Can Acapsil (MPPT) help my Hidradenitis Suppurativa?

The exact underlying cause of HS is unknown, but both genetic and environmental factors seem to be involved. Recently it has been established that HS is associated with an unusually reduced microbiome. The biofilm in HS affected areas is thinner than usual and it contains fewer bacteria1 and the composition of microbes shows differences to what is usually seen in healthy comparable individuals2.

MPPT (Acapsil) removes wound infections by optimising the microbiome through its support of the immune system. Therefore, when the boils and abscesses rupture creating an opening in the skin, MPPT will help getting the infection under control and the healing process underway. The quicker an outbreak is controlled, the less tunnelling the infection will be able to create and the less scar tissue is formed.

How should the wound be cleaned before the first MPPT application?

In general, water is the best medium for wound cleaning. It removes large parts of slough and hence undesirable microbes effectively; in particular if it is applied with the pressure that can be achieved by using a wash-bottle or a large syringe.

If a large contusion zone or extensive amounts of slough are present in the wound and not satisfactorily removable with water, 3% hydrogen peroxide (H2O2) can be used in its role as a light chemical debrider.

The use of antiseptics is discouraged and we strongly advise against the use of antiseptics that accumulate in the tissue, e.g. Chlorhexidine.

After cleaning the wound with water, dab it dry with a lint-free swab. It is now ready for application of MPPT.

Water is preferable for wound cleaning… but – Why can hydrogen peroxide (H2O2) be useful in some cases?

It is to be recognised that some wounds have a contusion zone consisting of tissue balancing on the edge between being viable (being able to live) and unviable and therefore destined to die off sooner or later. It is preferable to get rid of the unviable tissue as early in the wound healing process as possible as dead and dying tissue provide an outstanding breeding ground for microbes that are adverse to healing. Other wounds have large amounts of slough that proves very hard to remove even if using pressurised water.

Accelerates kill-off of unviable tissue and leaves viable tissue unharmed

Hydrogen peroxide generally has the ability to kill off the unviable tissue which can then be easily removed as soft necrotic slough. Moreover, if used in the 3% concentration recommended for wounds and washed off with water directly subsequent to the foaming process, i.e. within a minute or less, it will not harm the viable tissue.

Before the first application of MPPT, wounds with large amounts of intractable slough and/or a substantial contusion zone can therefore in some instances benefit from the light chemical debridement that H2O2 can offer

Body holds natural degrading enzyme preventing build-up

As hydrogen peroxide is being used in the normal physiology of the body, the body itself naturally holds an enzyme that degrades H2O2. This prevents the damaging effects on healthy cells and renders it a relatively safe debrider.

 

Antiseptics

Hydrogen peroxide also falls within the definition of an antiseptic. If for any reason it is considered necessary to use an antiseptic before the application of MPPT, it is strongly advised NOT to choose one that is cytotoxic resulting in the impairment of healing as is the case for e.g. PHMB and its derivatives, Iodine and its derivatives, Silver in the forms used in clinic, and Chlorhexidine.

A better option would be Hydrogen peroxide 3% or 70% Isopropyl alcohol or 70% normal alcohol.

Once MPPT is started, use only water

Once MPPT is being used on the wound, the body’s own immune system starts to select and sustain the microbiota in the wound that is beneficial to the healing process. In order not to interfere with this desirable process, it is recommended only to wash with water between applications.

 

Contraindications

The use of H2O2 is contraindicated in very deep or large wounds due to risk of gas embolism. Link MHRA update

 

References:

Drosou A et al. (2003) Antiseptics on Wounds: An Area of Controversy. Wounds. 2003;15(5)

Faria G et al. (2009) Chlorhexidine-induced apoptosis or necrosis in L929 fibroblasts: A role for endoplasmic reticulum stress. Toxicol Appl Pharmacol. 2009 Jan 15;234(2):256-65

Sanchez IR et al. (1988) Chlorhexidine diacetate and povidone-iodine cytotoxicity to canine embryonic fibroblasts and Staphylococcus aureus. Vet Surg. 1988 Jul-Aug;17(4):182-5.

Mohammadi Z (2008) Chlorhexidine gluconate, its properties and applications in endodontics. Iran Endod J. 2008 Winter; 2(4): 113–125

Why may some ulcers need more applications of MPPT than wounds?

Diabetic foot ulcers and venous leg ulcers originate as secondary symptoms of a primary disease process that affects the entire body, i.e. diabetes and cardiovascular disease, respectively.

Among the symptoms of both diseases are ulcers, and in particular diabetic foot ulcers and venous leg ulcers. Both types of ulcers are caused by internal disease processes in the body as opposed to wounds that are typically caused by external factors such as trauma or surgery.

So, the origin of ulcers is to be sought within the body and their emergence is a sign that the disease processes have advanced to the point where the structures and tissue under the ulcerated area are seriously impaired.

That is why the use of MPPT on ulcers may diverge slightly to its use on wounds. MPPT will support the immune system in the fight against undesired colonisation and it will facilitate strong granulation in the ulcerated area. Part of granulation is angiogenesis, i.e. the creation of novel blood vessels. Renewed blood supply enables new tissue formation and thereby healing. This is what is typically seen in all ulcers receiving MPPT.

However, depending on the degree of advancement of the primary disease in the underlying structures, the body will be able to progress to closing the wound or, in advanced cases, the body will make progress at first but the disease will then overpower the newly induced healing progress. This is reflected in a slow-down of the healing and potential reappearance of slough and is the indication that an additional application of MPPT to re-boost the process is desirable.

The experience with MPPT is, that it can continue to support the healing of ulcers in all the disease stages – including non-healing ulcers – until closure. However, the number and frequency of applications are individual to the patient and directly dependent on the degree of advancement of his/her primary disease.

What is primary intention, secondary intention and tertiary intention healing?

Healing by first intention or Primary intention healing happens when the wound edges are approximated e.g. by sutures, staples or glue.

Healing by second intention or Secondary intention healing takes place when the wound edges cannot be approximated and the wound needs to heal from the bottom.

Tertiary intention healing is a combination of both of the above, i.e. the wound cannot be stitched up immediately but it can after a while.

 

Healing by primary intention

The condition for enabling primary healing is that the wound edges are sharp and completely clean and free of microbes as is the case with a wound produced via surgical incision (in a sterile environment). It is also possible to close some cuts caused by trauma via primary intention but they need to be sutured within 4 to 6 hours after the incident in order for the wound edges not to have become too inflamed, colonised or necrotic. The advantage of primary healing is that the time to closure is short which reduces the risk of infection and, furthermore, the scarring is limited. If the wound edges cannot be approximated, the wound will need to heal by second intention.

Healing by secondary intention

Secondary intention healing implicates that the wound edges cannot be approximated. This can be the case if there is not enough skin in order to pull the edges together without causing stasis in the area, as is often the case in venous leg ulcers, or if the tissue loss is extensive with a need for considerable new tissue generation as e.g. in fourth degree burns. It is also the case if the wound area is dirty or colonised or the wound edges are not sharp and clean as both would be the case in blast trauma wounds. Secondary intention healing is almost always necessary in dehisced (sprung open) surgical wounds as the tensile strength of the peri-wound tissue (the wound edges and the tissue just next to them) has proven too weak to sustain the tension of e.g. sutures or staples.

Secondary healing will typically be characterised by visible granulation tissue and the scar will be bigger than in wounds healed by first intention. The simple fact alone that wounds healing by second intention will be open for longer will render them at high risk of infection. Furthermore, as they will typically be colonised and often dirty and infected they will be prone to complications.

Healing by tertiary intention

In tertiary intention healing, there is a need for the wound to be open for a period of time before it can be sutured. Examples can be a wound left open to allow drainage and later is closed or a wound that is left to heal by secondary intention but encounters complications, where after a very thorough debridement is performed followed by an approximation of the wound edges.

MPPT in wounds to heal by non-primary intention

MPPT is intended for use in secondary and the first part of tertiary intention healing. It supports infection removal and prevention, autolytic debridement as well as granulation and epithelialisation, i.e. the wound healing process itself.

What is the difference between a wound and an ulcer?

A wound is caused by an external force whereas an ulcer is caused by an internal problem.

That was the short answer. The more extended explanation is the following:

In an ulcer, the primary tissue breakdown is internal, i.e. the lesion is caused by an underlying disease or other internal reason. This disturbance of the tissue will typically be gradual.

In a wound, the primary tissue breakdown is caused by a force originating from the external world and the disturbance of the tissue will typically be acute.

This is the logical and most updated definition of these two terms. It is based on the differences in appearance of the lesion, the cause (aetiology), the way the body responds (physiology) and disease processes (pathology). These factors are similar within each group (wounds versus ulcers) and from a medical perspective, the interventions required and treatment options available as well as potential outcomes share greater similarities within each group than compared to the other group (wounds vs. ulcers).

 

The inflammatory factors, proteases, immune cells as well as the microbiome on the surface of a lesion must be at a balance in order for healing to proceed. An unbalance is present in both ulcers and wounds that do not heal properly. However, these unbalances differ by their composition. Likewise, physiological differences in expression of cell types are encountered between wounds and ulcers. Ulcers could be said to be in a chronically inflamed state.

Dressing techniques and frequency often differ between ulcers and wounds. Ulcers are often dressed once or twice weekly at walk-in clinics. Major wounds usually require daily changes. e.g. major trauma (with excessive necrosis leading to excessive microbial growth, which leads to toxin release and excessive toxin absorption by the body) can lead to rapid death and therefore require acute and maybe extensive care.

The reason for this is the common assumption that mortality directly from ulcers is rare and, therefore, ulcers are considered of less clinical concern than wounds.
The death from a major trauma wound is definitely more spectacular and easily linked to the wound than the death from an ulcer.
Ulcers cause death in a much slower and invisble way. When ulcers become chronic, they host an array of bacteria and fungi directly next to the very thin-lined blood vessels (capillaries and venules) which makes them an easy and frequest entry point for these infecting agents into the blood stream causing septicaemia – also called blood poisoning – which is likely to be followed by sepsis / septic shock and death.

Also, chronic ulcers will often over time extend down to the bone surface and cause a secondary infection in the bone. Bone infection is also called osteomyelitis.

Finally, chronic wounds and ulcers often battle with skin infection in the skin surrounding the ulcer. This skin infection is called cellulitis.

Both osteomyelitis and cellulitis rank among the types of infection typically associated with sepicaemia and sepsis.

Consequently, ulcers are potentially more lethal than is presently commonly recognised.

 

The prevention of either an wound or an ulcer turning chronic is of paramount clinical importance.

 

Examples of ulcers are

– Venous leg ulcers – caused by cardiovascular disease

– Diabetic foot ulcers – caused by diabetes mellitus

– Pressure ulcers – caused by vascular stasis in the area

– Radiation burns – where the ionizing radiation penetrates deep into the tissue causing primary damage to the vascular structures which leads to skin lesions as secondary damage.

 

Examples of wounds are

– Trauma wounds – caused by accident

– Surgically induced wounds – caused by incision

– Thermal burns – caused by external heat

 

This definition of wounds versus ulcers has been used for many years. However, it has been defined here because it has been interrupted by a period in which the definition was based solely on the age of the lesion. Clinically this definition was a step backwards and not forwards as the age of any lesion can be described by the use of the words “acute” and “chronic”.

 

MPPT supports healing of both wounds and ulcers.

 

Reference:

Herman MH (2010) Wounds and Ulcers: Back to the Old Nomenclature. Wounds 22(11):289–293

Can MPPT benefit burns?

Yes.

The skin hosts a microbiome, which is a complex ecosystem of bacteria, fungi, viruses and mites living in a balance that is influenced by a long array of factors and is different between individuals and even between locations on the same individual. The microbiome does not only live as a “extra layer” on top of the skin but extends well down through the layers that together constiture the skin.

When skin suffers thermal burn, the temperature is usually elevated to the extend that the skin microbiome is not only disturbed but killed off completely. This includes both the wound bed itself and the skin adjacent to the wound bed. The microbiota seeking to colonise the wound, now completely open for invasion, is, therefore, less likely to consist of microbes moving in from the patient’s usual mircobiota. The competition for the open space is equally open to “any” microbe present in the environment of the patient. This again causes an increased likelihood of invasion by microbes that the body does not recognise to be acceptable inhabitants.

This causes a higher likelihood of leading to an imbalance of the microbiome and is assumed to be one of the main reasons why thermal burn wounds are so prone to infection compared to other wounds.

The microbiome has been shown to form part of the skin’s defences against infection from the outside world. A wound cannot, and does not need to, be kept sterile for a long period of time, e.g. for the period of the entire healing process. However, the microbiome needs to be reestablished in a controlled and balanced manner.

Only the patient’s own immune system knows the composition of the correct microbiome for the individual patient. Therefore it is necessary that the immune system governs and controls the invasion of the microbes and their settling in and reestablishement of their ecosytem.

MPPT effectively supports the immune system in restablishing the balance of the microbiome and will therefore contribute with substantial benefits to prevent infection and support the healing of thermal burn wounds.

What is necrosis?

Necrosis is the cell death that takes place when they have been damaged irreversibly.

Necrotis tissue is dead tissue or tissue injured beyond repair – non-viable tissue. This can be a portion of soft tissue or an organ.

It is often present in wounds and in order for a wound to heal, the dead (necrotic) tissue must be removed and substituted (repaired) with newly generated tissue (granulation).

Necrotic tissue provides an ideal growth medium for bacteria.

There are two major types of Necrotic tissue:

Eschar, which is a hard black crust-like structure.

Soft necrotic tissue, which is moist, white/yellow/grey slough.

What is debridement? And what types of debridement exist?

Debridement is the process of removal of non-viable tissue (necrosis) and foreign material, e.g. sand, from a wound to expose healthy tissue.

A wound containing necrotic tissue cannot heal.

Necrotic tissue provides an ideal growth medium for bacteria.

 

There are five major techniques of debridement:

Autolytic debridement:
Supporting the body’s own immune system to dissolve and remove dead tissue. Under normal circumstances, the immune system carries out highly effective debridement. However, the body’s immune system can be inhibited in performing this task by substances such as proinflammatory factors, proteases, bacterial toxins and enzymes and similar which typically are present in the exudate and necrotic tissue on the surface of complicated wounds. If these substances can be effectively removed, however, the wound will be speedily and effectively cleaned by the body’s immune system which means it will undergo autolytic debridement.

Surgical debridement / Sharp debridement:
Surgically cutting away the necrotic tissue using a scalpel or a pair of scissors.

Chemical debridement / Enzymatic debridement:
Usually, the chemical debridement method makes use of enzymes but other compounds can also be used in order to dissolve dead tissue. The most commonly used enzyme is collagenase. This is only available as a pharmaceutical and duration of application (few hours) must be strictly adhered to as it can otherwise cause harm.

Biological debridement:
Also known as maggot therapy it consists of living larvae of Lucilia sericata (greenbottle fly) being applied directly onto the wound where the larvae will eat necrotic tissue and pathogenic bacteria.

Mechanical debridement:
A saline-moistened dressing is placed on a wound and allowed to dry. It will adhere to the surface underneath. When the dressing is removed, the tissue adheres to the dressing, thereby being pulled away from the wound. It does not distinguish between dead and living tissue and will therefore in addition to the dead tissue also remove new forming cells. Apart from being very painful, it is also delaying healing, as the generating new cells are not protected but being pulled off with the gauze.

MPPT supports the immune system to perform autolytic debridement.
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