Experiences with Gentian Violet as a Wound Dressing Agent
Introduction: More than 2,000 products are available for wound dressings, with prices ranging from a few cents to several thousand dollars per application. If one dressing agent is not successful, is a more costly one likely to be effective?
This is not necessarily so. We have found that gentian violet (GV) can be an effective, inexpensive option for certain wounds when other agents have not been successful.
Methods: After mitigating deformities, deep infections (bursa, scar, and bone) and ischemia-hypoxia, a small percentage of lower-extremity wounds failed to improve with interventions that ranged from negative pressure wound therapy to active ingredient-impregnated ointments. Serendipitously, we began using GV as a wound dressing agent for certain well-defined wound types that were not improving with other agents.
Results: GV was utilized for the following three nonhealing wound types: 1) small, superficial wounds usually with underlying bony deformities; 2) superficial wounds when moisture control and skin maceration are problems; and 3) ischemic wounds associated with peripheral artery disease and/or vasculitis. Zinc oxide, another inexpensive agent, is often used in conjunction with GV and is applied around the wound margins for its drying effects. Nearly all of the wounds refractory to other dressing agents have either healed or improved enough to become easily managed and allow restoration of functional lower-extremity activities when GV was used as the wound dressing agent. In a couple of situations, other interventions became necessary when new problems such as pathological fracture or unrelated wounds at other sites developed.
Conclusions: We used GV in three subsets of superficial wounds, which had been refractory to other interventions.
The clinical improvements we observed using GV now justify using this agent on selected wounds at earlier stages in patients’ wound courses. The ease of application and the economies of GV have made this agent an increasingly used intervention in our armamentarium of wound care products.
In managing difficult-to-heal wounds, the following five strategies must be addressed:1
- Management of the wound base
- Protection and stabilization of the wound environment
- Optimal medical management, especially with respect to diabetes management, cardiac activity, and renal function
- Selection of the wound dressing agent
- Wound perfusion-oxygenation
Of the five strategies, selection of the wound dressing agent is the most challenging. This is because there are more than 2,000 choices. Often different vendors have products that for all practical purposes have the same mechanisms of action, challenging wounds typically pass through different stages of healing — each stage with a preferred dressing agent.
Figure 1. The continuum of healing in the challenging wound and the changes in wound dressing agents as the wound improves
Legend: As the wound transitions through the different stages of healing, wound dressing agent requirements change in the direction of becoming less complicated to use and less costly. The use of gentian violet fits in this less complicated and less costly category.
Finally, there are a variety of reasons why wound healing is not progressing. There is an enormous range of charges for wound dressing agents. They can vary from a few cents to many thousands of dollars for each application (Table 1). Caregivers’ time for dressing applications must also be factored into the cost of wound management. Consequently, costly agents that require infrequent dressing changes can be more cost-effective than less-expensive agents. When dressings are not complex, willing family members can do or supplement the dressing changes, which is also a cost- effective technique.
With respect to healing of the difficult wound, we have observed four clearly defined stages.2 These include an initial deterioration stage, which is typically manifested by slough, dehiscence, and/or infection of the wound. The second stage is a resting stage in which wound deterioration is no longer occurring, but improvement is not yet taking place. We label this the latent stage of the healing. Angiogenesis is the predominant finding in the third stage in the healing of the difficult wound. Finally, wound healing culminates with closure and epithelialization.
Several corollaries must be appreciated with the stages of wound healing. First, each stage may require a different dressing agent (Figure 1). Second, there is great variation in the times required for each stage to evolve, which may vary from several days to several months. Third, in reality the wound heals in a continuum of responses such that elements of two or more stages may be observed in the healing wound at any one time. We label the wound healing stage based on the predominant finding of the wound base.
Reasons difficult-to-heal wounds fail to improve include ischemia-hypoxia; unresolved deep infection of bone, bursa, or reactive cicatrix formation; underlying deformity; uncontrolled bioburden; malnutrition; matrix metalloproteinases; transudates into the wound base from inadequate edema control with wound margin maceration and inflammation; requirement for steroids or other anti- inflammatory agents; and inadequate compliance with wound care (Table 2).
Hence, the wound care provider must be aware of all these reasons and base the wound dressing agent selection on what is most important and effective for the particular stage of the healing wound.
If one dressing agent is not successful, is a more costly one likely to be effective (Table 1)? This is not necessarily so.
After thousands of patients’ experiences, we observed that gentian violet (GV) in special circumstances is an effective alternative when other wound dressing agents have not been effective, exceed caregivers’ capabilities, and/or become prohibitively expensive. However, this agent should be used only for the appropriately selected wound as described in our methods selection.
This paper describes some of our observations with using GV for three types of difficult-to-heal wounds, the situations in which it has been ineffective, and conditions for which it is a logical choice for the wound dressing agent.
|Mechanisms||Estimated Procurement Costs**||Comments|
|Gentian Violet||Chemical induced anti-bacterial, fungal & helminthic properties; Possibly hinders mitochondrial activity & microbes cell growith;||$3 for 30 cc bottle||Does not appear to interfere with granulation tissue & epithelialization|
|Antibacterial ointments||Cyclic peptides which disrupt both gram+ & gram- bacteria by interfering with cell wall & peptidoglycan synthesis||$5-$6 for 1 oz. tube||Multiple choices; some such as mupiricin are 5 to 10 times more expensive|
Coverings & films
Provides a moist enviornment; some with antibacterial and/or deodorizing effects
Mesh types allow exudate egress
|$10-$30 for small size wound||Pieces trimmed for additional dressing changes from same package|
|Broad antimicrobial activity due to silver; absorptive properties from fibers||~$70 for box of 10 4 x 4 sq inch pads||As above; typically trimmed to conform to wound|
|Iodine has antimicrobial activity; starch component absorbs fluids; keeps wound environment moist||~$40 to $65 for 40 gm tube||Dressing changes every 1 to 3 days depending on wound exudation|
|Maintains moist enviornment; osmotic effects kill bacteria & reduce edema, promotes healing; induces wound contraction||~$20 for 1.5 oz. tube||Healing effects include angiogenesis, granulation tissue formation, contraction & collagen synthesis|
|Collagenase dissolves protein material in wound base & secondarily stimulates granulation tissue||~$120 for 4 oz. tube||Should be applied daily to the thickness of a nickel on the wound base|
|Bioengineered platelet derived growth factor to stimulate many aspects of wound healing||~$600 for 1 oz. tube||Premarket approval based on reduction of wound surface area studies|
|Negative pressure wound therapy||Micro and macro negative pressure stresses to promote wound healing; removal of secretions||~$100 per day to rent equipment||Absorbent sponge changes twice a week kabout $60 per set-up|
|Bioengineered wound coverings||Coverings for healthy based wounds to promote angiogenesis and keratinization. Multiple OR applications are often required||
$80 (Oasis®) to $2000
(Dermagraft®) per sheet
|In clinic applications possible; others: Nlox®, Epifix®, Graphix®, Appligraft®, etc.|
Operating room applied
(Alloderm®, Integra®, Graftjacket®)
|Xenograft derived, some bilayered such with silicon & biodegradable collagen||As above, but $8000-$10000 for operating room||
In clinic applications possible; others: Nlox®, Epifix®, Graphix®, Appligraft®, etc. Multiple OR applica often required
Notes: * Costs does not include caregiver expenses.
**Many of the agents can be used for multiple applications
The information using GV in this paper is observational. It reflects our use in wounds in which healing seemed to be stalled with other agents (Figures 2 and 3). GV is an aniline, cationic dye that is recognized by the World Health Organization as a wound dressing agent.3 It has drying as well as antimicrobial properties, which includes antifungal, antibacterial, and anthelmintic effects.4
Figure 2. Heel wound size reduction and elimination of maceration
Legend: Improvement (reduction in size & elimination of maceration) in a chronic (2 years), stable heel wound after 6 weeks of daily Gentian Violet applications. The 4 cm tract closed. This occurred after a variety of wound dressing agents including bioengineered skin had been used.
The wound base laid directly on the periostrium over the calcaneus wth total absence of the soft tissue heel pad. The patient refused surgery to debulk the plantar surface of the calcaneus.
Note the use of zine oxide (white rim in right photo) used for moisture control of this highly transudative wound.
A common use of GV is for managing thrush infections of the mucus membranes, but it is also used for superficial wounds, especially in countries south of the United States border. Before initiating a randomized control trial with our institutional review board, we show in this paper situations in which we have used GV for superficial wounds that are not improving with other agents.
|Ischemia/hypoxia*||Lack of oxygen for metabolism and infection managing needs||Revascularization, medical management, hyperbaric oxygen|
|Unresolved deep infection*||Osteomyelitis, infected bursa and/or infected cicatrix||Debridement, antibiotics|
|Underlying Deformity*||Mechanical problems, mal perforans ulcers||Surgical interventions|
|Uncontrolled bioburden||Ischemic, non-viable tissue in wound base||Debridement, wound dressing agents, and antibiotics|
|Malnutrition||Inadequate substrates for healing, inability to generate a response to infection||Supplements, feeding tubes, hyperalimentation|
|Matrix Metalloproteins (MMPs)||Protein derivatives that interfere/inactivate wound healing responses||Use of MMP inhibitors|
|Wound transudation||Inadequate moisture control often complicated by hypo-albumenia (malnutrition); skin maceration and infection from the moisture||Edema control, moisture barriers and absorbent agents|
|Steriods/Anti-inflammatory agents||Interfere with wound healing and infection control responses; for mitigation of collagen vascular diseases||Taper doses, vitamin C|
|Inadequate compliance||Lack of comprehension, motivation, adequate care and/or insight||Education, assistance in care, frequent rechecks|
Note: * Over 90% of our patients hospitalized with diabetic foot ulcers had one or more elements of ischemia-hypoxia, deep infections and/or deformity in their hospitalization requiring wounds. We label these three wound healing confounders the "Troublesome Triad."
After mitigating deformities, deep infections (bursa, scar, and bone), and ischemia-hypoxia, a small percentage of lower-extremity wounds fail to improve with customary interventions such as negative pressure wound therapy, bioengineered dressings, silver impregnated ointments, etc. (Table 1). For the superficial, chronic stable wound, we began using GV as a wound dressing agent. As our observations increased, we began using GV in a variety of superficial wounds in which other agents had been used, but progress was not occurring. This has evolved to the point of becoming comfortable with recommending GV for specific wounds and defining its indications and contraindications. Thus far, we have used GV as the wound dressing agent for more than 25 patients with difficult-to-heal wounds.
Figure 3. "Stalled" wounds in which gentian violet simplified wound care, reduced size of wound, or achieved healing
Legend: GV applications with reasons why it was used: 1) Moisture control, 2) Soft tissue atrophy/absence plus moisture control, 3) Chronic-stable, 4) Ease of wound care, 5) Chronic-stable and 6) Soft tissue atrophy/absence.
Wounds 4, 5 and 6 have healed; GV continued in others because of slowly decreasing wound size and user "friendliness" after using a variety of other wound dressing agents.
Our observations have demonstrated three situations in which GV has been effective (Figures 2 and 3). First, we have used it in a subset of wounds that we label as “chronic- stable,” in which the wounds were neither improving nor worsening but were not so severe that they did not appreciably interfere with the patients’ activities and lifestyles.5 These wounds were small — that is, less than 3 cm in diameter — superficial and had vascular bases. Invariably, a variety of other products from films to ointments to bioengineered dressing had been used before switching to GV as the wound dressing agent. Many of the patients in this group had underlying bony prominences, but surgical removal of them was problematic because of concerns about healing or making the plantar surface unstable for weight bearing (i.e., “the cure could be worse than the disease”).
The patients in this subset liked using GV for its simplicity of application and economies. In this group, we observed gradual reduction in the surface areas of the wound due to epithelialization of its margins, but only a few healed completely because of the underlying deformity.
A second subtype of nonhealing wound for which GV was an effective wound dressing agent was in wounds in which fluid leakage through the wound base was a prominent feature. This occurred in patients with fluid retention from lymphedema, venous stasis disease, or combinations of these. The surrounding skin margins, because of the fluid leakage, were invariably macerated and inflamed. Many of the patients had courses of antibiotics because it was difficult to ascertain whether the inflammation was from cellulitis or irritation from the maceration. All patients in this group had previously used dressing agents to absorb secretions. Often the dressings became saturated with moisture, smelly, and colonized with bacteria between dressing changes, even if done twice a day. For this group, a one-two-three-four protocol was used. The moist, macerated skin at the wound margins was pared down to healthy-appearing epithelium. Next, the film or fibrous membrane was cureted to a bleeding base. GV was then coated on the wound base. Finally, zinc oxide, an effective moisture barrier and controlling agent, was applied to the previously macerated, debrided skin margins. Like GV, a tube of zinc oxide is inexpensive, costing only a couple of dollars. As in the first subtype, the patients appreciated the ease of application but also were pleased that moisture and odor control were managed so well with this technique. A third subtype of chronic nonhealing wound for which we have used GV is for the patient with atrophy and/or absence of soft tissue under the ulceration complicated by advanced peripheral artery disease and/or ulcers secondary to vasculitis. This group is differentiated from the first group because of absence of underlying, possibly surgically correctable, bony deformities. GV was used in this group after healing progress was not observed with other wound dressing agents and was preferred by the patient and their caregivers because of the “friendliness” of the GV dressing technique.
GV is not the answer for every wound, but there are reports of its use in a variety of wound types.6-8 We have not used it in wounds with bases wider than 4 cm in diameter. Although we are unaware of toxicity when GV is used locally on wound bases, we feel other techniques, especially surgical interventions such as debridements, deformity correction, and grafting are needed for larger wounds. GV was not found to be effective in radiotherapy-induced moist skin desquamation.9 We also observed lack of effectiveness in chronic, refractory venous stasis ulcers in which underlying cicatrix needed to be excised before successful skin coverage could be achieved. In addition, we do not advocate using GV over exposed bone or tendon. We use an algorithm approach for making decisions about using GV for our patients with chronic wounds (Figure 5).
Figure 4. Gentian violet bottles and methods of application
Legend: GV is avaliable in one ounce and two ounce bottles; note the Spanish labels in the one-ounce bottles.
The cotton tip of a cotton-tipped applicator is wetted with GV and then "painted" into the open wound — almost like being an artist. For punctate wounds, the wooden end of the applicator is used for coating the wound base with GV.
A minor complaint expressed by some patients using GV is that it “stains everything.” Almost anything GV comes in contact with is stained a dark blue, including dressing coverings, skin, and clothes. That is advantageous as well as problematic. We have observed that the GV stains the skin adjacent to the wound and persists until the stained skin desquamates. However, the stain does not persist on granulation tissue. Consequently, with each dressing change, removal of the gauze covering is in effect achieving an autolytic debridement of the wound base. The skin-staining problem is mitigated by educating the care provider to apply a light coat of GV only over the wound base with a cotton- tipped applicator (Figure 4). With this technique, a 30 cc bottle of GV can be used for multiple applications. When GV is applied lightly, a single gauze layer is usually sufficient for preventing the dye from staining clothing. The donning of gloves, while not required, will prevent care providers from getting GV stains on their fingers.
Figure 5. Our algorithm for using gentian violet
Legend: When the above criteria are met, we recommend using GV for the three subsets of chronic stable wounds.
Notes: * Usually used in conjunction with zinc oxide as a moisture barrier and to prevent maceration of the skin.
**Typically wound bases rest on bone and is frequently observed in patients with hidebound skin, vasculitis/collagen vascular disease and/or aging.
Since the stain persists on tissues, we question how frequent the GV applications need to be done. While we presently recommend applying GV once a day to the wound base, preliminary observations with every other day and even weekly applications seem to show its effectiveness. However, if moisture control for the wound base is needed, daily applications are advised to prevent moisture accumulation in the dressing from irritating the wound and surrounding tissues.
GV has been incorporated in foam dressings and in combinations with methylene blue with positive reports of its effectiveness.9-12 We have had experiences with Hydrofera Blue® but have not used it for the indications we use for selecting GV (Figure 5).
The use of GV for wounds lends itself to randomized control trials (RCTs). Our decision to use GV was based on observations that healing was stalled with other agents. Our observations, while supportive of the effectiveness of GV, could be substantiated with RCTs that assess each of the three permutations (underlying deformity, moisture control, and ischemic-hypoxic wound types) described in the observations/results section above. Not only could its effectiveness be confirmed, but studies could show its cost-benefits. If the decision is made to “live” with a chronic-stable wound, it is unlikely any other wound dressing agent could be less expensive.
GV had been used as a “last resort” intervention in many of our patients’ wounds that had been refractory to other interventions. The clinical improvements we have observed using GV now justify using this agent on superficial and mildly cavitary wounds at earlier and earlier stages in the patients’ wound courses. The ease of application and the economies of GV have made this agent an increasingly important intervention in our armamentarium of wound care products.
- Strauss MB, Aksenov IV, Miller SS. MasterMinding Wounds. North Palm Beach, Florida: Best Publishing Company; 2010. Part III, The strategic management of problem wounds; p.192-292.
- Strauss MB, Miller SS, Aksenov IV. Challenges of wound healing. Wound Care and Hyperbaric Medicine. 2010; 2(1): 28-46.
- WHO Model Prescribing Information: Drugs Used in Skin Diseases. Geneva: WHO; 1997. Available from: http://apps.who.int/medicinedocs/en/d/Jh2918e/23.5.html#Jh2918e.23.5
- Docampo R, Moreno SN. The mechanism and mode of activity of gentian violet. Drug Metab Rev. 1990; 22(2-3):161-78.
- Strauss MB, Aksenov IV, Miller SS, Nhan L. The end-stage wound: its determination and … management. Wound Care and Hyperbaric Medicine. 4(4):19-26.
- Fairid KJ, Kelly K, Roshin S. Gentian violet 1% solution in the treatment of wounds in the geriatric … patient: a retrospective study. Geriatr Nurs. 2011 Mar-Apr; 32(2):85-95.
- Coutts PM, Ryan J, Sibbald RG. Case series of lower-extremity chronic wounds managed with an antibacterial foam dressing bound with gentian violet and methylene blue. Adv Skin Wound Care. 2014 Mar; 27(3 Suppl 1):9-13.
- Choudhary KN, Soni PP, Sao DK, Murthy R, Deshkar AM, Nanda BR. Role of gentian violet paint in burn wound management: a prospective randomized control trial. J Indian Med Assoc. 2013 Apr; 111(4):248-50.
- Wainwright M. In defence of “dye therapy.” Int J Antimicrob Agents. 2014 Jul; 44(1):26-9.
- Gollins S, Gaffney C, Slade S, Swindell R. RCT on gentian violet versus a hydrogel dressing for radiotherapy-induced moist skin desquamation. J Wound Care. 2008 Jun; 17(6):268- 70, 272, 274-5.
- Applewhite AJ, Attar P, Liden B, Stevenson Q. Gentian violet and methylene blue polyvinyl alcohol foam antibacterial dressing as a viable form of autolytic debridement in the wound bed. Surg Technol Int. 2015 May; 26:65-70.
- Sibbald RG, Ovington LG, Ayello EA, Goodman L, Elliott JA. Wound bed preparation 2014 update: management of critical colonization with a gentian violet and methylene blue absorbent antibacterial dressing and elevated levels of matrix metalloproteases with an ovine collagen extracellular matrix dressing. Adv Skin Wound Care. 2014 Mar; 27(3 Suppl 1):1-6.