A Closer Look At Topical Therapies In Wound Care

John Giurini, DPM, FACFAS, and Allyson Berglund, DPM

   Debridement of DFUs is one of the most important aspects of initial diabetic wound management.15 Often, clinicians can perform debridement quickly in the office with a scalpel or in the operating room if required for cases involving deep infection or those requiring anesthesia.

   However, when a wound has a large amount of nonviable tissue, one may employ topical enzymatic debridement therapies. Diabetic foot ulcers that require frequent debridement of necrotic tissues also may benefit from more frequent enzymatic therapy application.

   Collagenase (Santyl, Healthpoint Biotherapeutics) is a well known enzymatic debridement agent that works by breaking up the peptide bonds specific to collagen, therefore promoting healthy granular tissue.16 Researchers have also shown that collagenase is safe and effective for necrotic wounds as well as wounds with higher bioburden.17

Pertinent Insights On Non-Adherent, Hydrogel And Hydrocolloid Dressings

Diabetic foot ulcers that appear dry with little to no exudate, such as the ulcer in the photo at right, often have surrounding hyperkeratosis or necrotic debris within the wound. One must properly remove this nonviable material from the wound before any topical treatment can be effective. Clinicians can often accomplish this with sharp debridement in the office. Once there is adequate wound bed preparation and a healthy granular base is present, the physician can select from several topical therapies for appropriate management.

   It is well known that maintaining a moist environment facilitates wound healing with several actions. These actions include: prevention of tissue dehydration and cell death; accelerating angiogenesis; increasing breakdown of necrotic tissue or fibrin; and providing an environment for optimal transport of cytokines and growth factors, allowing appropriate target cell stimulation.18 Topical therapies that help support a moist environment include non-adherents, hydrocolloids and hydrogels.

   Non-adherents or low adherent dressings have been regarded as the standard treatment for most DFUs.15 These are relatively simple dressings that are designed to be atraumatic and provide a somewhat moist environment. Structurally, they consist of fine mesh-type gauze that is typically impregnated with vaseline or petroleum.19 Other benefits to traditional non-adherent dressings include low cost, their relatively hypoallergenic properties and the ability to use them in conjunction with other topical therapies, making them extremely versatile. Common commercial non-adherent dressings include Adaptic (Systagenix), Xeroform (Covidien) and Telfa (Covidien).

   Hydrocolloids, with the most popular one being Duoderm (ConvaTec), are characterized as being occlusive to wound exudate, absorbent and adherent. These types of topical therapies are structurally, cross-linked dispersions of gelatin, pectin and carboxymethylcellulose along with other complex polymers and adhesives.15 The polysaccharides and polymers absorb wound exudate, expanding and creating the adherent barrier to provide a moist wound environment. While a meta-analysis has shown that there is no significant difference between using a traditional non-adherent and a hydrocolloid, authors have recommended that the clinician choose an appropriate topical therapy based on wound exudate or the lack thereof.20

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