Hydrofiber dressing with silver: a treatment option for Pemphigus vulgaris

Received on: 4 November 2011
Approved on: 6 May 2012
This study was carried out at the
Dermatology Department of the Complexo
Hospitalar Padre Bento de Guarulhos – São
Paulo (SP), Brazil.
Financial support: This study was funded by
the São Paulo State Department of Health.
Conflict of interest: None

Abstract

Pemphigus vulgaris is a serious condition characterized by blisters and mucocutaneous erosions, which is treated systemically and topically. Some affected patients present lesions in the integument that are resistant to available therapies. Hydrofiber with silver is a retainer and humidifier dressing with broad bacterial spectrum, which is effective in treating wounds and bullous diseases. The authors describe a case of Pemphigus vulgaris with lesions on the face and neck that was treated with hydrofiber with silver dressing. There was an improvement in the lesions within 10 days.

Keywords: WOUND HEALING, OCCLUSIVE DRESSINGS, AUTOIMMUNE DISEASES

INTRODUCTION

Pemphigus vulgaris (PV) is an acquired autoimmune disease that is clinically characterized by blisters and mucocutaneous erosions. Before the introduction of treatment with corticoids in the early 1950s, the mortality of PV was estimated at 75%.1

Most PV patients are treated with systemic corticosteroids, usually prednisone (doses of 1-2mg/kg/day) and adjuvant immunosuppressant drugs, such as azathioprine, mycophenolate mofetil, cyclophosphamide, methotrexate, and gold, with good clinical response within a few days. Patients who do not present significant improvement can be treated with methylprednisolo ne pulse therapy or cyclophosphamide. Immunoglobulin and plasmapheresis may also be used. Sulfones can be used in mild cases or in resistant PV mucosal lesions.1,2 Topical therapy, with corticoids and topical antibiotics, and hydrotherapy is also necessary in some cases. Patients with a moderate level of the disease – mainly restricted to mucous membranes –can rarely be treated with only topical therapy. Some patients, however, are resistant to those therapeutic options.1,3 Silver sulfadiazine is widely used to treat burns topically, though pain due to the frequent change of dressings is commonly reported. Aquacel® hydrofiber (ConvaTec, São Paulo, Brazil) is a humidifier retainer dressing that is safe and effective for treating deep burns. After its effectiveness was proven, Aquacel Ag® was created with the addition of 1.2% silver, which provided a broad antimicrobial spectrum.4,5 This article describes the successful use of occlusive hydrofiber dressings with silver in the treatment of resistant PV lesions on the face.

CASE REPORT

A 29-year-old male patient, alcoholic, smoker, user of illegal drugs (cocaine and crack) was diagnosed as having PV two years previously; the diagnosis was confirmed by biopsy. The patient presented bullous lesions, which were exulcerated and sometimes infected, with frequent recurrence. He used prednisone (40-60mg/day) and dapsone (100-200mg/day), but frequently interrupted the treatment of his own accord.

The patient was hospitalized in the Dermatology Unit of the Complexo Hospitalar Padre Bento de Guarulhos on several occasions, sometimes in the Intensive Care Unit. During his last admission, he presented exulcerations, crusts, and lesions that were infected throughout the tegument. All lesions responded to systemic therapy (antibiotics and immunoglobulin), except for the crusty lesions on the face, which were debrided, nonetheless recurred in less than 24 hours (Figure 1). A decision was made to use hydrofiber occlusive dressings with silver. The dressings were cut and applied as a mask. Two consecutive dressings were used, which were left in place for five days each, totaling 10 days of treatment. The patient experienced significant improvement in the lesions (Figure 2).

DISCUSSION

PV is an autoimmune bullous disease that affects the skin and mucosa, with significant morbidity, requiring rigorous clinical treatment, infection control, and monitoring for life. In addition to systemic treatment with steroids, immunosuppressants, and immunoglobulin, local care is very important. Up until the beginning of the 21st century, the topical treatment options were restricted to topical corticoids, antibiotics, and anesthetics. 1,3 In the present case report, the authors observed that some areas of the patient''''''''s tegument healed slowly (in the facial region and in some isolated areas of the body). In conjunction with the hospital''''''''s dressing team, the authors researched the most appropriate dressing available in the department at the time.

Dressings containing silver sulfadiazine cream have been used to heal burn wounds for many decades due to its antimicrobial properties. However, its major disadvantage is the need for frequent changes (once or twice daily), causing recurrent pain due to trauma, local maceration, cytotoxicity to fibroblasts, and bacterial resistance.6,7 Consequently, an important requirement for the management of burn wounds is to obtain a topical formulation that can maintain an adequate antimicrobial environment for prolonged periods, thus eliminating the need for frequent change of dressings and reducing the pain. That requirement was found in the hydrofiber dressing containing ionic silver, 7 which was why the authors'''''''' chose that dressing type to treat the patient in question. In 2010, Muangman and colleagues described a study comparing the effectiveness of a dressing with 1% silver sulfadiazine and the hydrofiber dressing with silver for treating second-degree burns. The results suggested that the latter was more effective; it caused less pain and was less expensive and more convenient, with fewer dressing changes.4

In 2008, a case of toxic epidermal necrolysis in 86% of the body was described, which was successfully treated after eight days of exclusive use of hydrofiber dressing containing ionic silver. 8 In the present case report, healing was achieved in a similar time –10 days. In the literature, only one report was found that described a patient with PV lesions on 62% of the tegument, who was effectively treated with hydrofiber dressing containing ionic silver. That patient had a poor initial response to treatment with systemic corticosteroids and topical silver sulfadiazine, but presented marked improvement in the healing of the wounds with the hydrofiber dressing, which was associated with a reduction in the discomfort after the application of dressings. 3 This improvement was corroborated by the authors'''''''' report.

CONCLUSION

PV lesions respond well to silver sulfadiazine, however they require daily changes in painful areas. Therefore, occlusive hydrofiber dressings containing ionic silver allowed a reduction in the number of changes and, consequently, in pain. They also promoted faster-than-expected healing. A recognized limitation in the present report was the absence of a comparison between Aquacel Ag® – the effectiveness of which was proven – and other dressings.

References

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