Objective: To describe a patient with a massive Grade IV pressure ulcer that responded rapidly to treatment with topical phenytoin and to review the literature supporting the use of this therapy.
Case summary: A 55-year-old morbidly obese white man (266 kg), with respiratory failure secondary to obesity-hypoventilation syndrome and heart failure, developed pressure ulcers on his lower back and sacrum with the first 2 weeks of hospitalization. Traditional methods of treatment were unsuccessful, and by day 79, the wound involved the entire lumbosacral area and buttocks, and had extensive undermining and sinus tract formation. Within 2 days of applying topical phenytoin, fresh granulation was apparent. After 54 days of treatment, nearly all the sinus tracts were healed. Four months after treatment with topical phenytoin had facilitated the healing of the wounds, even though the patient's multiple underlying medical problems had not resolved.
Discussion: Phenytoin has been used in the healing of pressure sores, venous stasis and diabetic ulcers, traumatic wounds, and burns. Many of the existing clinical studies have methodologic flaws, such as inappropriate statistical analysis, inadequate control groups, and the absence of randomization and double-blinding. Nevertheless, all the studies have reported enhancement of wound healing, with insignificant adverse effects. Phenytoin may promote wound healing by a number of mechanisms, including stimulation of fibroblast proliferation, facilitation of collagen deposition, glucocorticoid antagonism, and antibacterial activity.
Conclusions: Phenytoin promoted the healing of a massive necrotizing soft tissue wound that was unresponsive to conventional treatment. Clinical success in this difficult case and the other reports in the literature suggest that phenytoin is effective in would healing and deserves further investigation.