Key Insights On Selecting Wound Care Modalities

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Key Insights On Selecting Wound Care Modalities
Here one can see a dorsal wound with extensive fibrotic, nonviable tissue overlaying the dorsal ankle over the patient’s extensor tendon. (Photo courtesy of Jonathan Moore, DPM)
Here one can see the same dorsal wound after four to six weeks of using Panafil along with debridement. As you can see, there is now a healthy, granular wound bed that is ready for closure with adjunctive modalities. (Photo courtesy of Jonathan Moore, DPM
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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

   Q: What is your preference for a wound that has fibrous debris in it that still needs autolytic debridement?

   A: While Dr. Espensen says sharp debridement is the gold standard, he says enzymatic debridement agents such as Accuzyme and Gladase “work very well.” Dr. Karlock concurs, noting that he prefers Accuzyme for alert debridement but has also used Santyl and Gladase occasionally. Dr. Espensen adds that Panafil is a little less potent but also less painful.

   Dr. Jeffcoate opts for either an alginate (in possible combination with a hydrogel) or an iodine-containing preparation, whether it is a commercial iodine impregnated gauze or iodine cadexomer beads. Very occasionally, Dr. Jeffcoate says he will use a silver-sulfadiazine paste (Flamazine).

   According to Dr. Espensen, maggot therapy is also effective within a short period of time, and is a “very inexpensive” option compared to other debridement methods.

   Q: What products do you use on a highly exudative wound on the plantar foot?

   A: Dr. Jeffcoate usually employs an alginate or a foam dressing, whichever “preparation is sufficiently absorbent.” Dr. Espensen concurs, noting that he will either use foam dressings, calcium alginate or activated charcoal dressings.

   For the highly exudative wound, Dr. Karlock employs the Acticoat absorbent dressing and has traditionally used a non-silver alginate such as Kaltostate. When it comes to neuropathic draining wounds with surrounding hyperkeratotic tissue, he uses Iodosorb to “try to dry out the macerated tissue and absorb any exudate.” When a patient has a classic diabetic neuropathic plantar wound, Dr. Karlock says he usually uses Iodosorb for the first week or two to dry out the macerated tissue, promote wound healing and decontaminate the wound.

   Often, a high level of exudate indicates infection, according to Dr. Espensen. He adds that silver dressings are available “in many types for nearly all types of wounds.”

   Q: What roles do you see for the use of new silver-based dressings and collagen-based products?

   A: In his recent experience with silver dressings, Dr. Karlock says the Acticoat absorbent dressing works well. He notes that he has had some success with Aquacel Ag. Dr. Espensen says the silver ions in silver-based dressings are “extremely effective” against fungus, gram-positive and gram-negative bacteria including methicillin resistant Staph aureus (MRSA), methicillin resistant Staph epidermis (MRSE) and vancomycin resistant Enterococci (VRE).

   However, Dr. Espensen cautions that some of these dressings release higher levels of silver, which may damage both fibroblasts and epithelial cells, and, in effect, be counterproductive to wound healing.

   While silver-containing products are promising, Dr. Jeffcoate would like to see more data confirming their efficacy. One large multicenter trial of a silver-containing product was completed over a year ago but he notes results have not been published yet.

   Dr. Jeffcoate says he would also like to see more studies on collagen-based products. There are two trials on Promogran that Dr. Jeffcoate knows of and he says neither study confirmed the product’s efficacy in treating diabetic foot ulcers. Dr. Espensen says he uses collagen-based products “regularly with good outcomes.”

Dr. Espensen currently serves as Section Chair and Chief of Podiatry at Providence St. Joseph Medical Center in Burbank, Calif. He also serves as Associate Director and Director of Research at the Providence Diabetic Foot Center. He also has a private practice in Burbank, Calif.

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