be challenging to manage. A combined approach can lead to faster healing and better outcomes for individuals with DFUs.

Case presentation

This case report presents a 70-year-old man with a 15-year history of diabetes who developed a diabetic foot ulcer. The patient was undergoing treatment with routine therapy. Despite the severity of the ulcer, a combination therapy approach, including larva therapy, Medi honey ointment, and silver alginate dressings, was implemented, leading to successful healing.

Clinical discussion

By combining these three treatment modalities, we may be able to achieve a synergistic effect and maximize wound healing and infection control benefits.

Conclusion

The combined use a honey-based Media Honey ointment and silver alginate larva therapy can be an effective treatment option for diabetic foot ulcers.

Highlights

• •Diabetic Foot Ulcers can lead to amputation.
• •Diabetic Foot Ulcers do not respond to common approaches.
• •Diabetic Foot Ulcers can be managed by Larva Therapy, Medi Honey ointment, and Silver Alginate Dressings

1. Introduction

Diabetic foot ulcers are a common complication of diabetes and can be challenging to manage [1]. The prevalence of diabetic foot ulcers estimated that up to 25 % [2]. Several adjunctive therapies have been explored to aid in the healing of diabetic foot ulcers, including larva therapy, honey, and silver alginate dressings [3].

Larva Therapy (Maggot Debridement Therapy): Larva therapy, also known as maggot debridement therapy (MDT), involves the application of sterile fly larvae to clean and debride the wound [4]. The larvae secrete enzymes that break down necrotic tissue, promoting wound debridement [5]. They also have antimicrobial properties that help control infection [4]. Larva therapy has been shown to be effective in promoting wound healing and reducing bacterial burden in several studies [6].

Honey has been used for centuries as a natural wound dressing due to its antimicrobial and anti-inflammatory properties [7]. It provides a moist wound environment, which is conducive to healing. Honey also stimulates tissue growth and helps prevent infection [8].

Silver alginate dressings are composed of calcium alginate fibers combined with silver, which has broad-spectrum antimicrobial properties. These dressings provide a moist wound environment and help manage exudate [9]. The silver ions released from the dressing help control bacterial growth in the wound. Silver alginate dressings have been found to be effective in reducing bacterial colonization and promoting wound healing in diabetic foot ulcers [10].

Combining larva therapy, honey, and silver alginate in treating wounds holds great promise for maximizing wound healing and infection control benefits by debriding the wound, promoting tissue regeneration, providing microbial protection, and creating a clean healing environment, ultimately accelerating the healing process and improving outcomes in patients with chronic or infected wounds. The work has been reported in line with the SCARE 2020 Criteria [11].

2. Presentation of case

The patient is a 70-year-old man with a 15-year history of diabetes, who suffered from an infection after the amputation of the right big toe and a wound on the sole of the foot (Fig. 1; video 1). He was hospitalized in a hospital, Urmia, Iran for 30 days.

Fig. 1.

Patient's DFU.

2.1. Diabetes management

The patient is being treated with insulin and his HbA1c is about 9, indicating bad diabetes control. However, the patient also suffers from heart disease. Commercial Medi Honey ointment made from honey contains 100 % active Leptospermum honey in a hydrocolloidal suspension and commercial Silver Calcium Alginate dressing containing 1 % silver were used to treat the wound. However, the patient also has heart disease and an EF of 25 %. Cardiac medications include nitroglycerin, metoprolol, and losartan 25 mg, which were temporarily discontinued due to persistent hypotension.

The patient's plan includes ongoing wound care with regular dressing changes using a honey-based Media Honey ointment and a silver alginate dressing. Blood sugar level will be monitored, and insulin treatment will be changed if necessary. The patient's blood sugar was controlled every 6 h, and based on the measurement results, the following protocol was applied subcutaneously: 150 < BS < 200 2unit, 200 < BS < 250 4unit, 250 < BS < 300 6unit, 300 < BS < 350 8unit, BS > 350 10unit. Heart condition will be carefully monitored, and the medications will be adjusted accordingly. Regular check-ups will be scheduled to assess the wound healing progress and general health.

2.2. Wagner's classification

Wagner's classification is a system used to categorize different stages of diabetic foot ulcers, which helps in determining appropriate treatment and prognosis. It was developed by Dr. M. Wagner in 1981 and has since been widely used in clinical practice.

The classification system consists of five stages:

Stage 0: No open ulcer, but presence of pre-ulcerative lesions, such as areas of erythema, edema, or callus formation. Stage 1: Superficial ulcers involving the epidermis and dermis, but not extending to deeper tissues. Stage 2: Deeper ulcers involving tendons, ligaments, joint capsules, or bone, but without abscess or osteomyelitis. Stage 3: Deep ulcers with abscess formation or osteomyelitis (infection of the bone). Stage 4: Gangrene or deep ulcers with extensive tissue necrosis involving the entire foot. It is worth noting that our patient has been classified as stage 3.

2.3. Treatment history

The patient's treatment began with six sessions of larval therapy every other day (Fig. 2). However, due to the patient's poor control over weight-bearing and walking, the treatment duration was extended to approximately six months.

Fig. 2.

Maggot therapy.

Larva therapy which involves the application of medical maggots to wounds, has been shown to be highly effective in debriding necrotic tissue, stimulating angiogenesis, and promoting wound healing. The maggots secrete enzymes that break down dead tissue, while also releasing antimicrobial substances that can combat bacterial infections (Fig. 3).

Fig. 3.

DFU following maggot therapy.

The protocol for larva therapy contained to phase:

Phase 1:

• •Assess and document the size, location, and severity of the diabetic foot ulcer.
• •Cleanse the wound thoroughly with a sterile saline solution.
• •Apply a sterile dressing to protect the wound bed.
• •Introduce medical-grade maggots to the wound by placing them in contact with the wound bed.
• •Cover the wound with a breathable dressing that allows airflow but prevents maggots from escaping.

Phase 2:

• •Assess the progress of the wound healing process.
• •Remove the maggots using a sterile forceps.
• •Cleanse the wound with a sterile saline solution.
• •Apply a sterile dressing to protect the wound bed.
• •Reintroduce maggots to the wound.
• •Cover the wound with a breathable dressing.

Media Honey ointment and a silver alginate dressing were used every 72 h during treatment. on the other hand, has long been recognized for its potent antibacterial properties. It contains hydrogen peroxide and other components that can inhibit the growth of various bacteria, including antibiotic-resistant strains. By incorporating honey into the treatment regimen, it can provide an additional layer of protection against bacterial infections, further reducing the risk of complications and promoting faster healing (Fig. 4).

Fig. 4.

Medi Honey ointment.

Silver alginate a type of wound dressing that contains silver ions, has also been widely used for its antimicrobial properties. Silver ions have shown effectiveness against a broad range of bacteria, fungi, and even some viruses. By introducing silver alginate into the wound bed, it creates an environment that inhibits bacterial growth and promotes a clean, sterile healing environment (Fig. 5). The combination therapy approach proved effective in facilitating the healing of the diabetic foot ulcer. Over several weeks, the wound demonstrated significant progress, with reduced size, clean granulation tissue formation, decreased pain, and absence of infection signs (Fig. 6).

Fig. 5.

DFU after Alginate dressing.

Fig. 6.

DFU after combination therapy.

3. Discussion

Diabetic foot ulcers can be difficult to heal and often require a multidisciplinary treatment approach [12]. A promising approach is the combined use of Medi Honey ointment made from honey and silver alginate larval therapy [7,13]. Medi Honey ointment made from honey is a medicinal honey that has antibacterial properties and can promote wound healing. For centuries, it has been used as a natural medicine for various diseases, including wounds [14]. The high sugar content of honey creates an osmotic effect that removes moisture from the wound, creating an optimal healing environment. Honey also contains enzymes that help remove dead tissue and stimulate the growth of new tissue [7]. On the other hand, silver alginate worm therapy involves the use of medical grade worms to clean and clean the wound. These worms secrete enzymes that break down dead tissue, effectively cleaning the wound and speeding healing [10].

Additionally, worms have antimicrobial properties by releasing bioactive substances that combat infection-causing microorganisms, which effectively reducing bacterial colonization in the wound. These maggots can break down and consume necrotic tissue, promoting wound healing and preventing infection. Medi Honey ointment made from honey and silver alginate larvae may provide synergistic benefits in the treatment of diabetic foot ulcers. Honey can create a moist environment for the wound and accelerate healing, while maggot therapy can effectively clean the wound and control infection.

This combined approach could lead to faster healing and better outcomes for people with diabetic foot ulcers. Additionally, for optimal results, other aspects of diabetic foot ulcer treatment, such as offloading techniques and optimal diabetes management, should be included in the treatment plan.

The combination of Medi honey, larva therapy, and silver calcium alginate dressing shows promising results in the treatment of diabetic foot ulcers. Medi honey, renowned for its antibacterial and anti-inflammatory properties, aids in wound healing by creating a moist environment, promoting tissue regeneration, and preventing infection. Larva therapy involves the controlled application of medical grade maggots, which selectively clean necrotic tissues, stimulate granulation tissue formation, and release antimicrobial substances. The silver calcium alginate dressing, on the other hand, further enhances wound healing by providing an optimal wound environment, absorbing excess exudate, and releasing silver ions with its antimicrobial activity. This combination therapy addresses multiple aspects of diabetic foot ulcers, such as infection control, wound debridement, tissue regeneration, and bacterial colonization prevention, ultimately accelerating the healing process and improving patient outcomes. However, further research and controlled clinical trials are necessary to establish its effectiveness and safety as a standard treatment option.

4. Conclusion

The combined use a honey-based Media Honey ointment and silver alginate larva therapy can be an effective treatment option for diabetic foot ulcers. This approach can promote wound healing, control infection, and improve outcomes for individuals with these ulcers. However, it is important to consult with healthcare professionals for proper guidance and supervision.

The following is the supplementary data related to this article.

Ethical approval

Ethical approval is exempt/waived at our institution.

Funding

None.

Author contribution

Rasoul Goli and Fatemeh Nikkhah: Study concept, data collection, writing the paper and making the revision of the manuscript following the reviewer's instructions. Naser Parizad and Navid Faraji: Study concept, reviewing and validating the manuscript's credibility.

Guarantor

Rasoul Goli.

Research registration number

Not applicable.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

None.