dressing selection in chronic wound management

7/28/2019 Dressing Selection in Chronic Wound Management

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24 January 2002 Vol 92 No 1 Journal of the American Podiatric Medical Association

Prior to 1960, the ideal wound healing environment

was believed to be dry, and the goal of therapy was

crust or scab formation.1 To achieve this goal, clini-

cians used dressing products made from cotton or

wool that functioned mainly to cover and conceal the

wound.2, 3 Dressings were generally thought to be

unimportant in the healing process. This viewpoint

was challenged by groundbreaking research by Win-

ter4 demonstrating that epithelialization in partial-

thickness porcine wounds occurred two times fasterin a moist versus dry environment. Hinman and

Maibach5 substantiated these findings in human par-

tial-thickness wounds, leading to the concept that

dressings have the potential to interact with the

wound environment and affect healing instead of act-

ing as passive coverings.

Wound healing experts now accept that a moist

wound environment is advantageous to wound heal-

ing. Benefits include enhanced keratinocyte and fibro-

blast proliferation, keratinocyte migration, collagen

synthesis, angiogenesis, wound contraction, autolytic

debridement, and wound closure.6, 7

However, despiteevidence supporting moist wound healing, many clin-

icians fear that the same environment that promotes

wound healing also supports bacterial growth and

wound infection.8 Hutchinson and McGuckin9 per-

formed a secondary analysis of over 100 studies com-

paring infection rates in more than 4,000 wounds

treated with occlusive dressings or nonocclusive

conventional dressings (predominantly gauze) and

found that the overall infection rate was 2.6% with

occlusive dressings versus 7.1% with conventional

dressings (P< .001). The decreased infection rate of

occlusion dressings may be secondary to the large

number of activated neutrophils present in the

wound fluid, the prevention of exogenous bacterial

contamination, and the prevention of tissue desicca-

tion and necrosis, which provide a culture medium

for bacteria.9-11 Thus, the evidence supports the con-

cept that a moist wound environment is beneficial tohealing and results in a decreased risk of infection.

In the last three decades, hundreds of dressings

have been developed that provide a moist wound en-

vironment. Clinicians should be aware of the charac-

teristics of an ideal dressing and be able to differenti-

ate between the different dressing categories so that

appropriate decisions regarding topical therapy of

chronic wounds can be made.

Characteristics of an Ideal Dressing

The ideal dressing maintains a moist wound environ-ment, absorbs excess exudate, eliminates dead space,

does not harm the wound, and provides thermal in-

sulation and a bacterial barrier. The clinician can

judge the potential performance of a dressing by ex-

amining it for these characteristics.

A dressing that maintains a moist wound environ-

ment is described as moisture retentive.6 The degree

of moisture retentiveness is measured by the mois-

ture vapor transmission rate.6, 7, 12 This rate, often re-

ported as g/m2/24 hr, refers to the passage of water

Dressing Selection in ChronicWound Management

Susie Seaman, MSN, NP, CETN*

The concept of moist wound healing has been examined and gradually

accepted by wound care clinicians during the last 40 years, and has led to

the development of hundreds of dressings that support a moist wound en-

vironment. This article discusses the characteristics of an ideal dressing

in an effort to assist clinicians in making appropriate dressing choices

from common categories, including transparent films, hydrocolloids,

foams, absorptive wound fillers, hydrogels, collagens, and gauzes. Reim-

bursement issues are also discussed. (J Am Podiatr Med Assoc 92(1):

24-33, 2002)

*Nurse Practitioner, Grossmont Hospital Wound Healing

Center, 5555 Grossmont Center Dr, La Mesa, CA 91942.


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Journal of the American Podiatric Medical Association Vol 92 No 1 January 2002 25

vapor from the wound bed, through a dressing, to the

outside environment. A dressing is moisture reten-

tive when its moisture vapor transmission rate is less

than 840 g/m2/24 hr.10 The moisture vapor transmis-

sion rate varies widely among dressings. Occlusive

dressings, such as hydrocolloids, have a moisture

vapor transmission rate of less than 300 g/m2/24 hr;

more permeable dressings, such as gauzes, have amoisture vapor transmission rate of 1,600 g/m2/24 hr.6

In comparison, the transepidermal water loss rate, a

concept similar to moisture vapor transmission rate,

is 4 to 9 mg/m2/hr (96 to 216 g/m2/24 hr) in intact skin,

and 80 to 90 mg/m2/hr (1,920 to 2,160 g/m2/24 hr) in

partial- and full-thickness wounds.13, 14 Generally, a

moisture-retentive, occlusive dressing with a low

moisture vapor transmission rate is used to maintain

a moist wound bed in dry or low-exudating wounds.

In contrast, wounds with high amounts of exudate re-

quire a more permeable dressing with a high moisture

vapor transmission rate. As this dressing absorbsdrainage, it evaporates off into the environment.

Using a dressing with a low moisture vapor transmis-

sion rate on this type of wound would result in dress-

ing leakage, periwound skin maceration, and the need

for frequent dressing changes. The clinician should be

familiar with the general moisture vapor transmission

rates for the different dressing categories so that ap-

propriate dressings can be prescribed.

Although a moist wound environment is impor-

tant in wound healing, excessive moisture can con-

tribute to delayed healing and further breakdown of

the skin. Unmanaged exudate may contribute to in-creased wound bacterial counts, periwound skin

maceration, wound odor, and increased cost of care

because of the need for frequent dressing changes.12

Clinicians should consider a dressings absorptive ca-

pacity as well as its moisture vapor transmission rate

when exudate absorption is required.

Gently packing a wound with depth, undermining,

or sinus tracts prevents premature wound closure at

the skin level and subsequent abscess formation.15

Packing also wicks exudate from the wound base,

preventing pooling of wound fluid. However, wounds

should not be overpacked since excessive pressureon fragile tissue can lead to further damage. Many

wound fillers, such as alginates and starch copoly-

mers, gel and conform to the wound bed as they ab-

sorb, thus minimizing pressure to the wound bed.

Products that contain harmful chemicals, such as

antiseptic solutions, should be avoided in chronic

wounds.15, 16 As Rodeheaver17 states, Dont put in a

wound what you wouldnt put in your eye. The ideal

dressing should not harm the wound bed or sur-

rounding skin upon removal. For example, a wet-to-

dry gauze dressing adheres to viable and nonviable

tissue; upon removal, it can cause significant pain

and tissue damage. In comparison, the gelling quali-

ties of many absorptive wound fillers allow for atrau-

matic removal. Also, most adhesive dressings do not

adhere to the moist wound bed. Some of these dress-

ings, however, may strongly adhere to the surround-

ing skin, thus traumatizing it when the dressing is re-moved. Clinicians should seek a balance between

dressing adherence and atraumatic removal when

using these products.

The temperature of the wound should be main-

tained as close to ideal body temperature as possible

so that normal cellular processes can be preserved.12

This is achieved by using retentive dressings and

changing the dressing only when necessary. Clini-

cians should follow package insert instructions re-

garding the frequency of dressing changes. Most

dressings can stay in place up to 7 days, depending

on the amount of exudate.It has been demonstrated in vitro that bacteria

can move rapidly through several layers of saturated

gauze and that a layer of cellophane can halt its

movement.18, 19 Many dressings, including transparent

films, hydrocolloids, and some foams, provide a bar-

rier against outside contamination. This is particularly

important in the treatment of wounds in the buttocks

area of incontinent patients. When using dressings

that do not provide a bacterial barrier, such as gauze

or wound fillers, the clinician can use a transparent

film as a secondary dressing to add the barrier func-

tion. However, the addition of the film may decreasethe moisture vapor transmission rate and affect the

dressings ability to handle exudate.

While many modern dressings provide a majority

of ideal characteristics, few dressings contain all of

them. Clinicians should examine patients and

wounds individually, take into consideration the

goals of therapy (Table 1), review the indications and

contraindications for each dressing, and then decide

on a dressing. Dressing selection is an ongoing pro-

cess. As the wound improves or deteriorates, clini-

cians must be prepared to change the dressing pre-

scription.

Dressing Categories

Transparent Films

Transparent films are thin, clear polyurethane dress-

ings with an adhesive layer that adheres to intact

skin, but not to a moist wound bed.20 They do not

have absorptive capacity, but they do transmit mois-

ture vapor. Films used in wound care have average


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moisture vapor transmission rates of 300 to 800

g/m2/24 hr.6, 21, 22 In contrast, films used over intra-

venous line sites require a higher moisture vapor

transmission rate to prevent moisture accumulation

under the dressing and subsequent poor adherence.

These films have moisture vapor transmission ratesup to 3,700 g/m2/24 hr and should not be used on

open wounds.23 Although films are moisture vapor

and gas permeable, they are impermeable to bacteria

and liquids.

Transparent films are indicated for dry to minimal-

ly-exudating and superficial wounds; they also may be

used over absorptive fillers on full-thickness wounds.

Films provide an ideal environment for softening dry

eschar through autolytic debridement. They should

not be used on infected wounds, wounds with heavy

exudate, or on patients with fragile periwound skin.

Unfortunately, films are commonly used on skin tears

and when the film is later removed, the skin may be

reinjured from dressing adherence to intact skin.

Transparent films provide protection from friction

and contribute to autolytic debridement and pain re-duction. They allow ongoing visual assessment of the

wound and are waterproof, flexible, and may stay in

place for up to 7 days. Transparent films are not ab-

sorptive, however, and excess drainage can lead to

periwound skin maceration. Films also may be diffi-

cult to apply.

When transparent films are used, a piece large

enough to cover at least 1 inch of the surrounding skin

should be applied for good dressing adherence. A liq-

uid skin sealant can be used to improve adherence on

Table 1. Selecting the Appropriate Dressing

Wound

Characteristic Goal of Therapy Dressing Examples

High exudate Exudate absorption Absorptive wound fillers

Foams (high moisture vapor transmission rate)

Collagens

Gauze

Low exudate Maintain moisture Hydrocolloids

Foams (low moisture vapor transmission rate)

Transparent films (secondary dressing over filler)

No exudate Add moisture Hydrogels

Amorphous for wounds with depth

Sheet for superficial wounds

Transparent films: add small amount of amorphous hydrogel

under film for rapid hydration

Hydrocolloids: slower hydration than hydrogels or films

Clinically infected Systemic treatment Use dressing appropriate for amount of exudate,

of infection but change dressing daily

Wick away exudate Avoid occlusive dressings

Wound cleansing Antimicrobial dressings may be usedSaline irrigation (35 mL syringe/19 g needle)

High infection risk Prevent infection Use dressing appropriate for amount of exudate, but change dressing

Immunosuppression every 1-3 days

Ischemic ulcer Use occlusive dressings with caution

Diabetic foot ulcer

Wound location Prevent wound contamination Use adhesive dressings (f ilms over fi ller , hydrocol lo ids, foams) in the

sacral area to protect from incontinence

Prevent maceration Avoid dressings that will compress with ambulation and ooze onto

on plantar foot surrounding skin (eg, hydrocolloids, paste wound fillers)

Skin quality Fragile skin Avoid adhesive dressings; use a sheet hydrogel on skin tears secured

with gauze wrap or nettingRisk of contact sensitivity Avoid adhesive dressings or products with sensitizing preservatives

Periwound maceration Use skin sealants on surrounding skin for protection


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the surrounding skin before the dressing is applied.

The dressing should be changed when exudate leaks

onto intact skin, or at least every 7 days. A small

amount of amorphous hydrogel can be added under

the film to speed autolytic debridement of dry eschar.

Hydrocolloids

Hydrocolloids are adhesive, wafer dressings that in-

teract with wound fluid to form a moist gel over the

wound bed. Absorptive ingredients may include car-

boxymethyl cellulose, gelatin, pectin, or guar gum.20

Adhesives are added for dressing adherence. The ab-

sorptive layer is covered by a film that is imperme-

able to fluid, gases, and bacteria. Due to their low

moisture vapor transmission rate of less than 300

g/m2/24 hr, hydrocolloids are also virtually imperme-

able to moisture vapor.

Hydrocolloids vary by brand. Most are translucent

so that the wound and amount of exudate accumula-tion can be monitored. Some hydrocolloids are ta-

pered, which prevents rolling of the dressing edges,

and some are surrounded by adhesive tape or trans-

parent film. Many sizes and shapes are available, and

some fit the sacral area and bony prominences better

than others.

Hydrocolloids are indicated for wounds with low

to moderate exudate, partial- or full-thickness

wounds, and granulating or necrotic wounds. They

are frequently applied in the treatment of pressure

and venous ulcers and may be used over absorptive

wound fillers.Hydrocolloids should not be used on clinically in-

fected wounds, wounds with heavy exudate, or on

patients with fragile surrounding skin. Although not

a contraindication in the package insert, most wound

care experts recommend caution when used on dia-

betic foot ulcers or ischemic ulcers due to the in-

creased risk of infection with these wounds, especial-

ly when left covered for long periods of time.

Hydrocolloids provide protection from friction

and exogenous bacterial contamination, and pain re-

duction. They are ideal at providing an environment

for autolytic debridement of yellow fibrinous slough.However, hydrocolloids may strip fragile surrounding

skin upon removal and may cause periwound skin

maceration and wound odor; a potential for contact

sensitivity may also be present.24

When hydrocolloids are applied, at least 1 inch of

the surrounding skin should be covered to enhance

dressing adherence. A patch test for allergy should be

considered when using hydrocolloids on venous ul-

cers. Even if the patch test is negative, the patient may

later develop a contact sensitivity to the dressing.

Caregivers should be instructed to change the dress-

ing when the exudate is within 1 inch of the dressing

edge. Newer translucent hydrocolloids turn white as

they absorb exudate, which makes it easier to deter-

mine the location of the exudate under the dressing.

Caregivers should be educated in advance about the

odor and yellow drainage associated with this prod-

uct; they should also be assured that this is usuallynormal in the absence of other signs of infection.

Foams

Foams are composed of polymers, most commonly

polyurethane. They are some of the most variable

and versatile dressings for chronic wound care and

include thin and thick foams, adhesive and nonadhe-

sive foams, foams used to pack wounds, and sheet

foams, which are available with or without film cov-

erings. Moisture vapor transmission rates vary wide-

ly (800 to more than 5,000 g/m2

/24 hr)6, 21

based onthe thickness of the foam and its composition. For

example, a 4 mm-thick open-celled foam has a higher

moisture vapor transmission rate than foam with a

transparent film covering or an adhesive layer. There-

fore, the former dressing would be chosen for a high-

ly-exudating wound, and the latter would be used for

a wound with moderate exudate. Some thin foams

have intelligent characteristics and can self-adjust

their moisture vapor transmission rate based on the

amount of wound exudate.21

Foams are indicated for wounds with moderate to

high exudate, partial- or full-thickness wounds, gran-ulating or necrotic wounds, and wounds of any etiol-

ogy. They can be used on infected wounds if changed

daily. Foams can be used over creams, ointments, or

wound fillers.

Foams are not beneficial on dry wounds. Adhe-

sive forms should be used with caution on patients

with fragile skin. Foams decrease friction, but they

are not thick enough to provide pressure reduction

over bony prominences and should not be used for

this purpose.

Foam dressings provide protection, an environ-

ment for autolytic debridement, and may also helpdecrease exuberant granulation tissue. Nonadhesive

foams require tape or some other method to secure

them. Foams used to fill wounds may damage tissue

if overpacked.

When foam dressings are applied, nonadhesive

foams should be taped across the dressing, rather

than framed with tape, to keep the foam in contact

with the wound. At least 1 inch of surrounding skin

should be covered. Most foams should be changed

when the strikethrough drainage is within 1 inch of


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the edge of the dressing, or at least every 7 days.

Thick foams may be used over venous ulcers and

under compression wraps to provide increased local

compression, which will help control local edema

and may improve healing.25 Package inserts should

be referenced for individual instructions since the

performance of these dressings varies.

Absorptive Wound Fillers

Absorptive wound fillers include pastes, granules,

powders, pads, or ropes that absorb exudate and fill

dead space. These wound fillers are primarily com-

posed of alginates or starch copolymers, most of

which soften or gel as they absorb. Alginate dress-

ings are composed of naturally occurring polymers

of brown seaweed, specifically mannuronic or gu-

luronic acid, which are spun into fibers and formed

into pads or ropes.26 The type of alginic acid used, as

well as the ratio of sodium to calcium in the dressing,affects the dressings gelling properties and its ability

to maintain structural integrity as it absorbs. In

starch copolymer-based dressings, the source of the

copolymer may vary, although carboxymethyl cellu-

lose is a common component.

Absorptive wound fillers are indicated for wounds

with moderate to high exudate. The wounds may be

partial- or full-thickness, granulating or necrotic, and

of any etiology. Wound fillers may be used on infect-

ed wounds, if changed daily, and may be used under

other dressings, such as hydrocolloids or foams, to

increase dressing wear time. For example, a hydro-colloid with a 3-day wear time on a particular wound

may be left in place up to 4 to 5 days with the addi-

tion of an absorptive filler. Sheets are generally used

on wounds with minimal depth, and ropes, pastes,

and strands are used to fill deeper wounds.

Absorptive wound fillers should not be used on

low-exudating wounds. Many products, such as algi-

nates, will adhere to the dry wound and require

saline soaks to remove. These wound filler products

should not be used premoistened in a dry wound, as

they tend to dry out. Fillers should not be packed

into wounds with deep tunneling or deep undermin-ing. Large amounts of these products may be left be-

hind inadvertently, creating a foreign body and a

medium for bacterial growth. Gauze ribbon is the

only appropriate packing material for deep tunnels.

Absorptive wound fillers soften, gel, and conform

to the wound bed as they absorb, thus minimizing

trauma to the wound from overpacking and dressing

removal. They provide a moist wound environment

that promotes autolytic debridement. Their absorp-

tive capacity, especially with some of the starch

copolymers, may reduce the required frequency of

dressing changes. Alginates are mildly hemostatic.

Absorptive wound fillers require a secondary dress-

ing and severe adherence (especially alginates) may

occur if the dressing dries out.

When using absorptive wound fillers, the sec-

ondary dressing should be selected based on the

amount of exudate. For example, on a highly-exudat-ing wound, the filler should be covered with gauze or

an absorbent pad, and the dressing should be

changed when the drainage strikes through to the

outside. As drainage decreases, foams, hydrocol-

loids, or films can be used, depending on the amount

of exudate. Many wound fillers should only be

packed until the wound is 1/3 to 1/2 full. Since the per-

formance of these products varies, clinicians should

refer to package inserts for instructions.

Some creams or powders may be considered wound

fillers although they do not absorb exudate. Table 2

lists common wound healing products and distin-guishes between absorptive and nonabsorptive fillers.

Hydrogels

Hydrogels, which are water in gel form, provide mois-

ture to a wound. They are composed of 60% to 94%

water, with polymers, and humectants.20 Sheet hydro-

gels have a three-dimensional structure supported by

cross-linked polymers.12 Amorphous gels are pack-

aged in tubes, foil packets, or as saturated gauze pads.

Amorphous gels are available as sterile and single use,

or as preserved and multiuse. Some hydrogels includeother ingredients, such as alginate, collagen, or starch

copolymer, which provide some exudate absorption.

These products primarily offer wound hydration, not

significant exudate absorption. In fact, some products

that are called hydrogels are only 20% water and are

highly absorptive. Since they do not donate water to

the wound, they should not be considered hydrogels

and should be deemed exudate absorbers instead.

Hydrogels are indicated for dry to minimally-exu-

dating wounds, granulating or necrotic wounds, and

any wound etiology, except a dry ischemic ulcer.

Amorphous gels may be used on infected wounds ifchanged daily. Sheet hydrogels should be used on su-

perficial wounds with less than 0.5 cm depth; amor-

phous hydrogels should be used on full-thickness

wounds with depth. Amorphous gels can be used as

wound fillers, with or without gauze packing.

Hydrogels should be avoided on wounds with

heavy exudate or on intact skin. Sheet hydrogels are

not recommended for use on infected wounds. A dry

eschar on an avascular foot with no healing potential

should not be moistened.


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Table 2. Common Wound Healing Products

Product Company Product Company

Transparent Films

BLISTERFILM Kendall

CarraSmart Film Carrington Laboratories

Comfeel Film Coloplast

Cutifilm Beiersdorf-Jobst

mefilm MlnlyckeOpSite Smith + Nephew

POLYSKIN Kendall

ProCyte Bard Medical

Tegaderm 3M

TRANSEAL DeRoyal

Hydrocolloids

CarraSmart Carrington Laboratories

Comfeel Plus Coloplast

Cutinova Hydro Beiersdorf-Jobst

DuoDERM ConvaTec

Exuderm Medline

Hydrocol Bertek

Procol DeRoyal

RepliCare Smith + Nephew

Restore Plus Hollister

Sorbex Bard Medical

Tegasorb 3M

ULTEC Kendall

Foams

Allevyn Smith + Nephew

Biatain Coloplast

CarraSmart Foam Carrington Laboratories

CURAFOAM Kendall

Cutinova Foam Beiersdorf-Jobst

Flexzan Bertek

LYOFOAM ConvaTec

mepilex MlnlyckeMitraflex Mlnlycke

POLYDERM DeRoyal

Polymem a Ferris

Sof-Foam Johnson & Johnson

Tielle a Johnson & Johnson

VigiFOAM Bard Medical

Absorptive Wound Fillers

Alginates:

AlgiDERM Bard Medical

AlgiSite Smith + Nephew

CarraGinate Carrington Laboratories

Comfeel SeaSorb Coloplast

CURASORB KendallKALGINATE DeRoyal

KALTOSTAT ConvaTec

melgisorb Mlnlycke

Restore CalciCare Hollister

Sorbsan Bertek

Tegagen 3M

Others (mainly starch copolymers):

AQUACEL ConvaTec

Bard Absorption Dress ing Bard Medical

Absorptive Wound Fillers - Others (continued)

Comfeel Powder or Paste Coloplast

FlexiGel STRANDS Smith + Nephew

Comfeel Triad Coloplast

Nonabsorbent fillers:

MULTIDEX Gel or Powder DeRoyal

Biafine Medix Pharmaceuticals

Americas

Hydrogels

Amorphous:

Biolex Wound Gel Bard Medical

Carrasyn Carrington Laboratories

Purilon Gel Coloplast

CURAFIL Kendall

Curasol Healthpoint

DuoDERM Hydroactive

Sterile Gel ConvaTec

IntraSite Smith + Nephew

normlgel MlnlyckeNuGel Collagen Wound Gel Johnson & Johnson

Restore Hydrogel Hollister

SoloSite Smith + Nephew

Tegagel 3M

Sheet:

AQUAFLO Kendall

AQUASORB DeRoyal

CarraDres Carrington Laboratories

ClearSite CONMED

CURAGEL Kendall

Elasto-Gel Southwest Technologies

Flexderm Bertek

NuGel Wound Dressing Johnson & Johnson

Vigilon Bard Medical

Collagens

100% collagen:

hyCURE Hymed Group

Medifil (particles, pads, gel) BioCore Medical Technologies

SkinTemp BioCore Medical Technologies

Combination Products:

FIBRACOL Johnson & Johnson

WounDres Collagen Hydrogel Coloplast

Antimicrobials

Acticoat Smith + Nephew

Arglaes Medline

Iodosorb Gel and Iodoflex Pad HealthpointKERLIX A.M.D. Kendall

Silveron Silveron Consumer Products

Contact Layers

Adaptic Non-Adhering Dressing Johnson & Johnson

Dermanet DeRoyal

mepitel Mlnlycke

N-terface Winfield Labs

Tegapore 3M

This list is not all-inclusive of every dressing on the market. No inferences should be made regarding the inclusion or exclu-

sion of products on this list.aComposite dressings


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Hydrogels provide a moist environment for autolyt-

ic debridement. They are nonadhesive and conform to

the wound bed. Sheet hydrogels are very soothing and

cooling when applied to painful wounds such as su-

perficial burns or skin tears. The potential for peri-

wound skin maceration is a disadvantage of these

products, however, and some products that lack suffi-

cient levels of humectants may dry out in the wound.On low-draining superficial wounds, sheet hydro-

gels only need to be changed every 4 to 7 days. On

wounds usually packed with saline-moistened gauze,

which may dry out, the gauze may be saturated with

amorphous hydrogel instead to maintain a moist

wound bed. The frequency of these dressing changes

is based on keeping the wound moist. If the wound

dries out after 1 day, the dressing should be changed

daily. If the wound stays moist longer, the dressing

should be changed less frequently. The choice of a

secondary dressing over an amorphous hydrogel

should be based on the moisture level of the wound.Gauze should be used for wounds with some exudate

and inherent moisture, and less permeable dressings

should be used if the wound dries out. The addition

of a transparent film over hydrogel-saturated gauze

will often maintain a moist wound bed and decrease

the need for frequent dressing changes.

Collagens

Collagen dressings are available as sheets, powders,

particles, and ropes that absorb exudate, and gels

that provide moisture to wounds. The collagen is ob-tained from bovine, avian, or porcine sources. While

some products are 100% collagen, others are com-

bined with products such as alginates or hydrogels.

Studies have claimed that adding exogenous collagen

to a wound promotes hemostasis and chemotaxis,

and that collagen dressings act as matrices for new

cell ingrowth.27-29 However, there have been no large,

randomized, controlled trials demonstrating im-

proved healing in chronic wounds. In addition, many

small studies that have declared the efficacy of these

products lack adequate control to allow strong con-

clusions to be made. It is well understood that in thewound healing process, break-down products of en-

dogenous extracellular matrix are chemotactic for

inflammatory cells.30 However, it should not be as-

sumed that exogenous collagen is chemotactic. Even

if it is, it is not known if its application improves

wound healing outcomes. In addition, the structure

of the collagen affects its ability to act as a matrix.

For example, cell ingrowth into collagen sponges

and bioengineered tissue has been demonstrated,29

but it is not known if a collagen powder that melts

away rapidly will provide this matrix, and thus im-

prove wound healing.

Collagen powders, particles, and pads are used for

highly-exudating wounds. Sheets are used for wounds

with low to moderate exudate; gels are used for dry

wounds. Collagen dressings may be used on granu-

lating or necrotic wounds, partial or full-thickness

wounds, and on any wound etiology. Sensitivity tothe source of the collagen is the main contraindica-

tion for these products, and absorptive forms should

not be used on dry wounds.

Collagen products are highly absorptive and main-

tain a moist wound environment, which promotes

autolytic debridement and pain reduction. Since col-

lagen liquefies as it absorbs, it allows for atraumatic

removal. Collagen dressings may stay in place up to 7

days and require a secondary dressing, which should

be selected based on the same principles applied to

absorptive wound fillers. An increase in drainage is

frequently seen in the first few days of treatmentwith collagens. Some of the powder or particles can

be mixed with saline to form a paste for easier appli-

cation. The pad version may expand as it absorbs;

therefore, overpacking should be avoided. Products

differ between manufacturers and package inserts

should be reviewed.

Gauze

Gauze remains one of the most common dressings

used in wound care today. Gauze dressings may be

composed of natural or synthetic materials, or acombination of both, and may be woven or nonwo-

ven.31, 32 Woven gauze, which is made by forming

threads with the desired fibers and then weaving

them into a fabric, is commonly used for packing.

However, woven gauze has lower absorption capaci-

ty than nonwoven gauze and has a higher tendency

to dry and adhere to the wound bed. Woven gauze is

associated with a high amount of lint, which can lead

to significant fiber debris left in the wound. Nonwo-

ven gauze is made by blending, not weaving, fibers;

no thread development is necessary. This gauze has

superior absorbency, tends to be less adherent to thewound bed, and has a very low amount of lint. Nu-

merous brands and combinations of these products

are available.

Gauze is indicated for wounds with heavy exu-

date, especially when the exudate is so significant

that it would not be cost-effective to use an absorp-

tive wound filler. For example, a patient with a post-

operative seroma in the groin that drains a tremen-

dous amount of serous fluid may require dressing

changes four to six times daily. Dry nonwoven gauze


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packing, covered with absorbent pads, would be the

most cost-effective choice for this patient. A patient

with a draining fungating tumor would also benefit

from gauze dressings. The use of specialty dressings

would not change the eventual outcome for this pa-

tient, and the use of a nonadherent contact layer,

covered by gauze, may be the best option for drain-

age containment. Gauze is also indicated as a prima-ry dressing over ointments, enzymes, and growth fac-

tors, and as a secondary dressing over wound fillers

and hydrogels. Gauze is contraindicated when it

would adhere to viable tissue and cause trauma upon

removal.

Gauze is universally available, easy for caregivers

to use, and facilitates mechanical debridement of

necrotic tissue. However, the debridement is nonse-

lective and will harm viable tissue when it adheres.

Other disadvantages of gauze include its propensity

to dry out, leading to wound dessication. To maintain

continually saline-moistened gauze, the packing mustbe remoistened numerous times daily, a task that is

time- and labor-intensive. Lastly, cotton fibers left in

the wound may cause prolonged inflammation and

interfere with wound healing.33

Wet-to-dry dressings should be avoided because

of pain and tissue damage upon removal. If the pa-

tient has enough exudate, the wound will not dry out,

and gauze may be a viable option for packing. Rib-

bon gauze should be used for packing tight tunnels.

Wounds should be packed lightly to avoid pressure

on fragile tissue.

Other Dressings

Contact layers. Contact layers are applied directly

to the wound and act as a nonadherent interface be-

tween the wound and the secondary dressing. Most

contact layers are meshed to allow exudate to pass

through, and some are impregnated with petrolatum

to improve nonadherence. Contact layers are fre-

quently used over creams, ointments, or growth fac-

tors, and are then covered with gauze. The layers

provide a low-cost moist wound healing method.

Composite dressings. These products are com-binations of different dressing categories and include

island dressings, in which the central portion of the

dressing is a foam or absorbent pad that may be cov-

ered and framed with a transparent film.

New dressings. Manufacturers are developing

new dressings that interact with wounds to promote

healing more successfully than moist wound healing

alone. Hyalofill (ConvaTec, Skillman, New Jersey) is a

soft, conformable polymer dressing composed of an

ester of hyaluronic acid, a glycosaminoglycan nor-

mally present in extracellular matrix.34 When packed

into a wound, it forms a soft, cohesive gel that should

be changed every 3 to 7 days. In a well designed, ran-

domized pilot study of 30 patients with diabetic foot

ulcers, weekly application of Hyalofill showed a sta-

tistically significant improvement in wound closure

over the control group (P< .05).35 A large, random-

ized, controlled trial is currently underway, and thisdata must be reviewed before any firm conclusions

can be made about this product.

Another new, interesting dressing is Oasis (Cook,

Spencer, Indiana), which is composed of dehydrated

porcine small intestinal submucosa. This product

claims to provide a matrix for cell ingrowth and

growth factor delivery to the wound. However, de-

spite multiple reports on the development of this

product, and positive results demonstrating its use as

a cell scaffold in animal studies,36 there have been no

large controlled studies demonstrating enhanced

chronic wound healing as compared to placebo.These studies are necessary before any conclusions

can be made regarding the efficacy of this product.

Antimicrobial dressings. Dressings that contain

antimicrobials may benefit patients with wound in-

fections, patients at risk for infection, and patients

with malodorous wounds. These products differ

from topical antibiotics in that they are actual dress-

ings that may or may not require a secondary dress-

ing. Iodosorb Gel and Iodoflex Pad (Healthpoint,

Fort Worth, Texas) are absorptive wound fillers with

iodine complexed in a starch copolymer (cadexomer

iodine). These products contain slow-release iodineand have been shown to decrease bacterial counts in

wounds without cytotoxicity.37, 38 These dressings are

highly absorptive; each gram absorbs 6 mL of fluid.

Both products require a secondary dressing, which

should be chosen based on the amount of exudate.

Other antimicrobial dressings use silver technolo-

gy to control bacterial burden in the wound. These

dressings contain silver ions with broad-spectrum ac-

tivity against many organisms, including methicillin-

resistant staphylococcus aureus and vancomycin-

resistant enterococci.39, 40 Silver ions kill bacteria

rapidly and remain nontoxic to human cells. In addi-tion to reducing bacterial counts in wounds, these

dressings may have a positive effect on wound heal-

ing by decreasing proteolytic activity, specifically

matrix metalloproteinase activity, and by reducing

inflammation.41 Silver dressings are available in a va-

riety of forms, from transparent films and island

dressings to absorptive fillers and foams. Some of

these products will slow-release silver in the wound

for up to 7 days.

A new antimicrobial dressing, Kerlix AMD (Kendall,


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Mansfield, Massachusetts), is available as woven

gauze rolls or sponges that contain 0.2% polyhexam-

ethylene biguanide, an antimicrobial commonly used

in products such as contact lens solutions and baby

wipes. Kerlix AMD is used to decrease bacterial colo-

nization within the dressing and reduce bacterial

penetration through the dressing. Unpublished stud-

ies have demonstrated the dressings ability toachieve the latter, as well as maintain epithelializa-

tion rates similar to saline-moistened gauze. Since

this gauze dressing may dry out readily, a moist

wound environment can be maintained by periodical-

ly adding saline to the packing or covering it with a

film dressing. Antimicrobial dressings are adjuncts in

the care of patients with wound infections. These pa-

tients should be treated primarily with systemic an-

tibiotic therapy.

Reimbursement

The majority of the dressings reviewed in this article,

whether used as primary or secondary dressings, are

reimbursed by Medicare and most insurance compa-

nies.42 The dressings must be medically necessary for

the treatment of a wound caused by or treated by a

surgical procedure; or debrided by any method (sharp,

mechanical, enzymatic, or autolytic). Table 3 lists the

required components of a prescription for wound

dressings, as well as conditions not covered. Clini-

cians should work with local suppliers who are will-

ing to provide Medicare and insurance billing for pa-

tients. In addition, a knowledgeable supplier canassist clinicians with daily to weekly dressing use

guidelines, or this information can be accessed on

the Internet.

Conclusion

With literally hundreds of dressings to choose from,

it is imperative for any clinician who treats patients

with chronic wounds to be familiar with the charac-

teristics of an ideal dressing. These characteristics

include maintenance of a moist wound environment,

absorption of excess exudate, elimination of deadspace, prevention of harm to the wound, and the pro-

vision of thermal insulation and a bacterial barrier.

The clinician should identify the goals of care for

each individual patient and wound, and then choose

from the common dressing categories to assist in at-

taining these goals. Appropriate selection and use of

dressings that optimize the local wound environment

are part of the overall treatment plan of the patient

with a chronic wound. This plan should also include

assessing and treating underlying pathology, treating

infection, debriding nonviable tissue, and addressing

systemic factors that affect wound healing.

References

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Table 3. Reimbursement Issues

Include on the prescription:

Type of dressing

Size of dressing (must be appropriate to wound size)

Number and amount to be used at one time (with each

dressing change)

Frequency of dressing change

Expected duration of need

Signed and dated prescriptionNo more than one months supply may be provided at one

time, unless there is documentation to support medical

necessity

A new prescription is required when:

A new dressing is added

An increased quantity of an existing dressing is needed

At least every 3 months for each dressing used, even if

the quantity stays the same

Dressings not covered:

Management of drainage from a nonsurgical cutaneous

fistula

Stage I pressure ulcers

1st degree burns

Wounds caused by trauma that do not require surgicalclosure or any type of debridement

Venipuncture or arterial puncture sites

Additional items not covered:

Wound cleansers or irrigating solutions (saline)

Dressing kits (all dressings must be individualized for

each patient)

Skin sealants or barriers

Gauze and other dressings used to cleanse or debride

the wound, but not left in the wound


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8. KANNON GA, GARRETT AB: Moist wound healing with oc-

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mission rates in burns and chronic leg ulcers: influence

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tact dermatitis from hydrocolloid dressings. Am J Con-

tact Dermat 8: 236, 1997.25. FALANG AV: Venous ulceration. J Dermatol Surg Oncol

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ence of microcrystalline collagen on wound healing.

Proc Soc Exp Biol Med 140: 896, 1972.

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lyophilized bovine collagen matrix in postoperative

wound healing. Dermatol Surg 25: 303, 1999.

29. PURNA SK, BABU M: Collagen based dressings: a review.

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30. SILVER IA: Cellular Signalling in Wound Healing, in

Chronic Wound Healing: Clinical Measurement and

Basic Science, ed by R Mani, V Falanga, CP Shearman,et al, p 124, WB Saunders, London, 1999.

31. PONDER RB, KRASNER D: Gauzes and related dressings.

Ostomy Wound Mgmt 39: 48, 1993.

32. WEIR DM, BOHANAN BG, HOCKENBROCHT GP, ET AL: Im-

proved wound packing and debridement : evaluation of

a new fabric sponge. Wounds 4: 216, 1992.

33. LAWRE NCE JC: Dressings and wound infection. Am J

Surg 167 (suppl 1A): 21S, 1994.

34. CONVATEC WEB SI TE. Available at: http://www.convatec.

com. Accessed October 25, 2001.

35. EDMONDS ME, FOSTER AVM, WILSON S, DOXFORD M, ET

AL: The management of indolent neuropathic ulceration

of the diabetic foot with Hyalofill. Oral abstract pre-

sented at the 13th Annual Symposium on AdvancedWound Care, April 3, 2000, 2000; Dallas, TX.

36. COOK GROUP WEB SITE. Available at: http://www.cooksis.

com/technology.html. Accessed October 25, 2001.

37. HOLLOWAY GA, JOHANSEN KH, BARNE S RW, ET AL: Multi -

center trial of cadexomer iodine to treat venous stasis

ulcer. West J Med 151: 35, 1989.

38. DANIELSE N L, CHERRY GW, HARDING K, ET AL: Cadexomer

iodine in ulcers colonised by pseudomonas aeruginosa.

J Wound Care 6: 169, 1997.

39. WRIGHT JB, HANSE N DL, BURRELL RE: The comparative

efficacy of two antimicrobial barrier dressings: in vitro

examination of two controlled release silver dressings.

Wounds 10: 179, 1998.

40. WRIGHT JB, LAM K, BURRELL RE: Wound management inan era of increasing bacterial antibiotic resistance: a

role for topical silver treatment. Am J Infect Control

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41. DEMLING RH, DESANTI L: The role of silver in wound

healing. Wounds 13 (suppl A): 4, 2001.

42. SCHAUM K: Steps to reimbursement success for 2000.

Step 3: write orders to justify medical necessity. Adv

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Additional References

Advances in Skin and Wound Care: 1999 Directory, Spring-

house Corp, Springhouse, PA, 1999

(www.woundcarenet.com).Ostomy/Wound Management: 2001 Buyers Guide, Health

Management Publications, Malvern, PA, 2001

(www.woundsource.com).

The Wound Product Sourcebook 2001: Kestrel Health Infor-

mation, Williston, VT, 2001 (www.woundsource.com).

dressing selection in chronic wound management

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