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ORIGINAL ARTICLE
Effects of Topical Kiwifruit on Healing of Chronic Bedsore
Gholamreza Mohajeri &Masoumeh Safaee &
Mohamad Hossein Sanei
Received: 21 May 2012 /Accepted: 17 January 2013 / Published online: 31 January 2013
#Association of Surgeons of India 2013
Abstract Kiwifruit (Actindia deliciosa) is demonstrated to
have antibacterial and pro-angiogenic effect. Moreover, this
fruit contains proteolytic enzymes (actinidin) and ascorbic
acid. Considering these properties and based on the results
of recent animal studies, we carried out this study to evalu-
ate the effects of kiwifruit on bedsore in clinical settings.
Forty patients with stage 2–3 sacral bedsores, preferably
paraplegic, quadriplegic, and/or hemiplegic, were allocated
into two groups of experiment and control. Under local
anesthesia and sedation, ulcers of the experiment and con-
trol groups were dressed with pure extract of kiwifruit and
normal saline, respectively, on a daily basis for 21 days. The
ulcers were examined and photographed weekly. Pre- and
postintervention biopsies were taken from the ulcers to
perform microbiological and histological study. Mean re-
duction in surface area of bedsore in the experiment group
was significantly higher than the control group (486.47 vs.
117.38 mm, p<0.001). The amount of collagen and granu-
lation tissue were significantly higher in experiment groups
than the control group (pvalue 0.005 and 0.02, respective-
ly). Significantly higher levels of angiogenesis and vascu-
larizationwerefoundinthekiwifruit-treated patients
(p<0.02). In addition, obvious antibacterial effect was ob-
served in the kiwifruit group. Natural compounds in the
kiwifruit, including protein-dissolving enzymes (actinidin)
and antibacterial agents, improve different aspects of the
wound healing process. Based on its benefits and safety,
we conclude that using kiwifruit is a simple, applicable, and
effective way for treatment of bedsore.
Keywords Kiwifruit .Bedsore .Wound healing
Introduction
Pressure ulcer is a pretty debilitating and common problem
that affects disabled elderly patients. The incidence varies in
different institutions; for instance, recent studies on bedrid-
den patients estimated it to be 3.9–7.1 % in hospitalized
patients, 4.3–13.9 % in nursing home residents [1–4], and
up to 39 % in those with spinal cord injuries [5]. Patients of
intensive care units have the highest rate of this sort of ulcer
[4]. Pressure ulcers can result in enormous expenditures for
patients, as well as for medical centers, and also produce
pain, loss of economic productivity, significant infirmity,
and high mortality rate [6,7].
Prompt identification and intervention are fundamental for
successful treatment of chronic wounds. The focus of wound
bed preparation should be on providing a moist environment,
in addition to accelerated granulation tissue formation, angio-
genesis, and reduced bacterial load in the ulcer.
More than 80 % of the world’s population rely on tradi-
tional medicine including plant-based products for treatment
of various skin problems, especially wound infections and
ulcers [8]. The explanation of the concept of topical medic-
inal herbs is ascribed to Avicenna, the Persian physician and
scholar (980–1037 AD)[9].
It is currently accepted that kiwifruit contains potent
protein-dissolving enzymes (actinidin) and antibacterial
agents that could play an important role in wound healing
process. Based on several in vitro and animal studies, the
kiwifruit has proven effects in ulcer debridement, angiogen-
esis, and disinfection; moreover, it has dramatic effects on
healing process of burn wounds [9,10]. Given the above,
G. Mohajeri :M. Safaee (*):M. H. Sanei
Department of Thoracic Surgery, Al-Zahra Hospital,
Isfahan University of Medical Sciences,
Shohaday e Soffeh St, Isfahan, Iran
e-mail: safaee.masumeh@yahoo.com
Indian J Surg (December 2015) 77(Suppl 2):S442–S446
DOI 10.1007/s12262-013-0869-5
this study was purposed to investigate the effectiveness of
fresh kiwifruit dressing on treatment of pressure ulcers.
Materials and Methods
In a randomized clinical trial study, by maintaining the respec-
tive rules of research ethical and investigative committee of
the hospital, 40 patients with pressure ulcer at stages 2 or 3
(Table 1) were divided randomly in two groups (groups K and
C). Patients of neither group had obvious finding of underly-
ing osteomyelitis, radiologically and clinically. Routine low-
pressure air mattress was used for all bed-bound patients.
Albumin levels were taken to ensure proper nutrition in each
case. At first, mandatory wound bed preparation such as
removal of nonviable tissue and drainage of abscess was done
for patients who need emergent intervention. The wounds
were anesthetized by local lidocaine 1 %, accompanied by
sedation with ketamine hydrochloride under sterile condition,
and the first specimen from wound place for primary culture
and histological studies was taken, upon arrival, to determine
initial size of the wound. All samples were photographed.
Wound of all patients were kept in environment of the hospital
under study and had sterile dressing.
Twenty-four hours later, wounds were irrigated with sterile
normal saline in all groups. The ulcers were covered with
prepared kiwifruit, in group K. Pure extract of fresh kiwifruit
after being completely mashed by a mixer was poured in
gavage syringe of 50 cc at bedside, and it was placed on the
whole surface of the wound with 3-mm thickness. In group C,
the wounds were dressed with Vaseline sterile gauze without
using any additional agents. In both groups, ulcers were
covered with sterile gauze, which were affixed to skin with
Omnifix (Braun, Melsungen, Germany), a latex-free, nonwo-
ven retention tape. Maintaining sterility, dressings were
changed twice daily in both groups following irrigation with
sterile normal saline. Macroscopically, wound evaluation was
performed every day with digital camera for up to 3 weeks. In
day 21, wound biopsy and culture were obtained under sterile
condition following administration of local anesthesia to the
wounds to be sent after photography for culturing and histo-
pathology was performed. The surface of the ulcers was
measured on the grid-scored digital photos by Sigma Scan
PRO® version 5.0 computer software.
The specimens were stained with hematoxylin and eosin
(H&E), Masson (collagen marker), and CD31 immunohis-
tochemistry (IHC) marker, and one pathologist who is
blinded to the experiment groups accomplished pathological
investigation under Olympus optical microscope. In terms
of pathological survey, parameters such as epithelialization,
inflammation, granulation, collagen synthesis, and vascular-
ization (angiogenesis) were investigated with the following
Table 1 Macroscopic and
microscopic changes
a
Data presented as mean ± SD
b
Data presented as mean rank
c
Data presented as percentage
Case Control pvalue
Day 0 Day 21 Day 0 Day 21
Wound Surface
(mm
2
)
a
866.24±181.18 379.77 ±93.50 737.58 ± 139.94 620.19± 121.36 <0.0001
Epithelializtion
b
0.72 0.72 0 0 1
Vascularization
b
0.22 1.8 0 0.75 0.001
Collagen formation
b
0.42 2.1 0.33 0.60 <0.0001
Inflammation
b
2.27 2.11 1.75 0.92 0.001
Granulation
b
0.11 1.83 0 0.50 0.001
Percentage positive
wound culture
c
72 % 44 % 83 % 67 % 0.17
Fig. 1 Progress of wound
healing in a patient treated with
kiwifruit
Indian J Surg (December 2015) 77(Suppl 2):S442–S446 S443
scoring system: 0, none; 1, minimal; 2, mild; 3, moderate;
and 4, maximum.
Streptococcus,Staphylococcus aureus,Staphylococcus
coagulase negative, and Pseudomonas aeruginosa were
the organisms investigated in the cultures that were taken
from the ulcers. The data of all groups were evaluated by
SPSS software V.16. All data were analyzed by the Krus-
kal–Wallis test, Mann–Whitney test, and Chi-square tests. A
p<0.05 was considered as statistically significant.
Results
Forty patients with pressure ulcers were enrolled in a random-
ized clinical study. Macroscopic and microscopic changes are
summarized in Table 1. Significant wound healing activity
was observed in patients treated with the kiwifruit compared
with those who received the reference standard treatments.
Macroscopic Findings
1. Woun d a re a : Applying kiwifruit extract significantly
accelerated scar detachment in the experiment group.
The scars detached spontaneously from the wound beds
in B2 group patients later than day 21, whereas this
happened before day 21 in the experiment group.
Measurement of wound area showed significant reduction
in wound size of group B1 as compared with that of group
B2 in the first and 21st days of the experiment (p<0.006)
(Fig. 1).
2. Down stage of the wound: Evaluation of wound stage
showed significant reduction in group B1 as compared
with B2 in the first and 21st days of the experiment
(p<0.049).
3. Macroscopic hyperemia and edema: In group B1, mac-
roscopic hyperemia and edema levels were higher on
days 3 and 5 in comparison to the corresponding control
groups. However, between days 11 and 20, the level
was significantly lower than that of the control group
(p<0.05).
Microscopic Findings
The results of histological scoring of the patients at the end
of the third week and its comparison with the values at the
beginning of the experiment are shown in Table 1, and the
histopathological samples are presented in Figs. 2and 3.
1. Epithelialization: Because most patients with bedsore
had stages 2 and 3 lesions, even after 21 days, only
16.3 % of patients with stage 2 bedsore recovered to
stage 1, and epithelialization was observed (p<0.3).
Fig. 2 Histopathology sample of a patient treated with kiwifruit. a
Section showing low density of inflammatory cell in the dermis and
increased collagen bundles (H&E). bModerate-density vascular
formation in dermis (IHC staining with CD31). cModerate collagen
bundle deposition in the dermis (Masson trichrome staining)
Fig. 3 Histopathology sample
of a patient of the control group.
aSection showing loose dermis
collagen bundle associated with
inflammatory cells (Masson
trichrome staining). bLow
density of vascular structure
(IHC staining with CD31)
S444 Indian J Surg (December 2015) 77(Suppl 2):S442–S446
2. Granulation score: The granulation score was higher in
groups B1 compared with group B2, and the difference
was statistically significant (p< 0.02).
3. Inflammation score: In group B1, the number of inflam-
matory cells was lower than that in group B2, but the
difference was not statistically significant (p<1).
4. Collagen formation: The amount of collagen in group
B1 was found to be significantly more than that in group
B2 (p<0.005).
5. Angiogenesis: Vascularization score in group B1 was
found to be significantly higher than that in group
B2 (p<0.02).
Microbiological Findings
Significant antibacterial activity was observed in patient
treated with the kiwifruit (B1) compared with control group
(B2). The difference was statistically significant (p<0.001).
Microscopic evaluation of wounds for blood vessel count
and wound-base collagen deposition revealed significant dif-
ference between the two groups. The number of patient with
ischemic ulcers (such as those with Burger’s disease) was not
enough for statistical evaluation. Nevertheless, it was observed
that, compared with the experiment group, scar tissue in these
patients required a longer time for autolysis detachment.
Discussion
The history of using herbal dissolving enzymes for chemical
wound debridement dates back to World War II [11]. Sci-
entists try to investigate the effectiveness of herbal products,
which have been used in Asia and Africa for centuries, in
the treatment of different types of wound [12]. Pressure
wound is one of these sorts of wound. Bedsore is a common,
costly, and debilitating type of wound that usually afflicts
people with advanced age, physical or cognitive disability,
or multiple health problems [13]. Based on the suggested
safety and efficacy for application of kiwifruit wound dress-
inginpreviousanimalstudy[14], we investigated this
method on human cases with bedsore and found it a useful
method. Previous studies have reported various clinical
effects for kiwifruit, such as debridement of dead tissue
and antibacterial effect [10,15].
This was confirmed in our study: kiwifruit extract accel-
erated scar detachment significantly. This effect may be
attributed to some ingredients of kiwifruit including ascor-
bic acid that works as an scavenger, and a strong protein-
dissolving enzyme called actinidin [10,15]. Actinidin is one
kind of cysteine proteases (CPs) found in kiwifruit, which is
responsible for the well known proteolytic and meat-
tenderizing effect of kiwi [14,16]. These substances make
kiwifruit a good option for herbal debridement.
Supporting previous studies, in this study, kiwifruit
showed significant antibacterial properties [10,14]. It may
be related to the composing ingredients of kiwifruit. High
concentration of CPs in many fruits such as kiwi is believed
to have antibacterial, antifungal, and even anti-insect role
[10,16]. In vitro studies reported the antibacterial activity of
18 fractions of kiwifruit extracts against gram-positive and
gram-negative bacteria, and fungi [10,17]. Because wound
infection is a common problem in patients with bedsore,
especially those with fecal incontinence, kiwifruit dressing
can be helpful regarding infection control.
Better vascularization, found in pressure wounds dressed by
kiwifruit, is similar to animal findings [14]. Although angio-
genic compounds are found in several plants such as Aloe vera,
they have not been reported in kiwifruit [18]. Hence, it is
thought that kiwifruit may be rich in some sorts of angiogen-
esis modulators that are essential for the healing process [14].
In addition to macroscopic improvement, histologic evalu-
ation of wounds showed that kiwifruit dressing significantly
increases granulation score and collagen formation. Given
these positive effects, it is not surprising to find significantly
reduced wound surface, as well as improved wound sage, in
kiwifruit-treated bedsores.
A major concern in the treatment with herbal medications
is unknown side effects including allergic reactions. Fortu-
nately, similar to the previous experience on rats [14], no
significant anaphylactic reaction was seen in patients treated
with kiwifruit.
In light of the useful characteristics of kiwifruit including
debridement of devitalized tissue—without detrimental
effects on the healing process—angiogenesis, and antibac-
terial effect, we can conclude that this method is a simple,
applicable, and effective way for the treatment of bedsore.
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