Products & technology

Periwound skin management of

chronic lower-limb wounds with
use of a novel multi-ingredient skin
cleanser: a single-centre study

The condition and moistness of periwound skin has been directly linked
to the success of wound bed preparation and wound healing. This
study investigates the use of a novel skin cleanser designed to enhance
periwound recovery, in a population of 61 patients seeking outpatient
care at the wound clinic of Kuala Lumpur General Hospital for lower limb
wounds. All patients underwent baseline assessment of their wounds
using the TIME assessment technique for the wound bed and the
Harikrishna Periwound Skin Classification for periwound skin, followed by
treatment with the skin cleanser as well as the appropriate dressings and
Authors (clockwise from the treatment adjuncts. Of the 61 patients assessed on periwound condition
top left): during the 7-month observation period, 3 patients had complete wound
Harikrishna KR Nair, Abdul Khan
healing, 50 patients progressed to healthy wounds, 4 patients had
A, Ben Z Oh, Tengku Ibrahim TZA
macerated periwound skin and another 4 patients had dry periwound
skin after the completion of the trial. All patients with wounds exhibiting
inflammation with or without superimposed infection experienced
resolution of these issues following use of the skin cleanser.

T
he periwound skin is an important or absence of nonviable tissue, presence or
component of the triangle of wound absence of infection, moisture balance of the
assessment, which is a three-pronged wound, and whether the edges of the wound
approach to wound management. (Dowsett are undermined or non-advancing (Dowsett
and von Hallern, 2017). It has been defined and Newton, 2005). These principles serve to
as an area of skin up to 4 cm from the wound aid health professionals in removing barriers
Harikrishna KR Nair is a edge, although this area may be expanded to to wound healing in hard-to-heal wounds.
Professor and Head of Wound include any area of skin extending outwards Protection of the periwound skin is an integral
Care Unit, Department of from the wound which is at risk of damage. part of this strategy, and the hitherto lack of a
Internal Medicine, Hospital (Dowsett, 2015). This area is often under threat standardised assessment tool for evaluation of
Kuala Lumpur; Abdul Khan A is from maceration due to excessive exudate, the periwound area led to the development of
a medical doctor, formulated the dry skin, hyperkeratosis and excoriation from the (Nair, 2019; Nair et al, 2020). The HPSC is a
Botrem Restoractiv INTENSIVE trauma or dressing removal, and the resultant validated clinical tool for assessment of both
intricate care wash; Ben Z Oh periwound skin damage may prolong wound the wound bed and periwound skin health
is a medical officer wound care healing time and impact a patient’s quality of on a scale of 0 to 5, with Class 0 being normal
unit Hospital Kuala Lumpur; life (Cameron, 2006). skin, Class 1 denoting fibrous tissue or tissue
Tengku Ibrahim TZA is a The TIME framework is a well-established otherwise at risk, Class 2 being wounds with
cofounder of Botrem Healthcare, tool used by clinicians to structure an approach exudate, and Classes 3 and 4 being inflamed
manufacturer of Botrem to wound management, by categorising the wounds without and with infection respectively.
products. wound according to four principles: presence Class 2 exudative wounds are further divided

20 Wounds Asia 2021 | Vol 4 Issue 3 | ©Wounds Asia 2021 | www.woundsasia.com

 Products & technology

Table 1.Harikrishna Periwound Skin from the patients attending the wound care
Assessment outpatient clinic at Hospital Kuala Lumpur for
wounds of the lower limb from June 2020 to
Class Subtype Periwound condition
January 2021. These included patients with
0 Normal diabetic foot ulcers (DFU) and venous leg
1 Fibrous tissue/tissue at ulcers (VLU), with or without inflammation
risk and infection. Informed consent was obtained
2 A Exudate centred with for all patients (both verbal and written)
desiccation for participation in this study, use of the
B Exudate centred with skin cleanser, and medical photography for
maceration documentation and study purposes. All patients
were treated for a standard duration of 12 weeks
C Exudate centred with
allergy and reassessed with measurement of wound
size, photography, and evaluation of healing.
3 Inflammation without
All wounds were assessed upon recruitment
infection
using the TIME framework as well as the HPSC
4 Inflammation with method. All patients subsequently underwent
infection
mechanical debridement via sterile gauze
5 Atypical (senescent cells/ soaked in a diluted solution of the cleanser
cancer/subcutaneous (Botrem Restoractiv INTENSIVE intricate care wash
emphysema) skin cleanser) as per manufacturer’s instructions.
The appropriate dressings were applied along
with any specific treatment such as topical or
in Class 2A for those centred with desiccation, systemic antibiotics.
Class 2B for those centred with maceration, and
Class 2C for those centred with allergy. Class 5 Results
is a separate category for wounds with atypical We recruited 61 patients for this study, about
cells, for instance pre-cancerous wounds or half (29 out of 61) had wounds with fibrous
active carcinoma, or subcutaneous emphysema. tissue or tissue otherwise at risk fitting HPSC
(Nair et al, 2020) The HPSC thus serves both as class 1 at baseline (Figure 1). Of the remainder,
a useful clinical assessment tool as well as an 25 patients had exudative wounds (defined
objective method for evaluation of the efficacy as HPSC Class 2) with 16 patients fulfilling the
of measures to protect the periwound skin criteria for HPSC Class 2A, 8 patients for HPSC
(Table 1). Class 2B, and 1 patient for HPSC Class 2C. There
were four patients with inflamed wounds without
Methodology infection (HPSC Class 3) and three patients had
Patients were selected via convenient sampling inflammation with infection (HPSC Class 4)

Figure 1. Periwound condition on recruitment Figure 2. Periwound condition on last study date
30 50 n Normal
n Fibroustissue/tissue
at risk
40 n Exudate centred
with maceration
20 n Inflammation without
infection.
30

20
10

10

0 0
Class 1 Class 2A Class 2B Class 2C Class 3 Class 4 Class 5 Class 0 Class 1 Class 2B Class 3

22 Wounds Asia 2021 | Vol 4 Issue 3 | ©Wounds Asia 2021 | www.woundsasia.com

Key words: Figure 3. Venous leg ulcer Harikrishna Periwound Skin Assessment Class 1
■ Bacteria (fibrous tissue) showing complete healing after 46 days of treatment with
■ Garcinia mangostana
skin cleanser
■ Wound healing Day 1: 9cm x 5cm Day 46: Wound healed
■ Wound infection

Figure 4. Harikrishna Periwound Skin Assessment Class 4 wound

(inflammation with infection) showing resolution of infection and
inflammation and reduction in wound size by 75% after 27 days of treatment
Day 1 10cm x 10cm Day 27 5cm x 5cm

(Figure 1). None of our study patients had atypical end of the study period without superimposed
wounds with carcinoma or pre-cancerous tissue infection or inflammation. However, four patients
(HPSC Class 5). had dry periwound skin (HPSC Class 2A) and
Following treatment with the novel skin another four had macerated skin (HPSC Class 2B)
cleanser over three months, the majority at the end of the treatment period (Figure 2).
experienced favourable outcomes from use of This could be accounted for by multiple patient
the cleanser (Figure 2). There were three patients factors including suboptimal :nutrition, poor
who had complete healing with wound closure, personal care, or complicated wounds requiring
whereas 50 patients had healthy wounds by the treatment modalities beyond the scope of the

Wounds Asia 2021 | Vol 4 Issue 3 | ©Wounds Asia 2021 | www.woundsasia.com 23

 Products & technology

Figure 5. Patient with Harikrishna Periwound Skin Assessment Class 2C wound

at baseline, showing dry periwound skin at the end of the treatment duration
Day 1 15cm x 10cm Day 147 Day 174 6cm x 4cm

methods of this study. No allergic reactions to it was 6cm x 4cm with dry periwound skin.
the skin cleanser were reported throughout the
study period. Discussion
Figure 3 shows a 46-year-old male with a VLU DFUs and VLU being hard-to-heal wounds, have
and a Harikrishna Periwound Skin Assessment many factors affecting the wound healing rate.
Class 1 (fibrous tissue). On presentation the VLU Vasculopathy, neuropathy and dermopathy cause
was 14 days old wound with comorbidities of poor lower limb circulation necessary for recovery,
diabetic mellitus on OHA. The wound was cleaned requiring an adjunct treatment approach to augur
with normal saline until patient was referred to improvement. Early stage wounds with exudate
wound care unit. After 46 days of treatment with and inflammation are often compounded by skin
skin cleanser the wound completely healed. dryness and bacterial infection compromising
Figure 4 shows a 39-year-old male infected the healing process. These factors need to be
eczema wound and a Harikrishna Periwound managed holistically effectively for symptoms
Skin Assessment Class 4 wound (inflammation reduction to ensure improved recovery of the
with infection). On presentation the wound wound bed.
was 10 days old with and the patient was Periwound moistness, as an enabler can
disabled. He went for treatment at emergency improve the ability of the surrounding skin to
department for cellulitis and after that was channel nutrients to the wound bed aiding
referred to wound care unit for further its recovery, notwithstanding the use of other
management. The infection and inflammation treatment adjuncts.
resolved, and the wound size reduced by 75% This single-centre study reinforces the link
after 27 days of treatment. between optimal management of the periwound
Figure 5 shows a 47-year-old male with VLU area and favourable wound healing, as validated
wound and a Harikrishna Periwound Skin by the TIME method as well as the HPSC. Previous
Assessment Class 2C. On presentation the studies have shown a link between a moist
wound was 30 days old and the patient had periwound area and increased wound bed
hypertension, diagnosed in 2017, and was on recovery, attributed to the improved channelling
antihypertensive treatment. The patient went of micronutrients to the wound bed and
for treatment at nearest district clinic and prevention of wound desiccation.
wound was cleaned with normal saline, he was The application of the novel skin cleanser
referred to wound care unit because wound to the wound bed and periwound area has
was getting bigger. On day 1 the wound, thus been shown to result in optimal wound
measured 15cm x 10cm. The wound reduced in recovery in the vast majority (53 out of 61) of
size throughout the treatment and on day 174, our study patients. It is notable that resolution

24 Wounds Asia 2021 | Vol 4 Issue 3 | ©Wounds Asia 2021 | www.woundsasia.com

 Assessment: a holistic framework from wound
of inflamed wounds with or without infection assessment to management goals and treatments.
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the ingredients used in the novel skin cleanser Dowsett C, Gronemann MN, Harding K (2015) Taking
are those shown in vitro and in vivo studies to wound assessment beyond the edge. Wounds Int
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be bacteriostatic and/or bactericidal, and may
September 2021)
theoretically improve bacterial balance in wound
Cameron J (2006) Exudate and care of peri-wound
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2017; Lim et al, 2019; Matulyte et al, 2020; Nair, Dowsett C, Newton H (2005) Wound bed preparation:
2019 Rembe, 2020; Suryani et al 2020). These TIME in practice. Wounds UK 58–70. https://tinyurl.
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buckthorn oil, super-oxidised sodium hypochlorite Nair HKR, Chong SS, Othman AM (2020) Validation of
Harikrishna Periwound Skin Classification for wound
and hypochlorous acid and Acacia Senegal gum.
assessment. J. Wound Care 29(Sup4):S44–S48. https://
Although our study population is not sufficiently doi.org/10.12968/jowc.2020.29.sup4.s44
large to conclusively attribute any resolution of Cutting KF, White RJ (2002) Avoidance and management
infection and inflammation to the usage of these of peri-wound maceration of the skin. Prof Nurse
natural antimicrobials, these encouraging results 18(1):33–35.
are grounds for further study. Rembe JD, Huelsboemer L, Plattfaut I et al (2020)
No allergic reactions to the skin cleanser were Antimicrobial hypochlorous wound irrigation
solutions demonstrate lower anti-biofilm efficacy
reported throughout the study period. However,
against bacterial biofilm in a complex in-vitro human
at least one patient with an exudative wound plasma biofilm model (hpbiom) than common wound
complicated with eczema (HPSC Class 2C) reported antimicrobials. Front Microbiol 11:564513 (2020).
dry periwound skin at the end of the treatment https://doi.org/10.3389/fmicb.2020.564513
period despite regular use of the skin cleanser. Nair HKR (2019) Use of a novel therapy to manage
Various factors may account for this outcome periwound skin in a specialised wound centre.
2(1):48–49. https://tinyurl.com/hrhknk56 (accessed 23
including concurrent use of topical emollients, September 2021)
flare of the underlying eczema, or compliance to Suryani S, Sariani S, Earnestly F et al (2020) A
moist dressing. Nevertheless, a reduction in wound comparative study of virgin coconut oil, coconut
size by 84% (15cm x 10cm at recruitment, 6cm oil and palm oil in terms of their active ingredients.
x 4cm at end of treatment) was reported for this Processes 8:402. http://dx.doi.org/10.3390/pr8040402
patient, indicating an overall positive outcome for Anzaku AA, Akyala JI, Obianuju EC (2017) Antibacterial
activity of lauric acid on some selected clinical
wound healing. Further study into the daily use
isolates. Ann Clin Lab Res 5, 1–5 (2017). https://doi.
of diluted washes in the management of chronic org/10.21767/2386-5180.1000170
dermatological conditions is encouraged. Matulyte I, Jekabsone A, Jankauskaite L et al (2020) The
essential oil and hydrolats from Myristica fragrans
Limitations seeds with magnesium aluminometasilicate as
The cleanser has an allergy disclaimer. excipient: Antioxidant, antibacterial, and anti-
inflammatory activity. Foods 9(1):37. https://doi.
Ingredient descriptions are on the label for those
org/10.3390/foods9010037
sensitive to its use. Furthermore, larger studies
Zhang WK, Tao SS, Li TT et al (2016) Nutmeg oil alleviates
would are required to confirm these results. chronic inflammatory pain through inhibition of
COX-2 expression and substance P release in vivo.
Conclusion Food Nutr Res 60, 30849 (2016). https://dx.doi.
org/10.3402%2Ffnr.v60.30849
This study shows that use of the Botrem
Restoractiv INTENSIVE intricate care wash skin Lim YS, Ok YJ, Hwang SY et al (2019)Marine collagen
as a promising biomaterial for biomedical
cleanser improves periwound moisture and applications. Mar Drugs 17(8):467. https://dx.doi.
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the recruitment of a larger patient population Koskovac M, Cupara S, Kipic M et al (2017) Sea buckthorn
and a wider range of wounds including pressure oil—A valuable source for cosmeceuticals. Cosmetics
injury, surgical wounds, and vasculopathic ulcers. 4(4):40. https://doi.org/10.3390/cosmetics4040040
Thus far it has been proven to be a safe and Hosseinpour M, Fazeli A, Agabeigi M (2012) Efficacy
non-detrimental adjunct to wound management of Acacia senegal for stoma care in children with
colostomy. Eur J Pediatr Surg 22(3):234–7. https://doi.
in our diabetic foot patients and an effective org/10.1055/s-0032-1308706
complement to our daycare treatment.  WAS Nair HKR (2019) Use of a novel therapy to manage
periwound skin in a specialised wound centre Wounds
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