Navigating the different stages of chronic wound healing can be quite challenging. Accordingly, these authors review the role of proper wound dressing selection and pros and cons of dressings ranging from gauze and hydrocolloid dressings to calcium alginate dressings and foams.
Chronic skin ulcerations affect millions of people in the United States with an attributable annual cost of at least $3.6 billion.1 In addition to the tremendous financial burden, the prolonged and sometimes interrupted healing process associated with chronic wounds can affect the patient’s quality of life due to impaired mobility and substantial loss of productivity.
Chronic wounds also pose a significant management challenge to healthcare professionals.2 Technical advances along with better understanding of the complex cellular and biochemical mechanisms of the wound healing process have led to the development of a plethora of wound dressings over the past decade. It is often difficult to navigate through the extensive array of dressing choices.
Wound healing is an orchestra of highly integrated cellular events as opposed to a defined single event. Successful wound management requires an understanding of the healing process along with knowledge of the properties of the various available dressings. While the ultimate goal in most cases is prompt healing, one must remember that this is a dynamic process requiring a series of adaptive smaller goals as the wound progresses through the repair trajectory. One should select dressings to best suit the various stages of wound healing.
Most challenges arise with chronic wounds where healing fails to proceed through an orderly and timely process. When this occurs, wounds stagnate and may deteriorate. While a topical dressing may be part of the solution, one should investigate reasons for the relapse. To heal, wound beds must have balanced hydration, an advancing wound edge and be free of necrotic tissue and critical colonization.3-5 Other factors that can impair wound healing include repeated trauma and compromised host or vascular status.6-8
The most advanced dressing will be ineffective if one does not address factors that impede healing. Arbitrary dressing selection can result in unnecessary cost with an increased risk of complications associated with delayed wound healing.
Wound care is a holistic practice. Consider multiple factors prior to initiating therapy including the ability, accessibility and resources of the patient and care provider. What is labeled as non-adherence may be instead an inability to follow through with the plan of care due to physical, social and/or community barriers.9 Dressing cost may be another deterring factor. Prescribing a dressing that is not reimbursed or is too costly for the patient may lead to inadequate follow through.
How Dressings Enhance Healing
Wound dressings, for the most part, facilitate preparation and advancement of the wound bed.10 The ideal dressing should provide a moist healing environment, infection control, pain relief, and be easy and safe to use.11 Dressings for diabetic foot ulcers should be able to withstand shear forces, absorb exudates, allow for drainage and not be too bulky in the shoe.12 Dressings can assist with debridement, trauma protection, reduction of hypergranular tissue, inflammation and bacterial load. Dressings can also facilitate neovascularization, granulation and epithelial growth.13 Treatment goals may progress through autolytic debridement, subsequent granulation formation and drainage absorption, and finally the enhancement of reepithelialization. Repeated assessment is essential since the initial dressing protocol may not be appropriate to closure.
Wound dressings can be passive, active or interactive. Passive dressings mainly serve as a wound covering to protect the wound. Active dressings deliver topical treatments to the site and create a moist environment. Interactive dressings not only create a moist wound environment but also interact with the wound bed components to further promote wound healing.14
A Guide To Indications And Contraindications For Gauze Dressings
Plain gauze is a passive dressing, which clinicians may use as primary or secondary cover dressings or as packing material. Gauze comes in woven and non-woven sponges and rolls. Non-woven dressings have longer strands than woven dressings and create a stronger pad with improved fluid wicking properties.
When cut, woven gauze can leave fibers in the wound, acting as a foreign body and perpetuating inflammation.15 Rolled gauze does not have high retentive qualities unless thickly layered. While these dressings are inexpensive, they require frequent changing and ultimately incur higher cost due to care time and the volume of product used.16
The “wet to dry saline gauze dressing” is no longer recommended because of its properties of non-selective debridement, disruption of newly formed tissue and pain upon dressing removal.17
What You Should Know About Hydrogel Dressings
Hydrogel dressings can hydrate and maintain a moist wound bed as well as liquefy necrotic tissue. Hydrogels are cross-linked polymer gels that are comprised of up to 80 percent water and may contain other materials depending on the manufacturer. Hydrogels are non-adherent so they do not harm the wound bed or surrounding skin. Selection of a specific hydrogel dressing depends on the amount of moisture required by the wound, frequency of dressing changes, depth of the wound, bacterial load and the amount of necrotic tissue. Keep in mind that the frequency of dressing changes with hydrogels must be able to sustain a moist wound bed status.
Hydrogel dressings come in gel, sheet, impregnated gauze and gelatinous fibers. The gel form and impregnated gauze donate the most moisture and are indicated for wounds that have a drier base.18 If hydrogel impregnated gauze is unavailable, one can use plain non-woven gauze impregnated with the gel.
While sharp debridement of a wound is often the first choice in wound debridement, clinicians may not fully accomplish this in the office setting and patients will need continued treatment at home.19,20 In cases of established eschars, the use of cross hatching and wound gel/impregnated gauze can initiate autolytic debridement.21 To avoid peri-ulcer skin irritation, regular dressing changes with cleaning/irrigation and maintenance debridement of liquefied tissue are necessary. Hydrogel sheets are useful for autolytic debridement of thinner non-viable tissue and to maintain moisture in an adequately hydrated but minimally draining wound. Dressing changes every three to seven days are usually adequate. Hydrogels may also maintain tendon integrity.22
Hydrogel dressings are considered primary dressings as one applies them directly onto the wound. Most insurance plans will approve a secondary or cover dressing for the wound in combination with hydrogel dressings. Gauze pads or foams are acceptable choices as secondary dressings.
There are few contraindications to the use of hydrogel dressings. They are not suitable for highly draining wounds and one should not use them on dry, stable eschar in a limb with poor arterial circulation until obtaining vascular consultation. Softening the eschar can allow for bacterial introduction and lead to gangrene.23
Maximizing The Efficacy Of Hydrocolloid Dressings
Hydrocolloid dressings generally consist of a semi-permeable film coated with an absorbent mass of sodium carboxymethylcellulose, pectin or gelatin. Upon contact with wound fluid, these occlusive dressings slowly gel and maintain a moist wound environment. Furthermore, they do not allow oxygen, water or bacteria into the wound. Accordingly, researchers believe these dressings facilitate angiogenesis, granulation and a slow autolytic debridement.24
One can use hydrocolloids on both full and partial thickness wounds. However, they are not suitable for highly draining or infected wounds as they have limited absorptive qualities and can promote maceration of the periulcer skin. The dressings can stay in place for three to seven days and are commonly used in settings such as home care and facilities where sharp debridement is not readily available. Their multiday wear time can decrease costs associated with care.25 Additionally, hydrocolloid dressings can help decrease pain at the wound site.26
Two common complaints associated with these dressings are the odor and murky drainage noted at time of dressing removal. Liquefied necrotic tissue is generally tan or brownish in color with an odor, and is often mistaken for purulent drainage. One should evaluate the wound for infection after cleansing, not immediately upon removal of the dressing.
Sharp debridement can be painful for venous leg ulcers. Hydrocolloids are an acceptable initial dressing choice for use under compression, especially when the wound has dry, fibrous slough. The dressing will soften the dry fibrous slough to facilitate sharp or mechanical debridement after one to two dressing changes. One can also use hydrocolloid dressings in conjunction with offloading for gentle debridement of posterior heel decubitus ulcers. However, plantar ulcers may be a relative contraindication for hydrocolloid dressings as they can cause maceration of tissue due to dependent drainage.
Hydrocolloids come in several forms with the most common form being a sheet with or without an adhesive border. One can use a hydrocolloid as a primary dressing, as a secondary dressing over an alginate when the drainage is moderate, or even over a hydrogel to further facilitate autolysis. Hydrocolloids are not cost effective for wounds that require more than three dressing changes a week. Similar to hydrogels, hydrocolloids are not appropriate for arterial wounds with dry stable eschar until there has been a team consultation.23,27
Pertinent Insights On Using Absorptive Dressings
Pedal and lower leg wounds are often associated with moderate amounts of drainage secondary to the dependent position. It is important to manage this in order to maintain moist wound healing and prevent maceration and subsequent destruction of peri-ulcer skin.28
In cases of high volume drainage, especially in the presence of edema, consider using a multilayer compression bandage with a layer of cast padding for absorption to wick away the drainage from the wound site until the drainage decreases and one can otherwise manage the wound.
When To Employ Calcium Alginate And Hydrofiber Dressings
Calcium alginate dressings are derived from the alginic acid that is extracted from brown seaweed. The gelatinous substance that is created during the filtering process can absorb up to 20 times its own weight. One can use these dressings to absorb wound exudate. The gel that forms upon wound fluid contact wicks away the bulk of the drainage from the wound bed and maintains a non-adherent moist environment conducive to healing. Alginates also have hemostatic properties.29
Calcium alginate dressings can reduce or prevent maceration of the peri-ulcer skin. However, with some alginates, once the gel has formed, the product liquefies and loses retentive properties. The frequency of dressing changes varies pending the amount of drainage. Highly exudative wounds may require daily changes while moderately exudative wounds may require changes twice a week.
Alginates are considered primary dressings and one should cover these with a secondary dressing of gauze, foam or hydrocolloid. Calcium alginate is not indicated for non-draining wounds or those with eschar as the dressing will further dry the wound bed. If the alginate adheres to the wound at the time of dressing change, one should modify the dressing plan either to use a non-adherent contact layer under the alginate or a different type of dressing altogether in order to avoid disruption of the healing tissue.30
Hydrofiber® dressings (Aquacel®, ConvaTec) are another choice for exudate absorption. These products gel at a faster rate than both alginates and hydrocolloids. They also retain their integrity with the dressing fibers remaining insoluble, thereby facilitating dressing removal.31
What About Foam Dressings?
Foam dressings are absorbent pads generally made from hydrophilic polyurethane foam. Available products have various absorption rates but as a class are moisture retentive and can remain in place for three to seven days depending on the amount of drainage. Due to their ability to maintain a balanced moisture environment, foam dressings can facilitate autolytic debridement. Some foam dressings have non-adherent contact layers and are good choices for fragile wound beds with drainage. Researchers have also found that these dressings decrease pain associated with dressing changes.26
Foam dressings offer additional padding over bony prominences and are comfortable and easy to apply. They come with or without adhesive borders and in a variety of shapes including heel dressings. Foams are an effective choice for use under compression bandaging with higher drainage. However, once saturated, foams can cause maceration if one does not change these dressings with appropriate frequency.
What Are The Advantages Of Non-Adherent Dressings?
Dressings should not adhere to the wound bed as disrupting the base may impede healing and cause discomfort to the patient.32 Hydrocolloids, alginates and hydrofibers, once gelled, will not adhere to the wound bed. Some foams have specialized non-contact layers to prevent damage to newly granulated tissue or surface reepithelialization. Several companies specifically offer patented non-adherent contact layers as part of their product lines.
Depending on the volume of wound care in your practice, it may be cost effective to carry these dressings. However, in some practices, it may be more frugal to carry the petroleum-based, non-adherent products.
Petroleum gauzes are thickly impregnated, retain moisture and will not allow drainage to pass through and lead to wound/peri-wound maceration. Do not use petroleum gauze on heavily draining wounds. One brand of petroleum impregnated gauze also includes 3% bismuth tribromophenate, which is helpful in deodorizing wounds.
Oil emulsion dressings are made of a knitted cellulose acetate fabric coated with a formulated petroleum emulsion. The knitted fabric allows wound fluid to move through the dressing and into a secondary absorbent dressing. These dressings are inexpensive, come in a variety of sizes and one can use them as a base primary dressing on the majority of wounds. However, oil emulsion dressings will dry out in one to two days when there is not significant drainage. Clinicians need to cover these dressings with a secondary moisture retentive dressing.
What You Should Know About Transparent Dressings
When waterproof or water resistant dressings are unavailable, a transparent dressing can be a waterproof secondary dressing on non-weightbearing surfaces and allow patients to shower. They conform nicely around toes and one may use them over small pieces of hydrocolloid or alginate.
Transparent dressings come in a variety of sizes and shapes, and are relatively inexpensive. They have no absorptive capabilities and one should not use them on a wound with more than scant drainage. However, clinicians can use these dressings on partial thickness wounds to facilitate autolysis due to their moisture retentive qualities.
Chronic wounds are associated with a high fiscal burden and decreased quality of life. Considering the volume of wound dressing choices on the market today, practitioners need to examine their practices and determine the products that would serve their populations best. Knowledge of the basic products, thorough wound care assessments and awareness of the patient’s needs and capabilities are essential factors to consider in optimal dressing selection in order to minimize the cost of care and complications associated with prolonged healing.
Dr. Wu is the Director of the Center for Lower Extremity Ambulatory (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. She is an Associate Professor for the Center for Stem Cell and Regenerative Medicine at the School of Graduate and Postdoctoral Studies at the Rosalind Franklin University of Medicine and Science. She is also an Associate Professor in the Surgery Department and the Associate Dean of Research at the aforementioned Scholl College of Podiatric Medicine.
Ms. Rivera is an instructor at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago. She is also a nurse practitioner with a specialty in wound and foot care at the Center for Lower Extremity Ambulatory Research (CLEAR).
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