10 Wound care
The stages of wound healing
Inflammatory phase
Case study 10.1 Penetrating wound with infection risk
Intervention
25% of the essential oil mix below in Hypericum perforatum macerated oil base:
• 40% Thymus vulgaris ct. thujanol
• 30% Lavandula latifolia [spike lavender]
• 10% Matricaria recutita [German chamomile]
• 10% Cistus ladaniferus [labdanum]
(Taken from the International Journal of Clinical Aromatherapy 3 (2b): 14–15)
stimulates the cells that create granulation tissue and inflammation plays an important role during the initial stages; while there is debris in the wound (dirt or other objects) the inflammatory stage can become extended, leading to a chronic wound.
Maturation and remodelling phase
Unfortunately, the process of wound healing is complex and fragile and many factors can interrupt its progress, leading to the formation of chronic non-healing wounds (see Box 10.1).
Box 10.1 Factors inhibiting wound healing
• Pre-existing disease, e.g. diabetes, cancer, venous or arterial disease, AIDS
• Certain medications that cause immune suppression, e.g. cortisone
• Location of wound, e.g. areas of pressure, friction, in flexures etc.
• Poor tissue perfusion in area of wound
(adapted from Harris 2006)
The presence of a slow-healing wound has significant physical, psychological, psychosocial and financial impact. The psychosocial impact is even greater if the wound is malodorous or on a visible part of the body. The longer a wound takes to heal, the greater the microbial load, with further risk of complications and delayed healing (Bowler et al. 2001). Thus the challenge is to find interventions that promote and accelerate normal wound healing without complications, as outlined in Box 10.1.
The role of essential oils
The choice and specification of dressing is very important to achieve the above objectives and wound healing agents should adhere to certain specifications (Leach 2008). Natural bases and essential oils can play numerous roles in promoting wound healing, providing a range of treatment options (Box 10.2).
Box 10.2 The roles of essential oils in wound healing
• Prevent and treat microbial contamination
• Debride the wound of slough and necrotic tissue
• Facilitate granulation and collagen formation
• Facilitate angiogenesis and tissue perfusion
• Increase the rate of wound contraction
(adapted from Harris 2006)
Few dressings satisfy all the criteria in Box 10.2, but it could be said that many plant extracts come close to being ideal wound-healing agents, e.g. aloe, calendula, hypericum and comfrey (Leach 2004), which leads to the question why are natural remedies, including aromatherapy, not used more widely in hospitals, hospices and the community? In 2002, John Kerr listed the following reasons:
• the current medical system is seen as effective, despite its shortcomings
• limited anecdotal evidence, although there has been more in recent years
• a reluctance by aromatherapists to innovate
• administrative problems (e.g. patient liability issues, insurance, medical codes of ethics etc.)
• lack of education due to intensive use of essential oils not being taught by the majority of aromatherapy schools.
Famous pioneer aromatherapists such as Gattefosse and Valnet were well aware of the healing effects of essential oils, but the first report in the aromatherapy literature of using essential oils for wound healing in hospital was by clinical aromatologist Alan Barker (1994). He explored the aromatic treatment of pressure sores based on his experience of working in the English National Health Service, suggesting the following:
• application of undiluted essential oils in the presence of large amounts of pus and the need for debridement
• use of diluted oils in either honey or macerated vegetable oils
• use of sprays of distilled water with added essential oils.
NB Now that hydrolats are available, these would be preferable to water with essential oils.
Later, Ron Guba (1998/1999) used 10% of CO2 extracts and essential oils in a cream containing a range of fixed oils on a number of wound types (venous ulcers, pressure sores, skin tears and abrasions) in nursing homes in Australia. The essential oils used were Lavandula angustifolia [lavender], Artemisia vulgaris [mugwort] and Salvia officinalis [sage], plus CO2 extracts of Matricaria recutita [German chamomile] and Calendula officinalis [calendula]. The most significant results were obtained with chronic wounds.
Kerr (2002) reported the results of three years’ work using essential oils for a range of wounds in Australian nursing homes. The main finding was that a 9–12% concentration of essential oils yielded better results than much weaker doses, with no side effects. The essential oils used included Lavandula angustifolia, Matricaria recutita [German chamomile], Pogostemon patchouli, Commiphora myrrha [myrrh] and Melaleuca alternifolia [tea tree] in Aloe vera gel.
Two American practitioners (Hartman & Coetzee 2002) conducted a study using Lavandula angustifolia and Matricaria recutita essential oils diluted in grapeseed fixed oil for the treatment of chronic ulcers of several months’ duration and resistant to conventional treatments (the experimental group), comparing them with a control group who continued to receive conventional wound care. The results confirmed improved healing times in the experimental group. An important observation was that all wounds in the experimental group appeared to worsen initially for up to 2 weeks, with increased exudate and erythema, after which they showed signs of healing. A possible reason for this may be the increase in circulation and vascular permeability encouraged by the essential oil application – thereby accelerating angiogenesis. This observation has been confirmed in the author’s own practice.
Primmer (2002) successfully treated a skin tear in an elderly patient using a mix of Lavandula angustifolia, Eucalyptus radiata [narrow-leaved peppermint], Matricaria recutita and Boswellia carteri [frankincense] at 3% dilution in sweet almond oil. When applied to the wound twice daily, a significant improvement was seen within 24 hours and the wound healed totally in 4 weeks with very little scarring, the therapist using this blend successfully several times with other patients.
Diane Ames (a family nurse practitioner and clinical aromatherapist) is endeavouring to integrate the use of essential oils into the healthcare system in Milwaukee. The cases dealt with were numerous – deep-seated infections, boils and abscesses, venous ulcers, several grades of pressure sore and fungating tumours, and all had good results (Ames 2006).
The author has found the following oils to be successful:
• Melaleuca alternifolia [tea tree] both neat and diluted for infected wounds, including those with methicillin-resistant Staphylococcus aureus (MRSA)
• Matricaria recutita and Lavandula angustifolia 50/50 at 10% dilution in macerated calendula oil for deep pressure sores.
In 2004, a team from Manchester Metropolitan University developed a dressing model for wounds to decolonize them from MRSA by vapour contact. This led to a phase 1 clinical trial on the effects of diffusion of essential oils to reduce infection risks. The study was carried out in the Burns Unit of Wythenshawe Hospital (Edwards-Jones et al. 2004) (see also Case 9.2 MRSA).
Commonly used essential oils in wound healing
Commiphora myrrha [myrrh]
Many aromatherapy texts cite myrrh as an effective wound healer from ancient times to the present (Price & Price 1999, Battaglia 1997, Kerr 2002), being specifically healing to bedsores, as it is highly antibacterial. It has an ability to increase the number of leukocytes in the blood (Bartram 1995) and is especially bacteriostatic against Staphylococcus aureus (one of the biggest bacterial wound invaders) and other Gram-positive bacteria (Price & Price 1999). The main constituents are sesquiterpenes, which may help decongest the wound and reduce inflammation (Price 1995). Myrrh can be bought as a resin but this should not be used for wounds – only distilled essential oil is safe for this purpose.
Abies balsamea [Canadian balsam/ balsam fir]
Canadian balsam is antiseptic against staphylococcus spp. and E. coli (Price & Price 2007), anti-inflammatory and cicatrizant, and is used by Native Americans for the treatment of burns, sores and cuts. It is high in monoterpenes (75–90%, mostly β-pinene), which may be why it is good for healing skin lesions and ulcerations. It is helpful for depression, nervous tension and stress-related conditions, all of which add healing properties on a different level. Non-toxic and non-irritating, it may be chosen instead of myrrh for its ease of use, being a much thinner solution (Fact sheet, Penny Price Aromatherapy (2010).
Citrus limon [lemon]
Lemon has been found to be the most effective oil for debriding and desloughing wounds (Penny Price 2003 personal communication). This may be due to the high monoterpene content (90–95%), which can be aggressive to skin and mucous surfaces (Price L 2003 personal communication). It has exceptional antibacterial qualities, having the ability to stimulate the body’s own white blood cells (Battaglia 1997). Lemon is useful in reducing wound odours and is both mentally and spiritually uplifting.