These expert panelists discuss which dressings to use for diabetic foot ulcers (DFUs), venous leg ulcers and pressure ulcers with varying degrees of drainage.
What are the most effective dressings to use with DFUs with no or mild drainage? What about DFUs with heavy drainage?
For Kazu Suzuki, DPM, CWS, dressing selection is mostly based on the location of each wound, the drainage amount and the personal preference of the patient. Often, he has to negotiate with patients on dressing preferences and what is the most appropriate dressing. For example, Dr. Suzuki says most patients prefer plastic adhesive-based bordered dressings (i.e. Mepilex Border, Mölnlycke Health Care) that allow them to shower normally. However, he notes such dressings may not be appropriate for a heavily draining wound or for patients with a sensitivity or allergy to the adhesive.
Barbara Aung, DPM, uses an alginate or foam dressing for DFUs with no or mild drainage. She notes that increased drainage could indicate infection or critically colonized wounds. Dr. Aung says alginates also work well to absorb heavy drainage.
In a neuropathic diabetic foot ulcer that has minimal to no drainage, Lawrence Karlock, DPM, will use a topical antibiotic such as mupirocin ointment once a day with a sterile dressing. He notes that mupirocin does not macerate wounds as other topicals can. Dr. Karlock recommends moist wound healing in wounds that have good granulation tissue.
For typical diabetic foot ulcers on the plantar foot or hallux, Dr. Suzuki utilizes polyurethane foam dressings with antimicrobial properties (i.e. RTD Foam Dressing, Keneric Healthcare, or Mepilex Ag, Mölnlycke Health Care). He applies the foam dressing directly to the wound or along with an antimicrobial contact layer (i.e. Cutimed Sorbact Wound Contact Layer, BSN Medical), and then wraps the foot with gauze wrap or a multilayer compression bandage. As Dr. Suzuki says, the goal is to have a thick dressing interface to cushion the wound bed and disperse any shearing forces from ambulation.
For a diabetic foot ulcer with no to mild drainage, Christopher Winters, DPM, prefers Mepitel (Mölnlycke Health Care) or Promogran Prisma (Acelity) with a foam that will allow some pressure relief and drainage absorption. For a DFU with heavy drainage, he prefers either Drawtex (Beier Drawtex Healthcare) or Mepitel Foam (Mölnlycke Health Care). Dr. Winters notes these dressings are very effective at absorbing moisture and holding it in place away from the wound.
In a wound that is heavily draining, Dr. Karlock will use an alginate-based product with or without the addition of silver. If the wound has a large amount of drainage with a macerated hyperkeratotic halo, he will use “good, old-fashioned” topical iodine. Dr. Karlock cites a review noting that topical iodine is an effective topical antibiotic, which does not impede wound healing.1 He also notes that iodine is effective against both Gram positive and Gram negative organisms, is inexpensive and will not cause any acquired bacterial resistance.
Most patients visit Dr. Suzuki’s wound care center once a week for a dressing change if the wound has no to minimum drainage. If the diabetic foot ulcer has heavy drainage, he may instruct the patient to change the dressing two or three times a week (or even daily), perhaps with the help of home health nurse visits or their own private caregivers. For heavily draining DFUs, Dr. Aung concurs. She instructs patients to change the dressings every two to three days until the drainage is controlled or perhaps once a day until there is reduced drainage. Once this occurs, then the patient can change the dressing less frequently (every five to seven days).
What are the most effective dressings to use with venous leg ulcers with no or mild drainage? What about venous ulcers with heavy drainage?
Dr. Winters would use Mepitel as a skin protectant for venous leg ulcers with mild drainage or a moisturizer such as CeraVe cream (CeraVe) with mild compression.
Dr. Aung ensures maximum offloading and applies multilayer compression dressing if the patient’s circulation status allows.
For venous leg ulcers, Dr. Suzuki recommends antimicrobial foam dressings with or without an antimicrobial contact layer, although he emphasizes the importance of concurrent compression to control the leg edema. Since venous leg ulcers tend to drain more than any other type of leg wounds, Dr. Suzuki recommends erring on the side of a wound dressing with high absorbency. He says there are many “super absorbent” wound dressings available and he uses them often along with an antimicrobial contact layer.
For heavily draining venous leg ulcers, Dr. Winters tends to use a combination of Promogran Prisma and a foam, preferably Mepitel. He will then use a three- or four-layer compressive dressing if the patient has adequate arterial circulation
Dr. Karlock recommends alginates to absorb a mildly or heavily draining venous wound, and combining that with aggressive compression therapy in a non-ischemic leg. He is “quick to use” skin substitutes on venous wounds if they become stagnant and no progress occurs clinically.
To control leg edema, Dr. Suzuki recommends judicious use of oral diuretics, leg elevation using recliner chairs, a pneumatic leg pump, a compression garment—including CircAid (Medi) or FarrowWrap (Jobst)—or multilayer compression bandages (i.e. Comprifore, BSN Medical).
What are the most effective dressings to use for pressure ulcers with no or mild drainage?
In pressure ulcers, especially heel pressure ulcers that have minimal drainage, Dr. Karlock will sometimes use a hydrocolloid dressing although he cautions that hydrocolloids can macerate a draining ulceration.
If there is dry eschar on heels, Dr. Suzuki says one could hydrate and soften the eschar by applying hydrogel or medical honey gel although he notes the complete removal of these thick eschars may take a few weeks.
Applying a bordered foam dressing (i.e. Mepilex Border) to bony prominences, especially posterior heels, actually reduces the incidence of pressure ulcers, according to Dr. Suzuki. For this reason, he uses bordered foam dressings as a preventative measure for all the ICU patients and high-risk patients (using the Braden Scale) on the regular (non-ICU) floor in his institution.
Dr. Winters uses foam dressings for pressure ulcers. In addition to alternate methods of pressure relief, he says foam dressings are best for ulcers with no or mild drainage as they give good pressure relief, and are comfortable for the patients.
Mohamed Hassan, DPM, notes that “the more expensive the dressing does not mean it is more effective.” He adds that sometimes, the opposite is true. Dr. Hassan emphasizes that an individualized treatment plan based on the patient’s health, comorbidities, psychological and socioeconomic status as well as the physical ability to care for the wound will play more major roles in healing an ulcer than the most expensive dressing.
Dr. Suzuki notes the goals with pressure ulcers are achieving cushioning and sheer force reduction as well as offloading. He often sees heel pressure ulcers or lateral ankle pressure ulcer over the lateral malleolus, which one can effectively “float” using Heelmedix (Medline) or the Prevalon boot (Sage Products) that are soft and bulky heel boots with heel cut-outs.
Dr. Aung tends to apply the dressing based on the current makeup of the wound, namely drainage or types of tissues present such as slough or necrosis, rather than the cause of the ulcer. Dr. Aung cites the efficacy of compression if the cause is deep vein disease, which often does not lend itself to vascular intervention.
Do you use antimicrobial wound dressings?
Although he notes a lack of robust medical evidence that antimicrobial dressings reduce the wound infection in vivo in actual patients, Dr. Suzuki is “a big advocate” of using antimicrobial dressings.
“As we create a semi-occlusive, warm and moist environment to the wound bed on purpose, sometimes a week at a time, I believe it makes a lot of sense to use silver or an otherwise bactericidal or bacteriostatic dressing to minimize the bacterial overgrowth,” explains Dr. Suzuki.
Anecdotally, Dr. Suzuki has seen a case of cellulitis when he ran out of antimicrobial dressing and had to use conventional dressings. In this case, it was regular Mepilex instead of Mepilex Ag. Saying silver dressings are only $1 to $2 more than the conventional wound dressings, he calls it “money well spent” to minimize wound infection and facilitate the best outcome in a wound care practice.
Dr. Winters uses antimicrobial dressings when he suspects a heavy biofilm environment. In these cases, he prefers Promogran Prisma and Iodoflex (Smith and Nephew). He does not rely solely on antimicrobial wound dressings in the presence of infection but says they are a good adjunct to debridement and antibiotics if necessary.
Dr. Aung is in private practice in Tucson, Ariz. She is a certified professional medical auditor and member of the American Academy of Professional Coders.
Dr. Hassan is a first-year resident at the Forum Health Podiatric Residency Program in Youngstown Ohio.
Dr. Karlock is in private practice in Austintown, Ohio. He is a Clinical Instructor for the Forum Health Podiatric Residency Program in Youngstown Ohio.
Dr. Suzuki is the Medical Director of the Tower Wound Care Centers 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 at Kazu.Suzuki@cshs.org.
Dr. Winters is affiliated with the American Health Network in the Indianapolis area and many hospitals in Indiana. He is board-certified in wound care by the Council for Medical Education and Testing, and is board-certified in the prevention and treatment of diabetic foot wounds and footwear by the American Board of Multiple Specialties in Podiatry.
1. Bigliardi PL, Villa MA. Povidone iodine in wound healing: a review of current concepts and practices. Int J Surg. 2017; 44:260–8.