ORIGINAL INVESTIGATION
Healing Effect of Sea Buckthorn, Olive Oil, and Their Mixture on Full-Thickness Burn Wounds Mitra Edraki, BSc, MSc; Armin Akbarzadeh; Massood Hosseinzadeh, MD; Nader Tanideh, DVM, MPH, PhD; Alireza Salehi, MD, MPH, PhD; and Omid Koohi-Hosseinabadi, BSc
ABSTRACT OBJECTIVE: The purpose of this study is to evaluate the healing effect of silver sulfadiazine (SSD), sea buckthorn, olive oil, and 5% sea buckthorn and olive oil mixture on full-thickness burn wounds with respect to both gross and histopathologic features. METHODS: Full-thickness burns were induced on 60 rats; the rats were then were divided into 5 groups and treated with sea buckthorn, olive oil, a 5% sea buckthorn/olive oil mixture, SSD, and normal saline (control). They were observed for 28 days, and the wounds’ healing process was evaluated. RESULTS: Wound contraction occurred faster in sea buckthorn, olive oil, and the sea buckthorn/olive oil mixture groups compared with the SSD and control groups. The volume of the exudates was controlled more effectively in wounds treated with the sea buckthorn/olive oil mixture. Purulent exudates were observed in the control group, but the others did not show infection. The group treated with sea buckthorn/olive oil mixture revealed more developed re-epithelialization with continuous basement membrane with a mature granulation tissue, whereas the SSD-treated group showed ulceration, necrosis, and immature granulation. The results show that sea buckthorn and olive oil individually are proper dressing for burn wounds and that they also show a synergetic effect when they are used together. CONCLUSION: A sea buckthorn and olive oil mixture could be considered as an alternative dressing for full-thickness burns because of improved wound healing characteristics and antibacterial property. KEYWORDS: full-thickness burns, sea-buckthorn, olive oil, silver sulfadiazine ADV SKIN WOUND CARE 2014;27:317Y23
INTRODUCTION Burns are one of the most common injuries seen the world over.1,2 Burns not only impair the cutaneous tissue locally, but may also cause
some systemic effects, such as loss of fluid and protein, sepsis, changes in the metabolic state, and involvement of the hematological and immune systems.3 Full-thickness burns involve both the outer layer (epidermis) and the underlying layer of the skin (dermis).3,4 Burn management involves a prolonged period of hospitalization, expensive medication, and surgical operations. Also, burns may cause patients to require long-term rehabilitation. However, some burns are not severe and can be handled outside the hospital setting in order to reduce both the burdens of cost and of hospitalization time.5 Many of the synthetic drugs used to treat burns are not costeffective because of their high expense. Some effective methods, such as recombinant growth factors and tissue-engineered wound dressings, are highly expensive and beyond the reach of most patients in the developing world. Current burn treatments also present chances for unwanted adverse effects. Currently, the most commonly used local treatment for a burn is 1% silver sulfadiazine (SSD), which is useful to keep the burn wound free from bacterial contamination. However, recent studies revealed that the healing process of fullthickness burn wounds is delayed by using SSD. Thus, researchers are looking for a better alternative burn dressing.6,7 Previous studies show that using traditional herbal medicine is effective for healing wounds. Traditional herbal medicine is gaining popularity because of its widespread availability, no or fewer adverse effects, moderate efficacy, and low cost as compared with synthetic drugs.8 Hippophae rhamnoides, which belongs to the Elaeagnaceae family, is commonly known as sea buckthorn. Sea buckthorn is a branched and thorny nitrogen-fixing deciduous shrub found most commonly in Asia and Europe. Sea buckthorn contains many bioactive substances such as flavonoids (isorhamnetin, quercetin, myricetin, kaempferol, and their glycoside compounds); carotenoids (>, A, C-carotene, lycopene); vitamins (C, E, K); tannins; triterpenes; glycerides of palmitic, stearic, and oleic acids, as well as some essential amino acids.9 Studies show that sea buckthorn has antioxidative, antimicrobial, adaptogenic, and tissue-regenerating properties.10Y12 Wounds treated with sea buckthorn have shown tissue regeneration and increased granulation
Mitra Edraki, BSc, MSc, is an Instructor of Pediatric Nursing, Community-Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Armin Akbarzadeh is a medical student, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Massood Hosseinzadeh, MD, is Assistant Professor of Pathology, Colorectal Research Center, Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran. Nader Tanideh, DVM, MPH, PhD, is Assistant Professor of Pharmacology, Stem Cell and Transgenic Technology Research Center & Pharmacology Department, Shiraz University of Medical Sciences, Shiraz, Iran. Alireza Salehi, MD, MPH, PhD, is Assistant Professor of Epidemiology, Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Omid Koohi-Hosseinabadi, BSc, is a laboratory animal technician, Center of Comparative and Experimental Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Acknowledgments: The authors thank Dr Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee Hospital for editorial assistance. The authors have disclosed that they have no financial relationships related to this article. Submitted August 26, 2013; accepted in revised form November 7, 2013. WWW.WOUNDCAREJOURNAL.COM
317
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
and tissue density, as well as less congestion, less edema, and less infiltration of the polymorphonuclear leukocytes.13 Olive oil can also be considered as a potential burn wound dressing because of its antibacterial and anti-inflammatory components, such as phenols and polyphenols.14 Olive oil is also rich in monounsaturated fatty acids that make it a proper dressing to preserve wounds from contamination.15 Because of the importance of free radicals in the pathophysiology of burning, administration of antioxidants may be helpful in the healing process. Furthermore, olive oil contains some important antioxidants in its components, such as vitamin E and phenol compounds (tyrosol, hydroxytyrosol, oleuropein, 1-acetoxypinoresinol, and [+]-pinoresinol).16,17 The aim of this study was to measure the healing effect of SSD, sea buckthorn, olive oil, and a 5% sea buckthorn/olive oil mixture on full-thickness burn wounds, individually and to compare in terms of both gross and histopathologic features.
METHODS Experimental Animals
stored at j20-C in an airtight plastic container until further use (yield 13.7% wt/wt). The high-performance liquid chromatography fingerprinting of each batch of the extract was carried out and maintained throughout the experiment, to avoid variation from batch to batch.
Burn Wound Model The rats were anesthetized by 90 mg/kg of ketamine (Alfasan International BV, Woerden, Holland) and 8 mg/kg of xylazine (Alfasan International BV) by intramuscular injection. The dorsal surface of the rat was shaved, and the underlying skin was cleaned with 70% ethanol. Full-thickness burn wounds were created using a columnar rod, made of aluminum (2.5 2.5 cm2 and 400-g weight), heated to 90-C. The rods were heated in 90-C water for 30 minutes before application. Hot rods were placed without pressure on the shaved areas of each rat once for 10 seconds. After each application, the rods were heated with hot water for at least 5 minutes. After the animals were recovered from anesthesia, they were housed individually in sterile cages.
Sixty male Sprague-Dawley rats (250 T 50 g), aged between 8 and 10 weeks and presenting with no illness, obtained from the animal colony of Shiraz University of Medical Sciences, Shiraz, Iran, were used for this study. The animals were maintained under a controlled environment in the university’s animal house at 22-C T 2-C, with 55% T 5% of atmosphere humidity and a 12-hour lightdark cycle. The experiments were performed in accordance with the regulations specified by the university’s Animal Ethics Committee and conformed to the national guidelines on the care and use of laboratory animals.
Study Protocol
Collection and Extraction of Plant Material
WOUND ASSESSMENT
The yellow, clear, and odorless olive oil (Olea europaea), which is extracted by pressing the fresh fruit of the olive, was used for this study. The berries of the sea buckthorn (H rhamnoides L) were collected from the Kazeroon region in the southwest of Iran in September 2012, a time when it grows widely. Fresh sea buckthorn berries were then cleaned and washed with water and rewashed with distilled water. The berries were then dried under shade in a clean, dust-free environment. The aqueous extract was prepared by soaking powdered dry berries in distilled water (1:5 wt/vol) at room temperature (25-C T 1-C). After 24 hours, the supernatant was decanted, and the residue was resoaked in fresh distilled water. The process was repeated 4 times for complete extraction. The supernatants were pooled, filtered through muslin cloth, and centrifuged at 5000g at 4-C. The supernatants obtained after centrifugation were frozen at j20-C and then lyophilized in Heto lyophilizer (The Virtis Company, Gardiner, New York). The lyophilized powder of the sea buckthorn leaf aqueous extract was
Gross Examination
ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
After cleaning the burns with normal saline, the rats were randomly assigned to 5 groups (n = 12), and different topical treatments were applied: sea buckthorn, olive oil, a 5% sea buckthorn/ olive oil mixture, SSD cream (1.0% wt/wt; Sina Daru Pharmaceuticals, Tehran, Iran), and normal saline (in only the control group). After applying the topical treatments, the burn wounds were dressed with sterilized dry gauze. These dressings were applied once daily during the study, with each treatment being applied after washing the burn wounds with normal saline.
The authors obtained an index from an assessment method for burn wounds created by Keast et al.18 The authors then modified the index from its original construction to assess the burn wounds’ condition during this study (Table 1). This assessment method is accurate, sensitive, and simple to apply. Assessment of the wound was done on days 1, 3, 5, 7, 10, 14, 21, and 28. To measure the wound surface area, the wounds were traced on a transparent paper. The transparent papers were sterilized by formaldehyde before use, and each one was used for 1 assessment in order to avoid the transmission of infection. The volume and quality of exudates of the burn wounds were also assessed by a clinician.
Histopathologic Examination Excisional biopsy from the skin and granulation tissue was performed on days 7, 14, 21, and 28 and fixed in 10% neutral formalin. Three cross-section samples were provided from each wound, were
318
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Surface Measure
Table 1.
The surface area of the wounds treated with olive oil was smaller on days 5 and 21 in comparison with SSD-treated wounds (Figure 1A). Figure 1D reveals that differences were not significant on days 3, 5, 7, and 10. On days 14 and 21, the wounds treated with sea buckthorn showed a significantly higher contraction compared with the control and SSD groups. Figure 2A shows that the sea buckthorn/olive oil mixture group had a significantly better wound contraction as compared with the individual sea buckthorn and olive oil groups on days 7 and 10.
BURN WOUND SCORING FOR CLINICAL ASSESSMENT, OBTAINED FROM AN INDEX PROVIDED BY KEAST ET AL18 Numerical Score
Measure
Exudate Volume
Exudate Quality
0 1 2 3 4 5 6 7
0 G0.3 0.3Y0.6 0.7Y1.0 1.1Y1.4 1.5Y1.8 1.9Y2.2 2.3Y2.5
None Smallb (scant) Moderated Largef (copious) V V V V
Serousa Serosanguineousc Sanguineouse Seropurulentg Purulenth V V V
Exudate Volume and Quality
a
Thin, watery, clear to yellow, usually odorless. Exudate fully controlled, nonabsorptive dressing may be used, wear time up to 7 days. c Thin, watery, pink to light red, usually odorless. d Exudate controlled, absorptive dressings may be required, wear time 2 to 3 days. e Frank blood, bright red. f Exudate uncontrolled, absorptive dressings required, dressing may be overwhelmed in less than 1 day. g Thin, watery, white to cream, possibly foul odor. h Thick, translucent to opaque, white to cream, possibly foul odor. b
then stained with hematoxylin-eosin, and were then observed for histopathologic changes under a microscope. This observation was double-blinded and performed by a pathologist and scored according to a modified scoring system for surgical wound healing taken from Abramov et al19 (Table 2). This scoring system was used to determine the healing grade in each treatment group sample. This scoring system is based on the following repair indices: epithelialization, collagenization, inflammation, ulcer, and necrosis. All morphometric parameters were recorded with Olympus DP12 Digital Camera system (Olympus Optical, Tokyo, Japan). Epithelialization was perused and compared in regard to the formation time.
Statistical Analysis Data are expressed as mean T SEM, and statistical significance between experimental and control values was analyzed by MannWhitney U test and paired t test in SPSS version 11.5 (SPSS, Chicago, Illinois). P G .05 was considered to be statistically significant.
Figure 1B and E show that the exudate volume of wounds in the groups treated with sea buckthorn and olive oil increased slightly during the first week and then decreased faster compared with the SSD and control groups. In comparison, no significant differences were seen between wounds treated with SSD and normal saline (control group). The sea buckthorn/olive oil mixture induced less exudate on the wounds in comparison with the individual sea buckthorn and olive oil groups. Figure 2B also reveals that the sea buckthorn group shows faster reduction of exudates compared with the olive oil group. Purulent exudate was found only in the control group. There were no significant differences among SSD, olive oil, and sea buckthorn except on day 3 when the olive oilYtreated group showed better exudate quality than did the SSD group (Figures 1C and F and 2C).
Histopathologic Assessment The mean scores of the sea buckthorn/olive oil mixture, olive oil, and sea buckthornYtreated groups were respectively higher compared with those treated with saline (control) and SSD, as shown in Figure 3. The histological examinations showed that tissue regeneration was much better in the burn wounds treated with the sea
RESULTS Macroscopic Assessment According to Table 1, lower scores indicate a better wound condition. The authors compared the scores of different treatment groups with one another and then identified significant differences between groups, which are indicated by caps in the graphs. Comparing olive oil (Figure 1AYC) and sea buckthorn (Figure 1DYF) individually with both SSD and control groups enabled the authors to evaluate the effectiveness of these 2 herbal products on the healing process of burn wounds. The effectiveness of the sea buckthorn/olive oil mixture was compared with both the individual sea buckthorn group and the olive oil group (Figure 2AYC). WWW.WOUNDCAREJOURNAL.COM
319
Table 2.
MODIFIED WOUND-HEALING HISTOPATHOLOGIC SCORING SYSTEM FROM INDICES PROVIDED BY ABRAMOV ET AL19 Scores Indices
1
2
3
Epithelialization
None
None
Partial
4
Complete, immature Collagenization None None Partial Complete, irregular Inflammation Severe Moderate Mild None Neovascularization None None G5/HPF 6-10/HPF Necrosis Extensive Focal None None Granulation tissue None Immature Mild Moderately mature mature
5 Complete, mature Complete, regular None 910/HPF None Fully mature
Abbreviation: HPF, high-power field. ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Figure 1. MACROSCOPIC COMPARISON (MEAN T SE) OF (A) OLIVE OIL AND SSD TREATMENT AND (B) SEA BUCKTHORN AND SSD TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY KEAST ET AL18
buckthorn/olive oil mixture compared with the SSD and normal salineYtreated burns. Although those wounds treated by SSD did not show any purulent tissue (which was also the case for sea buckthorn, olive oil, and the sea buckthorn/olive oil mixture groups), tissue regeneration was impaired. Figure 4A shows a sample photomicrograph of skin sections stained with hematoxylin-eosin from the group treated with sea buckthorn and olive oil mixture in which the injured tissue has repaired properly. Neovascularization was seen in the tissue, and collagen bundles were properly deposited among the fibroblast cells. Figures 4B and C compare the tissue of the sea buckthorn/olive oil mixtureYtreated group and SSD-treated group. On day 14, the sea buckthorn/olive oil mixtureYtreated group revealed more developed re-epithelialization with continuous basement memADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
brane with a mature granulation tissue, whereas the SSD-treated group showed ulceration, necrosis, and immature granulation.
DISCUSSION The results of the present study reveal that a sea buckthorn/olive oil mixture could be considered an effective dressing for full-thickness burns. This finding was perceived because of significant increase in wound contraction rate, little amount of exudate, no purulent exudates, and fast healing process. This increase in wound contraction might be due to the activity of the myofibroblasts because of wound strengthening on the extracellular matrix, as well as extracellular collagen fiber deposition to stabilize the contraction. Some studies suggest that sea buckthorn dressing on burn wounds may improve
320
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
of vascular endothelial growth factors in the recovering tissue, treated by sea buckthorn extraction.2 Furthermore, sea buckthorn is rich in vitamin A, and its topical use can improve the healing process.20 On the other hand, olive oil can also be considered as a potential burn wound dressing for some characteristics.1 Naturally, when a part of the skin is damaged, as occurs with burning, a layer of fatty acids is secreted on the impaired area by the cells in the stratum in order to restore the permeability barrier.21 Studies reveal that using a dressing of physiologic lipids on the impaired area of the skin can improve the permeability barrier homeostasis and help the healing process.22 Monounsaturated fatty acids are one of the most important parts of cell membrane, as they make the cell membrane more fluid.23 Another advantage of monounsaturated fatty acids is their antibacterial characteristics, which provide potential protection against contamination.15 Also, monounsaturated fatty acids are more resistant against oxidative stresses compared with polyunsaturated ones. Olive oil containing a high amount of monounsaturated fatty acids can be used as a proper dressing for burn wounds.24 Sea buckthorn and olives are rich in phenols and polyphenol compounds. These compounds have been shown to have antiinflammatory and antibacterial characteristics. It is known that free radicals, which are generated in injuries, may impair the wound healing process by damaging the macromolecules. The free radicalYscavenging property of sea buckthorn and olive oil could be due to antioxidants, such as vitamins (E, C, and K), flavonoids (catechin, rutin, quercetin, kaempferol and isorhamnetin), and their abundant polyphenols.25Y27 Although there is no doubt that SSD is an effective antibacterial agent, it delays the wound healing process. Some investigations indicated that SSD inhibits the proliferation of the keratinocytes
Figure 2. MACROSCOPIC COMPARISON (MEAN T SE) OF SEA BUCKTHORN, OLIVE OIL, AND THEIR MIXTURE TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY KEAST ET AL18
Figure 3.
expression of collagen type III, a predominant form of collagen, which helps to stabilize the contraction.13 Also, it was seen that sea buckthorn has a critical role in remodeling of the extracellular matrix by increasing the expression of matrix, metalloproteinase (MMPs) such as MMP-2 and MMP-9. These substances play a key role in all phases of the wound healing process by eliminating damaged proteins, facilitating cell migration, remodeling the granulation tissue, and regulating the activity of some growth factors. Higher new vessel formation in groups treated by the buckthorn/olive oil mixture or only sea buckthorn in comparison with others indicates that sea buckthorn had improved angiogenesis. Angiogenesis is an important part of the wound healing process; some studies suggest that this increase in angiogenesis is due to higher expression WWW.WOUNDCAREJOURNAL.COM
HISTOPATHOLOGIC SCORES (MEAN) COMPARISON OF SEA BUCKTHORN, OLIVE OIL, AND THEIR MIXTURE TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY ABRAMOV ET AL19
321
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Figure 4. A. HIGH-POWER MICROSCOPY OF GRANULATION TISSUE SHOWS FIBROBLASTS ADMIXED WITH COLLAGEN FIBERS AND NEOVASCULARIZATION FROM THE GROUP OF FULL-THICKNESS BURN WOUNDS IN SKIN OF RATS TREATED WITH SEA BUCKTHORN/OLIVE OIL MIXTURE. B AND C. HISTOPATHOLOGIC CHANGES ON DAY 8 AFTER WOUNDING OF FULL-THICKNESS BURN WOUNDS IN RAT SKIN. B. SILVER SULFADIAZINE GROUP WITH NO HEALING, ULCERATION (U), NECROSIS (N), AND IMMATURE GRANULATION (G). C. SEA BUCKTHORN/OLIVE OIL MIXTURE GROUP WITH COMPLETE EPITHELIALIZATION (E) AND TISSUE MATURATION
and fibroblasts, and this can impair the wound-healing process.7 In the authors’ study, the wounds treated by SSD showed latent wound contraction, and also it revealed nonpurulent but persistent exudates. In the pathohistological assessment, immature granulation and less angiogenesis in the SSD-treated group might be due to this impairing characteristic of SSD. In addition to previous investigations,14,27 the present study shows that both sea buckthorn and olive oil have antiseptic properties. According to the results of this study, whereas some of the rats in the control group showed infection, other groups did not reveal any infection during the study timeframe. This antibacterial property could be due to phenolic constituents of sea buckthorn and olive oil such as secoiridoids (oleuropein and derivatives), which are reported to have an inhibitory effect on pathogenic bacteria growth.28,29 Although the authors tried to eliminate the bias of the estimator by recruiting only 1 clinician and 1 pathologist for evaluation of the wounds, still the results of the study could be influenced because of its subjective nature.
CONCLUSIONS In conclusion, the study shows that sea buckthorn and olive oil are individually proper dressings for burn wounds, and they show a synergetic effect when they are used together. The 2 materials enhanced and accelerated the healing process of the burn wounds when compared with SSD, which is used as a current standard care for burn wounds. Clinical trials are needed for a better judgment about the healing effect of these natural products, but the present study reveals that a sea buckthorn/olive oil mixture could be considered as an alternative dressing for full-thickness burns, given its apparent wound healing characteristics and antibacterial property.
&
REFERENCES 1. Gurfinkel R, Palivatkel-Naim M, Gleisinger R, et al. Comparison of purified olive oil and silver sulfadiazine in the treatment of partial thickness porcine burns. Am J Emerg Med 2012;30:79-83. 2. Upadhyay NK, Kumar R, Siddiqui MS, et al. Mechanism of wound-healing activity of Hippophae rhamnoides L. leaf extract in experimental burns. Evid Based Complement Alternat Med 2011; 2011:659705. 3. Kumar V, Abbas AK, Aster JC. Robbins Basic Pathology. 9th ed. Philadelphia, PA: Elsevier Health Sciences; 2012. 4. Marx JA, Hockberger RS, Walls RM, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 7th ed. Philadelphia, PA: Mosby Incorporated; 2010. 5. Mashreky SR, Rahman A, Chowdhury SM, et al. Burn injury: economic and social impact on a family. Public Health 2008;122:1418-24. 6. Atiyeh BS, Costagliola M, Hayek SN, et al. Effect of silver on burn wound infection control and healing: review of the literature. Burns 2007;33:139-48. 7. Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res 2009;30:464-70. 8. Gray DC, Rutledge CM. Herbal supplements in primary care: patient perceptions, motivations, and effects on use. Holist Nurs Pract 2013;27:6-12. 9. Panossian A, Wagner H. From traditional to evidence-based use of Hippophae rhamnoides L.: chemical composition, experimental, and clinical pharmacology of sea buckthorn berries and leaves extracts. In: Evidence and Rational Based Research on Chinese Drugs. Vienna, Austria: Springer; 2013:181-236.
ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
322
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
10. Gupta A, Kumar R, Pal K, et al. A preclinical study of the effects of seabuckthorn (Hippophae rhamnoides L.) leaf extract on cutaneous wound healing in albino rats. Int J Low Extrem Wounds. 2005;4:88-92. 11. Negi PS, Chauhan AS, Sadia GA, et al. Antioxidant and antibacterial activities of various seabuckthorn (Hippophae rhamnoides L.) seed extracts. Food Chem 2005;92:119-24. 12. Saggu S, Divekar HM, Gupta V, et al. Adaptogenic and safety evaluation of seabuckthorn (Hippophae rhamnoides) leaf extract: a dose dependent study. Food Chem Toxicol 2007;45:609-17. 13. Upadhyay NK, Kumar R, Mandotra SK, et al. Safety and healing efficacy of sea buckthorn (Hippophae rhamnoides L.) seed oil on burn wounds in rats. Food Chem Toxicol 2009;47:1146-53. 14. Tafesh A, Najami N, Jadoun J, et al. Synergistic antibacterial effects of polyphenolic compounds from olive mill wastewater. Evid Based Complement Alternat Med 2011;2011:431021. 15. Desbois AP, Smith VJ. Antibacterial free fatty acids: activities, mechanisms of action and biotechnological potential. Appl Microbiol Biotechnol 2010;85:1629-42. 16. Owen RW, Giacosa A, Hull WE, et al. The antioxidant/anticancer potential of phenolic compounds isolated from olive oil. Eur J Cancer 2000;36:1235-47. 17. Visioli F, Bellomo G, Montedoro G, et al. Low density lipoprotein oxidation is inhibited in vitro by olive oil constituents. Atherosclerosis 1995;117:25-32. 18. Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D’Souza L. MEASURE: A proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen 2004;12:s1-s17. 19. Abramov Y, Golden B, Sullivan M, et al. Histologic characterization of vaginal vs. abdominal surgical wound healing in a rabbit model. Wound Repair Regen 2007;15:80-6. 20. Hunt TK. Vitamin A and wound healing. J Am Acad Dermatol 1986;15:817-21. 21. Mao-Qiang M, Elias PM, Feingold KR. Fatty acids are required for epidermal permeability barrier function. J Clin Invest 1993;92:791-8. 22. Feingold KR. Thematic review series: skin lipids. The role of epidermal lipids in cutaneous permeability barrier homeostasis. J Lipid Res 2007;48:2531-46. 23. Lodish H, Berk A, Kaiser CA, et al. Molecular Cell Biology. 6th ed. Vienna, Austria: Macmillan; 2008. 24. Rahman I, Qureshi MN, Ahmad S. Comparative study of fatty acid components in oils of different olive varieties grown in different regions of Pakistan by gas chromatographyYmass spectrometry. J Chinese Chem Soc 2012;59:46-50. 25. Bubonja-Sonje M, Giacometti J, Abram M. Antioxidant and antilisterial activity of olive oil, cocoa and rosemary extract polyphenols. Food Chem 2011;127:1821-7. 26. Medina E, de Castro A, Romero C, et al. Comparison of the concentrations of phenolic compounds in olive oils and other plant oils: correlation with antimicrobial activity. J Agric Food Chem 2006;54:4954-61. 27. Michel T, Destandau E, Floch GL, et al. Antimicrobial, antioxidant and phytochemical investigations of sea buckthorn (Hippophae¨ rhamnoides L.) leaf, stem, root and seed. Food Chem 2012;131:754-60. 28. Flores MIA, Romero-Gonza´lez R, Frenich AG, et al. Analysis of phenolic compounds in olive oil by solid-phase extraction and ultra high performance liquid chromatographyYtandem mass spectrometry. Food Chem 2012;134:2465-72. 29. Yogendra Kumar MS, Tirpude RJ, Maheshwari DT, et al. Antioxidant and antimicrobial properties of phenolic rich fraction of seabuckthorn (Hippophae rhamnoides L.) leaves in vitro. Food Chem 2013;141:3443-50.
Get fast news updates on the latest developments in the skin and wound care field.
Advances in
®
SKIN&WOUND CARE eNEWS
Sign up for our free monthly eNews and we’ll send you cutting edge information on what’s new in skin and wound care, plus we’ll include free links to Bonus Content and CME articles.
It’s easy and it’s free. To register, visit http://www.nursingcenter.com/aswcenews
WWW.WOUNDCAREJOURNAL.COM
323
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Healing Effect of Sea Buckthorn, Olive Oil, and Their Mixture on Full-Thickness Burn Wounds Mitra Edraki, BSc, MSc; Armin Akbarzadeh; Massood Hosseinzadeh, MD; Nader Tanideh, DVM, MPH, PhD; Alireza Salehi, MD, MPH, PhD; and Omid Koohi-Hosseinabadi, BSc
ABSTRACT OBJECTIVE: The purpose of this study is to evaluate the healing effect of silver sulfadiazine (SSD), sea buckthorn, olive oil, and 5% sea buckthorn and olive oil mixture on full-thickness burn wounds with respect to both gross and histopathologic features. METHODS: Full-thickness burns were induced on 60 rats; the rats were then were divided into 5 groups and treated with sea buckthorn, olive oil, a 5% sea buckthorn/olive oil mixture, SSD, and normal saline (control). They were observed for 28 days, and the wounds’ healing process was evaluated. RESULTS: Wound contraction occurred faster in sea buckthorn, olive oil, and the sea buckthorn/olive oil mixture groups compared with the SSD and control groups. The volume of the exudates was controlled more effectively in wounds treated with the sea buckthorn/olive oil mixture. Purulent exudates were observed in the control group, but the others did not show infection. The group treated with sea buckthorn/olive oil mixture revealed more developed re-epithelialization with continuous basement membrane with a mature granulation tissue, whereas the SSD-treated group showed ulceration, necrosis, and immature granulation. The results show that sea buckthorn and olive oil individually are proper dressing for burn wounds and that they also show a synergetic effect when they are used together. CONCLUSION: A sea buckthorn and olive oil mixture could be considered as an alternative dressing for full-thickness burns because of improved wound healing characteristics and antibacterial property. KEYWORDS: full-thickness burns, sea-buckthorn, olive oil, silver sulfadiazine ADV SKIN WOUND CARE 2014;27:317Y23
INTRODUCTION Burns are one of the most common injuries seen the world over.1,2 Burns not only impair the cutaneous tissue locally, but may also cause
some systemic effects, such as loss of fluid and protein, sepsis, changes in the metabolic state, and involvement of the hematological and immune systems.3 Full-thickness burns involve both the outer layer (epidermis) and the underlying layer of the skin (dermis).3,4 Burn management involves a prolonged period of hospitalization, expensive medication, and surgical operations. Also, burns may cause patients to require long-term rehabilitation. However, some burns are not severe and can be handled outside the hospital setting in order to reduce both the burdens of cost and of hospitalization time.5 Many of the synthetic drugs used to treat burns are not costeffective because of their high expense. Some effective methods, such as recombinant growth factors and tissue-engineered wound dressings, are highly expensive and beyond the reach of most patients in the developing world. Current burn treatments also present chances for unwanted adverse effects. Currently, the most commonly used local treatment for a burn is 1% silver sulfadiazine (SSD), which is useful to keep the burn wound free from bacterial contamination. However, recent studies revealed that the healing process of fullthickness burn wounds is delayed by using SSD. Thus, researchers are looking for a better alternative burn dressing.6,7 Previous studies show that using traditional herbal medicine is effective for healing wounds. Traditional herbal medicine is gaining popularity because of its widespread availability, no or fewer adverse effects, moderate efficacy, and low cost as compared with synthetic drugs.8 Hippophae rhamnoides, which belongs to the Elaeagnaceae family, is commonly known as sea buckthorn. Sea buckthorn is a branched and thorny nitrogen-fixing deciduous shrub found most commonly in Asia and Europe. Sea buckthorn contains many bioactive substances such as flavonoids (isorhamnetin, quercetin, myricetin, kaempferol, and their glycoside compounds); carotenoids (>, A, C-carotene, lycopene); vitamins (C, E, K); tannins; triterpenes; glycerides of palmitic, stearic, and oleic acids, as well as some essential amino acids.9 Studies show that sea buckthorn has antioxidative, antimicrobial, adaptogenic, and tissue-regenerating properties.10Y12 Wounds treated with sea buckthorn have shown tissue regeneration and increased granulation
Mitra Edraki, BSc, MSc, is an Instructor of Pediatric Nursing, Community-Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Armin Akbarzadeh is a medical student, Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. Massood Hosseinzadeh, MD, is Assistant Professor of Pathology, Colorectal Research Center, Department of Pathology, Shiraz University of Medical Sciences, Shiraz, Iran. Nader Tanideh, DVM, MPH, PhD, is Assistant Professor of Pharmacology, Stem Cell and Transgenic Technology Research Center & Pharmacology Department, Shiraz University of Medical Sciences, Shiraz, Iran. Alireza Salehi, MD, MPH, PhD, is Assistant Professor of Epidemiology, Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Omid Koohi-Hosseinabadi, BSc, is a laboratory animal technician, Center of Comparative and Experimental Medicine, Shiraz University of Medical Sciences, Shiraz, Iran. Acknowledgments: The authors thank Dr Nasrin Shokrpour at the Center for Development of Clinical Research of Nemazee Hospital for editorial assistance. The authors have disclosed that they have no financial relationships related to this article. Submitted August 26, 2013; accepted in revised form November 7, 2013. WWW.WOUNDCAREJOURNAL.COM
317
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
and tissue density, as well as less congestion, less edema, and less infiltration of the polymorphonuclear leukocytes.13 Olive oil can also be considered as a potential burn wound dressing because of its antibacterial and anti-inflammatory components, such as phenols and polyphenols.14 Olive oil is also rich in monounsaturated fatty acids that make it a proper dressing to preserve wounds from contamination.15 Because of the importance of free radicals in the pathophysiology of burning, administration of antioxidants may be helpful in the healing process. Furthermore, olive oil contains some important antioxidants in its components, such as vitamin E and phenol compounds (tyrosol, hydroxytyrosol, oleuropein, 1-acetoxypinoresinol, and [+]-pinoresinol).16,17 The aim of this study was to measure the healing effect of SSD, sea buckthorn, olive oil, and a 5% sea buckthorn/olive oil mixture on full-thickness burn wounds, individually and to compare in terms of both gross and histopathologic features.
METHODS Experimental Animals
stored at j20-C in an airtight plastic container until further use (yield 13.7% wt/wt). The high-performance liquid chromatography fingerprinting of each batch of the extract was carried out and maintained throughout the experiment, to avoid variation from batch to batch.
Burn Wound Model The rats were anesthetized by 90 mg/kg of ketamine (Alfasan International BV, Woerden, Holland) and 8 mg/kg of xylazine (Alfasan International BV) by intramuscular injection. The dorsal surface of the rat was shaved, and the underlying skin was cleaned with 70% ethanol. Full-thickness burn wounds were created using a columnar rod, made of aluminum (2.5 2.5 cm2 and 400-g weight), heated to 90-C. The rods were heated in 90-C water for 30 minutes before application. Hot rods were placed without pressure on the shaved areas of each rat once for 10 seconds. After each application, the rods were heated with hot water for at least 5 minutes. After the animals were recovered from anesthesia, they were housed individually in sterile cages.
Sixty male Sprague-Dawley rats (250 T 50 g), aged between 8 and 10 weeks and presenting with no illness, obtained from the animal colony of Shiraz University of Medical Sciences, Shiraz, Iran, were used for this study. The animals were maintained under a controlled environment in the university’s animal house at 22-C T 2-C, with 55% T 5% of atmosphere humidity and a 12-hour lightdark cycle. The experiments were performed in accordance with the regulations specified by the university’s Animal Ethics Committee and conformed to the national guidelines on the care and use of laboratory animals.
Study Protocol
Collection and Extraction of Plant Material
WOUND ASSESSMENT
The yellow, clear, and odorless olive oil (Olea europaea), which is extracted by pressing the fresh fruit of the olive, was used for this study. The berries of the sea buckthorn (H rhamnoides L) were collected from the Kazeroon region in the southwest of Iran in September 2012, a time when it grows widely. Fresh sea buckthorn berries were then cleaned and washed with water and rewashed with distilled water. The berries were then dried under shade in a clean, dust-free environment. The aqueous extract was prepared by soaking powdered dry berries in distilled water (1:5 wt/vol) at room temperature (25-C T 1-C). After 24 hours, the supernatant was decanted, and the residue was resoaked in fresh distilled water. The process was repeated 4 times for complete extraction. The supernatants were pooled, filtered through muslin cloth, and centrifuged at 5000g at 4-C. The supernatants obtained after centrifugation were frozen at j20-C and then lyophilized in Heto lyophilizer (The Virtis Company, Gardiner, New York). The lyophilized powder of the sea buckthorn leaf aqueous extract was
Gross Examination
ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
After cleaning the burns with normal saline, the rats were randomly assigned to 5 groups (n = 12), and different topical treatments were applied: sea buckthorn, olive oil, a 5% sea buckthorn/ olive oil mixture, SSD cream (1.0% wt/wt; Sina Daru Pharmaceuticals, Tehran, Iran), and normal saline (in only the control group). After applying the topical treatments, the burn wounds were dressed with sterilized dry gauze. These dressings were applied once daily during the study, with each treatment being applied after washing the burn wounds with normal saline.
The authors obtained an index from an assessment method for burn wounds created by Keast et al.18 The authors then modified the index from its original construction to assess the burn wounds’ condition during this study (Table 1). This assessment method is accurate, sensitive, and simple to apply. Assessment of the wound was done on days 1, 3, 5, 7, 10, 14, 21, and 28. To measure the wound surface area, the wounds were traced on a transparent paper. The transparent papers were sterilized by formaldehyde before use, and each one was used for 1 assessment in order to avoid the transmission of infection. The volume and quality of exudates of the burn wounds were also assessed by a clinician.
Histopathologic Examination Excisional biopsy from the skin and granulation tissue was performed on days 7, 14, 21, and 28 and fixed in 10% neutral formalin. Three cross-section samples were provided from each wound, were
318
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Surface Measure
Table 1.
The surface area of the wounds treated with olive oil was smaller on days 5 and 21 in comparison with SSD-treated wounds (Figure 1A). Figure 1D reveals that differences were not significant on days 3, 5, 7, and 10. On days 14 and 21, the wounds treated with sea buckthorn showed a significantly higher contraction compared with the control and SSD groups. Figure 2A shows that the sea buckthorn/olive oil mixture group had a significantly better wound contraction as compared with the individual sea buckthorn and olive oil groups on days 7 and 10.
BURN WOUND SCORING FOR CLINICAL ASSESSMENT, OBTAINED FROM AN INDEX PROVIDED BY KEAST ET AL18 Numerical Score
Measure
Exudate Volume
Exudate Quality
0 1 2 3 4 5 6 7
0 G0.3 0.3Y0.6 0.7Y1.0 1.1Y1.4 1.5Y1.8 1.9Y2.2 2.3Y2.5
None Smallb (scant) Moderated Largef (copious) V V V V
Serousa Serosanguineousc Sanguineouse Seropurulentg Purulenth V V V
Exudate Volume and Quality
a
Thin, watery, clear to yellow, usually odorless. Exudate fully controlled, nonabsorptive dressing may be used, wear time up to 7 days. c Thin, watery, pink to light red, usually odorless. d Exudate controlled, absorptive dressings may be required, wear time 2 to 3 days. e Frank blood, bright red. f Exudate uncontrolled, absorptive dressings required, dressing may be overwhelmed in less than 1 day. g Thin, watery, white to cream, possibly foul odor. h Thick, translucent to opaque, white to cream, possibly foul odor. b
then stained with hematoxylin-eosin, and were then observed for histopathologic changes under a microscope. This observation was double-blinded and performed by a pathologist and scored according to a modified scoring system for surgical wound healing taken from Abramov et al19 (Table 2). This scoring system was used to determine the healing grade in each treatment group sample. This scoring system is based on the following repair indices: epithelialization, collagenization, inflammation, ulcer, and necrosis. All morphometric parameters were recorded with Olympus DP12 Digital Camera system (Olympus Optical, Tokyo, Japan). Epithelialization was perused and compared in regard to the formation time.
Statistical Analysis Data are expressed as mean T SEM, and statistical significance between experimental and control values was analyzed by MannWhitney U test and paired t test in SPSS version 11.5 (SPSS, Chicago, Illinois). P G .05 was considered to be statistically significant.
Figure 1B and E show that the exudate volume of wounds in the groups treated with sea buckthorn and olive oil increased slightly during the first week and then decreased faster compared with the SSD and control groups. In comparison, no significant differences were seen between wounds treated with SSD and normal saline (control group). The sea buckthorn/olive oil mixture induced less exudate on the wounds in comparison with the individual sea buckthorn and olive oil groups. Figure 2B also reveals that the sea buckthorn group shows faster reduction of exudates compared with the olive oil group. Purulent exudate was found only in the control group. There were no significant differences among SSD, olive oil, and sea buckthorn except on day 3 when the olive oilYtreated group showed better exudate quality than did the SSD group (Figures 1C and F and 2C).
Histopathologic Assessment The mean scores of the sea buckthorn/olive oil mixture, olive oil, and sea buckthornYtreated groups were respectively higher compared with those treated with saline (control) and SSD, as shown in Figure 3. The histological examinations showed that tissue regeneration was much better in the burn wounds treated with the sea
RESULTS Macroscopic Assessment According to Table 1, lower scores indicate a better wound condition. The authors compared the scores of different treatment groups with one another and then identified significant differences between groups, which are indicated by caps in the graphs. Comparing olive oil (Figure 1AYC) and sea buckthorn (Figure 1DYF) individually with both SSD and control groups enabled the authors to evaluate the effectiveness of these 2 herbal products on the healing process of burn wounds. The effectiveness of the sea buckthorn/olive oil mixture was compared with both the individual sea buckthorn group and the olive oil group (Figure 2AYC). WWW.WOUNDCAREJOURNAL.COM
319
Table 2.
MODIFIED WOUND-HEALING HISTOPATHOLOGIC SCORING SYSTEM FROM INDICES PROVIDED BY ABRAMOV ET AL19 Scores Indices
1
2
3
Epithelialization
None
None
Partial
4
Complete, immature Collagenization None None Partial Complete, irregular Inflammation Severe Moderate Mild None Neovascularization None None G5/HPF 6-10/HPF Necrosis Extensive Focal None None Granulation tissue None Immature Mild Moderately mature mature
5 Complete, mature Complete, regular None 910/HPF None Fully mature
Abbreviation: HPF, high-power field. ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Figure 1. MACROSCOPIC COMPARISON (MEAN T SE) OF (A) OLIVE OIL AND SSD TREATMENT AND (B) SEA BUCKTHORN AND SSD TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY KEAST ET AL18
buckthorn/olive oil mixture compared with the SSD and normal salineYtreated burns. Although those wounds treated by SSD did not show any purulent tissue (which was also the case for sea buckthorn, olive oil, and the sea buckthorn/olive oil mixture groups), tissue regeneration was impaired. Figure 4A shows a sample photomicrograph of skin sections stained with hematoxylin-eosin from the group treated with sea buckthorn and olive oil mixture in which the injured tissue has repaired properly. Neovascularization was seen in the tissue, and collagen bundles were properly deposited among the fibroblast cells. Figures 4B and C compare the tissue of the sea buckthorn/olive oil mixtureYtreated group and SSD-treated group. On day 14, the sea buckthorn/olive oil mixtureYtreated group revealed more developed re-epithelialization with continuous basement memADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
brane with a mature granulation tissue, whereas the SSD-treated group showed ulceration, necrosis, and immature granulation.
DISCUSSION The results of the present study reveal that a sea buckthorn/olive oil mixture could be considered an effective dressing for full-thickness burns. This finding was perceived because of significant increase in wound contraction rate, little amount of exudate, no purulent exudates, and fast healing process. This increase in wound contraction might be due to the activity of the myofibroblasts because of wound strengthening on the extracellular matrix, as well as extracellular collagen fiber deposition to stabilize the contraction. Some studies suggest that sea buckthorn dressing on burn wounds may improve
320
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
of vascular endothelial growth factors in the recovering tissue, treated by sea buckthorn extraction.2 Furthermore, sea buckthorn is rich in vitamin A, and its topical use can improve the healing process.20 On the other hand, olive oil can also be considered as a potential burn wound dressing for some characteristics.1 Naturally, when a part of the skin is damaged, as occurs with burning, a layer of fatty acids is secreted on the impaired area by the cells in the stratum in order to restore the permeability barrier.21 Studies reveal that using a dressing of physiologic lipids on the impaired area of the skin can improve the permeability barrier homeostasis and help the healing process.22 Monounsaturated fatty acids are one of the most important parts of cell membrane, as they make the cell membrane more fluid.23 Another advantage of monounsaturated fatty acids is their antibacterial characteristics, which provide potential protection against contamination.15 Also, monounsaturated fatty acids are more resistant against oxidative stresses compared with polyunsaturated ones. Olive oil containing a high amount of monounsaturated fatty acids can be used as a proper dressing for burn wounds.24 Sea buckthorn and olives are rich in phenols and polyphenol compounds. These compounds have been shown to have antiinflammatory and antibacterial characteristics. It is known that free radicals, which are generated in injuries, may impair the wound healing process by damaging the macromolecules. The free radicalYscavenging property of sea buckthorn and olive oil could be due to antioxidants, such as vitamins (E, C, and K), flavonoids (catechin, rutin, quercetin, kaempferol and isorhamnetin), and their abundant polyphenols.25Y27 Although there is no doubt that SSD is an effective antibacterial agent, it delays the wound healing process. Some investigations indicated that SSD inhibits the proliferation of the keratinocytes
Figure 2. MACROSCOPIC COMPARISON (MEAN T SE) OF SEA BUCKTHORN, OLIVE OIL, AND THEIR MIXTURE TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY KEAST ET AL18
Figure 3.
expression of collagen type III, a predominant form of collagen, which helps to stabilize the contraction.13 Also, it was seen that sea buckthorn has a critical role in remodeling of the extracellular matrix by increasing the expression of matrix, metalloproteinase (MMPs) such as MMP-2 and MMP-9. These substances play a key role in all phases of the wound healing process by eliminating damaged proteins, facilitating cell migration, remodeling the granulation tissue, and regulating the activity of some growth factors. Higher new vessel formation in groups treated by the buckthorn/olive oil mixture or only sea buckthorn in comparison with others indicates that sea buckthorn had improved angiogenesis. Angiogenesis is an important part of the wound healing process; some studies suggest that this increase in angiogenesis is due to higher expression WWW.WOUNDCAREJOURNAL.COM
HISTOPATHOLOGIC SCORES (MEAN) COMPARISON OF SEA BUCKTHORN, OLIVE OIL, AND THEIR MIXTURE TREATMENT ON FULL-THICKNESS BURN WOUNDS IN RATS FROM AN INDEX PROVIDED BY ABRAMOV ET AL19
321
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
Figure 4. A. HIGH-POWER MICROSCOPY OF GRANULATION TISSUE SHOWS FIBROBLASTS ADMIXED WITH COLLAGEN FIBERS AND NEOVASCULARIZATION FROM THE GROUP OF FULL-THICKNESS BURN WOUNDS IN SKIN OF RATS TREATED WITH SEA BUCKTHORN/OLIVE OIL MIXTURE. B AND C. HISTOPATHOLOGIC CHANGES ON DAY 8 AFTER WOUNDING OF FULL-THICKNESS BURN WOUNDS IN RAT SKIN. B. SILVER SULFADIAZINE GROUP WITH NO HEALING, ULCERATION (U), NECROSIS (N), AND IMMATURE GRANULATION (G). C. SEA BUCKTHORN/OLIVE OIL MIXTURE GROUP WITH COMPLETE EPITHELIALIZATION (E) AND TISSUE MATURATION
and fibroblasts, and this can impair the wound-healing process.7 In the authors’ study, the wounds treated by SSD showed latent wound contraction, and also it revealed nonpurulent but persistent exudates. In the pathohistological assessment, immature granulation and less angiogenesis in the SSD-treated group might be due to this impairing characteristic of SSD. In addition to previous investigations,14,27 the present study shows that both sea buckthorn and olive oil have antiseptic properties. According to the results of this study, whereas some of the rats in the control group showed infection, other groups did not reveal any infection during the study timeframe. This antibacterial property could be due to phenolic constituents of sea buckthorn and olive oil such as secoiridoids (oleuropein and derivatives), which are reported to have an inhibitory effect on pathogenic bacteria growth.28,29 Although the authors tried to eliminate the bias of the estimator by recruiting only 1 clinician and 1 pathologist for evaluation of the wounds, still the results of the study could be influenced because of its subjective nature.
CONCLUSIONS In conclusion, the study shows that sea buckthorn and olive oil are individually proper dressings for burn wounds, and they show a synergetic effect when they are used together. The 2 materials enhanced and accelerated the healing process of the burn wounds when compared with SSD, which is used as a current standard care for burn wounds. Clinical trials are needed for a better judgment about the healing effect of these natural products, but the present study reveals that a sea buckthorn/olive oil mixture could be considered as an alternative dressing for full-thickness burns, given its apparent wound healing characteristics and antibacterial property.
&
REFERENCES 1. Gurfinkel R, Palivatkel-Naim M, Gleisinger R, et al. Comparison of purified olive oil and silver sulfadiazine in the treatment of partial thickness porcine burns. Am J Emerg Med 2012;30:79-83. 2. Upadhyay NK, Kumar R, Siddiqui MS, et al. Mechanism of wound-healing activity of Hippophae rhamnoides L. leaf extract in experimental burns. Evid Based Complement Alternat Med 2011; 2011:659705. 3. Kumar V, Abbas AK, Aster JC. Robbins Basic Pathology. 9th ed. Philadelphia, PA: Elsevier Health Sciences; 2012. 4. Marx JA, Hockberger RS, Walls RM, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Vol 1. 7th ed. Philadelphia, PA: Mosby Incorporated; 2010. 5. Mashreky SR, Rahman A, Chowdhury SM, et al. Burn injury: economic and social impact on a family. Public Health 2008;122:1418-24. 6. Atiyeh BS, Costagliola M, Hayek SN, et al. Effect of silver on burn wound infection control and healing: review of the literature. Burns 2007;33:139-48. 7. Fuller FW. The side effects of silver sulfadiazine. J Burn Care Res 2009;30:464-70. 8. Gray DC, Rutledge CM. Herbal supplements in primary care: patient perceptions, motivations, and effects on use. Holist Nurs Pract 2013;27:6-12. 9. Panossian A, Wagner H. From traditional to evidence-based use of Hippophae rhamnoides L.: chemical composition, experimental, and clinical pharmacology of sea buckthorn berries and leaves extracts. In: Evidence and Rational Based Research on Chinese Drugs. Vienna, Austria: Springer; 2013:181-236.
ADVANCES IN SKIN & WOUND CARE & VOL. 27 NO. 7
322
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ORIGINAL INVESTIGATION
10. Gupta A, Kumar R, Pal K, et al. A preclinical study of the effects of seabuckthorn (Hippophae rhamnoides L.) leaf extract on cutaneous wound healing in albino rats. Int J Low Extrem Wounds. 2005;4:88-92. 11. Negi PS, Chauhan AS, Sadia GA, et al. Antioxidant and antibacterial activities of various seabuckthorn (Hippophae rhamnoides L.) seed extracts. Food Chem 2005;92:119-24. 12. Saggu S, Divekar HM, Gupta V, et al. Adaptogenic and safety evaluation of seabuckthorn (Hippophae rhamnoides) leaf extract: a dose dependent study. Food Chem Toxicol 2007;45:609-17. 13. Upadhyay NK, Kumar R, Mandotra SK, et al. Safety and healing efficacy of sea buckthorn (Hippophae rhamnoides L.) seed oil on burn wounds in rats. Food Chem Toxicol 2009;47:1146-53. 14. Tafesh A, Najami N, Jadoun J, et al. Synergistic antibacterial effects of polyphenolic compounds from olive mill wastewater. Evid Based Complement Alternat Med 2011;2011:431021. 15. Desbois AP, Smith VJ. Antibacterial free fatty acids: activities, mechanisms of action and biotechnological potential. Appl Microbiol Biotechnol 2010;85:1629-42. 16. Owen RW, Giacosa A, Hull WE, et al. The antioxidant/anticancer potential of phenolic compounds isolated from olive oil. Eur J Cancer 2000;36:1235-47. 17. Visioli F, Bellomo G, Montedoro G, et al. Low density lipoprotein oxidation is inhibited in vitro by olive oil constituents. Atherosclerosis 1995;117:25-32. 18. Keast DH, Bowering CK, Evans AW, Mackean GL, Burrows C, D’Souza L. MEASURE: A proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen 2004;12:s1-s17. 19. Abramov Y, Golden B, Sullivan M, et al. Histologic characterization of vaginal vs. abdominal surgical wound healing in a rabbit model. Wound Repair Regen 2007;15:80-6. 20. Hunt TK. Vitamin A and wound healing. J Am Acad Dermatol 1986;15:817-21. 21. Mao-Qiang M, Elias PM, Feingold KR. Fatty acids are required for epidermal permeability barrier function. J Clin Invest 1993;92:791-8. 22. Feingold KR. Thematic review series: skin lipids. The role of epidermal lipids in cutaneous permeability barrier homeostasis. J Lipid Res 2007;48:2531-46. 23. Lodish H, Berk A, Kaiser CA, et al. Molecular Cell Biology. 6th ed. Vienna, Austria: Macmillan; 2008. 24. Rahman I, Qureshi MN, Ahmad S. Comparative study of fatty acid components in oils of different olive varieties grown in different regions of Pakistan by gas chromatographyYmass spectrometry. J Chinese Chem Soc 2012;59:46-50. 25. Bubonja-Sonje M, Giacometti J, Abram M. Antioxidant and antilisterial activity of olive oil, cocoa and rosemary extract polyphenols. Food Chem 2011;127:1821-7. 26. Medina E, de Castro A, Romero C, et al. Comparison of the concentrations of phenolic compounds in olive oils and other plant oils: correlation with antimicrobial activity. J Agric Food Chem 2006;54:4954-61. 27. Michel T, Destandau E, Floch GL, et al. Antimicrobial, antioxidant and phytochemical investigations of sea buckthorn (Hippophae¨ rhamnoides L.) leaf, stem, root and seed. Food Chem 2012;131:754-60. 28. Flores MIA, Romero-Gonza´lez R, Frenich AG, et al. Analysis of phenolic compounds in olive oil by solid-phase extraction and ultra high performance liquid chromatographyYtandem mass spectrometry. Food Chem 2012;134:2465-72. 29. Yogendra Kumar MS, Tirpude RJ, Maheshwari DT, et al. Antioxidant and antimicrobial properties of phenolic rich fraction of seabuckthorn (Hippophae rhamnoides L.) leaves in vitro. Food Chem 2013;141:3443-50.
Get fast news updates on the latest developments in the skin and wound care field.
Advances in
®
SKIN&WOUND CARE eNEWS
Sign up for our free monthly eNews and we’ll send you cutting edge information on what’s new in skin and wound care, plus we’ll include free links to Bonus Content and CME articles.
It’s easy and it’s free. To register, visit http://www.nursingcenter.com/aswcenews
WWW.WOUNDCAREJOURNAL.COM
323
ADVANCES IN SKIN & WOUND CARE & JULY 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
