Comparing a foam composite to a hydrocellular foam dressing in the management of venous leg ulcers: a controlled clinical study

Venous leg ulcers are the most prevalent form of chronic wounds in the Western world. The principles of moist wound healing coupled with the use of graduated compression bandaging have become the cornerstone of treatment for venous leg ulcers but not all moist dressings are alike. To compare the attributes of a foam composite dressing with those of a hydrocellular foam dressing in the management of venous leg ulcers, a prospective, randomized, comparative 12-week study was conducted in 15 centers in the US, Canada, France, Germany, and the UK. Dressings were changed and compression bandages applied per manufacturer recommendations and dressing performance was assessed at every dressing change and at the final evaluation. Patients with venous ulcers were randomized to treatment for 12 weeks with either hydrocellular foam (n = 52) or foam composite (n = 55) dressing. Healing differences between the groups were not statistically significant, with 36% of patients using foam composite dressing healed in a mean of 66 days and 39% of patients using hydrocellular foam dressing healed in a mean of 73 days. However, the foam composite dressing performed significantly better than the hydrocellular foam dressing with regard to condition of the periwound skin - 55% of patients in the foam composite group having healed or markedly improved surrounding skin compared to 37% of patients using hydrocellular foam (P = 0.03). The foam composite dressing was rated significantly better than the hydrocellular foam dressing ("very good" to "excellent") in level of satisfaction with conformability (87% and 75%, respectively, P = 0.05); being non-sensitizing (73% and 52%, respectively, P = 0.02); and ease of application (93% and 81%, respectively, P = 0.01). The findings reported in this study suggest that the foam composite dressing offers significant improvements in the quality of life of patients with venous leg ulcers as well as for their caregivers.     

Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot

The purpose of this retrospective study was to evaluate outcomes of people with large diabetic foot wounds treated with subatmospheric pressure dressing therapy immediately following surgical wound debridement. Data were abstracted from the medical records of 31 consecutive patients with diabetes, 77.4% male (n = 24), aged 56.1 +/- 11.7 years, presenting for care at two large multidisciplinary wound care centers. All patients received surgical debridement for indolent diabetic foot wounds and were subsequently started on a regimen of subatmospheric pressure dressing therapy delivered using a vacuum-assisted closure device for a mean of 4.7 +/- 4.2 weeks (mode = 2 weeks) using a protocol that called for cessation of therapy when the wound bed approached 100% coverage with granulation tissue with no exposed tendon, joint capsule, or bone. Outcomes evaluated included time to complete wound closure, proportion of patients achieving wound healing at the level of initial debridement, and complications associated with use of the device. The mean duration of wounds before therapy was 25.4 +/- 23.8 weeks. In patients treated with subatmospheric pressure dressing therapy, 90.3% (n = 28) of wounds healed at the level of debridement without the need for further bony resection in a mean 8.1 +/- 5.5 weeks. The remaining 9.7% (n = 3) went on to higher level amputation (below knee amputation = 3.2%, [n = 1] and transmetatarsal amputation = 6.5% [n = 2]). Complications included periwound maceration (19.4% [n = 6]), periwound cellulitis (3.2% [n = 1]), and deep space infection (3.2% [n = 1]). The authors concluded that appropriate use of subatmospheric pressure dressing therapy to achieve a rapid granular bed in diabetic foot wounds may have promise in treatment of this population at high risk for amputation and that a large, randomized trial is now indicated.     

Evaluation of two calcium alginate dressings in the management of venous ulcers

Calcium alginate dressings facilitate the management of highly exudating wounds such as venous ulcers. To evaluate and compare the performance of two calcium alginate dressings in the management of venous ulcers, a prospective, randomized, controlled clinical study was conducted among 19 outpatients at two wound clinics in California. Ten patients (53%) were treated with Alginate A and nine patients (47%) with Alginate B. Dressings were changed weekly and patients were followed for a maximum of 6 weeks or until the venous ulcer no longer required the use of an alginate dressing. At each dressing change, the wound was assessed and dressing performance evaluated. Absorbency of exudate, patient comfort during wear, ease of removal, adherence to wound bed, dressing residue following initial irrigation, patient comfort during removal, ease of application, and conformability were assessed. Patients using Alginate A experienced significantly less foul odor (P = 0.02) and less denuded skin (P = 0.04) than Alginate B at follow-up wound assessments. With the exception of conformability, Alginate A was rated significantly better than Alginate B (P less than or equal to 0.05) in all dressing performance assessments. No significant healing differences were observed. As the different performance characteristics of various calcium alginate dressings become more obvious in clinical practice, further study is warranted to determine their optimal effectiveness.     

Re-introducing honey in the management of wounds and ulcers - theory and practice

Dressing wounds with honey, a standard practice in past times, went out of fashion when antibiotics came into use. Because antibiotic-resistant bacteria have become a widespread clinical problem, a renaissance in honey use has occurred. Laboratory studies and clinical trials have shown that honey is an effective broad-spectrum antibacterial agent that has no adverse effects on wound tissues. As well as having an antibacterial action, honey also provides rapid autolytic debridement, deodorizes wounds, and stimulates the growth of wound tissues to hasten healing and start the healing process in dormant wounds. Its anti-inflammatory activity rapidly reduces pain, edema, and exudate and minimizes hypertrophic scarring. It also provides a moist healing environment for wound tissues with no risk of maceration of surrounding skin and completely prevents adherence of dressings to the wound bed so no pain or tissue damage is associated with dressing changes. Using appropriate dressing practice overcomes potential messiness and handling problems.     

Negative pressure wound therapy-associated tissue trauma and pain: a controlled in vivo study comparing foam and gauze dressing removal by immunohistochemistry for substance P and calcitonin gene-related peptide in the wound edge

Pain upon negative pressure wound therapy (NPWT) dressing removal has been reported and is believed to be associated with the observation that granulation tissue grows into foam. Wound tissue damage upon removal of the foam may cause the reported pain. Calcitonin gene-related peptide (CGRP) and substance P are neuropeptides that cause inflammation and signal pain and are known to be released when tissue trauma occurs. The aim of this controlled in vivo study was to compare the expression of CGRP and substance P in the wound bed in control wounds and following NPWT and foam or gauze dressing removal. Eight pigs with two wounds each were treated with open-pore structure polyurethane foam or AMD gauze and NPWT of 0 (control) or -80 mm Hg for 72 hours. Following removal of the wound filler, the expression of CGRP and substance P was measured, using arbitrary units, in sections of biopsies from the wound bed using immunofluorescence techniques. Substance P and CGRP were more abundant in the wound edge following the removal of foam than of gauze dressings and least abundant in control wounds. The immunofluorescence staining of the wound edge for CGRP was 52 ± 3 au after the removal of gauze and 97 ± 5 au after the removal of foam (P <0.001). For substance P, the staining was 55 ± 3 au after gauze removal and 95 ± 4 au after foam removal (P <0.001). CGRP and substance P staining was primarily located to nerves and leukocytes. The increase in CGRP and substance P immunofluorescence was especially prominent in the dermis but also was seen in subcutaneous and muscle tissue. Using gauze may be one way of reducing NPWT dressing change-related pain. New wound fillers designed to optimize granulation tissue formation and minimize pain issues presumably will be developed in the near future.     

Evaluating the effectiveness of a dressing for use in malodorous,exuding wounds

Malodorous, exuding wounds can cause problems for patients in terms of discomfort and social isolation. A prospective, noncomparative, multicenter study was conducted to evaluate the effectiveness of an odor-controlling dressing in the management of patients with chronic and acute exuding, malodorous wounds. Forty-six patients with various malodorous wounds (mean duration prior to study entry of 231.6 weeks) participated in the study. The majority of the patients were > 65 years of age (mean 70.7 years). Wound characteristics, odor, and dressing exudate absorption were assessed at baseline and at every dressing change (total: 348 dressing changes). Overall assessment of the dressing's ability was rated as good or excellent for odor control (91% of patients), exudate management (82%), and overall comfort (86%). Patient and nurse perception of odor were similar. While appropriate treatment to address the cause of exudate and wound odor remains a priority, the results of this study suggest that discomfort and isolation may be reduced through the use of odor-control dressings.     

Clinical effectiveness of noncontact, low-frequency, nonthermal ultrasound in burn care

Most burns are thermal and can be treated on an outpatient basis with conventional care that includes daily dressing changes, debridement, and infection control. These treatments can exacerbate pain associated with burns. Noncontact, low-frequency, nonthermal ultrasound therapy is delivered via sterile saline mist and has been used to cleanse and debride a variety of acute and chronic wounds, including burns, with less associated pain. This case series study evaluated low-frequency, nonthermal ultrasound therapy as an adjunct to conventional burn care in six nonrandomly selected outpatients with partial- to full-thickness thermal burns. The effectiveness of low-frequency, nonthermal ultrasound was assessed through changes in wound bed composition, exudate characteristics, and pain. Patients rated pain using a 10-point numerical rating scale (0 = no pain; 10 = extreme pain). Noncontact ultrasound treatments of 3 to 20 minutes (depending on wound size) were administered up to five times weekly. Conventional treatments included antibacterial ointments and nonadherent moist dressings. Treatment continued until wounds were predominately granulation tissue. As few as one noncontact ultrasound treatment caused slough to lift easily and granulation tissue to develop quickly. Pain rapidly resolved and all wounds healed and closed without surgical intervention. In this case series study, noncontact ultrasound treatment was an effective adjunct to conventional burn care.     

Outcomes of hyaluronan therapy in diabetic foot wounds

The purpose of this study was to evaluate outcomes of persons with neuropathic diabetic foot wounds treated with a hyaluronan-containing dressing. Data were abstracted for 36 patients with diabetes, 72.2% male, aged 60.0+/-10.7 years and a mean glycated hemoglobin (HbA(1c)) of 9.5+/-2.5% presenting for care at two large, multidisciplinary wound care centers. All patients received surgical debridement for their diabetic foot wounds and were placed on therapy consisting of hyaluronan dressing (Hyalofill, Convatec, USA) with dressing changes taking place every other day. Outcomes evaluated included time to complete wound closure and proportion of patients achieving wound closure in 20 weeks. Hyalofill therapy was used until the wound bed achieved 100% granulation tissue. Therapy was then followed by a moisture-retentive dressing until complete epithelialization. In total, 75.0% of wounds measuring a mean 2.2+/-2.2 cm(2) healed in the 20-week evaluation period. Of those that healed in this period, healing took place in a mean 10.0+/-4.8 weeks. The average duration of Hyalofill therapy in all patients was 8.6+/-4.2 weeks. Deeper (UT Grade 2A) wounds were over 15 times less likely to heal than superficial (1A) wounds (94.7 vs. 52.9%, Odds Ratio=15.9, 95% Confidence Interval=1.7-142.8, P=0.006). We conclude that a regimen consisting of moist wound healing using hyaluronan-containing dressings may be a useful adjunct to appropriate diabetic foot ulcer care. We await the completion of a multicenter randomized controlled trial in this area to either support or refute this initial assessment.     

A comparison of an opaque foam dressing versus a transparent film dressing in the management of skin tears in institutionalized subjects

Epidemiological studies suggest that at least 1.5 million skin tears occur each year in institutionalized adults. Despite this incidence, very little is known about the management of skin tears in elderly persons. Studies related to wound dressings and healing rates for these skin tears have rarely been reported in the medical literature. A randomized, prospective trial of 37 subjects compared the treatment of skin tears using either an opaque foam dressing or a transparent film dressing. Subjects had either a modified Payne-Martin Category II (25%-75% epidermal loss) or Category III (100% epidermal loss) skin tear. Category I skin tears (linear with no tissue loss) and skin tears greater than 48 hours old were excluded. Mean subject age was 85.1 +/- 9.7 years. Subjects were followed weekly until healed or for up to 21 days. Subjects in the comparison groups did not differ at baseline in age, sex, wound severity score, presence of diabetes, nutrition score, ambulation and mobility score, or mental status score. Complete healing occurred in 94% (16/17) of subjects treated with the foam dressing as opposed to 65% (11/17) of subjects treated with the film dressing (P < 0.05). Complete healing correlated only with dressing type (P < 0.05) and age (P < 0.01). No other factor was associated with the healing outcome. The number of dressing changes was similar in each group, 3.1 +/- 1.2 versus 3.4 +/- 1.1. Based on the results of this study, we conclude that this opaque foam dressing is a superior wound dressing for skin tears.     

Negative pressure wound therapy combined with acoustic pressure wound therapy for infected post surgery wounds: a case series

Acute infection of surgical incision sites often requires specialized wound care in preparation for surgical closure. Optimal therapy for preparing such wounds for a secondary closure procedure remains uncertain. The authors report wound outcomes after administering acoustic pressure wound therapy in conjunction with negative pressure wound therapy with reticulated open-cell foam dressing changes to assist with bacteria removal from open, infected surgical-incision sites in preparation for secondary surgical closure in three patients. Before incorporating acoustic pressure wound therapy at the authors' facility, the average negative pressure wound therapy with reticulated open-cell foam dressing course prior to secondary surgical closure was 30 days; with its addition, two of three patients underwent successful surgical closure with no postoperative complications after 21 and 14 days, respectively; one patient succumbed to nonwound-related complications before wound closure. Larger, prospective studies are needed to evaluate combining negative pressure wound therapy with reticulated open-cell foam dressing and acoustic pressure wound therapy for infected, acute post surgery wounds.     

Vacuum-sealed mesh graft transplantation in chronic cutaneous ulcers of the lower leg

BACKGROUND: The covering of defects caused by chronic ulcers on limbs affected by peripheral arterial disease or chronic venous insufficiency is often difficult due to extensive secretion and edema, while chronic bacterial contamination of the wound bed further compromises the conditions for successful healing. PATIENTS AND METHODS: Vacuum-sealed dressing (VSD) offers the option of a closed dressing system for moist wound care that assures firm contact with the wound surface and protection against contamination with nosocomial microbes and decontamination of existing bacteria by means of constant drainage of secretion independent of gravity. VSD is particularly useful in difficult wounds featuring extensive secretion and unfavorable localization and offers many advantages over conventional dressing techniques in terms of improved healing of skin transplants. A total of 35 patients with chronic leg ulcers were treated with vacuum-sealed mesh graft transplantation. RESULTS: Complete healing of the mesh graft transplant was observed in 20 patients (57%). Twelve patients (34%) experienced partial healing (75-90%) of the transplant, while three patients exhibited less than 75% healing of the graft and therefore required a second mesh graft transplantation. CONCLUSIONS: VSD is a simple, quick and inexpensive technique that promotes excellent healing of skin transplants. It is particularly useful in difficult wounds with extensive secretion and/or contamination or infection.     

Evaluating the use of hydrogel sheet dressings in comprehensive burn wound care

Comprehensive burn wound management comprises a challenging spectrum of acute, chronic, traumatic, and surgical wounds with a wide range of anatomical locations and depth. When processing of porcine and cadaver skin - items central to burn care management strategies - became problematic at one Hong Kong hospital, a commercially available cost-effective substitute dressing was urgently needed. After reviewing the characteristics and availability of several dressings, hydrogel sheet dressings were evaluated in a range of burn wound applications. Fifty wounds, including skin graft donor sites, acute partial-thickness burns, and excised full-thickness wounds in 30 consecutive patients were managed with the dressing. It also was used as a temporary dressing over meshed autografts and cultured cell applications. When hydrogel is applied, it is nonadherent; nursing staff reported general ease of use. When applying hydrogel to awkward areas (eg, posterior thigh donor sites), assistance was required to stabilize the large sheets while securing retention dressings. Patients reported no pain during and between dressing changes. No adverse events occurred. Clinical outcomes met or exceeded expectations and guidelines for dressing application and removal were developed. Based on the results obtained, prospective, randomized, controlled clinical studies to ascertain the efficacy and effectiveness of this dressing were initiated. Broader exploration of the advantages of hydrogel use in burn wound care is warranted.     

Highly Porous and Superabsorbent Biomaterial Made of Marine-Derived Polysaccharides and Ascorbic Acid as an Optimal Dressing for Exuding Wound Management

There are many modern wound dressings that have promising properties for repairing skin damage. However, due to various types of wounds and the problems they cause, there is still a great demand for new, effective healing strategies. The aim of this study was to create superabsorbent wound dressing made of marine-derived polysaccharides (agarose and chitosan) using the freeze-drying method. The secondary goal was its comprehensive evaluation for potential use as an external superabsorbent bandage for wounds with high exudation. Due to the well-known positive effect of ascorbic acid (vitamin C) on the healing process, biomaterial enriched with vitamin C was prepared and compared to the variant without the addition of ascorbic acid. It was shown that the produced foam-like wound dressing had a very porous structure, which was characterized by hydrophilicity, allowing a large amount of human fluids to be absorbed. According to in vitro tests on human fibroblasts, biomaterial was nontoxic and supportive to cell proliferation. Vitamin C-enriched dressing also had the ability to significantly reduce matrix metalloproteinase-2 production and to promote platelet-derived growth factor-BB synthesis by fibroblasts, which is desired during chronic wound treatment. The material has features of the eco-friendly wound care product since it was made of naturally-derived polysaccharides and was proved to be biodegradable. Importantly, despite degradable character, it was stable in the chronic and infected wound microenvironment, maintaining high integrity after 8-week incubation in the enzymatic solutions containing lysozyme and collagenases. The obtained results clearly showed that developed biomaterial possesses all necessary features of the external dressing for the management of exudate from both acute and chronic non-healing wounds.     

A study to compare a new self-adherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers

Pressure ulcers are common among elderly nursing home residents. To be effective in managing these wounds, a dressing should maintain a moist environment, facilitate healing, absorb exudate, remain in place for a number of days, and prevent trauma to the surrounding skin. An 8-week, open, randomized, multicenter, controlled study was conducted to compare the effects of a new self-adherent soft silicone dressing and a self-adherent hydropolymer dressing on Stage II pressure ulcers. Thirty-eight (38) residents participated in the study. Eighteen residents (mean age 83.8 years, range 74.9 to 95.1 years) were randomized to wound management with a soft silicone dressing, and the ulcers of 20 residents (mean age 82.5 years, range 66.4 to 91.9 years) were managed with a hydropolymer dressing. Wound healing, wound and surrounding skin characteristics, and ease of dressing removal were measured and documented. During the study, eight (44%) ulcers in the soft silicone group and 10 (50%) in the hydropolymer dressing group healed. Both dressings were changed approximately once a week and no differences in signs of inflammation, amount of exudate and odor, or incidence of leakage were observed. Damage to the surrounding skin, maceration, and dressing removal difficulties were less common with the soft silicone dressing. Differences in tissue damage between the two dressings were significant during weeks 1, 2, and 3 (P < 0.05). Studies with a larger sample size are needed to confirm these findings.     

Individualizing the use of negative pressure wound therapy for optimal wound healing: a focused review of the literature

Currently available research suggests that negative pressure wound therapy (NPWT) creates a moist wound healing environment, drains exudate, reduces tissue edema, contracts the wound edges, mechanically stimulates the wound bed, and influences blood perfusion at the wound edge, which may lead to angiogenesis and the formation of granulation tissue. Although no clear evidence is available that NPWT accelerates wound healing compared to other interventions or that one form of NPWT is better than another, preclinical research suggests that the most commonly used dressings, level of negative pressure, and application mode (continuous, intermittent, or variable) may not be optimal for all patients. To summarize available literature related to these NPWT choices, pertinent literature published between 2005 and 2010 was reviewed. Preclinical study results suggest that the maximal biological effect of NPWT at the wound edge often can be achieved at -80 mm Hg and that foam dressings may be advantageous for large defect wounds, whereas gauze dressings may be more suitable for smaller wounds or when scar formation or pain is a concern. Preclinical research results also suggest that intermittent or variable pressure application has a better effect on granulation tissue formation than continuous application. The variable pressure mode maintains a negative pressure environment at lower pressure settings without dramatic fluctuations inherent to intermittent (on-and-off) pressure. Prospective, controlled clinical studies are needed to compare NPWT to other advanced wound care protocols of care and to ascertain the effect of various NPWT methods and regimens on outcomes of care.     

Vakuumtherapie mit PHMB Gaze zur Behandlung postoperativer subkutaner Bauchdeckeninfektionen

Methods

In a prospective case control study of 16 patients, the healing rate of secondary suturing of subcutaneous wound infections after median laparotomy wounds for colorectal surgery was investigated, whereby the wounds had previously been conditioned using negative pressure wound therapy (NPWT) with polyhexamethylene biguanide (PHMB) gauze.

Results

After opening the infected wound the average wound volume was 203 ml. A débridement of the wounds was carried out to remove necrotic and sloughed tissue then the first NPWT dressing was applied. The NPWT with PHMB gauze could be changed on average every 3 days at the bedside which was possible because the pain level during each dressing change was recorded as an average of 1 on the visual analog scale (VAS). After an average of 3 NPWT dressing changes, the wounds showed no signs of infection and secondary suturing was carried out at the bedside using local anesthesia. For the first 7 patients, subcutaneously placed capillary drainage without suction was used in the wounds (group 1). As the healing rate was low (29?%) subcutaneously placed round channel drainage under suction were used for the next 9 patients (group 2) and the healing rate was 89?% after secondary suture. The average costs for NPWT treatment including labor costs were calculated as 322.20 EUR per patient.

Conclusion

All procedures could be performed at the bedside and all patients were satisfied with the treatment and results. The NPWT therapy with PHMB gauze provides an economic method for lowering the total treatment time and costs as well as unnecessary usage of operating theaters.     

Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds

Diabetic foot wounds present a great challenge to wound care practitioners. The objective of this pilot study was to determine whether vacuum-assisted closure (V.A.C.) therapy would afford quicker wound resolution as compared to saline-moistened gauze in the treatment of postoperative diabetic foot wounds. Ten patients were randomized into either the experimental V.A.C. group or control saline gauze group. Included in the study were diabetic patients 18 to 75 years of age who had a nonhealing foot ulceration. Excluded were those patients with venous disease, coagulopathy, or those who had active infections not resolved by initial surgical debridement. All foot ulcers were surgically debrided prior to initiation of V.A.C. or gauze treatment. In the experimental group, V.A.C. dressings were applied in accordance with manufacturer's protocol for chronic wounds and changed every 48 hours. In the control group, saline gauze dressings were applied at the time of surgical debridement and changed twice a day thereafter. Measurements and photos were obtained to document wound progress. Main outcome measures included: 1) time to satisfactory healing (calculated from date of initial debridement to date of definitive closure, and 2) change in wound surface area (calculated from initial wound tracing to final tracing). Satisfactory healing in the V.A.C. group was achieved in 22.8 (+/- 17.4) days, compared to 42.8 (+/- 32.5) days in the control group. Surface area changes of 28.4% (+/- 24.3) average decrease in wound size in the V.A.C. group, compared to a 9.5% (+/- 16.9) average increase in the control group during measurement period.