CME-ArticleSubmitted: 27.12.2013Accepted: 13.3.2014DOI: 10.1111/ddg.12351Joachim Dissemond has served as consul-tant and/or paid speaker for and/or participated in clinical trials sponsored by companies including 3M , B. Braun, BSN, Coloplast, Convatec, Draco, Har tmann AG, KCI, Lohmann & Rauscher, Medoderm, Sastomed, Systagenix, UCB and Urgo. Matthias Augustin has ser ved as consultant and/or paid speaker for and/or participated in clinical trials sponsored by companies that manufacture drugs used for the treat-ment of psoriasis including Abbott, Almirall, Amgen, Biogen Idec, Celgene, Centocor, Janssen-Cilag, Leo, Medac, MSD (formerly Esse x, Schering-Plough), Novar tis, Pfizer (formerly Wyeth). Sabine Eming has been advisor to Paul Har tmann AG. Tobias Ge-orge has received honoraria for lectures from Urgo and Lohmann & Rauscher. Hauke Schumann has been advisor to Birken AG. Thomas Horn, Sigrid Karrer, Markus Stcker declare no conflict of interest.Modern wound care practical aspects of non-interventional topical treatment of patients with chronic woundsSummar yJoachim Dissemond1 , Matthias Augustin2, Sabine A. Eming3 , Tobias Goerge4, Thomas Horn5, Sigrid Karrer6 , Hauke Schu-mann7, Markus Stcker8, for the working group for wound healing (AGW ) of the German Society of Dermatology (DDG)The treatment of patient s with chronic wounds is becoming increasingly complex. It was therefore the aim of the members of the working group for wound healing (AGW) of the German Society of Dermatology (DDG) to report on the currently relevant as-pects of non-interventional, topical wound treatment for daily prac tice. Beside neces-sar y procedures, such as wound cleansing and dbridement, we describe commonly used wound dressings, their indications and practical use. Modern antiseptics, which are currently used in wound therapy, usually contain polyhexanide or octenidine. Physic al methods, such as negative-pressure treatment, are also interesting options. It is always impor tant to objectify and adequately treat pain symptoms which often affect these patients. Mod ern moist wound therapy may promote healing, reduce complicati ons, and improve the qualit y of life in patients with chronic wounds. To-gether with the improvement of the underlying c auses, moder n wound therapy is an important aspect in the overall treatment regime for patients with chronic woun ds.(1) Cl inic for Dermatology, Univer sity Hospital Essen, Germany(2) Institute for Health Services Research i n Der matology and Healthcare (IVDP), Uni versity Medical Center, Hamburg- Eppendorf(3) Department of Dermatology, Universit y of Cologne, Cologne, Germany(4) Klinik fr Hautkrankheiten, IntroductionAllgemeine Dermatologie und Venerologie, University Hospital Mnster, Germany(5) Clinic and policlinic for Dermatology, Physiological wound healing is a complex pro cess. The primary goal of this t empo-rally and regionally cont rolled series of events is to restore tissue integrity and fun-c tion. In regard to the skin, the wound healing process encompasses a time period which depends on many factors and which may b e divided into several con secutive phases [1]. There is still no standard ized, accepted consensus on the definition of ch ronic wounds. Along with du rat ion, there are problems owing to the h ighly va-riable factors related to the pat hophysiology. Most cu rrent classifications are based only on time. In the following, chronic refers to wounds which have persisted for more t han eight weeks [2].Venereology and Allergology, Helios Klinikum Krefeld, Germany(6) Department of Dermatology, Universit y Hospi tal Regensbur g, Germany(7) Department of Dermatology, Freiburg University Hospital, Germany(8) Depar tment of Dermatology, Ruhr-University Bochum, Germany.Even if there is scant scientific evidence on the effectiveness of wound care products in accelerating the healing of chronic wounds, there is consensus among experts in the field concerning the use of modern wound care products, especially in regard to improving quality of life [2]. New discoveries in topical Section Editor Pr of. Dr. Jan C. Simon, LeipzigConflict of interest541 541 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME Articlewound care have made the treatment of patients w ith chronic wounds more complex. Thus it was the aim of the working group for wound healing (AGW) of the German Society of Dermatology (DDG) to present a review article on the current, relevant aspects of topical, non-interventional wound care for use in daily practice.Chronic wounds are presently defined as those which have per sisted for more than eight weeks.Modern wound careBefore treatment of any patient wit h a ch ronic wound b egins, the relevant under-lying factors should be diagnosed and, whenever possible, t reated. Wound healing may be promoted by topical wound care. The concept of moist wound care was pioneered by George D. Winter. In pre clinic al studies done in 1962, he showed that a moist wound milieu promoted wound healing [3].Today it is gen erally accepted that proper wound car e should aim to create a moist wound milieu.Wound cleansingAt the beginning of wound therapy, it is often necessary to perform dbride-ment, or at least to cleanse the wound. In addition to necrotic areas, fibrin, crusts, or dressing remnants must also be removed [4]. For wounds that are to be cleansed when changing the wound dressing, Ringer solution or phy-siological saline solution are the cleansers of choice. Sterility is no longer ensured once the container has been opened. Solutions which do not contain preservatives must be used immediately. For practical purposes, it is often more feasible to use cleansing solutions which contain preservatives, such as polyhexanide, or which are completely used up in a single dressing change. Care should be taken to ensure that the solution has been warmed to body temperature [5].The use of tap water is st rongly debated among experts [6]. T he German law on the prevention of in fection, and t he recommendations of the Commission for Hospital Hygiene and Infection Prevention (KRINKO) of the Robert Koch Institu-te (RKI), have unequivocally stated that only sterile cleansing liquids may be used for wound care. T he use of tap water is only permissible in Germany if filters with a maximum pore size of 0.2 m are used [7].Patients rarely pu rchase such filters, given their expense. Yet, for doctors offices and wound clinics, they represent a viable alternative if one wishes to con-tinue using tap water.DbridementDbridement should be as radic al as necessary, but as gentle as possible. Tre atment of chronic wounds often begins with mechanical dbridement. Mechanical dbri-dement using sterile compresses is often su fficient for removal of loosely adherent coatings, such as fibrin.For painfu l wounds, in partic ular, one t herapy option is to use a monofilament fiber product, which involves minimal pain. Firmly adherent coatings and necrotic areas usually have to be removed surgically. Other alternative s include biosurgical dbridement with medicinal larvae or physical dbridement with ultrasound, plas-ma, or laser. These methods are usually only of fered by specialized wound care centers. In out patient care, especially, autolytic techniques, such as hydrogels and proteolytic enzymes are used. For effect ive dbridement , it is imperat ive to plan the necessary pain therapy in advance and to discuss it with the patient [4, 8].542 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME ArticleTable 1 Requirements for modern wound dressings.Reasonable cost Conforms to body contours Atraumatic dressing changes Absorption of wound exudate (also with compression therapy) Permeable to oxygen, water vapor, and car bon dioxide Simple and complete removal Easy to apply Mechanical protection May be cut to size, or available in a variety of shapes and sizes Protection against microorganisms Sterile packaging Prevention of dehydration Contains hypoallergenic materials Contains non-toxic mater ialsThermal insulation Materials for modern wound careIn everyday practice, dressings are recommended as part of modern moist wound care for most chronic wound patients. No single dressing is optimal for all wound types (Table 1). In Germany, there are currently more than 1,000 different medical products for use in chronic wounds, and many manufacturers have their own declarations. This makes the steadily growing market for such products increasingly difficult to navigate (Figure 1). The following discussion focuses on only a few, widely used types of wound care products and briefly discusses their presumed modes of action [913].Activated carbonActivated carbon wound care dressings are made up of fibers consisting of carbonized cellulose products. The compresses reduce odors and absorb endotoxins, and t hey also have bactericidal properties. They are thus esp ecially suitable for foul-smelling wounds and ulc erated tumors.T he dressings are placed in the wound and fi xed in place with compresses. Some of the products available cannot be cut to siz e, as th is would leave activated carbon in the wound. For wounds with only a limited amount of exudate, the dres-sing should be moistened regularly. For wounds with a large amount of exudate, an absorbent secondary dressing should be used and the su rrounding area should be protec ted against maceration, as currently activated carbon dressings can only absorb a small amount of moist ure. The d ressing should be changed every 13 days.AlginateAlginate products consist of a loose d ressing structure made up of fibers which are composed of red or brown algae. Af ter contact with sod ium salts present in the blood or in wou nd secretions, t he alginate fibers absorb t he secretions to form a 543 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME ArticleFigure 1 Phase- and exud ate-depend ent use of wound products for the treatment of patients with chronic wounds.moist hydrophilic gel; bacteria and det ritus are enclosed in the gel structure. The speed and amount of gel formation depend on the amou nt of exudate absorbed and the fiber weave. Alginates are capable of absorbing up to 20 times their own weight. Depending on the product, calcium, zinc, or manganese is supplied to the wound milieu. Alginates are used for deep, jagged, or heavily exuding wounds, either for wou nd cleansing or to promote granulation. Given that alginates also have hemost-atic effects, they are also suitable for achieving hemostasis, for instanc e, following surgical dbridement.Depend ing on the type of wound and the amount of exudate, either dry or moist alginate is applied. Compresses may be placed in deep wou nds and po cket wounds; tamponade may also be used. For heavily exudative wounds, it is advisable to use an absorbent secondary d ressing for example a superabsorber. For clinically infected wounds, the dressing should be changed daily. For all other wounds, a new dressing should be placed every 25 days, depending on t he amou nt of exudate.BiosurgeryBiosurgery refers here to the treatment of wounds wit h med ical grade maggots. Species that are suitable for use in biosurgery include larvae belonging to the Lucilia sericata (gold fly), as they are capable of performing highly selective dbridement .Biosurgical dbridement does not cause bleed ing, and is associated with mini-

mal or no pain. Fly larvae have the potential for lysis of bacteria, includ ing me thi-cillin-resistant Staphylococcu s au reus (MRSA). The larvae are placed direc tly on 544 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME Articlet he wound. If free-roaming larvae are used, a cage must be built around the wound using t he net that comes wit h the larvae and gel strips or stoma paste. Nowadays, fly larvae are more common; these come contained in a BioBag. Depending on the wound shape, the bag should be moved every day, as it is only ef fective on the area over which it is directly placed. Highly absorbent compresses should be used as a secondary dressing. The dressing should be changed after 35 days.ChitosanChitosan is a biopolymer that is derived from chitin. It is available in wound dres-sings or as a spray. It is believed to promote various aspec ts of wound healing, given its positively charged surface. Chitosan products may be used in all phase s of wound t reat ment, af ter adequate dbridement has been performed. They may also be used for achieving hemostasis af ter surgical dbridement .T he wound dressing shou ld be c ut to size before being plac ed on the wou nd. W hen using the spray, it must be allowed to dry for at least 90 seconds before applying t he secondary dressing. Depending on the type of product, the dressing should be changed every 13 days.HoneyHoney wound care preparations come in tubes or as impregnated dressings. The osmotic effect, leading to wound dehydration, and low pH values, as well as the release of small amounts of hydrogen peroxide and methylglyoxal, exp-lain its antimicrobial properties as well as the often severe pain reported during treatment.G ive n that honey is a natural product, its effectiveness varies dep ending on the source of the produc t and the proc essing method s u sed. Honey-based pro-duc ts are u sed for wounds with a small amount of exudate for osmotic dbri-de ment and elimination of bac teria. The se products should be applied to the wound only, tak ing c are to avoid th e su rrounding area. How often to change the d ressing depends on how quick ly the honey is diluted by the exudate. Honey is water-soluble and can be washed off during dressing changes, which are done every 13 days.Hyaluronic acidHyaluronic acid wound dressings are available as gel, fiber compresses, micro-granules, and sprays; hyalu ronic acid products may also be used for tampona-de. Hyaluron ic acid forms a hydrophilic gel upon contact with wound exudate. Products contain ing hyaluronic acid are often used for wounds w ith a large amount of exudate to promote granulation and for wound cleansing.may be applied in its dry form, or combined with Ringer solution; gel formati-on is absolutely essential for the release of hyaluronic acid. The wound should be covered with a secondary dressing. The dressing should be changed after 13 days.Hydrofiber dressingsHydrofibers or aqua fibers are composed of sodiu m carboxyl cellulose. F luid ab-sorpt ion occ urs vertically on ly; no fluid should be released horizont ally. This is 545 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME Articleintended to avoid maceration about the wound margins. Hydrofiber dre ssings can rapidly absorb up to 40 times their weight in ex ud ate.After absorbing the wound exudate, the fibers rapidly transform into a firm, transparent gel. Hydrofiber products may be used for wounds with a large amount of exudate to promote granulation and for wound cleansing. The hydrofiber dressing is placed on the wound and may ex tend over the wound margin. The wound should be covered with a secondary dressing. The dressing should be changed after 13 days.Hydrogel dressingsHydrogels are preparations that contain up to 95 % water, along w ith organic ad-ditives such as pectin and starch , or gelling agents. Generally, a tube or syringe is used to plac e the gel in the wound. Hydrogel sheet s, which are placed on semi-per-meable fi lms, are available for wou nd therapy. Hydrogels can provide moisture to the wou nd as well as absorb excess wound exudate. They are especially suitable for dry wounds to facilit ate autolyt ic dbridement .Hydrogels may also be combined with various other dressing materials, in order to keep these or other structures (such as exposed tendons) moist. The hydrogel sheets are applied in 35 mm thick layers, and are then covered with impregnated gauze or semi-permeable film dressings. The dressing is changed every day for dbri-dement; during the granulation phase, the dressing should be changed every 23 days.Hydrocolloid dressingsHydrocolloid dressings are made of a polyurethane film or foam, on which there is a self-adhesive mass made of elastomers and adhesives, with particles that are capable of swelling to absorb large amounts of exudate (such as gelatin, car-boxymethyl cellulose, or pectin). As it absorbs the wound exudate, the hydrocol-loid mass liquefies to form a viscous gel. Hydrocolloids are used mainly for su-perficial wounds, with little exudate, to promote granulation or epithelization.Self-adhesive hydrocolloid dressings may also be applied without a second ary dressing; these conform to body contours. The dressing should extend 2 3 cm beyond the wou nd margin to ensure that it adheres suf ficiently without leading to mac eration of intact skin. Depending on the amount of exudate, hyd rocolloid dressings may be left on the wound for 35 days.Impregnated gauzeImpregnated gauze dre ssings are fiber nets which are coated with oint ments, hy-drocolloid, silver, or silicone. The impregnation prevents the dressing from sticking to the wound base. This type of dressing is primarily used for acute wounds, tem-porary coverage of chronic wounds, and to prevent the adhesion of other dressing materials. For chronic wounds, impregnated gauz e is generally unsu itable for use as the sole wou nd dressing.Depending on the wound and the product , the dressing should be changed af ter 17 days.CollagenCollagen wound care pro duct s are currently available in fleece, powder, or sponge form. Different mechanisms of action have been described, especially conc erning modificat ion of t he pro-inflammatory wound milieu through protease binding.546 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME ArticleCollagen may be used for the promotion of granulation and epitheliz ation, especially in previously stagnant wou nd healing. Due to t heir hemostatic proper-t ies, t hey are also used after surgical dbridement. T hey are applied as a dry or moist dre ssing to the wound surface , extending to the wou nd margin. A secondary d ressing should be placed over the collagen dressing. Depending on t he product used, the dressing should be changed after 15 days. Most of t he collagen w ill have be en absorbed by the time of the d ressing change; it is usually only necessary to rinse of f any remain ing re sidue.FoamFoam dressings are made of non-irritating polyurethane foam. T he surfaces may be coated for example, with silicone or heat-treated. Foams may be used for moderately or strongly exuding wounds to promote granulation and epit-helization. If the dressing does not come with adhesive border or an additional superabsorber, it may be cut to size; the wound dressing should extend at least 2 cm over the wound margin. The dressing should be in direct contact with the wou nd be d.Depending on t he amount of exudate, the wou nd dressing shou ld b e changed after 17 days.SilverWound products may contain silver in the form of silver ions, elementary sil-ver, nanocrystalline silver, or anorganic silver complexes. Silver ions are either firmly attached to the dressing materials or they are released after contact with wound exudate. Silver ions form complexes w ith bacterial proteins, which lead to damage of the cell membrane, enzymes, or DNA, and irreversibly damage the bacteria.Wound d ressings cont aining silver are often used in patients with infected wounds. Depending on wh ich materials t he silver is attached to, the size of the d ressing may be modifie d to fit the individual wound. I n wounds with litt le exu-date, the dressing should be moistened regularly. Depend ing on the product, the d ressing should be changed after 17 days.Polyacrylate super-absorbersPolyacrylate super- absorbers consist of neutralized , cross-linked polyacrylic acid molecules. They can absorb up to 100 times their own weight and store the exudate in their polymer structure.Polyacrylate super-absorbers inhibit excessive protease activity and normalize t he wound micromilieu. They thus support wound cleansing and t he formation of granulation tissue. Depending on the amount of exudate , the dressing should be changed af ter 13 days.Proteolytic enzymesProteolytic enzymes enable selective dbridement, which may be accomplished without pain or ble eding. They are safe, quick and easy to apply. Yet treatment can t ake a very long time. If the wound margin is not protected, maceration of the surrounding area may occ ur. At present, an ointment with collagenase, and a gel with streptodornase/streptokinase are available. 547 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME ArticleThe preparations are applied, af ter mechanical wound cleansing, in 25 mm layers. They should be covered with non- adhesive dressings. Depending on the chosen preparation, the wound dressing should be changed after 1224 hours.Other productsThere are many other products which do not clearly belong to one of the afore-mentioned groups. Of particular interest are advanced wound care products which are also de clared as wound (kick)starters. These are a new, highly diverse group of therapies for use in wound treatment. Their primary aim is to ac tively in fluence the wound milieu.By interacting wit h the wound, they are intended to alter the wound milieu or wou nd surface. Advanced wound care products are used in chron ic wounds which, despite optimal, cau sal therapy, remain hard-to-heal.The aim of products containing collagen and cellulose (PromogranTM ; Systagenix), nano-oligosaccharide factor (NOSF, UrgoStartT M; Urgo), or polyhy-drated ionogens (PHI-5, TegadermT M Matrix; 3M), is to directly reduce matrix metalloproteinases (MM Ps) [14, 15]. A test procedure is also currently offered (WoundchekT M; Systagenix) for detecting increased levels of various proteases (increased protease activity [EPA]). Currently used grow th factors include pla-telet-derived grow th factor (PDGF), which is available as a gel (RegranexTM ; Janssen-Cilag) for the treatment of diabetic foot syndrome, as well as epidermal growth factor (EGF), which comes in a wound dressing (NeodermT M; Trime-dicales) [16]. Another new, innovative product uses porcine hemoglobin in the form of a spray (G ranuloxT M; Sastomed), which may be applied directly to the wound surface, along with conventional wound products. The spray is suppo-sed to transport oxygen from the air into the wound, and is thus suitable for all types of hypoxic wounds [17]. There is also a paste, containing modified starch (poloxamer) that is intended to reduce wound pH levels (CadexomerTM ; Smith&Nephew) [18]. Other products contain, e.g., the extracellular mat-rix protein (ECM) amelogenin (XelmaTM ; Mlnlycke) [19], coagulation factor XIII (FibrogramminT M; CSL Behring) [20], the analgesic ibuprofen (Biatain IbuTM ; Many of the underlying ideas, and t he therapeutic approaches, relat ed to these wou nd care products are very interesting. One may expect that, in the futu re, more solid recommendations for their targe ted use may become available. At present, there is still lacking scientific dat a and high qualit y and controlled clin ical t rials are requ ired to proof their clinical effectiveness[1113].Contact allergens in wound therapiesThe current lit erat ure contains several report s of an increased incide nce of cont act sensit ization in patients w ith ch ronic wounds, compared to t he normal popula-tion. In pat ients with chronic venous leg ulcers, contac t sensitization rates of up to 80 % have been c ited. The most commonly identified contact allergens among these patients are wool wax alcohols (18 33 %), followed by aminoglycoside an-tibiotic s and balsam of Peru [22]. There are also increasing numbers of reports of contact sensit ization to product s which are used directly for wound treatment (Table 2) [23].It is important when selecting t est subst ances for patch test ing to also include wou nd dressing products.548 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME ArticleTable 2 Examples of allergens found i n woun d therapies which have been alr eady r eported in conjunc tion with contact sensitizati on in patients with chronic wounds.HydrocolloidsColophonium (up to 14 % of all patient s) Polyisobutyl derivatives (rarely) Carboxymethyl cellulose (rarely) Hydrogels Propylene glycol (up to 18 % of all patients) Fatty gauze Wool wax alcohols (up to 35 % of all pati ents) Arlacel 83 (rarely) Antimicrobial therapies PVP iodine (up to 20 % of all patients) Neomycin (up to 20 % of all patients) Cet yl stear yl alcohol (up to 17 % of all pat ients) Gentamicin (up to 10 % of all patient s) Benzoyl peroxide (up to 4 % of all patients) Cocamidopr opyl betaine (up to 3 % of all patient s)Negative pressure wound therapyNegative pressure treatment, or vacuum therapy, refers to various systems wh ich use an electronic cont rol unit to apply a specific suction level to the tissue. A pri-mary use for ne gat ive pressure wound therapy in t he treatment of patient s with ch ronic wounds in dermatology is wou nd bed preparation, with the aim of promoting granulation.wound healing, e.g., reduction of edema, wou nd cleansing, or me chan ical elimi-n ation of bacteria and wound secretions. The option of usin g the system with instillation allows for cleansing (also with antiseptic s) without removing the d ressing; hence, ne gative pressure therapy may also be u sed in clinic ally infe cted wound s. Disadvantages of negative pressu re therapy in clude the odor, irritation of the area arou nd the wound, and the sometimes considerable pain associa-ted with treatment. T he most important requirement for its use is that negative pressu re may be applied with an airtight seal. Cu rrent negative pressure thera-py systems consist of a sterile, replaceable sponge or coated gauze, and a non- collapsible tube system with a suction pump un it which generates negative pres-sure acc ording to ind ividual patient needs. Ch ronic wounds are usually treated w ith suc tion levels of 75125 mmHg. The surrounding skin should be prote cted against maceration. Protective polyacrylate or silico ne fi lms may be placed over the skin as a protec tive measure. For ch ronic wounds, negative pre ssure th erapy de vices may be le ft in place for 25 days. If pain occ urs whe n the dressing is ch anged, one may apply fatty gauze under the sponge or reduce the suction level or time [24, 2 5]. 549 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME ArticleOther physical t reatment methods which may be u sed in patients with chronic wou nds include electrostimulation therapy, ex tracorporeal shock wave therapy, hyperthermia, laser therapy, plasma therapy, u ltrasound, or wat er-filtered infra-red-A radiation [26 ].Bacteria and infectionsA prerequisite for efficient wound healing is the elimination, or avoidance, of cli-nically relevant wound infec tions. One should take into account that nearly every chronic wound is contaminated or colonized with microorganisms, and t hat this is generally clinically unproblematic. The diagnosis of a clinically relevant wound infe ction should t hus be based on the corresponding clin ical findings with the car-din al symptoms of tu mor, c alor, dolor, rubor, and fu nctio laesa. I n patients with suspected systemic infection, a blood count should be obt ained. In many patients with chronic wounds, both CRP and ESR are elevated, even when they do not have an infection. Other diagnostic c riteria include a fever and chills. Wit h a few exceptions, systemic antibiotic therapy shou ld only be given if there is a systemic infe ction.Specific hygien ic measures should be used in patients with problem bacteria, such as M RSA. I n patients with chronic wounds who have colonizat ion, but who do not have a systemic infection, topical t reat ment with modern antiseptics is con-sidered adequate [2729].In chronic wounds, a bacterial smear should be taken, whenever possible, from the wound surface for example using the Essener Rotary technique). The Essener Rotary technique involves applying gentle pressure to take the bacteriological smear from the wound surface, moving from the outer edge inward in a circular fashion to obtain a representative sample of bacteria for identification [30]. For deep wounds, extensive soft tissue infections, or in the framework of surgical intervention, biopsies should be taken from clinically suspicious areas.AntisepticsPolyhexanide (polyhexamethylene biguanide, PHMB) belongs to the biguanide substance class. Along with wound cleansing solutions containing preservatives, polyhexanide is also now increasingly found in hyd rogels and wound dressings as a first-line substance for use in antimicrobial wou nd therapy. Thus, in clin ical use, it is also more feasible to ensure the cont act time of ten minutes. Polyhex anide should not be used on ex posed cartilage, in the inner ear, or the CNSIn Germany, octenid ine is found in medications as octenidine dihydrochlori-de. A clear solution, octenidine w ith 2 % phenox yethanol is the fi rst-line choice for antimicrobial treatment of chronic wounds. The contact time for octenidine is at least two minutes. There is also a hyd rogel preparation which may be left in place for 24 hours. The octenidine solution should not be injected w ith pressure into the tissue, as this c an lead to necrosis. In addition, octenidine should not be used at the same time as povidone iodine, because iodine rad icals may be released wh ich can irritat e the tissue and cause discoloration.Preparations containing povidone iodine (polyvinylpyrrolidone [PVP] iodi-ne) have long been central to treatment in Germany of pat ients with acute, post- traumatic wounds, as well as for preoperative preparat ion. Problems include the high rate of contact sensitization, discoloration of wounds, which makes evaluation of the wound difficult , and potential inactivation due to blood, pus, and wou nd 550 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME ArticleTable 3 Modified mor phine hydr ogel for wound treatment developed in Essen. Compared to the NRF formulation, propylene glycol was replaced by polyhexanide (LavaseptT M ).Morphine hydrochloride trihydrate 0.1 g Ethylenediamine tetra-acetic acid sod ium salt 0.1 g Hydroxyethyl cellulose 400 4.5 g Lavasept concentrate 20 % 0.2 ml Purified water EuAB ad 100.0 gexudate. In hard-to-heal wounds, wit h Gram-negative bacterial such as Pseudomo-n as aeruginosa, it may be advisable to briefly use PVP iodine [2 , 5, 2729]. Studie s have also shown that PVP iodine preparations can effectively neutraliz e proteases and thus possibly have a positive influence on the wound healing process [31].PainPain is a complex subjective, perceptual phenomenon, which is influenced by nu-merous physiological, psychological, emotional, and social factors. Pain leads to a diminished qualit y of life, has a negat ive effect on patient compliance, and is an independent risk factor in delayed wound healing. Most patients with chron ic wounds report having at least temporary pain due to their wou nd. Pain intensit y may be evaluated using various sc ales. In Germany, the visual analogue scale (VAS) is the most widely used.It is important when measuring pain to determine ac tual pain as well as pain be tween dressing changes. For values =4, improved pain therapy and avoidance of pain should be the goal. For patients with painful wounds, one mu st seriously con-sider whether continuous systemic pain therapy, in accordance with the analgesic ladder of the World Health Organization ( WHO), may be advisable [32].Using other measures is also often helpful, if changing the dressing is pain ful. Firmly adherent dressings can be removed almost painlessly if they are soaked for at le ast 30 minutes prior to removal in Ringer solution. Crusts may be softened using compresses soaked in olive oil or ointment and removed atraumatically using a wooden spatula. Local anesthetics in the form of lidocaine and prilocaine cream are suitable as supportive therapy. The cream should be applied to the wound for at le ast 60 minutes before cleansing is performed [33]. The effectiveness may be incre ased by using occlusion wit h semi-permeable films. There are also wound d ressings available which release low- dose ibuprofen [21]. Morphine hydrogels are of ten highly ef fective; these may b e applied d irectly to the wound and lef t in place for 24 hours (Table 3) [34].ConclusionsIt is clearly evident that moist wound therapy, which is adapted to t he wound healing phases, and make s use of modern wound care products, can help ensu re an optimal wound milieu, avoid complications, improve the patients quality of life, and fac ilitate t he healing of chronic wounds. Still, c ausal treatment of the u nderlying disease(s), on the basis of a thorough and usually interdisciplinary d iagnosis, is the main requirement for long-term healing of chronic wounds. 551 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME ArticleReferences1 Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature 2008; 453: 31421.2 AWMF, S3-Leitlinie der Deutschen Ge sellschaft fr Wundheilung und Wundbehan-dlung, Lokaltherapie chronischer Wunden bei Patienten mit den Risiken periphere arterielle Verschlusskrankheit, Diabetes mellitus, chronische vense Insuffizienz. AWMF-Register Nr. 091/001. Aktueller Stand: 12.06.2012. http://www.awmf.org/up-loads/tx_szleitlinien/091001l_S3_Lokaltherapie_chronischer_Wunden_201206.pdf3 Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962; 193: 2934.4 Strohal R, Apelqvist J, Dissemond J et al. EWMA Document: Dbridement. An up-dated overview and clarification of the principle role of dbridement. J Wound Care 2013; 22 (Suppl. 1): 152.5 Kramer A, Daeschl ein G, Kammerlander G et al. Konsensusempfehl ung zur Auswahl von Wirkstoffen fr die Wundantiseptik. Zeitschrift fr Wundheilung 2004; 3: 11 020.6 Fernande z R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012; 2: CD003861.7 Schwarzkopf A, Assenheimer B, Bltemann A et al. fr den Vorstand der Initative Chronische Wunde e. V. Hygienefachliche und rechtliche Bewertung der Anwendung von Leitungswasser als Wundsplung. Wundmanagement 2012; 6: 1957.8 Doerler M, Re ich-Schupke S, Altmeyer P, Stcker M. Impact on wound healing and efficacy of various l eg ulcer dbridement techniques. J Dtsch Dermatol Ges 2012; 10: 62431.9 Brlmann FE, Ubbink DT, Nelson EA et al. Evidence-based decisions for local and sys-temic wound care. Br J Surg 2012; 99(9): 117283.10 Dissemond J. Evidenz-basier te Medizin versus Best Practice: Wie entwickelt sich die Behandlung des chronischen Ulcus cruris Deutschland? Wundmanagement 2012; 6(Suppl. 2): 611.11 Heyer K, Augustin M, Protz K et al . Effectiveness of advanced versus conventional wound dressings on healing of chronic wounds: systematic review and meta-analysis. De rmatol ogy 2013; 226: 17284.12 Kl ein S, Schreml S, Dolderer J et al. Evidenzbasierte topische Therapie chronischer Wunden nach dem T.I.M.E.-Prinzip J Dtsch Dermatol Ges 2013; 11: 81930.13 Palfreyman SJ, Nelson E A, Lochiel R, Michaels JA. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev 2006 3: CD001103.14 Meaume S, Truchetet F, Cambazard F et al. of the CHALLENGE Study Group. A ran-domized, controlled, double-blind prospective trial with a Lipido-Colloid Technology-Nano-OligoSaccharide Factor wound dressing in the local management of venous leg ulcers. Wound Repair Regen 2012; 20(4): 500 11.15 Weindorf M, Krber A, Klode J, Dissemond J. Nicht-interventionelle Untersuchung der Wirksamkeit und Ver trglichkeit von Te gadermT M Matrix bei Patienten mit therapiere-fraktren, chronischen Wunden. J Dtsch Dermatol Ge s 2012; 10: 41220.16 Perry BH, Sampson AR, Schwab BH et al. A meta-analytic approach to an integrated summary of efficacy: a case study of becaplermin gel. Control Clin Trials 2002; 23: 389408.17 Arenbergerova M, Engels P, Gkalpakiotis S et al. Topical hemoglobin promotes wound healing of patients with venous leg ulcers. Hautarzt 2013; 64:18086.18 Krbe r A, Freise J, Grabbe S, Dissemond J. Reduktion de s pH-Wertes im Ulcus cruris Correspondence todurch Cadesorb. Zeitschrift fr Wundheilung 2006; 11: 2304.19 Vowden P, Romanelli M, Peter R et al. The effect of amelogenins (Xelma) on hard-to-Prof. Dr. med. Joachim Dissemond Klinik und Poliklinik fr Dermatologie Venerologie und Allergologie Universittsklinikum EssenHufelandstrae 55 45122 Essen, GermanyE-mail: joachim.dissemond @uk- heal venous leg ul cers. Wound Repair Regen 2006; 14: 2406.20 Wozniak G, Noll T. Faktor XIII und Wundheilung. Hamostaseologie. 2002; 22: 5962.21 Gottrup F, Jrgensen B, Karlsmark T et al. Reducing wound pain in venous leg ulcers with Biatain Ibu: a randomized, controll ed double-blind clinical investigation on the performance and safety. Wound Repair Regen 2008; 16: 61525.22 Freise J, Kohaus S, Krber A et al. Contact sensitization in patients with chronic wounds: Results of a prospective investigation. J Eur Acad Dermatol Venereol 2008; 22: 12037.essen.de552 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME Article23 Machet L, Couh C, Perrinaud A et al. A high prevalence of sensitization still persists in leg ulcer patients: a retrospective series of 106 patients tested betwe en 2001 and 2002 and a meta-analysis of 19752003 data. Br J Dermatol 2004; 150: 92935.24 Peinemann F, Sauerland S. Negative-pressure wound therapy: systematic review of randomized controlle d trials. Dtsch Arztebl Int 2011; 108(22): 3819.25 Ubbink DT, Westerbos SJ, Evans D et al. Topical ne gative pressure for treating chronic wounds. Cochrane Database Syst Rev 2008; 16: CD001898.26 Dissemond J. Physikalische Therapien des chronischen Ulcus cruris. Hautarzt 2010; 61: 38796.27 Dissemond J, Assadian O, Gerber V et al. Classification of Wounds at Risk (W.A.R. Score) and their antimicrobial treatment with pol ihexanide A practice-oriented ex-pert recommendation. Skin Pharm Physiol 2011; 24: 24555.28 Dissemond J, Gerber V, Kramer A et al. Praxisorientierte Empfehlung zur Behandlung kritisch-kolonisierter und lokal infizier ter Wunden mit Polihexanid. Wundmanagement 2009; 3: 628.29 OMeara S, Al-Kurdi D, Ol ogun Y, Ovington LG. Antibiotics and antiseptics for venous l eg ulcers. Cochrane Database Syst Rev 2010; 1: CD003557.30 Al Ghazal P, Krber A, Klode J et al. Evaluation of the Essen Rotar y as a new technique for bacterial swabs: re sults of a prospective controlled clinical investigation in 50 pa-tients with chronic le g ulcers. Int Wound J 2014; 11: 449.31 Eming SA, Smola -Hess S, Kurschat P et al. A novel property of povidon-iodine: Inhibi-tion of excessive protease levels in chronic non-healing wounds. J Invest Dermatol 2006; 126: 27313.32 Heinl in J, Schreml S, Babilas P et al. Cutaneous wound healing. Therapeutic inter ven-tions. Hautarzt 2010; 61: 61126.33 Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers. Cochrane Database Syst Rev 2010; 4: CD001177.34 Huptas L, Rompoti N, Herbig S et al. Schmerzreduktion bei Patienten mit chro-nischem Ulcus cruris durch ein neu entwickeltes Morphin-Gel: Erste Re sultate einer klinischen Untersuchung. Hautarzt 2011; 62(4): 2806. 553 2 014 De ut sc he De r m a t olog isc he Ge se l lsc ha f t ( DDG) . P u bli she d by J ohn Wile y & S o ns Lt d. | JDDG | 161 0- 03 79 /2 014/1 20 7

CME ArticleFragen zur Zertifizierung durch die DDA1. Wie lange muss eine Wunde mindes-tens bestehen, wenn sie entsprechend der aktuellen Leitlinienempfehlungen als chronisch bezeichnet werden kann?a) Wasserstoffperoxid-Lsungb) Ethacridinlactat-Lsungc) Polihexanid-Lsungd) Farbstoff-Lsungene) Mer bromin-Lsung 9. Wann sollte bei Patienten mit chro-nischen Wunden eine systemische Therapie mit Antibiotika erfolgen?a) Wenn auch systemische Infektions-zeichen vorliegen.a) 4 Wochenb) 6 Wochenc) 8 Wochend) 12 Wochene) 24 Wochenb) Wenn groe Mengen von Bakte-rien in Abstrichen nachgewiesen wurden.6. Welche Lebewesen werden im Rah-men der sogenannten Biochirurgie therapeutisch eingesetzt?c) Wenn MRSA in Abstrichen nachgewiesen wurden.a) Behandlung mit steril gezchteten d) Wenn sich Rtungen um die Blutegeln2. Welche Aussage zu Wundverbnden ist falsch? Wunden zeigen.b) Behandlung mit steril gezchteten e) Wenn ein gr ner Belag auf der Fliegenmadena) Hydrogele sind fr ein autolytisches Wunde besteht.c) Behandlung mit steril gezchteten Dbridement geeignet.Kangal-Fischenb) Wenn Hyaluronsureprodukte in d) Behandlung mit steril gezchteten 10. Welche Aussage zu Honig in der Wundbehandlung ist falsch?Kontakt mit Wundsekret kommen bildet sich ein hydrophiles Gel.Seeigelne) Behandlung mit steril gezchteten a) Fr die Wundbehandlung sind c) Kollagene sollen durch die Freiset-Seidenr aupenzung von Proteasen wirken. Honi gpr parationen aus Tuben und impr gni erte Wundauflagen erhlt-lich.d) Hydrofasern knnen Flssigkeit bis zu etwa dem 40fachen ihres Eigen-gewichts aufnehmen.7. Es sind aktuell Wundau flagen fr die Behandlung von Patienten mit chroni-schen Wunden erhltlich, die zudem ein Analgetikum enthalten. Welches Analgetikum wurde hier zugesetzt?b) Honi gpr parationen sind auch anti-e) Alginate wirken auch hmostyptisch.mikrobiell wirksam.c) Honi gpr parationen knnen fr ein osmotisches Dbridement einge-setzt werden.3. Welcher Inhaltsstoff wird derzeit bereits kommerziell in sogenannten Wundstartern fr die Wundtherapie verwendet?d) Durch die Anwendung von Honig-a) ASSb) Paracetamolc) Ibuprofend) Diclofenace) Cox-2-Hemmerprparationen kann es zu starken Schmerzen kommen.e) Honigpr parationen werden meist a) Plasminb) Fibrinc) Fibrinogend) Elastasee) Hmoglobinbei sehr exsudativen Wunden eingesetzt.8. Welche Aussage zu Spllsungen fr chronische Wunden ist richtig?a) Glukoselsungen sind eine Spll-4. Welcher der folgenden Verbandsys-teme eignet sich auch besonders gut fr den Einsatz bei ftiden, neoplasti-schen Wunden?sung der ersten Wahl.Liebe Leserinnen und Leser,der Einsendeschluss an die DDA fr die-se Ausgabe ist d er (15. August 2014). Die richtige L sung zum Thema Die n icht-syndromalen Ichthyosen aktueller Stand in Heft n o. 2 (Februar y 2014) ist: (1b, 2c, 3b, 4e, 5d, 6c, 7b, 8c, 9b, 10b).b) Der Einsat z von Leitungswasser kann als hygienisch unbedenklich empfohlen werden.c) Physiologische Kochsalzlsungen a) imprgnierte Fettgazeb) offenpor iger Schaumstoffc) Vakuumtherapied) Aktivkohleverbande) okkludierende Folienknnen nach Anbruch mindestens fr eine Woche verwendet werden, wenn sie gekhlt gelager t wurden.d) Wundspllsungen sollten bei Ap-Bitte verwenden Sie fr Ihre Einsendung das aktuelle Formblatt auf der folgenden Seite oder aber geben Sie Ihre Lsung online unter http://jddg.akademie-dda.de ein.plikation mglichst krperwarm sein.e) Wundspllsungen sollten mg-5. Welches Antiseptikum wird auch fr den Einsatz bei Patienten mit chronischen Wunden als ein Prparat der ersten Wahl empfohlen?lichst als Teilkrperbad angewendet werden.554 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07