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Curr. Pers. MAPs 18
Research article
Curr. Pers. MAPs, (2020); 3(1): 18-24
Current Perspectives on Medicinal
and Aromatic Plants
An International Journal
ISSN: 2619-9645 | e-ISSN: 2667-5722
The Efficiency of BIOAPIFIT® Wound Care Ointment in the Treatment of
Venous Ulcers
Višnja OREŠČANIN1* , Zrinka MIHALIĆ2, Josipa RODIĆ3,
Štefica FINDRI GUŠTEK2
*1 OREŠČANIN Ltd., Laboratory For Herbal Drugs Development, A. Jakšića 30, Zagreb-Croatia
2 Findri-Guštek Healthcare Institution, Ninska 5, Sesvete-Croatia
3 Family Medicine Clinic, Vilima Korajca 19, Zagreb-Croatia
*Corresponding author : vorescan@gmail.com
Received : 08/08/2019
Accepted : 31/03/2020
Abstract
Objective / Purpose: The objective of this study was efficacy assessment of Bioapifit® wound care
ointment consisted of honey, Cera flava, glycerin, the oil macerates of astringent and soothing herbs
combined with three essential oils for the treatment of venous ulcers. Materials and methods: 50 patients
with total 112 venous ulcers with the total surface area of 572.5 cm2 were treated 60 days (twice a day)
with Bioapifit® wound care ointment applied on conventionally cleaned wound and covered with bandage
during the whole course of the study. The healing process was assessed by Venous Clinical Severity Score
(VCSS) tool twice a month. Results: At baseline the mean value and standard deviation of the VCSS score
was 25.03 ± 4.37 and 25.53 ± 3.36 for females and males, respectively. The surface area ranged from 1.6 to
28.1 cm2 for females and from 1.60 to 29.20 cm2 for males. The mean value and standard deviation of the
total VCSS score following the treatment decreased to 6.26 ± 4.0 and 6.47 ± 3.9 for females and males,
respectively. Total number of active ulcers decreased from 112 to 17 and the total surface area of all ulcers
from 572.5 cm2 to 7.6 cm2. No side-effects were observed during the course of the study. Conclusion /
Discussion: Two months application of Bioapifit® wound care ointment resulted in complete closure of
84.8% of the ulcers and reduction in their surface area for 98.7% with the mean healing time of 37.2 days.
Key Words: Venous Ulcers, VCSS Tool, Honeybee’s Products, Herbal Macerate
© CUPMAP. All rights reserved.
1. Introduction
Venous ulcer, the latest stage of the chronic
venous disease, represents the area of
discontinuity of the skin, most often located
in the distal parts of the lower limbs
(Marinović Kulišić, 2016). It differs in size
and shape, sometimes including the entire
circumference of the extremities. Possible
causes of venous ulcers include inflammatory
processes resulting in leukocyte migration,
plasma cell and granulocyte activation,
increased activity of metalloproteinase,
endothelial damage, platelet aggregation, and
intracellular edema. Impaired muscle activity
represents another important risk factor
involved in the patophysiology of venous
ulcers (Collins and Seraj, 2010; Marinović
Kulišić, 2016).
The important risk factors are older age
(>50), body mass index (BMI) gender,
Oreščanin et al.
Research Article
Curr. Pers. MAPs 19
multiple childbirths, previous leg injuries,
deep venous thrombosis, inadequate
physical activity, smoking, static foot
disorders, family history, phlebitis (Collins
and Seraj, 2010; Marinović Kulišić, 2016).
Various management options were
developed so far for the treatment of chronic
venous disease (Collins and Seraj, 2010;
Marinović Kulišić, 2016) and include:
conservative treatment (compression
therapy, leg elevation, dressings), mechanical
treatment (vacuum- assisted closure),
medications (natural venoactive drugs,
pentoxifylline, glycosaminoglycans,
prostaglandine E1, aspirin, iloprost, oral zinc,
antibiotics/antiseptics), hyperbaric oxygen
therapy, surgical intervention (debridement,
human skin grafting, artificial skin, surgery
for venous insufficiency). The latest was
applied to the large ulcers with prolonged
duration not responded to the conservative
treatment. Since 1994 clinical assessment of
the severity of the chronic venous disease is
based on the CEAP (clinical, etiology,
anatomy, and pathophysiology) classification
system ranging from C0 with no disease
present to C6 with the presence of active
ulcers assessment of chronic venous
disorders (Marinović Kulišić, 2016).
Based on the elements of CEAP classification
the American Venous Forum, in 2000
developed the Venous Severity Score (VSS)
grading tool as the complementary system to
the CEAP classification. VSS classification is
necessary for the longitudinal monitoring of
the clinical condition of the patient during
and after the intervention. This classification
is combined with the degree of the severity of
the venous disease: Venous Disability Score
(VDS); Venous Segmental Disease Score
(VSDS); Venous Clinical Severity Score
(VCSS) (Marinović Kulišić, 2016).
The VCSS consist of ten descriptors (pain or
other discomfort, varicose veins, venous
edema, skin pigmentation, inflammation,
induration, active ulcer number, active ulcer
duration, active ulcer size, use of
compression therapy) graded from 0 (no
symptoms/disease) to 3 (highest degree of
the symptoms/disease) (Vasquez et al.,
2010).
The purpose of this work was testing of
clinical performance of Bioapifit® wound
care ointment composed of honey, glycerin,
herbal macerates of the astringent plants,
beeswax and three essential oils for the
treatment of 112 active venous ulcers.
2. Patient and Method
2.1. Study Design
The study was conducted at the following
locations: FINDRI GUŠTEK HEALTHCARE
INSTITUTION, Ninska 5a, Sesvete, Croatia
and FAMILY MEDICINE CLINIC, Vilima
Korajca 19 Zagreb, Croatia. The investigator
recruited the patients based on their medical
history, following the predefined inclusion
and exclusion criteria. The study protocol
was approved by the Ethics Committee of
Findri Gustek Health Care Center with
EudraCT number 2019- 001379-35.
50 patients (35 females and 15 males)
ranging from 57 to 77 years with total of 112
active ulcers and the total surface area of all
ulcers of 572.5 cm2 were included. All the
participants signed informed consent and
completed the questioner.
The patients were treated 60 days with the
product. The ointment was applied on the
previously cleaned wound twice a day by
nurse and covered with bandage during the
whole course of the study. At each changing
of the bandages each wound was cleaned
from the slough. Clinical evaluation of the
patients before and following the therapy
was done by Venous Clinical Severity Score
(VCSS) tool consisting of ten descriptors each
graded from 0 (no symptoms/disease) to 3
(worse possible symptoms/disease).
Oreščanin et al.
Research Article
Curr. Pers. MAPs 20
2.2. Description of investigational product
Bioapifit® wound care ointment is
homogeneous, greasy, viscous mass of
characteristic herbal odor and olive green
color with pH of 4.43±0.13. It consists of the
following ingredients: honey (certified
organic), beeswax (Cera flava), glycerol, the
macerates of the plant species: Plantago
major L., Achilea millefolium L., Quercus robur
L., Salvia officinalis L., Olea europaea L.,
Polygonum aviculare L., Symphytum officinale
L., Calendula officinalis L., Matricaria
chamomilla L., essential oils: Australian tea
tree (Melaleuca alternifolia (Maiden &
Betche, Cheel), thyme (Thymus vulgaris L. ct.
thymol), oregano (Origanum vulgare L.).
2.3. Statistical analysis
For statistical evaluation Statistica 11.0
software package was employed. The
description of the treated population was
done by basic statistics and frequency tables.
Statistical significance was set to p<0.05 in all
the tests performed. The differences in the
mean values of each parameter prior and
after the therapy as well as different
treatment periods were assessed by
Newman-Keuls test. The influence of the
predictor variables on the dependent
variable was tested by Multiple regression
method and General regression model
(Oreščanin, 2016).
3. Results
3.1. Description of the population
The study included 35 females and 15 males.
The number of childbirth ranged from 1 to 4
with majority of them (16 of 35) having two
childbirth. 75% of the participants had
previous leg injuries and 24% of them suffer
from deep venous thrombosis. 82% of the
participants had prevailing sedentary
lifestyle or occupation with inadequate
physical activity. Among the participants
68% of them are smokers. Family history of
venous disease was present in 80% of the
participants and phlebitis in 12% of them.
The basic statistical parameters for age and
body mass index expressed separately for
males and females as well as total population
is presented in Table 1. The female
population ranged from 57 to 77 years
(67.97±4.97) and males from 61 to 77 years
(67.60±4.81). Both female and male
participants were overweighed with BMI
ranging from 26.30 to 44.80 mg/m2
(33.80±4.61 mg/m2) and males from 28.70 to
42.90 mg/m2 (36.10±4.93 mg/m2). T-test
showed no significant difference between
males and females regarding age or BMI.
Table 1. The basic statistical parameters for age and body mass index separately for males and
females as well as total population.
Gender
Age
Body mass index
X±SD
Min.
Max.
X±SD
Min.
Max.
Female
67.97±4.97
57.00
77.00
33.80±4.61
26.30
44.80
Male
67.60±4.81
61.00
77.00
36.10±4.93
28.70
42.90
All
67.86±4.88
57.00
77.00
34.49±4.77
26.30
44.80
X-mean value; SD-standard deviation
The results of multiple regression analysis
showed very good, statistically significant
correlation between VCSS score and selected
predictor variables (R=76.7; p<0.0000). The
variables with the highest, statistically
significant contributions to the VCSS score
were BMI (p<0.0027), family history
(p<0.043) and age (p<0.047).
The results were completely in agreement
with those obtained by General regression
model expressed as Pareto chart of t-values
(Figure 1) which identified BMI, family
Oreščanin et al.
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Curr. Pers. MAPs 21
history and age as statistically significant
contributors to the total VCSS score.
Figure 1. Pareto chart of t-values testing for the
influence of predictor variable onto venous
clinical severity score before the treatment
3.2. Treatment efficiency
The results of the assessment of venous
ulcers according to the venous clinical
severity score (VCSS) following the treatment
with Bioapifit® wound care ointment were
presented in Table 2 and Figure 2. Prior to the
therapy the mean value and standard
deviation of the total VCSS score was 25.03 ±
4.37 and 25.53 ± 3.36 for females and males,
respectively (Table 2, Figure 2).
The number of active ulcers ranged from 1 to
4 and their surface area from 1.6 to 28.1 cm2
(10.94±9.26 cm2) for females and from 1.60
to 29.20 cm2 (12.65 ± 10.85 cm2) for males.
There was no significant difference between
males and females in all descriptors and the
total VCSS score or surface area of the ulcers
at baseline.
Table 2. Mean values and standard deviations for each descriptor and total value of venous
clinical severity score for male (M) and female (F) population at baseline (B) and following 60
days of the treatment (F) with Bioapifit® wound care ointment
Descriptor
F-B
F-F
M-B
M-F
Pain
3.00±0.00
0.54±0.51*
3.00±0.00
0.73±0.46*
Varicose veins
2.54±0.51
1.17±0.45*
2.73±0.46
1.27±0.59*
Venous edema
2.57±0.50
0.46±0.51*
2.87±0.35
0.60±0.51*
Skin pigmentation
2.77±0.43
1.31±0.47*
3.00±0.00
1.33±0.49*
Inflammation
2.57±0.50
0.26±0.44*
2.73±0.46
0.33±0.49*
Induration
2.63±0.49
0.63±0.60*
2.67±0.49
0.87±0.35*
Active ulcer number
2.09±0.78
0.37±0.49*
2.00±0.76
0.33±0.49*
Active ulcer duration
2.20±0.76
0.74±1.15*
2.07±0.70
0.33±0.49*
Active ulcer size
2.29±0.67
0.37±0.49*
2.27±0.59
0.33±0.49*
Use of compression therapy
2.37±0.69
0.40±0.55*
2.20±0.56
0.33±0.49*
VCSS-total score
25.03±4.37
6.26±4.59
25.53±3.36
6.47±3.72*
Following the 60 days of tropical treatment
with Bioapifit® wound care ointment all
descriptors of the VCSS score decreased
significantly. The mean value and standard
deviation of the total VCSS score was 6.26 ±
4.0 and 6.47 ± 3.9 for females and males,
respectively (Table 2, Figure 2). The total
number of active ulcers decreased from 112
to 17 and the total surface area of all ulcers
from 572.5 cm2 to 7.6 cm2. The mean value
and standard deviation for active ulcers
surface area following the therapy was 0.13 ±
0.21 cm2 for females and 0.19 ± 0.29 cm2 for
males.
4. Discussion and Conclusion
Two months of the topical treatment with
Bioapifit® wound care ointment resulted in
Oreščanin et al.
Research Article
Curr. Pers. MAPs 22
reduction of total VCSS score for app. 75%,
complete closure of 84.8% of the venous
ulcers and reduction in the ulcer’s total
surface area for 98.7% with the mean healing
time of 37.2 days.
Figure 2. Mean values and standard deviations
for total value of venous clinical severity score for
male (M) and female (F) population prior and
following 60 days of the treatment with
Bioapifit® wound care ointment.
Since venous ulcers are wounds that are very
difficult to heal, obtained results could be
attributed to the selection of the ingredients
with pH adjusting, osmotic, moisturizing,
astringent and coating effect. Among them,
honey was identified as most important
ingredient of the ointment which thanks to its
low pH value (4.16) creating an acidic wound
micro-environment necessary for healing
process. Debridement of slough and necrotic
tissue through autolytic debridement was
also present. Moreover, honey absorbed
wound exudates due to high osmotic
effect/high sugar content and created the
environment with low water activity that all
together supported wound closure and in the
same time prevented pathogens growth.
Previous studies connected antimicrobial
activity of honey against the pathogens
causing invasive wound infections including
methicillin- resistant Staphylococcus aureus
(MRSA) either to the production of hydrogen-
peroxide by glucose oxidize enzyme or non-
peroxide antimicrobial activity which could
be connected to low pH value, osmotic effect
of sugar, the presence of polyphenols and
flavonoides, carbohydrate and its break-
down Maillard products, aromatic acids, 10-
HAD defensin-1 protein, 1,2-dicarbonyl
compound methylglyoxal and bacillomycin F
antibiotic like polypeptide (Lusby et al., 2002;
Simon et al., 2009; Al-Waili et al., 2011).
It was confirmed that topical application of
honey (directly or in the form of various
types of wound dressing had very beneficial
effects on wound healing. The treatment of
pressure ulcers with honey alginate
(Vandamme et al., 2003) resulted with rapid
and complete wounds healing, reduced
inflammation and deodorizing effect.
Subrahmanyam et al., 2001 reported
significantly faster wound healing in the
patients treated with honey dressing
compared to those treated with silver
sulphadiazine. Moreover, completely sterile
wounds were obtained in 90% of honey
treated patients. It was reported that pH of
the wound has critical influence on its healing
potential since the wounds with pH higher
than 8 showed no reduction in size (Gethin et
al., 2008). Alam et al. (2014) summarized
beneficial effects of honey for the treatment
of diabetic wounds that were mostly
connected to its antimicrobial activity, low
pH value, hydrogen peroxide activity that all
together stimulated wound closure.
Debridement of slough and necrotic tissue
through autolytic debridement and
minimizing wound odor was another
important mechanism (Alam et al., 2014).
A significant improvement of venous ulcer
wound healing was observed following the
treatment with the honey-based dressing
(Alcaraz and Kelly, 2002). Mohamed et al.
(2014) reported complete wound closure
amputation wound after four weeks
continuous treatment with natural honey.
The treatment of foot ulcers with natural
honey once a day resulted in complete wound
closure within three weeks with no
contractures or scars (Mohamed et al., 2015).
The treatment of the patients with
neuropathic diabetic foot ulcers with manuka
Oreščanin et al.
Research Article
Curr. Pers. MAPs 23
honey impregnated dressings (Kamaratos et
al., 2014) resulted in complete healing after
31±4 days while in app. 78% of the patients
wound became sterile following one week of
the treatment which was in agreement with
the results obtained in the current study.
Researchers confirmed beneficial effect of
the astringent plants rich in soluble tannins
in the treatment of open wounds (Abascal
and Yarnell, 2005; Odukoya et al., 2007)
which could be explained by surface
coagulation of the proteins resulting in the
shrinking of the wound as well as by forming
the protective coating over damaged tissue.
For that purpose oil macerates of the plants
with strong astringent properties Plantago
major L., Achilea millefolium L., Quercus robur
L., Salvia officinalis L., Olea europaea L.,
Polygonum aviculare L., Symphytum officinale
L., were included in the product formulation.
Moreover, the macerates of marigold flowers
(Calendula officinalis L.) and chamomile
flowers (Matricaria chamomilla L.) were used
due to its soothing and calming effect to the
wounded skin (Oreščanin, 2016).
Additionally, herbal macerate was used in the
formulation due to its low pH and coating
effect. Moreover, the macerate created the
environment with no water activity which
was unsupportive for pathogens growth and
replication.
Glycerol was used in the formulation in order
to provide enough moisture content of the
wound necessary for the healing process.
Beeswax was employed not only because of
its emulsifying and thickening effect but also
for wound isolation and protection from the
microbial infection due to its excellent
coating effect (Oreščanin, 2016). Essential
oils served as natural preservatives and
wound malodor correctors.
Conflict of Interest
The authors declared that they have no
conflict of interest.
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