Bromelain-Based Debridement Shows Promise for Diabetic Foot Ulcers in Post Hoc Analysis
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A recent post hoc analysis of a multicenter, assessor-blinded, randomized controlled trial has revealed encouraging results for the use of bromelain-based enzymatic debridement (BBD) in the management of diabetic foot ulcers (DFUs).1 The findings suggest that BBD may significantly improve wound bed preparation and accelerate healing in patients with chronic diabetic wounds1—a very much at-risk population that podiatrists treat regularly.
Podiatrists are well aware that chronic wounds such as DFUs affect millions of Americans annually and represent a major burden to both patients and the healthcare system. Debridement is a critical step in the wound healing process, yet existing options may be invasive, painful, or slow to act. BBD, a mixture of proteolytic enzymes derived from pineapple stems, has been investigated for its debridement properties in burns and venous leg ulcers. This study marks an important step in evaluating its utility for diabetic foot ulcers.1
The trial enrolled 73 patients with chronic lower extremity ulcers, including venous, diabetic, and traumatic wounds. Patients were randomized in a 2:1 ratio to receive either 5% BBD gel or a gel vehicle (GV) control. Treatments were applied daily over two weeks (up to 10 sessions), followed by a 12-week observation period 2. The study met its primary endpoint, with 55% of patients across all wound types achieving complete debridement within two weeks, compared to 29% in the placebo group (p=0.04). This post hoc analysis focused specifically on the 19 patients with DFUs—12 in the BBD group and 7 receiving the GV control.
While not statistically powered due to its exploratory nature, the results were clinically notable. Within the initial two-week treatment window, complete debridement—defined as ≥90% removal of necrotic tissue—was achieved in 58% of patients in the BBD group compared to only 14% in the control group. Similarly, a clinically relevant granulation tissue threshold (≥75%) was reached in 42% of BBD-treated ulcers versus 17% with GV.1
Importantly, wound bed preparation, which the authors defined as complete debridement with substantial granulation tissue (≥75%), occurred in 75% of BBD-treated patients at any point during the study, compared to 43% of those receiving the control. Wound closure—complete epithelialization with no drainage or dressing required—was observed in 57% of BBD cases versus 25% in the GV group. Time to complete debridement and wound bed preparation was also significantly shorter in the BBD arm, with median times of 23 and 23.5 days, respectively, compared to 128 days and "not reached" (as less than 50% achieved wound closure within the study), in the control group.1
“BBD's unique enzymatic formulation demonstrates a multi-targeted proteolytic activity and a multifaceted mechanism of action,” said Robert Snyder, DPM, lead author on the poster. “It effectively and selectively debrides non-viable tissue, promotes healthy granulation, reduces bioburden and biofilm, exhibits anti-inflammatory properties, and maintains a moist wound environment conducive to healing”
“It rapidly progresses through the wound bed preparation phase, typically within four to five days, allowing timely transition to closure, whether by secondary intention, advanced therapies, or split-thickness skin grafting,” noted Dr. Snyder. “This efficiency may significantly accelerate overall wound healing.”
The findings from this poster suggest that bromelain-based enzymatic debridement may offer a clinically meaningful, non-surgical alternative for managing diabetic foot ulcers. The ability to achieve faster wound bed preparation and support closure positions BBD as a potentially valuable tool in the multidisciplinary wound care toolkit.
These promising early results warrant further validation through larger, statistically powered trials to confirm BBD’s efficacy and safety in DFU.
“I believe this represents a revolutionary advancement in wound care - one that has the potential to transform treatment practices and fill a critical gap with a highly effective therapeutic option,” said Dr. Snyder.
Disclosures: The agent studied in this poster is EscharEx (MediWound), which is currently in late-stage clinical development (ongoing Phase 3 trial), for venous leg ulcer and in preparation for a clinical trial for diabetic foot ulcers. Dr. Snyder is the Chief Medical Officer for MediWound, and Dr. Dove is a Clinical Consultant for MediWound.
References
1. Snyder RJ, David K, Ben Yaakov A, Haviv A, Dove C. Efficacy of bromelain-based debridement (BBD) in diabetic foot ulcers: A post hoc analysis. Poster presented at Symposium on Advanced Wound Care Spring, May 1-4, 2025, Grapevine, TX.
2. Shoham Y, Shapira E, Haik J, et al. Bromelain-based enzymatic debridement of chronic wounds: Results of a multicentre randomized controlled trial. Wound Repair Regen. 2021;29(6):899-907.
