|Year : 2019 | Volume
| Issue : 1 | Page : 84-88
Evaluation of chitosan impregnated with silver nanoparticles in the treatment of chronic venous leg ulcer: An open-label controlled study
Maha A Elgayyar1, Ahmed Abdelmoneim2, Khalid Mowafy3, Moustafa A Elsaied1, Mqdad Hasan Faqe1, Mohammad Ali Gaballah1
1 Department of Dermatology, Andrology and STDs, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Material Science and Engineering, Egypt-Japan University of Science and Technology, New Borg El Arab, Egypt
3 Department of Vascular Surgery, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Web Publication||14-Feb-2019|
Mohammad Ali Gaballah
Department of Dermatology, Andrology and STDs, Faculty of Medicine, Mansoura University, El-Gomhoria Street, Mansoura
Source of Support: None, Conflict of Interest: None
Background: The treatment of chronic venous leg ulcer (CVLU) is a major challenge. Much scientific advancement was made. Chitosan, derived from N-deacetylation of chitin, has been successfully used to promote wound healing. Silver nanoparticles (AgNPs) are used as bactericides. The aim of this work is to evaluate the efficacy and safety of chitosan alone or that impregnated with AgNPs compared to traditional compression bandage dressing in the treatment of CVLU. Materials and Methods: Thirty-eight CVLU patients completed the treatment for 3 months. They were treated with compression bandage and categorized into three groups: Group A included 12 patients used chitosan impregnated with the AgNPs, Group B included 11 patients used chitosan alone, and Group C included 15 patients used compression bandage alone. For all patients, routine investigations, lower limbs Duplex ultrasound and bacterial culture and sensitivity from the ulcers before and after treatment were done. Results: The healing of ulcers in the treated groups was mostly apparent in Groups A and C. Conclusions: Chitosan impregnated with AgNPs can be a hopeful treatment for CVLU. However, compression bandage alone is also effective for the treatment of CVLU.
Keywords: Chitosan, nanoparticles, silver, venous ulcer
|How to cite this article:|
Elgayyar MA, Abdelmoneim A, Mowafy K, Elsaied MA, Faqe MH, Gaballah MA. Evaluation of chitosan impregnated with silver nanoparticles in the treatment of chronic venous leg ulcer: An open-label controlled study. Clin Dermatol Rev 2019;3:84-8
|How to cite this URL:|
Elgayyar MA, Abdelmoneim A, Mowafy K, Elsaied MA, Faqe MH, Gaballah MA. Evaluation of chitosan impregnated with silver nanoparticles in the treatment of chronic venous leg ulcer: An open-label controlled study. Clin Dermatol Rev [serial online] 2019 [cited 2019 Jul 15];3:84-8. Available from: http://www.cdriadvlkn.org/text.asp?2019/3/1/84/252301
| Introduction|| |
Chronic venous leg ulcer (CVLU) is a chronic wound of the leg caused by venous insufficiency and shows no tendency to heal after 6 weeks of appropriate treatment or that did not fully heal completely after 12 months. CVLU is usually associated with significant morbidity, high cost of healthcare, loss of productivity, and reduced quality of life. The gold standard therapy for CVLU is the compression bandage. The addition of different substances to the compression therapy to accelerate ulcer healing was attempted but none of them yielded optimal results.
The synthesis of nanomaterials through nanotechnologies is of current interest due to their wide variety of applications in many fields of medicine. Silver nanoparticles (AgNPs) have its significant applications as bactericides, antimycotics, and anticancer agents. However, the actual mechanism of action is not clear. They may inactivate microorganisms by interacting with their enzymes, proteins, or DNA to inhibit cell proliferation.
Chitosan is derived from the N-deacetylation of chitin. It is a polysaccharide copolymer comprised of glucosamine and N-acetylglucosamine. It was extensively explored for biomedical applications due to its notable properties including biocompatibility, wound healing effect, anti-inflammatory, and antimicrobial activities. Chitosan electrospun nanofibers have been demonstrated as advantageous wound-healing biomaterials, improving cell adhesion, and proliferation in vitro and inducing a fast regeneration of both the epidermis and dermis tissues in vivo.
This work aims at evaluating the efficacy and safety of chitosan impregnated with AgNPs versus chitosan alone and compression bandage alone in the treatment of CVLU.
| Patients and Methods|| |
This study was carried out on patients with active CVLU recruited from the outpatient clinics of Dermatology, Andrology and STDs department and Vascular Surgery Department, Mansoura University Hospital. Preparations of chitosan alone and impregnated with AgNPs in gel form were performed by Materials Science and Engineering department, Egypt-Japan University of Science and Technology, Alexandria-Borg El Arab. Informed consent was obtained from every patient, and the Institutional Research Board for experimental and clinical studies at Faculty of Medicine, Mansoura University, approved the study.
Patients with CVLU of different sizes and durations with good general medical condition were included in this study. Inclusion was done after confirmation of diagnosis by color duplex ultrasound of lower limbs.
- Ulcer due to arterial disease (excluded clinically and by color duplex)
- Diabetic leg ulcer (excluded by history and random blood sugar)
- Ulcers due to autoimmune diseases
- Nonvenous causes of unilateral and bilateral lower limb edema
- Patient on systemic steroids or other immunosuppressive treatment
- Patients with systemic diseases such as hypertension, diabetic mellitus, and chronic liver and renal impairment
- Patients with history of shrimp allergy; as chitosan is derived from it.
Every patient was subjected to:
- Full history taking and general medical examination
- Leg assessment for signs of venous disease (e.g., varicose veins, stasis dermatitis, hemosiderin deposition, edema, lipodermatosclerosis, and atrophie blanche)
- Ankle joint mobility assessment as it is an important component of calf muscle pump function
- Arterial supply assessment with respect to safety of compression therapy, by palpation of pulses (dorsalis pedis and posterior tibial arteries)
- Local examination of the ulcer. The leg ulcer was measured by the modified Leg Ulcer Measurement Tool. Photographs with Canon Power Shot SX200 IS 12.1 Megapixel Digital Camera were documented.
The items of the ulcer evaluation included:
- Site, shape, and edge
- Dimensions (length and width in centimeters)
- Changes of dimensions after treatment
- Surface area before and after treatment
- Pain (present/absent)
- Discharge (present/absent).
- Patients were instructed to stop any topical antiseptics, topical and systemic antibiotics for 1 week then culture and sensitivity from the ulcer was done before starting and at the end of the study
- Color duplex ultrasound was done to evaluate vein anatomy and for assessing both reflux and obstruction within the deep, superficial or perforating veins, from the inferior vena cava to the calf veins. In addition, it was important to exclude ischemia and arterial disorders. It was performed with the patient in a standing position.
The patients were allocated by randomization (via closed envelopes) to either Group A, B, or C:
- Group A included 15 patients to whom compression bandage dressing impregnated with chitosan plus AgNPs as gel was applied. The dressing was done as the following technique: a piece of gauze was moistening with normal saline solution and then used to clean the ulcer from exudates, pus, and debris. Then, dry gauze was used to dry the ulcer. After that, the gel was applied to the ulcer as a thin layer. Then, the ulcer was covered with dry gauze, dry dressing, and compression bandage. Only 12 patients continued the study till its end
- Group B included 15 patients treated with compression bandage dressing containing chitosan gel only. Dressing was done as mentioned in Group A. Only 11 patients continued the study till its end
- Group C included 15 patients treated with compression bandage dressing without chitosan or AgNPs. Dressing was done as mentioned in Group A but without using any gel. All patients continued the study till its end
- For each patient, the dressing was applied twice/weekly till either complete healing of the ulcer or for a maximum of 3 months' duration.
Data management and statistical analysis
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (IBM Corporation, Foster City, CA, USA). Qualitative data were described using number and percentage. Quantitative data were described using minimum and maximum, mean and standard deviation and median. The comparison between different groups regarding categorical variables was tested using Chi-square test. When more than 20% of the cells have expected count <5, correction for Chi-square was conducted using Fisher's exact test or Monte Carlo correction. For abnormally distributed data, comparison between two groups were done using Mann–Whitney test. Correlations between two quantitative variables were assessed using Spearman coefficient significance of the obtained results was judged at the 5% level. P value is statistically significant if ≤0.05.
| Results|| |
Out of 45 patients, 38 patients (30 males and 8 females) with CVLU aged from 15 to 62 years completed the study till its end. Duration of the ulcers ranged from 1 to 5 years. Pain was present in all cases. About 81.6% of ulcers were in gaiter area (the area between the ankle and the calf). All patients showed abnormal color duplex ultrasound findings in venous system of lower limbs [Table 1]. All patients showed purulent discharge and were positive for bacterial culture.
With treatment, the pain disappeared gradually in all groups. There were significant decreases in ulcers surface area in Groups A and C [Table 2]. In addition, 11 out of 38 patients (28.95%) showed complete healing and closure of the ulcers; one (8.3%) in Group A, six (54.6%) in Group B, and four (26.6%) in Group C. Furthermore, purulent discharge disappeared, and bacterial culture became negative by the end of the study, especially in Group A [Table 3].
|Table 2: Ulcers surface area before and after treatment in different groups|
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|Table 3: Epidemiological characteristics of the patients, local examination, and bacterial culture in the studied groups|
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| Discussion|| |
In the present study, CVLU was in the gaiter area of the leg in 31 patients (81.6%). Grey et al. reported that venous ulceration appears in the gaiter area in about 85%–95% of cases especially in the medial aspect over the medial malleolus.
All patients showed abnormal color duplex ultrasound findings in the form of abnormalities in superficial venous system, valves, and perforators. Siddiqui and Bernstein reported that the color duplex ultrasound scanning is the de facto standard for evaluation of venous obstruction and the location and extent of reflux in CVLU.
Bacterial culture and sensitivity were done from all ulcers as all of them showed purulent discharge. This follows Siddiqui and Bernstein who recommended bacterial culture and sensitivity once wound infection was suspected. Bacterial cultures in the present work were positive for all ulcers before starting the treatment. However, re-evaluation after 3 months showed negative cultures especially in Group A who were treated with chitosan with AgNPs while positive cultures were more in Group C treated with compressing bandage only.
This can be due to that AgNPs have a strong antimicrobial effect as it binds to bacterial wall, enzymes, and DNA. In addition, chitosan showed strong antifungal and bactericidal effects against Gram-positive and Gram-negative bacteria., Thus, the use of chitosan impregnated with AgNPs is expected to have better antimicrobial effects than chitosan alone.
Healing of ulcers was significant by the end of the study in Groups A and C as there were significant decreases in ulcers surface areas by the end of the study. Yet, comparisons between different groups regarding the percentage of decreases in ulcer surface area showed nonsignificant differences and Group B showed the highest percentage of this decrease followed by Group A and lastly Group C. This is in agreement with Sandoval et al. who reported better healing of chronic leg ulcers using chitosan gel than compression bandage alone.
In addition, in the present work, 11 out of 38 patients (28.95%) showed complete healing and closure of the ulcers; about half of them were in Group B who were treated with chitosan only. This can be attributed to that the sizes of ulcers were the smallest in Group B while the possible cytotoxicity of silver dressings on fibroblasts decreased healing in Group A.
Chitosan has evidenced healing properties as it provides a nonprotein matrix for three dimensional tissue growths activates macrophages for tumoricidal activity and stimulates proliferation and histoarchitectural tissue organization. Chitosan gradually depolymerizes to release N-acetyl-b-D-glucosamine which initiates fibroblastic proliferation, helps in ordered collagen deposition and stimulates increased level of natural hyaluronic acid synthesis at the wound site. This helps in faster wound healing and scar prevention. Finally, chitosan blocks nerve endings reducing pain.,
No adverse effects were found in the studied groups, and no complications related to the chitosan were observed in the present study in accordance with patients of Sandoval et al. and Boynueǧri et al. throughout the study period.
In spite of their higher unit cost, the use of chitosan advanced dressing resulted in shorter hospital stays and reduced the need for antibiotics and surgical debridement and amputations which allowed the patient to return to work earlier. From the different studies reported in literature, chitosan seems to be an excellent candidate dressing material for the wound healing applications.
Chitosan with AgNPs may show healing rate lower than chitosan alone in spite of having better antimicrobial effects. Zou et al. reported that all silver dressings tested were found to reduce the viability and change the cell morphology of the diabetic fibroblasts leading to decrease cell proliferation and collagen synthesis.
On the other hand, evidence exists that the most potent modern-day forms of silver do not have a deleterious cytotoxic effect on other cell types rather than the bacterial cells. In addition, other authors reported that silver-impregnated dressing did not significantly affect healing rates of CVLU. The debate over the cytotoxicity of silver dressings on fibroblasts continues. This could in part explain the midway healing of Group A where Chitosan with AgNPs dressings was applied. Hence, further investigations in this area are needed.
Compression therapy is considered the mainstay of therapy, especially in poor patients. It improves venous flow and lymphatic drainage, and reduces the superficial venous pressure and reflux while increasing the local hydrostatic pressure, that causes reduction of volume overload in the venous system, reduction of edema, and decreased extravasation of macromolecules. Furthermore, compression enhances fibrinolysis, preventing trapping of important mediators for wound healing and decreasing the rate of ulcer recurrence. Multilayered bandage systems are the most useful as they provide sustained pressures when applied correctly and provide cushioning, have absorptive capacity and require less frequent dressing changes.
The main limitations that affected the results of the present study were the small number of cases and the big differences of surface areas among groups due to randomization. Further works on a larger sample size with more homogeneous distribution of patients in groups are recommended.
| Conclusion|| |
Chitosan impregnated with AgNPs can be a hopeful treatment for CVLU. However, it needs more studies and investigations on large scale of patients. Compression bandage alone is also effective and can be used with success, especially in poor patients who cannot afford different chitosan treatments.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rahman GA, Adigun IA, Fadeyi A. Epidemiology, etiology, and treatment of chronic leg ulcer: Experience with sixty patients. Ann Afr Med 2010;9:1-4.
] [Full text]
Kahle B, Hermanns HJ, Gallenkemper G. Evidence-based treatment of chronic leg ulcers. Dtsch Arztebl Int 2011;108:231-7.
Tang JC, Marston WA, Kirsner RS. Wound healing society (WHS) venous ulcer treatment guidelines: What's new in five years? Wound Repair Regen 2012;20:619-37.
Mata A, Palmer L, Tejeda-Montes E, Stupp SI. Design of biomolecules for nanoengineered biomaterials for regenerative medicine. Methods Mol Biol 2012;811:39-49.
Zhang H, Wu M, Sen A. Silver nanoparticle. In: Cioffi N, Rai M, editors. Nano-Antimicrobials and Related Materials. New York: Springer; 2012. p. 3-45.
Panácek A, Kolár M, Vecerová R, Prucek R, Soukupová J, Krystof V, et al.
Antifungal activity of silver nanoparticles against Candida
spp. Biomaterials 2009;30:6333-40.
Das S, Das J, Samadder A, Bhattacharyya SS, Das D, Khuda-Bukhsh AR, et al.
Biosynthesized silver nanoparticles by ethanolic extracts of Phytolacca decandra
, Gelsemium sempervirens
, Hydrastis canadensis
and Thuja occidentalis
induce differential cytotoxicity through G2/M arrest in A375 cells. Colloids Surf B Biointerfaces 2013;101:325-36.
Singh AK, Talat M, Singh PD, Srivastava ON. Biosynthesis of gold and silver nanoparticles by natural precursor clove and their functionalization with amine group. J Nanopart Res 2010;5:1667-75.
Tchemtchoua VT, Atanasova G, Aqil A, Filée P, Garbacki N, Vanhooteghem O, et al.
Development of a chitosan nanofibrillar scaffold for skin repair and regeneration. Biomacromolecules 2011;12:3194-204.
Burrows C. Leg ulcers. Wound Care Can 2008;8:16-8.
Ketoz S, Balakrishnan N, Read CB, Vidakovic B. Encyclopedia of Statistical Sciences. 2nd
ed. Hobken NJ: Wiley-Interscience; 2006.
Leslie E, Geoffrey J, James M. Statistical analysis. In: Leslie E, Geoffrey J, editors. Interpretation and uses of Medical Statistics. 4th
ed. Oxford: Scientific Publications; 1991. p. 411-6.
Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ 2006;332:347-50.
Siddiqui AR, Bernstein JM. Chronic wound infection: Facts and controversies. Clin Dermatol 2010;28:519-26.
Lansdown AB. Silver. I: Its antibacterial properties and mechanism of action. J Wound Care 2002;11:125-30.
No HK, Park NY, Lee SH, Meyers SP. Antibacterial activity of chitosans and chitosan oligomers with different molecular weights. Int J Food Microbiol 2002;74:65-72.
Seyfarth F, Schliemann S, Elsner P, Hipler UC. Antifungal effect of high- and low-molecular-weight chitosan hydrochloride, carboxymethyl chitosan, chitosan oligosaccharide and N-acetyl-D-glucosamine against Candida albicans
, Candida krusei
and Candida glabrata
. Int J Pharm 2008;353:139-48.
Sandoval M, Albornoz C, Muñoz S, Fica M, García-Huidobro I, Mertens R, et al.
Addition of chitosan may improve the treatment efficacy of triple bandage and compression in the treatment of venous leg ulcers. J Drugs Dermatol 2011;10:75-9.
Mudge EJ. Recent accomplishments in wound healing. Int Wound J 2015;12:4-9.
Stone CA, Wright H, Clarke T, Powell R, Devaraj VS. Healing at skin graft donor sites dressed with chitosan. Br J Plast Surg 2000;53:601-6.
Veleirinho B, Coelho DS, Dias PF, Maraschin M, Ribeiro-do-Valle RM, Lopes-da-Silva JA, et al.
Nanofibrous poly(3-hydroxybutyrate-co-3-hydroxyvalerate)/chitosan scaffolds for skin regeneration. Int J Biol Macromol 2012;51:343-50.
Boynueǧri D, Ozcan G, Senel S, Uç D, Uraz A, Oǧüş E, et al.
Clinical and radiographic evaluations of chitosan gel in periodontal intraosseous defects: A pilot study. J Biomed Mater Res B Appl Biomater 2009;90:461-6.
Morshed G, Mashahit MA, Ramadan MA. A comparative study between Chitosan and Povidone Iodine as dressing solution for chronic wounds. Kasr El Aini Med J 2012;18:19-22.
Zou SB, Yoon WY, Han SK, Jeong SH, Cui ZJ, Kim WK, et al.
Cytotoxicity of silver dressings on diabetic fibroblasts. Int Wound J 2013;10:306-12.
Roberts CD. Reply to cytotoxicity of silver dressings – Time to think and react by Nagoba, et al.
Int Wound J 2013;10:617.
Michaels JA, Campbell B, King B, Palfreyman SJ, Shackley P, Stevenson M, et al.
Randomized controlled trial and cost-effectiveness analysis of silver-donating antimicrobial dressings for venous leg ulcers (VULCAN trial). Br J Surg 2009;96:1147-56.
Kirsner RS, Vivas AC. Lower-extremity ulcers: Diagnosis and management. Br J Dermatol 2015;173:379-90.
[Table 1], [Table 2], [Table 3]