優碘可促進傷口癒合(4)

游朝慶醫師

優碘粉的實證—動物及人體實驗

   最後來討論另一種優碘---cadexomer-iodine優碘粉（iodosorb），大多數對優碘粉的研究都是人體實驗，只有3篇是使用豬的研究，Mertz¹於1994年發表使用感染MRSA（methicillin-resistant Staphylococcus aures）的豬的部分皮層（partial thickness）傷口(n=120)，比較優碘粉cadexomer-iodine，cadexomer不含優碘的粉及沒有治療，結果發現，優碘粉可促進表皮位移(epidermal migration)，並剪少細菌（MRSA）的量，於1999年Mertz²又重複類似的實驗，但這次只作對於MRSA的抗菌研究，結果還是優碘粉可有效對抗有抗藥性的MRSA細菌，Lamme³則是將優碘粉用在豬的全層皮膚（full thickness）傷口，和生理食鹽水做對照比較，結果表皮再生(epidermal regeneration)及上皮化(epitheliation)都明顯增加(p<0.05)。

   在人體實驗方面，就糖尿病足部傷口(diabetic foot ulcer)而言，Apelqvist⁴比較12個患者使用優碘粉，另12個患者接受標準治療(gentamicin solution, streptokinase or saline gauze)，結果兩組差不多。

   就壓瘡(pressure ulcer)而言，Moberg比較16個患者使用優碘粉，18個患者使用標準治療(saline, enzyme-base or non-adhesive dressings)，結果優碘粉可有效降低膿瘍、去除壞死組織及降低疼痛，並且能促進傷口癒合（8週後傷口各縮小76％及57％）。

   就靜脈性潰瘍(venous leg ulcer)而言，Danieslen⁶研究優碘粉在19個靜脈性潰瘍並綠膿桿菌感染的效果（此研究無對照組），所有患者並接受彈繃加壓治療，結果結果在第一週有65％培養不到細菌，12週時則有75％培養不出細菌，平均在12週時傷口縮小32.9％。Hansson比較優碘粉(n=56)，人工皮(hydrocolloid dressing, n=48)及油性紗布(paraffin gauze，n=49)，所有患者均有接受彈繃加壓治療，結果平均傷口面積各縮小62%，42％及24％。而最常被引用的是Skog⁸的研究，其將93個靜脈性潰瘍患者隨機使用優碘粉或其他標準治療（enzyme preparations, dextranomer, fucidic acid, typure pwder, polymix of silver nitrate），兩組都接受彈繃加壓治療，經過6個禮拜的治療，優碘粉組的傷口面積縮小34％，而對照阻止有縮小5%，且證明優碘組可有效殺菌。

   然而若都不使用彈繃加壓治療，Stewart⁹比較優碘粉(n=42)及保濕凝膠(intrasite gel，n=46)，結果傷口癒合速兩者差不多，可見，在靜脈性潰瘍的治療，『彈繃加壓』是很重要的因素，而優碘粉能輔助加速彈繃加壓的作用。

   接下來有7篇類似的研究，但都沒有說明有無使用彈繃加壓治療。其中有兩篇^10,11認為優碘粉對傷口癒合無明顯改善，但另外7篇^12-18則認為可有效幫助傷口癒合，降低細菌量及減少感染。

   總之，在慢性傷口方面沒有任何研究說優碘粉有害傷口癒合，相反地，大部分研究都認為優碘粉對慢性傷口是有幫助的，只不過在靜脈性潰瘍部分，建議還是需要搭配彈性繃帶（或彈性襪）加壓治療。

附註：本系列單元主題的架構主要來自於Angel, DE; Morey, P; Storer, J, The Great Debate over Iodine in Wound Care Continues: A Review of the Literature, Wound Practice & Research: Journal of the Australian Wound Management Association, Vol. 16, No. 1, Feb 2008: 6-21, http://www.awma.com.au/journal/1601_01.pdf

1. Mertz PM, Davis SC, Brewer LD et al. Can antimicrobials be effective without impairing wound healing? The evaluation of a cadexomer-iodine ointment. Wounds: Compend Clin Res Pract 1994; 6(6):184-192

2. Mertz PM, Oliveira-Gandia MF & Davis SC The evaluation of a cadexomer-iodine wound dressing on methicillin resistant Staphylococcus aureus (MRSA) in acute wounds. Dermatol Surg 1999; 25(2):89-92.

3. Lamme EN, Gustanfsson TO & Middelkoop E. Cadexomer-iodine ointment shows stimulation of epidermal regeneration in experimental full thickness wounds. Arch Dermatol Res 1998; 290:18-24.

4. Apelqvist J & Tennvall RG. Cavity foot ulcers in diabetic patients: a comparative study of cadexomer-iodine ointment and standard treatment. Acta Derm Venereol 1996; 76:231-235.

5. Moberg S, Hoffman L, Grennert M-L et al. A randomized trial of cadexomer-iodine in decubitus ulcers. J Am Ger Soc 1983; 31(8):462-465.

6.Danieslen L, Cherry GW, Harding K et al. Cadexomer-iodine in ulcers colonised by Pseudomonas aeruginosa. J Wound Care 1997; 6(4):169-172.

7. Hansson C. The effects of cadexomer-iodine paste in the treatment of venous leg ulcers compared with hydrocolloid dressing and paraffin gauze dressing. Int J Dermatol 1998; 37:390-396.

8.Skog E, Arnesjö B, Troëng T et al. A randomized trial comparing cadexomer-iodine and standard treatment in the out-patient management of chronic venous ulcers. Br J Dermatol 1983; 109:77-83

9. Stewart AJ & Leaper DJ. treatment of chronic leg ulcers in the community: a comparative trial of Scherisorb and Iodosorb. Phlebol 1987; 2:115-121.

10. Moss C, Taylor AEM & Shuster S. Comparison of cadexomer-iodine and dextranomer for chronic venous ulcers. Clin Exp Dermatol 1987; 12:413-418.

11. Steele K, Irwin G & Dowds N. Cadexomer-iodine in the management of venous leg ulcers in general practice. Practitioner 1986; 230:63-68.

12. Floyer C & Wilkinson JD. Treatment of venous leg ulcers with cadexomer iodine with particular reference to iodine sensitivity. Acta Chir Scand 1988; 544(Suppl):60-61

13. Harcup JW & Saul PA. A study of the effect of cadexomer-iodine in the treatment of venous leg ulcers. Br J Clin Pract 1986; 40:360-4.

14. Hillström L. Iodosorb compared to standard treatment in chronic venous leg ulcers: a multicentre study. Acta Chir Scand 1988; 544:53-56.

15. HollowayAG, Johansen KJ, Barnes RW multicenter trial of cadexomer- iodine to treat venous stasis ulcer. West J Med 1989; 151:35-38

16. Laudanska H & Gustavson B. In-patients treatment of chronic varicose venous ulcers: a randomised trial of cadexomer-iodine versus standard dressing. J Int Med Res 1988; 16:428-435.

17.Ormiston CM, Seymor MTJ, Venn GE et al. Controlled trial of iodosorb in chronic venous ulcers. Br Med J 1985; 291:308-310

18. Tarvainen K. Cadexomer-iodine (iodosorb) compared with dextranomer (Debrisan) in the treatment of chronic leg ulcers. Acta Chir Scand 1988; 544(Supp):57-59.