Efficacy of Topical Phenytoin Compared to Conventional Wound Dressing

This report presents an integrative review of the efficacy of topical phenytoin compared to conventional wound dressings in the management of various ulcers. The study examines the background of wound care, including the challenges associated with traditional dressings and the potential benefits of phenytoin. It outlines the objectives, significance, and methodology of the review, which includes an in-depth literature search, data evaluation, and analysis. The report also details ethical considerations, a proposed timetable, and a budget for conducting the research. Several case studies are included, highlighting the application of phenytoin in treating different types of ulcers, with a focus on its impact on wound healing, hospital stays, and overall patient outcomes. The review emphasizes the advantages of topical phenytoin, such as its availability and potential cost-effectiveness, while acknowledging the need for further research, especially in the form of randomized control trials. The findings suggest that topical phenytoin may improve the wound healing process, potentially reducing the number of days to heal and decreasing the length of hospital stays. The report concludes with a discussion of the implications for nursing practice and future research directions.

Running head: NURSING
An integrated review of the efficacy of topical phenytoin compared with conventional
wound dressing in the management of various ulcers
Student Name
University Name
Author Note

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Table of Content
s
1. Title.....................................................................................................................................2
2. Abstract...............................................................................................................................2
3. Background and literature review.......................................................................................3
4. Objectives...........................................................................................................................6
5. Significance of study/rationale...........................................................................................7
6. Integrative study as a methodology....................................................................................7
6.1. Advantages..................................................................................................................8
6.2. Disadvantages..............................................................................................................8
7. Research method.................................................................................................................9
7.1. Problem formulation....................................................................................................9
7.2. Literature search/Data collection...............................................................................10
7.3. Data evaluation..........................................................................................................10
7.4. Data analysis..............................................................................................................11
7.5. Interpretation and presentation..................................................................................11
8. Ethical considerations.......................................................................................................12
9. Timetable and research budget.........................................................................................13
10. References.........................................................................................................................14

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1. Title
An integrated review of the efficacy of topical phenytoin compared with conventional
wound dressing in the management of various ulcers.
2. Abstract
Background: Wounds have been sustained by individuals over the world for a number of
reasons. The impact of traditional wound dressings has already been observed to create
discrepancies in the healing procedure of the ulcer wounds. Hence, there is an opportunity
of improvising the dressing by administering topical phenytoin in place of conventional
dressings and observing their effect. It has been studied by Borda et al., (2018) that
patients with a chronic wound/ulcer tend to have a longer stay at the hospital for the
treatment with unpredictable wound healing times.
Aims: The purpose of the study is to improve the wound healing procedure to reduce the
number of hospital stays in patients and days to heal the ulcer of the patient.
Methodology: This research paper suggests a research project in the method of an
integrative literature review to study the consequence of topical phenytoin in place of
conventional dressing for the treatment and management of various kinds of ulcers. A
brief literature review is presented in the form of a proposal encircling around the
research aim that is mentioned above. Moreover, the proposal also presents with the
objectives, the significance of the study with an appropriate rationale. To conduct the
study in a methodological manner, correct data analysis, evaluation and suitable
interpretations and presentations are implemented. In accordance with conducting the
research, a budget with a timetable is proposed with relevant ethical considerations.

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Expected Outcome: The result obtained will be analysed to understand the effect on the
hospital stay of the individual who have sustained wounds and ulcers. In addition to this,
it is expected that there will be a reduction in the number of days to heal the wound if
moisture is applied.
Keywords: conventional dressing, topical phenytoin, ulcer wounds, hospital stay, wound
healing
3. Background and literature review
When the skin sustains an injury in which the living tissue is damaged, a wound is
formed. If the wound is not sealed with a sanitized cloth, there is a high chance of
sustaining an infection (Haney, Pletzer & Hancock, 2018; Vargas, Mansila & Solis,
2016). There are various types of wound that are sustained by an individual like abrasion,
puncture or lacerations (Paul & Sharma, 2015). A wound is dressed to avoid the
spreading of infection (Sehgal et al., 2019). As medical technology is getting advanced
day by day, there are certain developments to improve the patient condition (Meah et al.,
2016). Recent medical advancements have enhanced the dressings that could be provided
to patients suffering from chronic wounds (Zarrintaj et al., 2017). An ulcer is a result of
uncontrolled diabetes and pressure and shearing of the skin. Patients have a prolonged
stay in the hospital due to neurological complications and peripheral vascular
insufficiency (Sunshein & Samouilov, 2017). The location and the bacterial load
determines how the ulcer can be managed (Lalezari et al., 2017). Improvement in the
management of ulcer can be improved by several medical researches.
The proposed integrative review is expected to be providing the audience with a
better understanding of the effect of using phenytoin in the treatment of ulcers. It has been
previously observed to keep the wounds dry, however moist wound healing is perceived

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to be more effective in recent times (Powers, Higham, Broussard & Phillips, 2016). A
faster wound healing is promoted by tissue growth from the moisture wound. As a form
of conventional therapy, saline dressing or povidone-iodine dressing are used (Powers,
Higham, Broussard & Phillips, 2016). For the wound to be healed effectively within the
stipulated time involves a great understanding of the wound that has been observed in the
individual (Shakeri et al., 2017). A faster wound healing is observed with a moist wound
dressing as it promotes bacterial barrier while encouraging transmission of vapour and
increases collagen synthesis by proliferating fibroblasts (Gonzalez, Costa, Andrade &
Medrado, 2016). For the acceleration of wound healing, several therapies like negative
pressure wound therapy, hyperbaric oxygen therapy and epidermal growth factors were
developed (Kumar, Pavan, Arava & Kiran, 2015). In these cases, the patient experiences
an increase in the cost of the treatment. This places the patients facing an economic
burden, thus there is a continuous experimentation for medical professionals to treat.
There are evidences which show the effect of phenytoin in Hansen’s disease, decubitus
and venous stasis ulcers (Kumar, Pavan, Arava & Kiran, 2015). Because the price of ulcer
wound management is high, topical phenytoin should be administered after accounting
the many benefits of the widely-available drug (Kumar, Pavan, Arava & Kiran, 2015).
The usage of phenytoin in the treatment of ulcers and wounds was first observed
in 1939 by Kimball. They had used phenytoin in the treatment of gingival hyperplasia.
This is the initial study which generated the interest in further studies for the benefits of
phenytoin (Shakeri et al., 2017). A study was conducted by Shapiro in 1958, with the aim
of evaluating the beneficial impacts of phenytoin on healing of wounds amid patients who
were epileptic and suffered from gingival hyperplasia. The patients were administered
oral phenytoin before the operation. The patients showed less pain with less inflammation
and an accelerated healing procedure. This could be accredited to the fact that phenytoin

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application increased deposition of collagen that is required for effective healing of
wounds. Earlier studies have been conducted to understand the degree of benefits of
phenytoin in wound and ulcer healing. The process of wound healing involves the
understanding the four phases – coagulation and haemostasis phase, inflammatory phase,
proliferation phase and maturation phase (Singh, Young & McNaught, 2017). The
efficacy of phenytoin has also been demonstrated in neovascularisation, which in turn is
mediated by fibroblastic activity stimulation, and activation of a range of connective
tissue components. Studies have been conducted to understand the effect of topical
application of phenytoin to the wounds (Shakeri et al., 2017). It was observed that the
application of phenytoin enhances the healing process by decreasing the collagenase
activity, enriching the formation of the tissues by stimulating proliferation of the
fibroblast and decreasing the release of wound exudates (Shakeri et al., 2017). Moreover,
it was also found that it helps in the removal of Klebsiella spp, Staphylococcus aureus,
Escherichia coli and other gram-negative bacteria (Bharadva et al., 2017). However, no
evidence as such is present to prove its effect on inflammatory cells and
neovascularization for wound healing. Several types of research have been conducted
which suggests that phenytoin accelerating the procedure of wound healing by the
inhibition of glucocorticoid activity, increasing the secretion of alkaline phosphatase and
increase in the tensile strength of the wound (Shakeri et al., 2017). This impact on wound
healing was also related to a decrease in the latent phase, prior to the wound healing
maturation. There have been pieces of evidence where the nature of the injury sustained
by the individual like burn and warfare wounds, have healed the wound by a localized
application of phenytoin (Shakeri et al., 2017). Similarly, other researchers have also
elaborated on the efficacy of administering phenytoin powder by stating that it
accelerated healing time of the wound in complicated war wounds. However, despite

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having such positives relating to the benefits of phenytoin, there is considerably less
research with more discrepancies in the statistical analysis with an absence of double-
blinding and randomized control trials (Shakeri et al., 2017). In addition, phenytoin
administration has also been correlated with an acceleration in granulation formatting,
followed by an intensification in the tensile strength of the wound.
A suitable dressing of the wound should be maintaining a moist environment and
an appropriate tissue temperature by allowing gas exchange (Dhivya, Padma & Santhini,
2015). Tissue temperature and gas exchange enhances the healing procedure of the
wound and ulcers while maintaining sterility (Dhivya, Padma & Santhini, 2015). The
study conducted by Selvaraj and Jeevaraman, (2016) used two groups, out of which one
group was advised topical phenytoin and the other acted as a control group and was
advised regular saline and betadine dressing. The patients were selected at random but
chronic non-healing wounds inpatients were excluded from the study to avoid errors. The
research study conducted by Hajong et al., (2016), found that phenytoin helped in early
healing of the foot ulcers in patients suffering from diabetes. They had undertaken 100
patients out of which half were administered with phenytoin powder tablet. The topical
application of the tablet with the component phenytoin makes it easier for the drug to
reach the target site and express their mechanism of action.
4. Objectives
The objectives to conduct the integrative review are:
1. To understand the effect of phenytoin in reducing the length of hospital stays for a
patient
2. To observe the impact of topical application of phenytoin on the number of days it
takes to heal

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3. To compare the consequence of phenytoin over conventional wound dressing methods
5. Significance of study/rationale
People who have chronic wounds have been observed to be staying in the hospital
for a longer period. The administration of topical phenytoin has been observed to increase
the wound healing process when compared with conventional wound dressing procedures
(Shakeri et al., 2017). The proposed integrative review is expected to be providing the
audience with a better understanding of the effect of using phenytoin in the treatment of
ulcers. This research proposal aims to make the audience aware of the effect of topical
phenytoin in the treatment of ulcers and wounds with a significant reduction in hospital
stays. Hence, conducting the integrative literature review will help in gathering the
appropriate knowledge in understanding the benefits of the application of phenytoin on
wounds and ulcers. The nursing practitioners and physicians were hoping to get a positive
outcome of this review for the result to be implemented in hospital organizations.
Phenytoin is readily available in the market in the form of lotions and drugs which proves
to be good for countries where other forms of treatment are not freely available (Prasad et
al., 2017). The treatment that is provided by the hospitals in the form of conventional
dressing tends to be more expensive as there are medical advancements. Phenytoin
dressing reduces the number of days in the hospital thereby, reducing the costs of the
patients in economically down ridden countries (Alefan, Amairi & Tawalbeh, 2018).
6. Integrative study as a methodology
The methodology that is to be used in the integrative review research will be based on
the model proposed by Whittemore and Knafl, (2005). The integrative survey technique is
a methodology that permits for the consideration of different procedures (for example
experimental and non-experimental research) and can possibly play a more prominent job

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in evidence-based practice for nursing. The integrative survey adds to the introduction of
changed points of view on a marvel of concern and has been pushed as imperative to
nursing science and nursing practice. The above research proposal will be divided into
five stages: problem formulation, literature search/data collection, data evaluation, data
analysis and interpretation and presentation.
6.1. Advantages
Whittemore and Knafl help in considering a wider range of methodologies with
evidence-based practice to assist in an efficient integrative review. When a broader
range of evidence and researches are available, the scientist or the researcher finds an
opportunity to analyse, scrutinize and further evaluate the possibilities underpinning
the complexity of the information in regards to the research topic (Whittemore and
Knafl, 2005). In a way, secondary researches provide better aspects of understandings
in accordance to the perspectives underlying the research problem in a broader
meaning. Secondary researches are very vital while studying the deeper facets of
already studied issues in the context of the research topic. Secondary researches are
beneficial and a very important tool in exploratory and explanatory studies where the
researcher or the observer has to understand the intricacies of the psychological,
socio-cultural and psychosocial parameters of the research study.
6.2. Disadvantages
In the integrative study, the five stages give rise to the risk of errors and bias. This
arises when inadequate sampling of the evidence and the data have been gathered
from many literature and internet sources, personal bias impacting the evaluation of
the data with inaccurate data analysis and omission of the data during the
interpretation and the presentation of the whole research report. There is a decrease in
the risk of errors and biases when the methodology that has been structured has been

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strictly followed. The conclusions that have been drawn on the research study that
will be conducted will be valid.
7. Research method
The five-stage methodology steps that have been described above will be discussed in
detail in the following paragraphs.
7.1. Problem formulation
There are many stages in the integrative review which require clear addressing
of the variables that are of interest to facilitate in making the review success. A simple
literature search using the PICO (Population, Intervention, Control and Outcome)
acronym will be used to review the relevant definitions (Whittemore and Knafl,
2005). The target Population will be the people who have suffered chronic wounds
which have turned into ulcers. The Intervention will be the topical application of
phenytoin to the area where the ulcer is observed. Control will be the conventional
wound dressing provided to the patients sustaining wound ulcers. The Outcomes will
comprise of reduction in the days of hospitalisation as well as lesser number of days
for the ulcers to heal.
The studies and the evidence which will be a part of the research study have
been chosen on the basis of the existing methodology similar to the one proposed as
well as new advancing method for the management of ulcers in patients. Agencies and
organizations which relate to the wound management for the patients' release
information on a regular basis about the recent advancements which will be
considered for increasing the efficiency of the data.

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7.2. Literature search/Data collection
For an effective literature search, key search terms for the study needs to be
identified. The integrative review relating to the management of ulcer by topical
phenytoin application, a number of key terms like ulcer, management, Singapore, foot
ulcer, wound dressing, conventional, phenytoin, reduce hospital stays, number of days
to heal ulcers and dressing effect. There is a possibility of the list being expanded by
using related terms by truncating the already mentioned key terms. Boolean operators
like AND and OR may also be used to increase the efficiency of the search.
There is another aspect to be considered while planning a literature review.
Databases will be used for the review are ProQuest, Medline, Embase, ScienceDirect,
CINAHL and PubMed. They provide the researcher with a wider scope to get easy
access to a range of research articles encircling around the topic. The only
disadvantage of database searching is that not all evidence is generated on the
concerned topic for which further search methods are to be executed. Google Scholar
provides with a number of research articles which can be referred to get a clear
understanding of the study. In addition to this, reference lists of the articles, research
registries and government policies will also be searched to understand the current
scenario.
7.3. Data evaluation
Because of the inclusion of several sources of evidence, the evaluation of the data
for the integrative research differs from the traditional systematic reviews. For this
reason, quality criteria and multiple designs complicate the whole procedure of the
evaluation procedure (Whittemore and Knafl, 2005). The study which is proposed
may include varying type and scope of research like qualitative, quantitative and
mixed-methods study, discussion encircling the aspects of the primary sources needs

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to be considered. For documentation, a table will be formulated in the form of a data
extraction form to fill relevant information regarding the articles chosen. The aim,
research design, sample, intervention and outcome will all be tabulated in the table to
make it easier for the researcher to evaluate and arrive at a distinct conclusion.
7.4. Data analysis
While conducting integrative research, the analysis of the data and the evidence
gathered is one of the major aspects that need to be considered to make effective
integrative review research. The analysis stage is the most difficult phase due to
which many errors arise. As per the method that is proposed by Whittemore and
Knafl, (2005), the analysis of the evidence and the data involves data reduction, data
display, data comparison, conclusion drawing and verification. In the case of the
research report that is proposed, data reduction will be achieved by dividing the
primary data into subgroups by the type of evidence and data that have been gathered
during the literature search. This can be displayed in the form of a table to make it
easier for the reader to understand. The representation provided by the tables will help
in drawing a relationship between the number of days the ulcer requires to heal and
length of the hospitalisation due to this with the application of topical phenytoin to the
area of the wound. It is after this that a conclusion will be structured and presented as
per the evidence that has been gathered.
7.5. Interpretation and presentation
The interpretation in the research study is an integral part which deals with the
extracting the meaning out of the evidence and the data that has been obtained from
the literature sources. For the research study that is to be conducted, the proper
meaning of the results of each and every article that has been chosen needs to be
understood to arrive at a distinct conclusion. Some articles provide the reader with a

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positive result while others with a negative result. All the results will be
acknowledged and ascertained as to why that was observed. The possibility of this
affecting the present research needs to be recognized. The researcher will find
possible reasons as to why there was an observation of positive and negative results.
In the research study to be conducted, there is a high chance of obtaining statistical
information from articles which needs to be interpreted correctly so as to arrive at a
possible conclusion.
The presentation of the research will be structured in an appropriate way so as to
make it clear to other researchers and the readers about the study and its benefits. A
report will be made which will include all the research methodologies with proper
results that have been obtained and their interpretation. The language which will be
used will be aligning with the target audience in a clear and concise language such
that it is easier to grasp. There may come an occasion where a presentation would also
have to be given in front of the principal investigators. In a case like this, a
presentation will be made with the relevant information, in short, to make the
investigator understand the reason why this research was conducted and what were
the results that were obtained.
8. Ethical considerations
The research proposal is an integrative review of the literature with no participants
involved in the study. In spite of this, there are certain ethical considerations that need to
be made before proceeding with the review. It is the ethical responsibility of the author, to
be honest, and diligent when including evidence in the review (Atjonen, 2018). In
addition to this, the author must also conduct thorough research of the data that has been
obtained while noting discrepancies in the results and the probable conflicts of interest.

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There should be no instance of biases in the data that has been collected by checking all
the details and efficiently evaluating it for better understanding.
This integrative review will consider the above-stated measures to make sure there are
no misinterpretations of evidence which are presented. These measures need to be
undertaken by the author as the review paper will hold the potential to change current
policies relating to the concern that has been researched (Chandler & Shapira, 2016).
While researching this study, the author also declares that there are no current or potential
conflicts of interests that exist with regards to this research study. The future well-being
can face an impact when policies will be changed by incorporating topical phenytoin
applications on ulcers for the improved wound healing process.
9. Timetable and research budget
The research timetable that will be suitable for this research to be conducted with
enough evidence is proposed below:
January 2019 Background research
February 2019 Literature review
March 2019 Data collection
April 2019 Data analysis
May 2019 Writing conclusion
The sole researcher in the research being conducted is the author and the nature of the
research is an integrative research review which makes it easier by not making any direct
budgetary considerations. The research will undertake a secondary approach to perform the
study and hence, there are no direct budgetary considerations as such. The computer available
in the university will be used to search the literature over the internet as resources and write

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reports individually. In addition to this, meals and travel costs to various research institutes to
gather real data and understand the necessary concepts will be solely borne by the author.
10. References
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