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Key Considerations With Dressing Selection In Wound Care

With the plethora of wound dressings available, how can you choose the right dressing for your patients? Assessing the merits and drawbacks of current and emerging dressings, these authors share their experience with multi-layer dressings, wound cleansers, dressings that facilitate wound debridement and others.

In our wound care practice, we diagnose and treat various etiologies of lower extremity wounds including diabetic foot ulcers, venous leg ulcers, pressure ulcers and other wounds. As there are hundreds of wound dressings and topical treatments available in the United States today, it is often a challenge for practitioners to match a particular wound to an appropriate dressing and topical treatment.

Although most dressing manuals may be divided by the ingredient (i.e., hydrogel, alginate, etc.), we took a different approach here to categorize the dressing products based on their functions. This article is not meant to be a comprehensive catalog of the products available in the U.S. Rather, this is a list of what we use in our institution and what has worked well in our hands.

Each clinician should choose one or two products from each category we list below based on the availability in the institution. Most dressings have a few years of shelf life and simplifying your dressing formula can minimize waste. In terms of cost perspective, the clinician needs to think of the wear time as well. For example, super absorbent dressings may appear expensive at first but if patients can wear them for seven days, these dressings may be cost-effective in comparison to conventional dressings that may need daily changes that have costs for material and labor.

We also encourage practitioners to keep an open mind and try out new products that come out every year as our dressing formulary has certainly evolved over time along with new inventions. We even encourage new practitioners to try on the new dressings themselves for a few days to see how they feel in terms of comfort.

Here is an overview of some topical treatment modalities available to wound care professionals in the U.S. We mention different categories of wound care dressings below with their active properties. One must keep in mind the importance in providing appropriate therapy while determining the dressings’ characteristics (i.e., matching the drainage amount). Consider patient comfort in selecting a dressing, which should maintain the moist wound condition and compression (when appropriate) to facilitate an optimal wound healing rate. Although it is our local wound care methods that heal the wound, we caution that improper topical treatment (for example, using Betadine on a clean, healing wound or an occlusive dressing on a moist wound) can impede wound healing.

Choosing An Effective Wound Cleanser

Use wound cleansers to remove contaminants, foreign debris and exudate from the wound surface, or to irrigate a deep cavity wound. The ingredients of wound cleansers may include surfactants, moisturizers and/or antimicrobials. There are dozens of different wound cleansers on the market that can help with reducing biofilm and cleansing of the wound in order to facilitate optimal wound healing.

Hypochlorous acid solutions. These products are relatively new to the wound market. Hypochlorous acid is a naturally occurring antimicrobial substance in white blood cells. Although it may sting slightly when one applies it to an open wound, hypochlorous acid is otherwise safe to use on open wounds and mucous membrane, including the mouth and eyes, as the acid is non-cytotoxic and rigorously tested for safety. We use hypochlorous acid solution, which has great anti-odor properties, frequently before and after wound debridement, and with applications of moistening dressings and dry skin substitute grafts. Brand example products of this category include Vashe Wound Solution (SteadMed Medical), Puracyn Plus (Innovacyn) and others.

Gentle wound cleansers. Gentle wound cleansers are water-based solutions with lubricants and humectants. This formulation may aid mechanical cleansing/debriding of acute and chronic wounds including stage I-IV pressure ulcers, diabetic foot ulcers, pre/post-surgical wounds and burns. Brand examples are WoundClenz OTC (Century Pharmaceuticals), 3M Wound Cleanser (3M) and others.

Antiseptic temporizing agents. This category of products is not appropriate for healing wounds. However, physicians frequently use antiseptic temporizing agents for their broad-spectrum antimicrobial property. Antiseptic temporizing agents may aid in controlling infections, deodorizing and temporizing infected or gangrenous wounds until you can debride the wound in a more thorough manner. In some cases, you may use these agents for palliative wound care to keep the wound (for example, a dry gangrenous toe) as aseptic as possible while you are working with vascular specialists for revascularization planning. Some of these products contain alcohol, which has a drying effect to control bacterial growth. Products for this category include Dakin’s Solution (Century Pharmaceuticals), Betadine solution (Purdue Pharma) and others.

What You Should Know About Dressings That Help Debride The Wound

In between debridements or in place of sharp debridement procedures, some dressings provide wound debridement in a mechanical, enzymatic, autolytic or biological manner. Along with sharp debridement, topical treatments help in removing non-viable tissues from the wound surface, which is an important first step that we cannot overlook.

Hydrogel. A hydrogel is a water-based gel that gradually rehydrates the wound surface. Due to the hydrogel’s osmotic fluid flow, which is aided by a naturally occurring enzyme (such as collagenase) in the human body, hydrogels can be helpful in cleaning chronic wounds covered with dry eschar and other chronic scar tissues with autolytic debridement. Many inexpensive and generic hydrogel products are available. We often use PluroGel Burn and Wound Dressing (Medline Industries), a new product with unique property that handles well, is 100 percent water-soluble and rinses off very easily.

Medical-grade manuka honey. Manufactured in New Zealand, manuka honey comes from certain species of flowers that are scientifically proven to be strongly antimicrobial, effective even against resistant strains of bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Since it contains high level of sugar, manuka honey is also an osmotic debriding agent that cleans out the wound along with the fluid movement from the wound base to the dressings. Manuka honey dressing comes in many forms, such as gel, hydrocolloid and foam. Brand examples in the manuka honey dressing family include ManukaHd (ManukaMed), MediHoney (Derma Sciences/Integra LifeSciences), TheraHoney (Medline Industries) and others.

Collagenase. Collagenase is a biologic ointment that breaks down collagen within the contaminated wound bed with enzymatic debridement action. As it is a biologic product and prescription item, collagenase can be expensive and cost-prohibitive for some patients. The only product available in the U.S. is Santyl (Smith & Nephew).

Medical-grade maggots. The Food and Drug Administration (FDA) has approved medical-grade maggots as a “medical device,” available as a jar or a bag of sterilized maggots. Patients have maggots over the wound for 48 hours at a time, wash them off with hydrogen peroxide and then reapply a fresh batch as necessary. As maggots have saliva that dissolves non-viable tissue but does not harm healthy skin, maggots do provide highly effective and selective debridement of chronic wounds. Disadvantages are the time-sensitive nature of the modality (one must order the maggots ahead of time), cost (an approximate cost of $100 per treatment) and the possible “yuck” factor experienced by the patient and your nursing staff. Manufacturers include Monarch Lab and BioMonde.

Pertinent Insights On Dressings With A Primary Contact Layer

The primary contact layer makes direct contact with the wound and it is important to select a dressing that is non-adherent to prevent unnecessary pain with dressing changes. We should note that traditional “wet-to-dry gauze” dressing fails in this regard. While the dressing can provide some mechanical debridement, it can be extremely painful upon removal unless the patient has diabetes with profound peripheral neuropathy.

It may also be beneficial to use an antimicrobial dressing in this primary contact layer, possibly to hasten the healing process and prevent wound infection. Although there is no real-life data supporting the claim that antimicrobial dressings may reduce wound infection, it is our position that antimicrobial dressings are well worth the cost (usually $1 more per dressing versus non-antimicrobial counterparts). This is because we are creating a moist wound environment on often heavily contaminated, biofilm-covered chronic wounds. Furthermore, wound infection can be devastating in some of our frail patients, leading to limb loss, sepsis or even death.

Bacteria-binding plastic mesh. This is a thin layer of plastic mesh with an antimicrobial, bacteriostatic coating that is inexpensive and effective in infection control. As bacteria-binding plastic mesh is a dry plastic piece of contact layer, it passes fluid and moisture freely, and one can use the mesh for any type of wounds. Also, we have yet to see an allergic reaction to this particular dressing after using it on thousands of patients since its introduction. A brand example is Cutimed Sorbact WCL (BSN Medical).

Petrolatum contact dressings. A 3% bismuth-infused petrolatum-impregnated gauze (Xeroform, Covidien) is an inexpensive and widely available non-adherent gauze dressing. Bismuth is an antiseptic agent that is also anti-odor. Bismuth gives a bright yellow color to the otherwise pale and non-adherent plain petrolatum (Vaseline) gauze, also known as Adaptic (Acelity) and other dressings. We often use these dressings over the incision line as the first line of defense in incision protection and the dressings are easy to remove. Note that these petrolatum gauze dressings can be more occlusive than the regular gauze or plastic mesh as we have noted above. When our patients are allergic to bismuth, we may use Cutimed Sorbact, plain petrolatum gauze or a silicone-adhesive plastic mesh dressing (such as Mepitel (Mölnlycke Health Care)) instead.

Silver-coated primary dressings. Metal ions, such as silver and iodine, are antimicrobial. Silver ion is strongly antimicrobial regardless of the strain or resistance level. Silver can be infused in various contact layer or absorbent dressings, such as alginates or hydrofiber dressings, presumably to reduce the bacteria count of the wound surface and reduce the infection rate. Brand examples are Acticoat Antimicrobial Barrier Dressing (Smith and Nephew), Silvercel (Acelity), Aquacel Ag (ConvaTec) and Mepilex Ag (Mölnlycke Health Care) and many others.

Selecting A Dressing With A Secondary Absorbent Layer

Super absorbent dressing. Some dressings are combination products of non-adherent mesh with polymer dressing that absorbs a large amount of fluid in order to prevent periwound maceration. Some of these dressings are thin and one can layer the dressings on top of one another to increase the fluid absorption. Super-absorbent dressings work well with the multi-layer compression layer dressing clinicians use for venous leg ulcers and patients can change these dressings once a week. Brand examples includes Cutisorb (BSN Medical) and Drawtex (SteadMed Medical).

Polyurethane foam dressing. This is a wide category of dressings that are cushioned, absorbent and protective to the wound bed as well as for bony prominences. A bordered foam dressing is simply a foam dressing with adhesive plastic backing, which allows patients to shower when they apply the dressing carefully without wrinkles. Some border foams also feature silicone adhesive to minimize iatrogenic skin tears upon removal. The latest research on pressure ulcers suggests that applying bordered foam dressings on bony prominences reduces pressure ulcer development.1 In our institution, physicians apply bordered foam dressings to the buttocks and posterior heels on every ICU patient as well as pressure ulcers for high-risk patients on the regular floors of the hospital. Brand examples include Allevyn Life (Smith and Nephew), Mepilex Border (Mölnlycke Health Care) and RTD Wound Dressing (Keneric Healthcare).

“Do-it-yourself” combination dressings. You can improvise and combine any “primary contact layer” and “secondary absorbent layer” to create super absorbent dressings. Our favorite is to combine a Cutimed Sorbact contact layer with a foam dressing to create a non-adherent, soft, protective and super-absorbent combination. You may add abdominal pads to this combination if you want additional padding and absorbency.

What You Should Know About Multi-Layer Compression Bandages

For patients with venous disease or lymphedema, the application of graduated multi-layer compression bandages can decrease lower extremity edema and facilitate wound healing by forcing fluid from the interstitial spaces back into the venous and lymphatic compartments. While one wraps the bandage with constant stretching tension, the circumference of leg decreases as you move from calf to the ankle, thus providing “graduated compression” with the highest pressure at the ankle.

Although we have used two- to five-layer compression bandage systems, the end results are the same and they are all designed to provide anywhere between 20 and 40 mmHg compression at the ankle. We should note that applying this kind of dressing takes certain skills and several minutes. Additionally, there is a CPT code 29581 (+ laterality modifier) for getting reimbursed for the “application of multilayer compression bandage.” Brand examples include Jobst Comprifore Multilayer System (BSN Medical), Profore (Smith and Nephew), 3M™ Coban™ 2 Two-Layer Compression System (3M) and others.

A Few Thoughts On Cellular And Tissue-Based Products And Skin Grafts

Relatively new products in the wound care market for the last decade, cellular and tissue-based products and skin grafts are among the game changers that have dramatically improved our wound closure rate versus standard of care. In general, we categorize them as human-cell based versus animal-product based grafts.
Human-cell based grafts are rather expensive but work remarkably well in wound closure versus moist wound dressings (standard of care). Brand examples include EpiFix (MiMedx), NuShield (NuTech/Organogenesis), Apligraf (Organogenesis), AlloDerm (BioHorizons) and others.

On the other hand, animal-based products are often synthesized from animal byproducts, such as porcine intestines, bovine tendon collagen, fish skin and others. Brand examples includes Oasis Wound Matrix (Smith and Nephew), PuraPly (Organogenesis), Integra Wound Matrix Dressing (Integra LifeSciences) and others. These grafts may be more inexpensive than human-based products but we find they may be less efficacious in wound healing. Having said that, we may never see head-to-head studies of these grafts as it may be cost-prohibitive to conduct such studies. We should mention that all these grafts are reimbursable for the technical application fee (CPT codes 15271-15275) as well as for the material itself (Q-code with four-digit numbers).

How Split-Thickness Skin Grafts Can Work Alongside Dressings

Although split-thickness skin grafts (STSG) are not dressings, we would like to include this surgical approach to achieve swift wound closure by using the patient’s own skin as an autograft. One usually obtains the STSG in a hospital setting. The STSG is most appropriate for chronic wounds that failed cellular and tissue-based grafts. A STSG is also appropriate for a large open wound that requires immediate coverage. One example would be a third-degree burn excision in the OR.

Harvest sites are often an ipsilateral inner calf, plantar foot or lateral thigh. We can further categorize STSG as thin (0.005-0.012 inches), intermediate (0.012-0.018 inches) or thick (0.018-0.030 inches), based on the thickness of the harvested graft. The most commonly used STSG in our setting is the intermediate 0.012 to 0.018 inches, given that we use STSG for granular wound bed coverage. It is important to dress the STSG application site with a compression dressing or negative pressure wound therapy (NPWT) to avoid seroma and hematoma, which can lead to graft failure.

Salient Insights On NPWT In Healing Wounds

For large, gaping or tunneling wounds, NPWT has been the gold standard therapy for the last 20 years. Delivering negative pressure at the wound site through a unique, proprietary dressing helps draw wound edges together, remove infectious materials and actively promotes the formation of granulation tissue. In our experience, NPWT facilitates granulation tissue formation about twice as fast as conventional dressings. We have found NPWT is also useful in covering exposed tendon and bones as long as good blood flow is established to the area.

Portable, disposable NPWT devices are also available but insurance reimbursement has been a challenge. Today, we have a NPWT device that allows continuous instillation and irrigation of the infected wounds, and instillation can reduce the length of stay in the acute-care hospital setting.2

Similarly, one may place NPWT along an incision to prevent dehiscence in certain surgical closures. Brand examples include the VAC Therapy System (Acelity), Invia (Medela) and Renasys (Smith and Nephew) and others.
 
Other Useful Modalities For Wound Healing

Hyperbaric oxygen therapy (HBOT). Hyperbaric oxygen therapy is a medical therapy that involves a patient being in a monoplace or multiplace chamber so he or she can breathe 100 percent oxygen in a pressurized room or chamber, 60 to 90 minutes at a time, at a pressure of 2.0 ATA or above. Under these conditions, the oxygen concentration in the plasma increases 10-fold temporarily, delivering therapeutic effects that last for several hours. In most cases, the patient has daily treatment for 20 to 30 sessions to achieve the maximal therapeutic effects. We should note that HBOT is an adjunct therapy alongside proper local wound care and may be helpful for deep diabetic foot ulcers (Wagner grade 3 or worse), severely infected wounds, compromised flaps or radiation wounds.

On the other hand, physicians administer so-called “topical” hyperbaric oxygen therapy in a chamber that encases an extremity and applies pressurized oxygen. Unfortunately, the oxygen absorption through the skin or wound base is minimal. Even though patients may benefit from air compression providing some form of therapeutic effect, the Undersea and Hyperbaric Medical Society does not recognize topical oxygen as true HBOT.3

Pneumatic compression pumps. These pumps are durable medical equipment that provide pneumatic compression therapy via inflatable sleeves and an electric programmed compression pump. One can use pneumatic compression pumps to treat chronic vascular problems such as lymphedema and venous insufficiency, including venous leg ulcers. Although we have found that insurance coverage is making it increasingly difficult to provide these devices at minimal cost to our Medicare patients, patients can purchase similar devices from Amazon.com, etc. Brand examples include Flexitouch System (Tactile Medical), NormaTec Pneumatic Compression Device (NormaTec Medical) and others.

Platelet-derived growth factor (PDGF) gel. Although its FDA indication is limited to diabetic neuropathic foot ulcers, PDGF gel stimulates fibroblast proliferation to increase growth of granulation tissue. When one uses this appropriately as an adjunct to good ulcer care, PDGF can increase the rate of wound closure.4 The drawback is that PDGF is a prescription item and can be expensive to some patients. Clinicians also need to refrigerate the PDGF gel to ensure its effectiveness. Currently, Regranex (Smith and Nephew) is the only such product available in the U.S.

Dr. Suzuki is a staff physician of the Department of Surgery at Cedars-Sinai Medical Center in Los Angeles. Dr. Suzuki can be reached at Kazu.Suzuki@cshs.org.

Dr. Samouhi is a Chief Podiatric Surgical Resident at Cedars Sinai Medical Center in Los Angeles.

References

1.    Mölnlycke Health Care. Available at http://www.molnlycke.us/Documents/GLOBAL%20-%20ENG/Wound%20Care/ConsesusStatement.pdf
2.    Kim PJ, Attinger CE, Crist BD, et al. Negative pressure wound therapy with instillation: review of evidence and recommendations. Wounds. 2015; 27(12):S2–S19.  
3.    Weaver LK. Hyperbaric Oxygen Therapy Indications, Thirteenth Edition, 2014. Available at https://www.uhms.org/images/indications/UHMS_HBO2_Indications_13th_Ed._Front_Matter__References.pdf .
4.    Wieman TJ, Smiell JM, Su Y. Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebo-controlled double-blind study. Diabetes Care. 1998;21(5):822-827.

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By Kazu Suzuki, DPM, and Pegah Samouhi, DPM
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