Post Matrixectomy
Topical Medications: A Comparative Study
AmeriGel® Wound Dressing (Oakin™) (Amerx
Health Care Corp., Clearwater, FL)
Versus Silvadene (SSD) (Monarch
Pharmaceuticals, Bristol, TN)
 Abstract
Phenol and sodium hydroxide matrix ablations
are the most commonly practiced nail surgical techniques used
to treat ingrown and symptomatic nail deformities.1-4 Post-operatively,
podiatric physicians require their patients to perform frequent
soaks and dressing changes. Non-compliance by patients has
been a long-standing issue and no viable alternative has been
available to address this concern. This study demonstrates
that without post-operative soaking, patient's outcomes are
enhanced, risk of cross-contamination from soaking is eliminated
and healing times reduced.
Current Practices
The main disadvantage to both sodium hydroxide
and phenol procedures is the creation of a
chemical injury that denatures proteins much as a thermal burn
would do. 5 Primary considerations in topically treating a
chemical cauterization (burn) include keeping the site infection
free and clear of necrotic tissue, while allowing exudates
to drain freely from the wound site without maceration.
No single medication has yet been established as a standard
for matrixectomies. In a review of current textbooks,
the following citations were found:
- I currently prescribe, for all my patients who have undergone
phenol nail procedures, daily post operative foot soaks of
warm water and Epsom salts followed by the application of
several drops of Cortisporin Otic solution (Neomycin and
Polymixin B sulfates and Hydrocortisone otic solution) the
day after the procedure is performed.6
- Patients are advised to expect some serous drainage (days
to weeks) representing the chemical burn induced by the phenol.
The duration and the amount of drainage can be limited significantly
with the use of non-steroidal anti-inflammatory medications.
In addition, patients are advised to soak the foot in luke
warm saline 10-15minutes t.i.d. Prolonged
drainage might suggest a low-grade superficial infection
and, for this reason, application of Neosporin or Betadine
following the soaks is helpful. Patients may wear sandals
for a day or two and then regular shoes as tolerated. Patients
return in 3 days for removal of clot and debris. They are
also encouraged to clean the surgical area with a sponge
or cloth as a means of ongoing debridement.7
- The P&Ainvolves three, 30-second applications
(causing the nail bed and matrix to appear ashen gray) of
90% phenol followed by rinsing with alcohol (70-90% isopropyl
or ethyl), then copious saline lavage and application of
silver sulfadiazine cream and a sterile bandage. The NaOH
procedure involves application of 10% NaOH until the matrix
and nail bed tissues appear ashen gray-brown (about 20-30
seconds); followed by acetic acid (vinegar) rinse, then copious
saline lavage, silver sulfadiazine cream, and a sterile bandage.
The main disadvantage to both the P&A and NaOH procedures
is the creation of a chemical injury that denatures proteins
much as a thermal burn would do. The wound remains open and
draining for 3-4 weeks.5
Current trends within podiatric medicine are reflected in
a recent survey, conducted by Amerx Health Care Corp. at a
major podiatry conference, in which 100 podiatric physicians
at random responded. The results of this survey show that 45%
of podiatric physicians use Silvadene to dress their matrixectomies
and instruct their patients to soak frequently. The remaining
55% use various topical antibiotic preparations that help prevent
infection but still require soaking. An average of 30
% of patients are non-compliant with post-operative instructions,
specifically with soaking.
Study Purpose
The purpose of this study therefore, was to determine
which product would require post operative soaking that is
the traditional intervention used in healing matrixectomies.
Product Descriptions
Silvadene (Silver Sulfadiazine) (SSD) Wound Dressing: is a
prescriptive topical based broad range antimicrobial (bactericidal)
and antifungal agent indicated for use on burns and skin infections.
Some possible side effects of SSD are maceration, inflammation
and impairment of re-epithelialization and collagen deposition.8 Silvadene
is contraindicated for use in those patients who are hypersensitive
to SSD or any of its ingredients.
AmeriGel® (Oakin™) Wound Dressingis
an over the counter topical bactericidal and autolytic debridement
agentclassified by the FDA as a hydrogel wound
filler. AmeriGel® is indicated for use on stage I-IV pressure
ulcers, diabetic skin ulcers, venous stasis ulcers and 1st & 2nd
degree burns, post-surgical incisions, cuts and abrasions.
AmeriGel®’s primary ingredient is Oakin, an oak extract
(Tannins) that act locally by proliferating proteins to the
wound site and decrease cell membrane permeability. In micological
testing (In Vitro), oak extract is bactericidal against 49
gram+ and gram- microorganisms. AmeriGel® Wound Dressing
is contraindicated for those patients who are hypersensitive
to oak or any of its ingredients.
Methodology
In this case study research, the authors evaluated the outcome
of two topical dressing medications used to heal a bilateral
post matrixectomy procedure in order to assess the need for
soaking. One patient, a healthy 49yo male, non-compromised,
non-diabetic with controlled hypertension underwent a bilateral
phenol nail ablation (Fig. 1.) Although this study was performed
utilizing phenol, similar results can be reproduced using sodium
hydroxide.
A traditional matrixectomy was performed without any changes
or modifications in technique. The only difference was that
one toe was dressed with Silvadene and the other with AmeriGel®
Wound Dressing after the alcohol flush.
Results
 |
|
 |
Pre-phenolization
(Fig. 1)
|
Post-phenolization
(Fig. 2)
|
After the procedure was completed (Fig. 2), Silvadene was
applied to the left toe and AmeriGel® to the right toe, and
then bandaged. The patient was instructed to keep the
dressings dry, intact and to return for a follow up visit in
48 hours.
This picture (Fig. 3) was taken immediately after removing
the dressings. The left toe shows maceration and a need
for debridement. The right toe shows a clean debris free
nail bed that needs only to be re-dressed. Note the difference
in the nail beds of the right toe between post-phenolization
(Fig. 2) and 48 hours later (Fig. 3.)
This demonstrates the benefit of AmeriGel®'s autolytic debridement. The
patient reported that the left toe was sore and tender, while
the right toe was asymptomatic. Silvadene was discontinued
per the patient's request and AmeriGel® was applied bilaterally
thereafter.
 |
48 hours post-procedure
(Fig.3)
|
The patient resumed normal bathing/showering
48 hours post-procedure, blotted the nail bed dry and applied
a thin layer of AmeriGel® to the site. A band-aid was
placed around the toe and resumed normal daily activities. Dressing
changes were performed daily. The patient returned for
a follow-up visit 9 days post-procedure (Fig.4.)
Discussion
It should also be noted that the toe was dressed
initially with AmeriGel® for 48 hours, therefore even if a patient
skips a dressing change, the medication remained effective.
A reduction in post-operative complications and healing time
are other factors to be considered. Total healing time for
this patient was 16 days until the drainage ceased. Comparatively,
per the citation in the Podiatry Institute Manual, wounds remain
open and draining for 3-4 weeks (using SSD.)5 This demonstrates
that AmeriGel® can reduce the healing times.
Conclusion
The 48-hour post-procedure picture (Fig. 3) clearly demonstrates
an ideal nail bed. This shows that the autolytic debridement
properties in AmeriGel® would be beneficial over SSD usage and
did not have the potential to macerate the wound. By eliminating
the major non-compliance factor (soaking), the patient’s outcomes
are enhanced by minimizing the risk for cross-contamination
from soaking. Further, polyethylene glycol (PEG) is known to
neutralize phenol. Therefore, podiatric physicians who use
phenol would benefit from using AmeriGel® Wound Dressing, as
its basic substrate is PEG.
References
- Laco J: "Nail Disorders," in Principles and
Practice of Podiatric Medicine, ed by V Hetherington,
p 520, Churchill Livingstone, New York, 1990.
- Foley G, Allen J: Wound Healing after toenail avulsion,
Foot 4: 88, 1994.
- Rinaldi R, Sabia M, Gross J: The treatment and prevention
of infection in phenol alcohol matrixectomies, JAPA 72: 453,
1982.
- Zuber T, Pfenninger J: Management of ingrown toenails,
Am Fam Physician 52:181, 1995.
- Malay DS: "Reconstructive
surgery of basic conditions and deformities,"in The Podiatry Institute Manual, A
Handbook of Podiatric Medicine and Surgery, ed by
DS Malay, p 152, Podiatry Institute Publishing, Inc., Tucker,
GA, 1999
- Banks AS, Downey MS, Martin DE,
et al: "Nails," in McGlamry's
Comprehensive Textbook of Foot and Ankle Surgery,
Vol 1, 3rd edition, p 226, Lippincott Williams & Wilkins,
Philadelphia, 2001.
- Johnson KA: "Phenol matrixectomy," in, Master
Techniques in Orthopaedic Surgery, The Foot and Ankle,ed
by RC Thompson, Jr., p 19, Lippincott-Raven, Philadelphia,
1997.
- Demling RH, DeSanti L: The Role of Silver Technology
in Wound Healing, Part 1, Effects of Silver on Wound
Management, Wounds 13: 7, 2001.
Authors:
William J. Beaton, DPM
800 5th Avenue S.
St. Petersburg, FL 33701
PH: 727-896-4615
FX: 727-869-4616
Email: wjbeaton2@aol.com
Art W. Simonetti, LPN, MBA
1001 Starkey Rd. #4
Largo, FL 33771
PH: 727-507-8515
Email: aws@amerxhc.com
|
