The proper selection of a wound dressing can greatly facilitate wound healing. Accordingly, the panelists share their thoughts on dressing selection, antimicrobial dressings and emerging dressings in wound care.
How do you select your dressing in your practice setting?
John Steinberg, DPM, FACFAS, uses “a very practical approach” to dressings. He stresses the importance of realizing that the dressing is not likely the factor that will “heal the wound” or not.
“Your debridement, offloading and other medical/surgical management will likely be the source of healing while the role of the dressing is to provide an appropriate environment for that healing to take place,” notes Dr. Steinberg.
“First and foremost, the condition of the wound will determine the type of dressing best suited for achieving the immediate goal, whether (it is) exudate management, autolytic debridement, promotion of granulation, etc.,” concurs Desmond Bell, DPM, CWS.
In his wound care center, Kazu Suzuki, DPM, CWS, stocks about 50 different kinds of dressings (including various sizes). He and his colleagues try to keep the dressings organized and minimize the inventory as most dressings have a few years of shelf life listed in the expiration dates on their sterile packages. He selects the wound dressings mainly based on two factors: to match the amount of wound drainage and whether he wants to use the antimicrobial dressings.
Dr. Bell notes that one must consider the cost of the dressing. If one is treating a hospitalized patient, the choices may be limited to what is on the formulary or contract, adds Dr. Bell. Seeing patients in multiple settings and facilities can present a challenge as he points out that one may have to change dressing orders if a patient gets transferred in the middle of treatment. Patients who are in home health situations are often limited further by access to dressings, according to Dr. Bell. He acknowledges that home health agencies in general have become very stringent when it comes to the types of dressings they will provide.
Do you favor antimicrobial dressings or regular sterile dressings?
When Dr. Suzuki was in residency training over 10 years ago, he learned that, “If the wound is clean, all you need to use is a sterile dressing and you don’t necessarily have to use antimicrobial dressings.” Nonetheless, he expresses doubt in that conventional belief, citing more and more data on biofilm impeding the healing of chronic wounds.
Therefore, Dr. Suzuki says it may be beneficial to use an antimicrobial dressing on most wounds to hasten the healing process even if wounds are not clinically infected. As Dr. Suzuki notes, it appears that to break down the biofilm over the chronic wound, one would have to combine debridement along with a topical antimicrobial (biocide) agent or dressings.1 The conventional belief is that antimicrobial dressings may reduce wound infection although he says he has not seen any real-life data supporting the claim.
More often than not, Dr. Bell will use use sterile rather than antimicrobial dressings.
“We are always concerned with the potential for bacterial resistance, not to mention the cost, especially if a wound is clinically improving or is without signs of infection,” explains Dr. Bell.
Likewise, while he will certainly utilize some antimicrobial dressings, Dr. Steinberg has greatly reduced this practice recently. He emphasizes the importance of assessing the individual wound and determining if surface infection/contamination is a concern. If so, Dr. Steinberg recommends a short course of a topical antimicrobial dressing. If there is no infection concern, Dr. Steinberg would follow the N.I.C.E. data out of the United Kingdom that basically found a low level of evidence for the effectiveness of antimicrobial dressings.2
What kind of antimicrobial dressing do you use?
Dr. Suzuki uses a lot of silver-based dressings, such as Mepilex Ag (Molnlycke) or Aquacel Ag (Convatec). He also frequently uses the Sorbact (BSN Medical) dressing, which is a plastic mesh with antimicrobial coating. Dr. Suzuki says Sorbact is inexpensive in comparison to silver dressings.
Dr. Steinberg uses a variety of antimicrobial dressings. He often uses oxidized regenerated cellulose/collagen/silver topical dressing materials as an adjunct when applying bioengineered alternative tissue grafts in the clinic. Dr. Steinberg also likes to use a silver containing foam dressing, citing its ability to provide a moisture balance in the wound environment
If he does use antimicrobial dressings, Dr. Bell uses one of the following: silver impregnated alginate, cadexomer iodine or antibiotic-saturated alginates. Dr. Suzuki will use the iodine-based antimicrobial Iodosorb gel and Iodoflex pads (Smith & Nephew).
When trying to “clean up” an especially foul smelling or dirty wound, Dr. Bell may moisten or saturate an alginate dressing with Dakin’s solution, which he uses until the situation becomes more stable. He does not use Dakin’s solution to “promote granulation” but to reduce the bacterial burden in an extreme situation.
When trying to manage a wound with persistent biofilm or a heavy bacterial burden/multiple organisms including methicillin resistant Staphylococcus aureus (MRSA), Dr. Bell may use a saturated alginate dressing once daily with a triple antibiotic solution of gentamicin-clindamycin-polymyxin (GCP solution). He has found this to be a great adjunct to concurrent oral or IV antibiotic therapy.
Dr. Suzuki also says medical honey products, such as Medihoney (Derma Sciences) and TheraHoney gel (Medline), have excellent antimicrobial properties. Dr. Steinberg also cites success with the medical honey containing dressings, finding no allergy concerns with this class of dressing even in highly sensitive patient populations.
However, Dr. Suzuki cautions that, although rare, he has had patients with silver and iodine allergies.
Do you have any favorite new dressings at the moment?
Dr. Steinberg is involved in a current multicenter clinical trial that involves a negative pressure wound therapy dressing with the addition of a wound irrigation system. As he notes, this system allows one to treat open surgical wounds with topical agents such as saline, acetic acid and detergents. Dr. Steinberg says this technological advance may prove to decrease biofilm and wound base colonization between surgeries and wound healing phases.
Dr. Suzuki and his colleagues have been using the latest iteration of Allevyn foam dressing, the Allevyn Life series (Smith & Nephew) “and we are very impressed by it.” He notes the dressing stays on the skin very well because it has very wide adhesive borders in comparison to most bordered dressings. Dr. Suzuki says Allevyn also features silicone adhesive (leaving no iatrogenic skin tears when removing the dressings) and a contoured foam pad. He notes this dressing doesn’t leave a skin mark and folds around the body part well. Dr. Bell notes that silicone materials have reduced trauma during dressing removal, can facilitate overall comfort and help decrease shearing in pressure ulcers.
Dr. Suzuki has also tried Drawtex dressing (SteadMed Medical), a hydroconductive dressing that actively “draws” wound drainage and absorbs it very well. He notes one can layer the Drawtex dressings on top of another to increase the fluid absorption. Dr. Suzuki says one cannot replicate this feature with conventional foam dressings.
In contrast, Dr. Bell notes the lack of any real recent technological breakthroughs when it comes to dressings.
“The existing technology gets tweaked and marketed, but honestly, I haven’t seen anything exceptional,” asserts Dr. Bell.
What is your approach when you encounter new dressings?
Noting that he is always curious about new dressings, Dr. Suzuki will put dressings on himself for a few days. “If the dressing is comfortable to me, I would be more willing to use it on my patients,” he says.
Even though wound dressings have been around for many years, Dr. Suzuki thinks there are many areas in which dressings can improve in terms of wear time and comfort. He also acknowledges cost considerations, especially the daily cost of the dressing. For example, he says the Cutisorb (BSN Medical) super absorbent dressing may appear expensive at first but it may be cost-effective as the dressings’ wear time is long (up to seven days) in comparison to conventional dressings that may need daily changes, which require costs for material and labor.
“If a manufacturer’s representative tells you about the wonderful and amazing results of the company’s latest and greatest dressing, ask for the data. Let’s see some evidence before we get too excited,” cautions Dr. Bell.
If a new dressing has merit, Dr. Bell will further examine the construct and features of the product. Emphasizing the importance of critical thinking, Dr. Bell will ask himself questions and try to play devil’s advocate while remaining skeptical. He will ask why is one dressing better than what is already available and has proven to be efficacious and safe. Dr. Bell also recommends further reading on the new products, citing Cochrane Reviews and PubMed as great starting points.
Dr. Steinberg also tries to think critically about dressing use and tries to avoid duplication/unnecessary expense. He argues that each clinic and provider needs to have a dressing list that can meet the needs of the patient population. There is very little human trial data on any of the dressings that he uses or proposes to use so requiring randomized, double-blinded trials in order to include a dressing wound be impractical. However, Dr. Steinberg will look at the clinical data on the dressing and then weigh that with the practical features that the materials will bring to his patients.
Dr. Bell is a board-certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.
Dr. Steinberg is an Associate Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is the Program Director of the MedStar Washington Hospital Center Podiatric Residency and the Co-Director of the Center for Wound Healing at the MedStar Georgetown University Hospital in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached via email at Kazu.Suzuki@CSHS.org .
1. Seth AK, Geringer MR, Nguyen KT, et al. Bacteriophage therapy for Staphylococcus aureus biofilm-infected wounds: a new approach to chronic wound care. Plast Reconstr Surg. 2013; 131(2):225-234.
2. Tan T, Shaw EJ, Siddiqui F, et al. Inpatient management of diabetic foot problems: summary of NICE guidance. Br Med J. 2011; Mar 23;342:d1280.