Dressings and topical agents containing hyaluronic acid for chronic wound healing.

BACKGROUND: Hyaluronic acid is synthesised in plasma membranes and can be found in extracellular tissues. It has been suggested that the application of hyaluronic acid to chronic wounds may promote healing, and the mechanism may be due to its ability to maintain a moist wound environment which helps cell migration in the wound bed. OBJECTIVES: To evaluate the effects of hyaluronic acid (and its derivatives) on the healing of chronic wounds. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was February 2022. SELECTION CRITERIA: We included randomised controlled trials that compared the effects of hyaluronic acid (as a dressing or topical agent) with other dressings on the healing of pressure, venous, arterial, or mixed-aetiology ulcers and foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 12 trials (13 articles) in a qualitative synthesis, and were able to combine data from four trials in a quantitative analysis. Overall, the included trials involved 1108 participants (mean age 69.60 years) presenting 178 pressure ulcers, 54 diabetic foot ulcers, and 896 leg ulcers. Sex was reported for 1022 participants (57.24% female). Pressure ulcers It is uncertain whether there is a difference in complete healing (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.58 to 2.35); change in ulcer size (mean difference (MD) 25.60, 95% CI 6.18 to 45.02); or adverse events (none reported) between platelet-rich growth factor (PRGF) + hyaluronic acid and PRGF because the certainty of evidence is very low (1 trial, 65 participants). It is also uncertain whether there is a difference in complete healing between lysine hyaluronate and sodium hyaluronate because the certainty of evidence is very low (RR 2.50, 95% CI 0.71 to 8.83; 1 trial, 14 ulcers from 10 participants). Foot ulcers in people with diabetes It is uncertain whether there is a difference in time to complete healing between hyaluronic acid and lyophilised collagen because the certainty of evidence is very low (MD 16.60, 95% CI 7.95 to 25.25; 1 study, 20 participants). It is uncertain whether there is a difference in complete ulcer healing (RR 2.20, 95% CI 0.97 to 4.97; 1 study, 34 participants) or change in ulcer size (MD -0.80, 95% CI -3.58 to 1.98; 1 study, 25 participants) between hyaluronic acid and conventional dressings because the certainty of evidence is very low. Leg ulcers We are uncertain whether there is a difference in complete wound healing (RR 0.98, 95% CI 0.26 to 3.76), percentage of adverse events (RR 0.79, 95% CI 0.22 to 2.80), pain (MD 2.10, 95% CI -5.81 to 10.01), or change in ulcer size (RR 2.11, 95% CI 0.92 to 4.82) between hyaluronic acid + hydrocolloid and hydrocolloid because the certainty of evidence is very low (1 study, 125 participants). It is uncertain whether there is a difference in change in ulcer size between hyaluronic acid and hydrocolloid because the certainty of evidence is very low (RR 1.02, 95% CI 0.84 to 1.25; 1 study, 143 participants). We are uncertain whether there is a difference in complete wound healing between hyaluronic acid and paraffin gauze because the certainty of evidence is very low (RR 2.00, 95% CI 0.21 to 19.23; 1 study, 24 ulcers from 17 participants). When compared with neutral vehicle, hyaluronic acid probably improves complete ulcer healing (RR 2.11, 95% CI 1.46 to 3.07; 4 studies, 526 participants; moderate-certainty evidence); may slightly increase the reduction in pain from baseline (MD -8.55, 95% CI -14.77 to -2.34; 3 studies, 337 participants); and may slightly increase change in ulcer size, measured as mean reduction from baseline to 45 days (MD 30.44%, 95% CI 15.57 to 45.31; 2 studies, 190 participants). It is uncertain if hyaluronic acid alters incidence of infection when compared with neutral vehicle (RR 0.89, 95% CI 0.53 to 1.49; 3 studies, 425 participants). We are uncertain whether there is a difference in change in ulcer size (cm2) between hyaluronic acid and dextranomer because the certainty of evidence is very low (MD 5.80, 95% CI -10.0 to 21.60; 1 study, 50 participants). We downgraded the certainty of evidence due to risk of bias or imprecision, or both, for all of the above comparisons. No trial reported health-related quality of life or wound recurrence. Measurement of change in ulcer size was not homogeneous among studies, and missing data precluded further analysis for some comparisons. AUTHORS' CONCLUSIONS: There is currently insufficient evidence to determine the effectiveness of hyaluronic acid dressings in the healing of pressure ulcers or foot ulcers in people with diabetes. We found evidence that hyaluronic acid probably improves complete ulcer healing and may slightly decrease pain and increase change in ulcer size when compared with neutral vehicle. Future research into the effects of hyaluronic acid in the healing of chronic wounds should consider higher sample size and blinding to minimise bias and improve the quality of evidence.

[Effectiveness of enteral nutritional therapy in the healing process of pressure ulcers: a systematic review]. / Efetividade da terapia nutricional enteral no processo de cicatrização das úlceras por pressão: revisão sistemática.

OBJECTIVE: To evaluate the effectiveness of enteral nutritional therapy (ENT) in the healing process of pressure ulcers (PU) in adults and the elderly. METHOD: A systematic review whose studies were identified through the databases of Cochrane, MEDLINE/PubMed, SciELO, LILACS, EMBASE, CINAHL, Web of Science, and manual searches. It included randomized clinical trials (RCTs) without delimiting the period or language of publication, which addressed adults and elderly patients with pressure ulcers in a comparative treatment of enteral nutritional therapy and placebo or between enteral nutritional therapy with different compositions and dosages. RESULTS: We included ten studies that considered different interventions. It resulted in more pressure ulcers healed in the groups that received the intervention. The included studies were heterogeneous with regard to patients, the type of intervention, the sample and the follow-up period, all of which made meta-analysis impossible. CONCLUSION: Although the enteral nutritional therapy demonstrates a promotion of pressure ulcer healing, sufficient evidence to confirm the hypothesis was not found.

Effectiveness of Enteral Nutritional Therapy in the Healing Process of Pressure Ulcers: A Systematic Review / Efectividad de la terapia de nutrición enteral en el proceso de cicatrización de las úlceras por presión: revisión sistemática / Efetividade da terapia nutricional enteral no processo de cicatrização das úlceras por pressão: revisão sistemática

OBJECTIVE To evaluate the effectiveness of enteral nutritional therapy (ENT) in the healing process of pressure ulcers (PU) in adults and the elderly. METHOD A systematic review whose studies were identified through the databases of Cochrane, MEDLINE/PubMed, SciELO, LILACS, EMBASE, CINAHL, Web of Science, and manual searches. It included randomized clinical trials (RCTs) without delimiting the period or language of publication, which addressed adults and elderly patients with pressure ulcers in a comparative treatment of enteral nutritional therapy and placebo or between enteral nutritional therapy with different compositions and dosages. RESULTS We included ten studies that considered different interventions. It resulted in more pressure ulcers healed in the groups that received the intervention. The included studies were heterogeneous with regard to patients, the type of intervention, the sample and the follow-up period, all of which made meta-analysis impossible. CONCLUSION Although the enteral nutritional therapy demonstrates a promotion of pressure ulcer healing, sufficient evidence to confirm the hypothesis was not found. .

OBJETIVO Evaluar la efectividad de la terapia de nutrición enteral en el proceso de cicatrización de las úlceras por presión en adultos y ancianos MÉTODO Revisión sistemática cuyos estudios fueron identificados por medio de las bases de datos Cochrane, MEDLINE/PubMed, SciELO, LILACS, EMBASE, CINAHL, Web of Science, y por búsqueda manual. Se incluyeron ensayos clínicos randomizados, sin delimitación de período e idioma de la publicación, que abordaron a pacientes adultos y ancianos portadores de úlceras por presión, en tratamiento comparativo entre terapia de nutrición enteral y placebo o entre terapia de nutrición enteral con distintas composiciones y dosificaciones. RESULTADOS Fueron incluidos diez estudios, que contemplaron diferentes intervenciones. Señalaron mayor cantidad de úlceras por presión cicatrizadas en los grupos que recibieron la intervención. Los estudios incluidos fueron heterogéneos con relación a los pacientes, la clase de intervención, la muestra y el tiempo de seguimiento, y los aspectos que hicieron inviable el metanálisis. CONCLUSIÓN Aunque la terapia de nutrición enteral demuestre favorecer la cicatrización de la úlcera por presión, no se encontraron evidencias suficientes para confirmar dicha hipótesis. .

OBJETIVO Avaliar a efetividade da terapia nutricional enteral no processo de cicatrização das úlceras por pressão em adultos e idosos. MÉTODO Revisão sistemática cujos estudos foram identificados por meio das bases de dados Cochrane, MEDLINE/PubMed, SciELO, LILACS, EMBASE, CINAHL, Web of Science, e por busca manual. Incluíram-se ensaios clínicos randomizados, sem delimitação de período e idioma da publicação, que abordaram pacientes adultos e idosos portadores de úlceras por pressão, em tratamento comparativo entre terapia nutricional enteral e placebo ou entre terapia nutricional enteral com diferentes composições e dosagens. RESULTADOS Foram incluídos dez estudos, que contemplaram diferentes intervenções. Apontaram maior número de úlceras por pressão cicatrizadas nos grupos que receberam a intervenção. Os estudos incluídos foram heterogêneos em relação aos pacientes, ao tipo de intervenção, à amostra e ao tempo de seguimento, aspectos que inviabilizaram a metanálise. CONCLUSÃO Embora a terapia nutricional enteral demonstre favorecer a cicatrização de úlcera por pressão, não foram encontradas evidências suficientes para confirmar essa hipótese. .

Efetividade da terapia nutricional enteral no processo de cicatrização das úlceras por pressão: revisão sistemática / Effectiveness of enteral nutritional therapy in healing process of pressure ulcers: a systematic review

Introdução: As Úlceras por Pressão (UP) são definidas como uma área de dano localizado à pele e tecidos subjacentes causados por pressão, cisalhamento, fricção e ou uma combinação destes. Apresentam outros fatores contribuintes, que são intrínsecos e extrínsecos ao sujeito, devido a essa etiologia multifatorial exibem elevada incidência e prevalência e constituem um problema de saúde pública, assim mostra-se a importância de pesquisas sobre a sua prevenção e tratamento. Com o intuito de minimizar a incidência e fornecer respaldo para o tratamento existem diversos guidelines que contemplam recomendações, dentre as quais a nutrição tem sido enfatizada e apontada como indispensável para o processo de cicatrização. Objetivo: Avaliar a efetividade da TNE no processo de cicatrização das UP em adultos e idosos. Metodologia: Revisão sistemática sobre o uso de terapia nutricional enteral (TNE) no processo de cicatrização das UP, utilizou-se as recomendações propostas pela Colaboração Cochrane. Incluíram-se ensaios clínicos randomizados (ECR), sem delimitação de período e idioma da publicação, que abordaram pacientes adultos e idosos portadores de UP, em tratamento comparativo entre TNE e placebo; ou entre TNE com diferentes composições e diferentes dosagens. Os estudos foram identificados eletronicamente por meio das bases de dados COCHRANE CENTRAL, MEDLINE, LILACS, EMBASE, CINAHL, Web of Science e por busca manual. Dois revisores independentes avaliaram e aplicaram os critérios de elegibilidade nos estudos, a fim de selecionar os relevantes. A qualidade metodológica foi avaliada por meio da "Ferramenta da Colaboração Cochrane para avaliação do risco de viés de ensaios clínicos randomizados". Os dados foram agrupados e analisados por desfechos. Resultados: Foram incluídos dez estudos, estes contemplaram diferentes intervenções, como arginina (N=1), vitamina C (N=2), colágeno hidrolisado (N=1), ornitina alfa-cetoglutarato - OKG (N=1), sulfato de zinco (N=1) e suplementos nutricionais mistos (N=4). Os estudos apontaram maior número de UP cicatrizadas nos grupos experimentais. O uso de 4,5 g de arginina em comparação a 9 g demonstrou promover benefício similar. Os suplementos nutricionais mistos exibiram maior taxa de cicatrização em comparação as fórmulas e/ou dieta padrão. O colágeno hidrolisado proveu aproximadamente o dobro da taxa cicatrização em comparação ao grupo controle. O grupo que recebeu OKG obteve redução da área de UP com área ? 8 cm2 e taxa mais elevada de cicatrização. Para o uso de vitamina C e sulfato de zinco, não há evidências de que favoreçam a cicatrização. Conclusão: Os estudos incluídos foram heterogêneos em relação aos pacientes, ao tipo de intervenção, amostra e tempo de seguimento, aspecto que inviabilizou a metanálise. Portanto, embora a TNE demonstre favorecer a cicatrização de UP, não foram encontradas evidências suficientes para confirmar essa hipótese. Sugere-se a condução de novos ECR com rigor metodológico, com amostras maiores e maior tempo de seguimento acerca da temática.

Introduction: Pressure Ulcers (PU) are defined as an area of localized damage to the skin and underlying tissue, caused by pressure, shear, friction, or a combination of them. Presenting other contributing factors that are intrinsic and extrinsic to the patients, due tothis multifactorial etiology, exhibits high incidence and prevalence and become a public health problem, thus showing the importance of research on its prevention and treatment. In order to minimize the incidence and provide support for the treatment, there are several guidelines that include recommendations, among which nutrition has been emphasized and identified as essential to the healing process. Aim: To evaluate the effectiveness of Enteral Nutrition Therapy (ENT) in the healing process of pressure ulcers (PU) in adults and elderly patients. Methodology: Systematic Review (SR) on the use of enteral nutrition therapy (ENT) in the healing process of the UP. It was used the recommendations proposed by the Cochrane Collaboration. It was included randomized controlled trials (RCTs) without delimiting period and language of publication, which addressed adult and elderly patients with PU in a comparative treatment of ENT and placebo; or between ENT with different compositions and different dosages. Studies were identified electronically through databases COCHRANE CENTRAL, MEDLINE, LILACS, EMBASE, CINAHL, Web of Science databases and manual search. Two independent reviewers assessed and applied the eligibility criteria in the studies in order to select the relevant ones. Methodological quality was assessed using the "Cochrane Collaborative Tool for assessing the risk of bias of randomized clinical trials". Data were pooled and analyzed by conclusions. Results: Ten trials were included, they contemplate different operations, such as arginine (N = 1), vitamin C (N = 2), collagen hydrolyzate (N = 1), ornithine alpha -ketoglutarate - OKG (N = 1) sulfate zinc (N = 1) mixed and nutritional supplements (N = 4). Studies point out more UP healed in the experimental groups. The use of 4.5 g of arginine as compared to 9 g, show further similar benefit. Mixed nutritional supplements exhibited higher healing rate compared to formulas and / or standard diet. Hydrolyzed Collagen provided roughly double the healing rate compared to the control group. The group that received OKG obtained reduction area in UP with areas ? 8 cm2 and higher rate of healing. For the use of vitamin C and zinc sulfate, there was no evidence favoring the healing process. Conclusion: The included studies were heterogeneous regarding patients, type of intervention, sample and follow-up time, an aspect that prevented the meta-analysis. So while ENT demonstrate promote healing of PU, not enough evidences to confirm this hypothesis were found. It is our suggestion to conduct new RCTs with methodological rigor, with larger samples and longer follow-up time on the theme.