The array of wound care products can be quite astounding. Choosing the right product(s) for your patient can be difficult. With this in mind, our panelists, strongly emphasizing case-by-case management, share their experiences, success stories and caveats with certain wound care products. Read on for what five expert panelists had to say about treating neuropathic ulcers, when to use growth factors and the role of wet-to-dry dressings.
Q: What wound care products do you use on the diabetic neuropathic ulcer?
A: All of the panelists agree that appropriate product selection is done on a case-by-case basis. Edwin Blitch, IV, DPM, adds that he considers several factors before prescribing a particular wound care regimen. These factors include: type and duration of the ulcer; anatomic location; patient compliance; comorbid conditions; and affordability.
In treating diabetic neuropathic ulcers, Jason Hanft, DPM, looks for products that provide a moist wound healing environment, bandages that maintain moist wound healing and other products that are easy for the patient to use. To that end, Dr. Hanft says he uses topical hydrogels, topical antibiotics and topical antibiotic bandages (i.e. Acticoat and Iodoflex).
For stable, dry and granulating wounds, Jordan Grossman, DPM, says he uses either normal saline moist to dry dressing changes or hydrogel for patients who are only compliant enough for once-a-day dressing changes. Dr. Blitch adds that many of the hydrogel products are quite effective in promoting re-epithelialization of chronic wounds that have a healthy base of granulation tissue.
For the macerated, neuropathic ulceration, Lawrence Karlock, DPM, emphasizes once-a-day application of Iodosorb gel with a dry, sterile dressing. Once the ulcer becomes more beefy with less hyperkeratotic tissue, Dr. Karlock will switch to one of the hydrogel dressings or even Bactroban cream on a daily basis.
Dr. Grossman also uses Bactroban, as well as silver-based products or acetic acid, to treat colonized or superficially infected wounds. When you see wounds with extensive infection, he says performing an I&D is essential for controlling the infectious process.
Barry Rosenblum, DPM, notes that he is a “firm believer” that the most important aspect of wound care is offloading. “In addition to an adequate debridement, (offloading) is probably more conducive to wound healing than any one particular product,” emphasizes Dr. Rosenblum.
Q: What is your favorite wound debridement agent?
A: Drs. Hanft and Rosenblum say their favorite debridement agent is a scalpel. More specifically, Dr. Hanft recommends sharp debridement of vascularized lower extremity wounds in order to initiate an acute wound healing phase, remove nonviable tissue and decrease bacterial count. Dr. Grossman also primarily relies upon sharp debridements for removing necrotic tissue.
Dr. Hanft says the only time he will use a debriding agent (enzymatic or topical) is when patients are dysvascular and cannot undergo debridement, and are non-bypassable.
Dr. Rosenblum adds that he has used Panafil in the past with some success, but only on certain wounds. While Dr. Grossman doesn’t use a lot of enzymatic debriding agents, when he does go that route, he uses Accuzyme. Dr. Karlock employs Accuzyme when performing aggressive debridement of a less necrotic ulcer with less eschar. Dr. Blitch also believes Accuzyme is a good option in the right situation.
“This product has assisted surgical debridements beyond that of any other product I have ever utilized in the past,” explains Dr. Blitch. “I have not found it uncomfortable for my patients after daily application. In fact, Accuzyme allows efficient enzymatic debridement on patients who are unable to tolerate excision of necrotic eschar with a surgical instrument.”
Dr. Karlock notes that he also uses Santyl and Polysporin powder, as “these agents seem not to be irritating to the ulcer itself and the surrounding skin.”
Q: Do you use growth factors? If so, when do you use them?
A: Dr. Blitch cautions that growth factor products tend to be cost-prohibitive for many patients. All of the panelists agree that you should reserve the use of growth factors for recalcitrant wounds that have failed conserative treatments. Dr. Grossman also uses growth factors on patients who have marginal blood supply.
Dr. Grossman says randomized controlled prospective studies have supported using growth factors for diabetic neuropathic ulcerations. While Dr. Karlock has used growth factors with success on vasculitic ulcers, he wasn’t that impressed with the clinical outcomes in the Regranex study, which he says showed “only a small increase in the percentage of healing with a growth factor versus the control group.”
Drs. Hanft and Rosenblum have used Regranex (becaplermin) and have found it helpful in facilitating increased granulation tissue in wounds. However, acknowledging the author Steed, Dr. Rosenblum cautions that using becaplermin isn’t a substitute for performing good wound debridement.
Dr. Blitch adds that he has had “several success stories” using Regranex, including some off-label use on patients with sickle cell disease.
Q: What other wound care products do you use and why?
A: Dr. Karlock says he uses topical agents such as Bactroban and IntraSite gel. Dr. Hanft notes that he uses the topical Acticoat not only to eliminate bacteria, but also to decrease bacterial burden in wounds that are not frankly infected.
Dr. Karlock occasionally uses Kaltostat for a highly draining wound, as well as Aquacel. Drs. Grossman and Rosenblum note that alginate products can be effective for highly exudative wounds, and Dr. Rosenblum adds that they’re also good for filling or packing voids.
When it comes to larger, deeper wounds, Drs. Grossman and Rosenblum are fans of using VAC therapy. Dr. Grossman has used the VAC after performing extensive debridements and/or after performing open amputations for severe diabetic foot infections. He praises the device for its constant suction of exudate, dressing changes every 48 hours and the ease of use for patients.
Drs. Grossman, Hanft and Rosenblum all have experience in using living skin equivalents for chronic wounds. Dr. Grossman has used Oasis to treat neuropathic ulcers. Dr. Rosenblum has employed Apligraf and Dermagraft in specific cases and found that “each of these can be helpful in stimulating a wound that has been slow to heal.”
He adds that hydrogels can be useful when a moist environment is favored or when wet-to-dry dressings have been too drying.
Q: Do you have any use for wet-to-dry dressings?
A: Each of the panelists has had experience in using wet-to-dry dressings. “Wet-to-dry dressings are certainly useful in the proper patient population,” says Dr. Blitch. “The problem with wet-to-dry dressings is that many physicians improperly use them as a panacea for wound care.”
Dr. Blitch will use wet-to-dry dressings in patients with deep necrotic wounds that exhibit evidence of a high microbial load. He prefers to use a dilute Dakin’s solution to moisten the dressing and then have the patient remove the materials when they are nearly dry. According to Dr. Blitch, the solution has an antimicrobial effect and the dressing change mechanically removes necrotic tissue that has adhered to materials.
Dr. Rosenblum uses the dressings but says he is less likely to use them with a larger void and hesitates to use them in cases of exposed tendons or cartilage. “In these cases, I may use a hydrogel product,” he says. “I will occasionally use dilute Betadine, especially when there is a relatively superficial wound with a moderate amount of exudates.”
Dr. Hanft does not use the standard wet-to-dry dressing, although he does frequently employ the wet to moist sterile water dressing or sterile saline dressing. When he uses the wet-to-moist dressing (frequently on wounds that require maintaining a moist environment and do not require autolytic debridement or elimination of bacterial burden), he does so in conjunction with Acticoat.
“In the last eight to 10 years, my utilization of wet dressings has decreased significantly with the invention and use of topical hydrogels and dressings that have a semi-permeable barrier,” notes Dr. Hanft.
At this point, Dr. Karlock says his only indication for wet-to-dry dressings is for a postoperative surgical wound. In that case, he would use it twice a day after an incision and drainage of an abscess, etc. He does not use the dressing otherwise as a standard treatment for outpatient wound care.
Dr. Blitch is a Fellow of the American College of Foot and Ankle Surgeons and practices in North Charleston, S.C.
Dr. Grossman is Chief of the Section of Podiatry of Akron General Medical Center in Ohio. He is also a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Surgery.
Dr. Hanft is a Fellow of the American College of Foot and Ankle Surgeons and practices in Miami, Fla.
Dr. Rosenblum is an Assistant Clinical Professor of Surgery at Harvard Medical School and is the Director of Podiatric Residency Training at the Beth Israel Deaconess Medical Center in Boston.
Dr. Karlock (pictured at the right) is a Fellow of the American College of Foot and Ankle Surgeons. He practices in Austintown, Ohio.