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Clinical Updates

Patricia Senet, MD

New Dressings for Wound Care and Ulcers

Patricia Senet

Monday, April 04, 2005

The beneficial effect of a moist wound environment has been well established for healing rate of acute wounds, pain relief, and debridement of chronic wounds.1 Modern dressings are occlusive or semi-occlusive, classified according to their performances such as absorbent capacity, hydrating ability, adhesive components, and debridement capacity.

The indications of modern dressings are now consensual, mainly based on their physical properties and on open studies rather than on well-designed controlled trials. Dressings are usually categorized as medical devices. Thus, contrary to medical drugs, the level of proof of efficacy does not require the implementation of large-scale, controlled, randomised, clinical studies. In fact, no significant difference has been demonstrated versus the reference treatment, which consists in ensuring a moist environment for the wound through the use of gauze soaked in physiological saline.2-4

Modern dressings optimize the natural healing process without accelerating it. They mainly improve the comfort and quality of life of patients and reduce the cost of care by allowing reduced frequency of dressing changes.2-4

Hydrocolloids

Description:

The inner layer of all hydrocolloids is composed of carboxymethylcellulose enclosed in an elastic adhesive mass. Hydrocolloids are available in thick or thin versions, in paste to fill cavity wounds, or in a variety of precut shapes aimed at different anatomical sites (heels, sacrum, elbows).

Dressing changes:

The rate of dressing changes is between a few days and a week, depending on the amount of exudate. As it interacts with the exudate, the dressing forms a yellow gel with a characteristic foul smell that can be mistaken for purulent discharge from the wound. An erythematous eruption around the wound is usually a nonallergic irritant reaction related to excessively frequent dressing changes.

Indications:

They can be used at all stages of healing. The film covering the sheet protects the wound from outside and allows patients to take a shower.5

Hydrogels

Description:

Hydrogels are insoluble cross-linked hydrophilic polymers, containing more than 80% water. They are available in an amorphous gel, in packaged tubes, or in sheet form. Gel form appears to be the most effective in releasing moisture into wounds. A secondary dressing, such as a hydrocolloid or a polyurethane film, is necessary.

Dressing changes:

The dressing is changed every 3 or 4 days.

Indications:

Hydrogels are indicated for dry wounds, dermabrasion, chemical peels, and superficial burns and at the debridement stage. They are among the most efficient products in softening a plaque of necrosis.

Polyurethane Films

Description:

Transparent film dressings are made up of a polyurethane membrane coated on one side with an adhesive. They are permeable to gases and moisture vapor but impermeable to water and bacteria. They have no absorbent capacity.

Dressing changes:

The rate of dressing changes ranges from 3 to 7 days.

Indications:

Films are indicated in superficial, poorly exuding wounds, such as skin tears6 and low-grade pressure ulcers, and at the epidermization stage of a wound, but they are mostly used as secondary dressings to hold another dressing or a catheter in place.

Alginates

Description:

These polymers are mainly composed of fibers of calcium alginate derived from seaweed. They are sometimes mixed with carboxymethylcellulose in varying percentages. They are commercially available in the form of sheets or ropes for cavities. They need to be covered with a secondary dressing (such as a polyurethane film or gauze). They have a high absorbent capacity and mild bacteriostatic and haemostatic effects.

Dressing changes:

The dressing is changed daily during the cleansing phase and every 2 or 3 days during granulation.

Indications:

They are indicated in heavily exuding wounds and infected or haemorrhagic wounds, mainly at the debridement stage.7

Hydrofibers

Description:

This dressing is made up of carboxymethylcellulose fibers and presented in the form of sheets or ropes. The absorbent capacity is almost 2 or 3 times that of alginates. It can be used like an alginate, in heavily exuding wounds, and has to be covered with a secondary dressing.

Dressing changes:

Under a hydrocolloid sheet, it can usually be changed every 3 or 5 days. On the surface of a wound, it interacts with exudate to form a cohesive gel, so hydrofiber dressings do not adhere to the wound.

Indications:

Studies have been performed essentially in the treatment of pressure sores, leg ulcers, and burns.8

Foam Dressings

Description:

Foam dressings are usually made up of a hydrophilic layer (microporous polyurethane) combined with a film as the outer layer. They are available in adhesive and nonadhesive forms as well as in thick or extra-thin versions. Hydroabsorbent or superabsorbent dressings are similar to foam dressings, coming from the diaper industry. Foam dressings are highly absorbent and do not disintegrate in the wound, preventing the odors that may be experienced with hydrocolloids. In their nonadhesive form, they can be used even if the skin around the wound is not irritated or macerated.

Dressing changes:

The rate of dressing changes ranges from 3 to 8 days.

Indications:

They are indicated particularly from the granulation stage to complete epidermization for exuding chronic wounds, donor graft sites, skin tears, and sutures.

Charcoal Dressings

Description:

These dressings contain a layer of charcoal combined with an absorbent dressing. Active charcoal absorbs odors from the wound, which are infected or colonized by anaerobic or gram-negative bacteria. These dressings can be moistened with physiological saline.

Dressing changes:

The dressing is changed every 1 to 2 days, and it needs to be covered with a secondary dressing.

Indications:

They are indicated as a primary or secondary dressing for infected wounds and for cancerous wounds.9

Silver-Coated Dressings

Description:

Silver acts as a broad-spectrum antibacterial agent.10 Most of these products contain other components, such as hydrocolloid, hyaluronic acid, alginate, or foam.

Dressing changes:

The dressing is changed every 1 to 2 days.

Indications:

Silver dressings are widely employed for the treatment of burns, infected wounds, or chronic wounds with a critical colonization and a high risk of infection.11 On the contrary to acute wounds and burns, the clinical benefit of a reduction in the wound's bacterial colonization is not established in chronic wounds.

Impregnated Meshes or Coated Nets

Description:

More recently designed impregnated meshes or coated nets are impregnated with hypoallergenic, neutral substances such as petroleum, paraffin, silicone, or carboxymethylcellulose. These interface dressings do not adhere to the wound and need to be covered with a secondary, absorbent dressing.

Dressing changes:

They are changed between once a day and twice a week.

Indications:

They are indicated for slightly exuding wounds such as dermabrasion, epidermolysis bullosa, burns, and laser wounds,12 or for chronic wounds, whatever the stage of the wound.

Hyaluronic-Acid-Based Dressings and Collagen Dressings

Description:

The rationale for the use of hyaluronic acid or collagen is to promote healing, because these proteins are present at a very high level in the dermis. Cream, impregnated tulles, and dressings containing hyaluronic acid, sometimes in combination with alginates, are available. Collagen dressings may contain antiprotease agents to restore the balance of the chronic wound environment. Their efficacy has been studied in leg ulcers and diabetic wounds.13,14

Dressing changes:

They have to be changed daily.

Indications:

They are mostly indicated in poorly exuding chronic wounds at the stage of granulation.15

Table 1. Principal trade names of the different dressings


Generic name Trade names*
 
Hydrocolloids Comfeel Plus, Duoderm E, Algoplaque HP, Askina Biofilm, SureSkin STANDARD, Restore, Hydrocoll, Tegasorb, Tetracolloid, Comfeel Plus Transparent, Duoderm Extramince, Askina Biofilm Transparent, SureSkin Extramince, Algoplaque Film, Hydrocoll Thin, Tegasorb Thin,Comfeel Plus Brûlures, Urgomed,Comfeel Plus Contour (standard, large), Algoplaque Sacrum, Hydrocoll Sacral, Hydrocoll Concave, SureSkin Border, Duoderm E Border, Algoplaque Border,Comfeel Pâte, Comfeel Poudre, Duoderm Pâte, Askina Biofilm Pâte, Algoplaque, Pâte
Hydrogels ComfeelPurilon, IntraSite Gel, Duoderm Hydrogel, NuGel, Askina Gel, Hydrosorb Plaque, normlgel, Urgo Hydrogel, SureSkin Hydrogel
Polyurethane films EpiView, Opsite Flexigrid, Opsite Post-Op, Tegaderm, DermaFilm, Visulin, Lumiderm 6000, Hydrofilm, Mefilm, Askina Derm, Opraflex, Epitect Film, Tegaderm Pad, Optiskin
Alginates Algosteril, Sorbsan, Urgosorb, Comfeel SeaSorb, Askina Sorb, AlgiSite, Melgisorb, Sorbalgon
Hydrofibers Aquacel
Foam dressings Allevyn Plaque, Tielle, Biatain, Askina Transorbent, Mepilex
Charcoal dressings CarboFlex, Carbonet, Actisorb Plus
Silver-coated dressings Acticoat, Aquacel Ag, Urgotül S.Ag
Impregnated meshes or coated nets Vaselitulle, Unitulle, Lomatuell, Jelonet Adaptic,Urgotül, Cellosorb, Physiotulle, Mepitel
Hyaluronic-acid-based dressings Hyalgin (AH fim), Hyalofill (AH),Hyalogran (AH + alginate), Jaloskin (AH film),Ialuset, Effidia
Collagen-based dressings Promogran

*All trade names are trademarks or registered trademarks of their respective owners, and are neither owned by nor licensed to Galderma.

 

Table 2. Indications of dressings depending on the stage and the appearance of the wound


Appearance/stage of the wound Dressings
Presence of black, dry, necrotic tissue Hydrogel
Presence of fibrin or moist necrotic tissue Hydrocolloid
Hydrogel if slightly exuding
Alginate or hydrofiber if heavily exuding
Cavity wound Alginate, hydrofiber, hydrocolloid paste
Foam dressing
Heavily exuding wound Alginate or hydrofiber if infected
Foam if no infection
Granulating wound Hydrocolloid, foam, impregnated meshes, or coated nets (hydrofiber, alginate, hydrogel)
Superficial wound, dermabrasion Hydrocolloid, foam, hydrogel
Superficial burn, donor graft site Film, impregnated meshes, or coated nets
Foul-smelling wound, cancerous wound Charcoal dressings
Infected wound Alginate, hydrofiber, charcoal dressings


References

  1. Martin P. Wound healing - aiming for perfect skin regeneration. Science. 1997;276:75-81.
  2. Nelson EA, Bradley MD. Dressings and topical agents for arterial leg ulcers (Cochrane Review). In: The Cochrane Library, Issue 3. 2004.
  3. Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association. Diabetes Care. 1999:1354-1360.
  4. Douglas WS, Simpson NB. Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. Br J Dermatol. 1995;132:446-452
  5. Senet P, Meaume S. Les pansements hydrocolloïdes. Ann Dermatol Venereol. 1999;126:71-75.
  6. Thomas DR, Goode PS, LaMaster K, Tennyson T, Parnell LK. A comparison of an opaque foam dressing versus a transparent film dressing in the management of skin tears in institutionalized subjects. Ostomy Wound Manage. 1999;45:22-24,27-28.
  7. Belmin J, Meaume S, Rabus MT, Bohbot S. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002;50:269-274.
  8. Foster L, Moore P, Clark S. A comparison of hydrofibre and alginate dressings on open surgical wounds. J Wound Care. 2000;9:442-445.
  9. Holloway S, Bale S, Harding K, Robinson B, Ballard K. Evaluating the effectiveness of a dressing for use in malodorous, exuding wounds. Ostomy Wound Manage. 2002;48:22-28.
  10. Thomas S, McCubbin P. An in vitro analysis of the antimicrobial properties of 10 silver-containing dressings. J Wound Care. 2003;12:305-308.
  11. Caruso DM, Foster KN, Hermans MH, Rick C. Aquacel Ag in the management of partial-thickness burns: results of a clinical trial. J Burn Care Rehabil. 2004;25:89-97.
  12. Newman JP, Fitzgerald P, Koch J. Review of closed dressings after laser resurfacing. Dermatol Surg. 2000;26:562-571.
  13. Veves A, Sheehan P, Pham HT. A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg. 2002;137:822-827.
  14. Vin F, Teot L, Meaume S. The healing properties of Promogran in venous leg ulcers. J Wound Care. 2002;11:335-341.
  15. Ortonne JP. A controlled study of the activity of hyaluronic acid in the treatment of venous leg ulcers. J Dermatol Treament. 1996;7:75-81.
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