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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 4 | Page : 515-519
Wound bed preparation using nonsurgical methods: A prospective comparative study of honey versus unripe papaya (Carica papaya)
Ugochukwu Uzodimma Nnadozie1, Charles Chidiebele Maduba2, Victor Ifeanyichukwu Modekwe3, Nicodemus O K. Obayi4, Okwudili Calistus Amu5, Okechukwu Valentine Onyebum6, Nneka Alice Sunday-Nweke6, Uche S D. Unigwe7, Ulebe Augustine Obasi6
1 Division of Plastic Surgery, Department of Surgery, Alex Ekwueme Federal University Teaching Hospital; College of Health Sciences, Ebonyi State University, Abakaliki, Ebonyi, Nigeria
2 Division of Plastic Surgery, Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi, Nigeria
3 Pediatrics Surgery Unit, Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria
4 College of Health Sciences, Ebonyi State University, Abakaliki, Ebonyi, Nigeria
5 Department of Surgery, University of Nigeria, Enugu Campus, Enugu, Nigeria
6 Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi, Nigeria
7 Infectious Disease Unit, Department of Medicine, University of Nigeria Teaching Hospital Enugu, Enugu, Nigeria
Correspondence Address:
Ugochukwu Uzodimma Nnadozie
Division of Plastic Surgery, Department of Surgery, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_10_22
Abstract
Background: The rapidity of wound bed preparation is determined in part by the type of dressing agent employed. The extension phase in which the wound is characterized by the presence of sloughs and eschar and microbial invasion could be managed nonsurgically. Objective: The objective of this study was to compare the rapidity of wound bed preparation using unripe papaya versus honey. Materials and Methods: Sixty-four patients were assigned into two equal groups, each dressed, respectively, with unripe papaya or honey. All selected patients were monitored for eschar separation and bacterial clearance time. Data obtained with a pro forma were analyzed with SPSS version 25. Results: Unripe papaya dressing had a mean eschar separation time of 5.53 ± 2.20 days and bacterial clearance time of 6.81 ± 3.64 days compared to the honey group which had an eschar separation time of 30.09 ± 27.90 days and bacterial clearance time of 15.33 ± 13.62 days. P <0.001 and P < 0.001, respectively, in comparing both outcome measures between the two groups. There was a statistically significant difference in both eschar/slough separation time and bacterial clearance time both in favor of the group prepared with unripe papaya. Conclusion: The use of unripe papaya was superior to honey in wound bed preparation with respect to eschar/slough separation, bacterial clearance ultimately resulting in reduced length of hospital stay.
Abstract in French Résumé
Contexte: La rapidité de la préparation du lit de la plaie est déterminée en partie par le type de pansement utilisé. La phase d'extension dans laquelle la plaie est caractérisée par la présence de mucosités et d'escarres et par une invasion microbienne pourrait être gérée de manière non chirurgicale. Objectif de l'étude: L'objectif de cette étude était de comparer la rapidité de la préparation du lit de la plaie en utilisant de la papaye non mûre par rapport au miel. Matériels et méthodes: Soixante-quatre patients ont été répartis en deux groupes égaux, chacun habillé respectivement avec de la papaye non mûre ou du miel. Tous les patients sélectionnés ont été suivis pour la séparation de l'escarre et le temps de clairance bactérienne. Les données obtenues à l'aide d'un pro forma ont été analysées à l'aide de la version 25 de SPSS. Résultats: Le pansement à la papaye non mûre Le temps moyen de séparation de l'escarre était de 5,53 ± 2,20 jours et le temps de clairance bactérienne de 6,81 ± 3,64 jours pour le groupe papaye non mûre, contre 30,09 ± 27,90 jours pour le groupe miel et 15,33 ± 13,62 jours pour le temps de clairance bactérienne. P < 0,001 et P < 0,001, respectivement, dans la comparaison des deux mesures de résultats entre les deux groupes. Il y a eu une différence statistiquement significative dans le temps de séparation de l'escarre/du bourbier et dans le temps de clairance bactérienne en faveur du groupe préparé avec de la papaye non mûre. Conclusion: L'utilisation de papaye non mûre était supérieure au miel dans la préparation du lit de la plaie en ce qui concerne la séparation de l'escarre/de la pellicule, la clairance bactérienne et, en fin de compte, la réduction de la durée du séjour à l'hôpital. la durée du séjour à l'hôpital.
Mots-clés: Clairance bactérienne, séparation de l'escarre, miel, papaye, lit de la plaie
Keywords: Bacterial clearance, eschar separation, honey, papaya, wound bed preparation
Introduction 
Wound bed preparation is an important aspect of wound care preceding definitive wound cover. During this process, the wound goes through its natural phases of extension, transition, and healing.[1] The rapidity with which it goes through these phases is in part determined by the dressing agent employed. The choice of dressing agent is also dependent on the phase of the wound. The wounds in the extension phase are usually characterized by a heavy presence of eschars and/or sloughs with features of infection. The wound is often arrested in the inflammatory phase for a protracted period resulting in the chronicity of wounds.[2] The aim of wound management at this stage is to achieve both cleansing of the wound bed and control of infection. In the transition phase, on the other hand, there is a gradual shift toward healing with the separation of eschars and commencement of granulation tissue formation. Infections are also being eradicated at this stage. In the healing phase, the granulation tissues are healthy, infections are wholly controlled, and dead tissues whether eschars or sloughs are no longer in existent. The wound at this stage is ready for coverage.
The management of the extension phase can be done with either surgical or nonsurgical debriding protocols. Nonsurgical options include autolytic, biological, and enzymatic debridement. The most desirable agent would be one, i.e. inexpensive, readily available, and capable of producing a wound suitable for closure in the shortest amount of time.[3],[4] The most commonly used nonsurgical debriding agents in our experience are honey and normal saline. Other autolytic agents such as hydrogels and alginates are less commonly used in low- and middle-income countries because of cost and limited availability. Historically, maggots have been used for wound debridement but we have scant experience with this modality.
Unripe papaya is a known source of the enzyme papain which has been used for enzymatic escharolysis and sloughectomy.[5],[6],[7] It is both effective and safe in wound bed preparation. This, however, is not in common practice in our region where papaya (Carica papaya), locally known as pawpaw, is readily available and affordable. Nigeria is the largest producer of papaya in Africa and one of the top five producers of this fruit in the world.[8],[9] The papaya is considered a food rather than a source of medicaments in Nigeria.
This study aims to compare the rapidity of wound bed preparation with respect to the eschar separation and bacterial clearance using unripe papaya or honey.
Materials and Methods Study design
This was a prospective comparative study of a group of patients who had wound bed prepared with honey and another group whose wound beds were prepared with unripe carica papaya locally sourced and processed.
Study setting
The study was carried out at the Division of Plastic and Reconstructive Surgery of the Surgery Department, Alex Ekwueme Federal University Teaching Hospital, Abakaliki, (AEFUTHA) Ebonyi State, Nigeria. It is a highly specialized center with a 720 bed capacity of which 200 beds are dedicated to different subspecialties in surgery and orthopedics. The plastic unit has six consultants and five senior registrars with 22 nurses 16 being trained and certified burns and plastic nurses. The division has a 20-bed capacity as well as shares patients with the orthopedic unit in another 80-bed unit.
Eligibility criteria
The inclusion criteria for the study which were met by all the patients were: all wounds were in the extension phase or early transition phase; all patients were in a stable systemic state; the patient declined or could not afford surgical debridement; and all patients gave consent for the study. Those excluded were patients on steroids, poor glycemic control, systemic instability, tobacco smokers, arterial and radiation ulcers, and all those who declined consent.
Ethical clearance
Approval for the study was obtained from the Research and Ethics Committee of the AEFUTHA. Written informed consent was also obtained from every participant before enrollment. The nature of the study and the potential complications was clearly explained to the participants. Refusal to participate did not attract any negative consequences to the patients or the patients' management.
Sampling method
A total of (64) patients were enrolled in the study. Due to the patient population in the center, we were determined to recruit every eligible patient who presented to the center in the 12-month study. In recruiting the participants, they were properly matched for sex, age, and etiology.
Study instruments
Data were collected using a pro forma developed by the research team based on related previous studies. The content of the pro forma was designed to provide relevant information such as sociodemographic and clinical characteristics of the participants and the wounds studied.
Procedure
This study was carried out from April 1, 2020, to March 31, 2021. Participants were enrolled on presentation to the burns and plastic surgery clinic or following a consult from other units of the hospital. They were categorized into Group A or B by the researchers in order of presentation taking note of the matching characteristics. The Group A patients had wound bed preparation with laser honey which is a medical grade honey sold over the counter in pharmacy shops as well as in the supermarkets. Medical-grade honey like laser honey is honey free from contaminants through gamma irradiation, filtration, and laboratory-controlled conditions. In Group A, honey was applied directly on the wound followed by gauze layers and crepe bandage.
The Group B patients, on the other hand, had grated unripe papaya applied directly on the wound followed by gauze layers and crepe bandage application.
In both groups, the change of dressing was done on an alternate day basis. Before the commencement of the chosen method of wound bed preparation, the wound was irrigated with normal saline, and the wound swab was taken for bacterial culture and antibiotics sensitivity.
The irrigation with normal saline was repeated on each change of dressing before applying the dressing agent. Following eschar or slough separation, the wounds were washed with normal saline and wound swabs for bacterial culture, and antibiotic sensitivity was repeated to monitor for bacterial clearance. Bacterial clearance is achieved when there is a negative/no growth on the wound swab culture. In addition to eschar separation and bacterial clearance, the granulation tissues were observed and judged adequate based on clinical parameters before wound cover was planned.
Data analysis
After the data collection, analysis was done using the IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. P <0.05 was considered statistically significant. The results were presented in prose and tables.
Results The study involved 64 patients 34 males and 30 females. Each group had 32 participants. The mean ages for the patients in the two arms of the study were close, 39.92 ± 21.77 for the papaya group and 42.69 ± 16.76 for the honey group [Table 1]. Eighty-one percent of the patients had lower extremity wounds. Trauma was the most common etiology of the wounds accounting for 45% of the total. Infection was the second-most common etiology (24%). The difference in times for bacterial clearance and suitability for wound closure was highly significant between the two groups. Satisfactory wound appearance was 5.53 ± 2.20 days in the papaya-treated group and 30.09 ± 27.90 days in those treated with honey (P < 0.001). Similarly, the time for bacterial clearance was 6.81 ± 3.64 in the papaya-treated group and 15.33 ± 13.62 days in those treated with honey (P < 0.001) [Table 2]. The serum albumin was higher in the honey-treated patients with statistical difference but had no significant effect. The p-value of 0.033 was slightly in favour of the honey group where the albumin is slightly higher. This however did not affect the outcomes as it is expected to rather enhance healing in the honey group which in as observed rather healed slower than the papaya group
Table 1: Sociodemographic and clinical characteristics of the participants Discussion Wound bed preparation is an essential phase of wound management preceding wound coverage. It involves wound cleansing through debridement and dressing as well as infection control, causal therapy, and wound bed conditioning.[10] These components are necessary to ensuring a wound bed that would support a split-thickness skin graft or flap cover. The TIME principle which emphasizes tissue care (T), inflammation/infection control (I), moisture balance (M), and wound edge (E) protocols has become the standard of care. The debridement of the wound bed is the most important element affecting the success of other components.[11]
Preparation of wound beds could take a longer time when done with nonsurgical options. Yet it remains a more commonly used approach in resource-constrained settings like ours. The nonsurgical options are endearing in the poor setting because they are cheap, minimize blood loss, and avoid anesthetic exposure and are a less invasive provoking minimal metabolic response to trauma.[12] The two commonly used options are honey and normal saline of which the former is preferred due to its additional anti-infective property. The cost of medical grade-honey has continued to rise due to increasing demands. Papaya, on the other hand, can be procured at little or no cost in most parts of Nigeria. This should endear its use among wound care providers in our locality of practice.
First, complete eschar/slough separation time was nearly six times longer in the honey-dressed group. This prolonged hospital stay comes with attendant increase in the cost of care, hospital bed stretch, and ultimate patient satisfaction. The continuing presence of eschars or sloughs impairs wound healing by serving as a nidus for microbes, releasing toxin to the wound and serving as a mechanical barrier to wound contraction. This is particularly so in the decubitus ulcers in which the sloughs are deeply hidden beneath the viable cutaneous tissues. These would have required prolonged honey dressing or multiple surgical debridements with its attendant cost and anesthetic exposures. The action of papains and chymopapains in unripe papaya is fast enough to ensure eschar separation and protect the tissues from oxidative stress.[5],[13] This has also been shown even in burns eschar in a similar short period.[12] Although there are genetically engineered collagenases which are used for enzymatic debridement, they are largely not readily available or affordable to our patients.[14]
Second, there was also a more rapid bacterial clearance in the unripe papaya-dressed group which was about two and a half times faster than the honey-dressed group. Unripe pawpaw contains active ingredients which have the ability to breakdown biofilms and allow both the systemic antibiotics and topical antiseptics to affect the microorganisms in the wound.[15] Some of these active elements in papaya have direct antibacterial effects against both Gram-positive and Gram-negative organisms including Staphylococcus aureus and Pseudomonas aeruginosa, respectively.[13],[15] These organisms are capable of preventing wound healing and also affecting wound cover if provided without ensuring their eradication.[16] In addition, eschar and/or slough removal reduces the bio-burden in the wound. This reduction in the bio-burden is necessary for the individual to recover systemically to be able to support wound healing.[17] This leads to return of positive nitrogen balance which not only encourages wound bed readiness but also supports the survival of wound cover with either split-thickness skin grafts or flap.
It was observed that there was faster granulation tissue formation with papaya dressing compared with the honey dressing method. The granulation tissue was both faster and clinically healthier. This could be explained by the ascorbic acid content of unripe papaya which is supplied locally to the wound. This is then utilized for collagen synthesis which is an important component of granulation tissue formation.[12]
The rapidity of eschar and slough separation, bacterial clearance, and granulation tissue formation results in a more rapid wound bed preparation in the unripe papaya-dressed group compared to the honey-dressed group. This achieves the goal of reduced length of hospital stay and easing of admission burden in the limited hospital facility in the resource poor setting.[18] This is aimed at reducing the financial stress on the economically constrained patients who pay out of pocket due to poorly developed health insurance program in the developing nations.[19],[20] This option of wound bed preparation brought overwhelming satisfaction on the patients due to significant reduction in the length of hospital stay. It is hoped that this modality of wound bed preparation when popularized in the subregion would bring a huge succor to these resource depleted long staying patients and a paradigm shift in the protocols for wound bed preparation among the economically constrained patients in the subregion.[21],[22]
The limitations of this study
This is a single-center study; a multicenter study will give a wider coverage. It could not also objectively compare the cost of papaya versus honey as most patients got the unripe papaya from their farms.
Conclusion The use of unripe papaya showed superiority to the use of honey in wound bed preparation in all the measured parameters. We therefore recommend its use in resource-poor setting where it is readily available and affordable. It would also be helpful to collaborate with pharmacists to have a uniform way of both processing and preserving it for use as necessary.
Previous publication
There is no previous publication of this manuscript in any form but, an oral presentation of this paper was made at the Conference of the Nigerian Surgical Research Society held in Abakaliki, Nigeria from July 1st to 3rd, 2021, and the abstract was published in the conference program and as a conference proceeding.
Ethical approval number
REC approval number 21/08/2020–September 09, 2020.
Acknowledgment
We appreciate the inputs made by our support staff, resident doctors, and house officers in providing this modality of care.
Financial support and sponsorship
The authors did not receive any form of funds or grants from individuals or corporate organizations. The cost of this research was borne by the researchers.
Conflicts of interest
There are no conflicts of interest.
References 
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