While there is quite an array of choices when it comes to choosing appropriate wound care modalities for lower-extremity wounds, there is not, as one panelist points out, a lot of published evidence for guidance. With this in mind, our expert panelists discuss a variety of wound care scenarios and how their clinical experience guides their decision-making on dressings and debriding agents.
Q: Given the multitude of wound care dressings available, how do you narrow down your choice of wound dressings?
A: Eric Espensen, DPM, and Lawrence G. Karlock, DPM, says it often comes down to clinical experience. Dr. Karlock says he has experimented with 20 to 30 different wound products over the last few years and has narrowed his choices based on his experience. He says he prefers one or two products for draining wounds, and one or two products when dealing with wounds that have a thick eschar.
William Jeffcoate, MD, FRCP, who practices in the United Kingdom (U.K.), says published evidence is “woefully thin” in regard to wound care products and their effect on lower-extremity ulcers in patients with diabetes. In light of this, Dr. Jeffcoate points to the adage that healing is promoted not so much by a wound care product per se as by the wound care process. Therefore, he tends to rely on simple principles of wound healing until there is more published literature to direct him otherwise.
Speaking from his clinical experience, Dr. Jeffcoate says he does not like occlusive or semi-occlusive dressings because they can cause maceration of the wound edge when they are left on too long. When debridement fails to remove surface debris, Dr. Jeffcoate employs an alginate- or an iodine-containing preparation.
However, he maintains there is a “desperate need for a robust comparison of outcomes” between different specialist clinics as well as more reliable measures of what constitute acceptable rates of healing. To that end, Dr. Jeffcoate says he is currently involved in a large, government-funded, multicenter study in the U.K. that is looking at three dressings (a simple non-adherent dressing, iodine impreganted gauze and a hydrofiber dressing) in diabetic foot ulcers. He hopes the study will yield valuable data by the anticipated completion in December 2006.
Q: Do you still utilize the traditional saline wet to dry dressing for foot wounds?
A: Dr. Jeffcoate says he has never used this dressing for diabetic foot wounds. Dr. Karlock notes he usually employs the dressing only within the first three to four days after performing an incision and drainage of infections. Otherwise, he says he has no use for the traditional dressing.
However, Dr. Espensen maintains that wet to dry dressings are inexpensive, easy and readily available. He typically utilizes them for inpatients who have large wounds that need moderate debridement and frequent dressing changes (up to four times a day). Dr. Espensen adds that wet to dry dressings are still the standard of care to which newer dressings are compared in clinical research trials.
Q: What is your preference for a wound that has a red, beefy and clean granular base?
A: Dr. Jeffcoate prefers a simple, non-adherent dressing while Dr. Espensen typically uses a moisture-retentive dressing such as a hydrogel. Dr. Karlock prefers to use Bactroban 2% Cream. He concedes that some may question whether he is “overtreating” the wound with a topical antibiotic initially designed for MRSA infections. However, Dr. Karlock doesn’t think this is much of an issue. He says the Bactroban Cream allows moist wound healing and doesn’t tend to macerate the skin like some of the other products including hydrogels.
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.
Dr. Jeffcoate is a consultant diabetologist who first established a multidisciplinary clinic for the management of diabetic foot ulcers in 1982. Together with his colleague, Dr. Fran Game, Dr. Jeffcoate established the Foot Ulcer Trials Unit (www.futu.co.uk ) in 2002 at the City Hospital in Nottingham, U.K.
Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.