Dressing Selection in Chronic Wound 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 environment. 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. Reimbursement issues are also discussed. (J Am Podiatr Med Assoc 92(1): 24-33, 2002)

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, clinicians 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 Winter 4 demonstrating that epithelialization in partialthickness porcine wounds occurred two times faster in a moist versus dry environment. Hinman and Maibach5 substantiated these findings in human partial-thickness wounds, leading to the concept that dressings have the potential to interact with the wound environment and affect healing instead of acting as passive coverings. Wound healing experts now accept that a moist wound environment is advantageous to wound healing. Benefits include enhanced keratinocyte and fibroblast proliferation, keratinocyte migration, collagen synthesis, angiogenesis, wound contraction, autolytic debridement, and wound closure.6, 7 However, despite evidence supporting moist wound healing, many clinicians fear that the same environment that promotes wound healing also supports bacterial growth and wound infection.8 Hutchinson and McGuckin9 performed a secondary analysis of over 100 studies comparing infection rates in more than 4,000 wounds treated with occlusive dressings or nonocclusive conventional dressings (predominantly gauze) and
*Nurse Practitioner, Grossmont Hospital Wound Healing Center, 5555 Grossmont Center Dr, La Mesa, CA 91942.

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 desiccation and necrosis, which provide a culture medium for bacteria.9-11 Thus, the evidence supports the concept that a moist wound environment is beneficial to healing and results in a decreased risk of infection. In the last three decades, hundreds of dressings have been developed that provide a moist wound environment. Clinicians should be aware of the characteristics of an ideal dressing and be able to differentiate 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 environment, absorbs excess exudate, eliminates dead space, does not harm the wound, and provides thermal insulation and a bacterial barrier. The clinician can judge the potential performance of a dressing by examining it for these characteristics. A dressing that maintains a moist wound environment is described as moisture retentive.6 The degree of moisture retentiveness is measured by the moisture vapor transmission rate.6, 7, 12 This rate, often reported as g/m2/24 hr, refers to the passage of water

24

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

vapor from the wound bed, through a dressing, to the outside environment. A dressing is moisture retentive when its moisture vapor transmission rate is less than 840 g/m2/24 hr.10 The moisture vapor transmission 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 a moisture 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/m 2/hr (96 to 216 g/m 2/24 hr) in intact skin, and 80 to 90 mg/m 2/hr (1,920 to 2,160 g/m 2/24 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 require a more permeable dressing with a high moisture vapor transmission rate. As this dressing absorbs drainage, it evaporates off into the environment. Using a dressing with a low moisture vapor transmission rate on this type of wound would result in dressing 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 appropriate dressings can be prescribed. Although a moist wound environment is important in wound healing, excessive moisture can contribute to delayed healing and further breakdown of the skin. Unmanaged exudate may contribute to increased 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 capacity 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 pressure on fragile tissue can lead to further damage. Many wound fillers, such as alginates and starch copolymers, gel and conform to the wound bed as they absorb, 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 surrounding 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 qualities of many absorptive wound fillers allow for atraumatic removal. Also, most adhesive dressings do not adhere to the moist wound bed. Some of these dressings, however, may strongly adhere to the surrounding skin, thus traumatizing it when the dressing is removed. Clinicians should seek a balance between dressing adherence and atraumatic removal when using these products. The temperature of the wound should be maintained 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. Clinicians should follow package insert instructions regarding 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 barrier 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 function. However, the addition of the film may decrease the 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 process. As the wound improves or deteriorates, clinicians must be prepared to change the dressing prescription.

Dressing Categories
Transparent Films
Transparent films are thin, clear polyurethane dressings 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 moisture vapor. Films used in wound care have average

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

25

Table 1. Selecting the Appropriate Dressing Wound Characteristic High exudate Goal of Therapy Exudate absorption Dressing Examples Absorptive wound fillers Foams (high moisture vapor transmission rate) Collagens Gauze Hydrocolloids Foams (low moisture vapor transmission rate) Transparent films (secondary dressing over filler) 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 Use dressing appropriate for amount of exudate, but change dressing daily Avoid occlusive dressings Antimicrobial dressings may be used Saline irrigation (35 mL syringe/19 g needle) Use dressing appropriate for amount of exudate, but change dressing every 1-3 days Use occlusive dressings with caution

Low exudate

Maintain moisture

No exudate

Add moisture

Clinically infected

Systemic treatment of infection Wick away exudate Wound cleansing

High infection risk Immunosuppression Ischemic ulcer Diabetic foot ulcer Wound location

Prevent infection

Prevent wound contamination Prevent maceration on plantar foot

Use adhesive dressings (films over filler, hydrocolloids, foams) in the sacral area to protect from incontinence Avoid dressings that will compress with ambulation and ooze onto surrounding skin (eg, hydrocolloids, paste wound fillers) Avoid adhesive dressings; use a sheet hydrogel on skin tears secured with gauze wrap or netting Avoid adhesive dressings or products with sensitizing preservatives Use skin sealants on surrounding skin for protection

Skin quality

Fragile skin Risk of contact sensitivity Periwound maceration

moisture vapor transmission rates of 300 to 800 g/m2/24 hr.6, 21, 22 In contrast, films used over intravenous 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 rates up 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 minimally-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 reduction. 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 absorptive, however, and excess drainage can lead to periwound skin maceration. Films also may be difficult 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 liquid skin sealant can be used to improve adherence on

26

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

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 interact with wound fluid to form a moist gel over the wound bed. Absorptive ingredients may include carboxymethyl cellulose, gelatin, pectin, or guar gum.20 Adhesives are added for dressing adherence. The absorptive layer is covered by a film that is impermeable 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 impermeable to moisture vapor. Hydrocolloids vary by brand. Most are translucent so that the wound and amount of exudate accumulation can be monitored. Some hydrocolloids are tapered, which prevents rolling of the dressing edges, and some are surrounded by adhesive tape or transparent 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 infected 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 diabetic foot ulcers or ischemic ulcers due to the increased risk of infection with these wounds, especially when left covered for long periods of time. Hydrocolloids provide protection from friction and exogenous bacterial contamination, and pain reduction. 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 ulcers. 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 dressing 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 determine the location of the exudate under the dressing. Caregivers should be educated in advance about the odor and yellow drainage associated with this product; they should also be assured that this is usually normal 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 nonadhesive foams, foams used to pack wounds, and sheet foams, which are available with or without film coverings. Moisture vapor transmission rates vary widely (800 to more than 5,000 g/m2/24 hr) 6, 21 based on the 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. Therefore, the former dressing would be chosen for a highly-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, granulating or necrotic wounds, and wounds of any etiology. 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. Adhesive 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 environment for autolytic debridement, and may also help decrease 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

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

27

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 composed of alginates or starch copolymers, most of which soften or gel as they absorb. Alginate dressings are composed of naturally occurring polymers of brown seaweed, specifically mannuronic or guluronic 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 cellulose 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 infected wounds, if changed daily, and may be used under other dressings, such as hydrocolloids or foams, to increase dressing wear time. For example, a hydrocolloid with a 3-day wear time on a particular wound may be left in place up to 4 to 5 days with the addition 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 alginates, 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 undermining. Large amounts of these products may be left behind 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 absorptive 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 dressing and severe adherence (especially alginates) may occur if the dressing dries out. When using absorptive wound fillers, the secondary dressing should be selected based on the amount of exudate. For example, on a highly-exudating 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, hydrocolloids, 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 performance 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 distinguishes between absorptive and nonabsorptive fillers.

Hydrogels
Hydrogels, which are water in gel form, provide moisture to a wound. They are composed of 60% to 94% water, with polymers, and humectants.20 Sheet hydrogels have a three-dimensional structure supported by cross-linked polymers.12 Amorphous gels are packaged 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 include other 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-exudating wounds, granulating or necrotic wounds, and any wound etiology, except a dry ischemic ulcer. Amorphous gels may be used on infected wounds if changed daily. Sheet hydrogels should be used on superficial wounds with less than 0.5 cm depth; amorphous 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.

28

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

Table 2. Common Wound Healing Products Product Transparent Films BLISTERFILM CarraSmart Film Comfeel Film Cutifilm mefilm OpSite POLYSKIN ProCyte Tegaderm TRANSEAL Hydrocolloids CarraSmart Comfeel Plus Cutinova Hydro DuoDERM Exuderm Hydrocol Procol RepliCare Restore Plus Sorbex Tegasorb ULTEC Foams Allevyn Biatain CarraSmart Foam CURAFOAM Cutinova Foam Flexzan LYOFOAM mepilex Mitraflex POLYDERM Polymem a Sof-Foam Tielle a VigiFOAM Absorptive Wound Fillers Alginates: AlgiDERM Bard Medical AlgiSite Smith + Nephew CarraGinate Carrington Laboratories Comfeel SeaSorb Coloplast CURASORB Kendall KALGINATE DeRoyal KALTOSTAT ConvaTec melgisorb Mlnlycke Restore CalciCare Hollister Sorbsan Bertek Tegagen 3M Others (mainly starch copolymers): AQUACEL ConvaTec Bard Absorption Dressing Bard Medical Company Product Company

Kendall Carrington Laboratories Coloplast Beiersdorf-Jobst Mlnlycke Smith + Nephew Kendall Bard Medical 3M DeRoyal

Absorptive Wound Fillers - Others (continued) Comfeel Powder or Paste Coloplast FlexiGel STRANDS Smith + Nephew Comfeel Triad Coloplast Nonabsorbent fillers: MULTIDEX Gel or Powder Biafine Hydrogels Amorphous: Biolex Wound Gel Carrasyn Purilon Gel CURAFIL Curasol DuoDERM Hydroactive Sterile Gel IntraSite normlgel NuGel Collagen Wound Gel Restore Hydrogel SoloSite Tegagel Sheet: AQUAFLO AQUASORB CarraDres ClearSite CURAGEL Elasto-Gel Flexderm NuGel Wound Dressing Vigilon Collagens 100% collagen: hyCURE Medifil (particles, pads, gel) SkinTemp Combination Products: FIBRACOL WounDres Collagen Hydrogel Antimicrobials Acticoat Arglaes Iodosorb Gel and Iodoflex Pad KERLIX A.M.D. Silveron Contact Layers Adaptic Non-Adhering Dressing Dermanet mepitel N-terface Tegapore DeRoyal Medix Pharmaceuticals Americas

Carrington Laboratories Coloplast Beiersdorf-Jobst ConvaTec Medline Bertek DeRoyal Smith + Nephew Hollister Bard Medical 3M Kendall

Bard Medical Carrington Laboratories Coloplast Kendall Healthpoint ConvaTec Smith + Nephew Mlnlycke Johnson & Johnson Hollister Smith + Nephew 3M Kendall DeRoyal Carrington Laboratories CONMED Kendall Southwest Technologies Bertek Johnson & Johnson Bard Medical

Smith + Nephew Coloplast Carrington Laboratories Kendall Beiersdorf-Jobst Bertek ConvaTec Mlnlycke Mlnlycke DeRoyal Ferris Johnson & Johnson Johnson & Johnson Bard Medical

Hymed Group BioCore Medical Technologies BioCore Medical Technologies Johnson & Johnson Coloplast Smith + Nephew Medline Healthpoint Kendall Silveron Consumer Products Johnson & Johnson DeRoyal Mlnlycke Winfield Labs 3M

This list is not all-inclusive of every dressing on the market. No inferences should be made regarding the inclusion or exclusion of products on this list. a Composite dressings

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

29

Hydrogels provide a moist environment for autolytic debridement. They are nonadhesive and conform to the wound bed. Sheet hydrogels are very soothing and cooling when applied to painful wounds such as superficial burns or skin tears. The potential for periwound skin maceration is a disadvantage of these products, however, and some products that lack sufficient levels of humectants may dry out in the wound. On low-draining superficial wounds, sheet hydrogels 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.

away rapidly will provide this matrix, and thus improve 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 granulating or necrotic wounds, partial or full-thickness wounds, and on any wound etiology. Sensitivity to the source of the collagen is the main contraindication for these products, and absorptive forms should not be used on dry wounds. Collagen products are highly absorptive and maintain a moist wound environment, which promotes autolytic debridement and pain reduction. Since collagen 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 treatment with collagens. Some of the powder or particles can be mixed with saline to form a paste for easier application. The pad version may expand as it absorbs; therefore, overpacking should be avoided. Products differ between manufacturers and package inserts should be reviewed.

Collagens
Collagen dressings are available as sheets, powders, particles, and ropes that absorb exudate, and gels that provide moisture to wounds. The collagen is obtained from bovine, avian, or porcine sources. While some products are 100% collagen, others are combined 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 improved healing in chronic wounds. In addition, many small studies that have declared the efficacy of these products lack adequate control to allow strong conclusions to be made. It is well understood that in the wound healing process, break-down products of endogenous extracellular matrix are chemotactic for inflammatory cells.30 However, it should not be assumed 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

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 a combination of both, and may be woven or nonwoven.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 capacity 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. Nonwoven gauze is made by blending, not weaving, fibers; no thread development is necessary. This gauze has superior absorbency, tends to be less adherent to the wound bed, and has a very low amount of lint. Numerous brands and combinations of these products are available. Gauze is indicated for wounds with heavy exudate, especially when the exudate is so significant that it would not be cost-effective to use an absorptive wound filler. For example, a patient with a postoperative seroma in the groin that drains a tremendous amount of serous fluid may require dressing changes four to six times daily. Dry nonwoven gauze

30

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

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 patient, and the use of a nonadherent contact layer, covered by gauze, may be the best option for drainage containment. Gauze is also indicated as a primary dressing over ointments, enzymes, and growth factors, 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 nonselective 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 must be 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 patient has enough exudate, the wound will not dry out, and gauze may be a viable option for packing. Ribbon 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 between 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 frequently used over creams, ointments, or growth factors, and are then covered with gauze. The layers provide a low-cost moist wound healing method. Composite dressings. These products are combinations 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 covered 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, randomized pilot study of 30 patients with diabetic foot ulcers, weekly application of Hyalofill showed a statistically significant improvement in wound closure over the control group (P < .05).35 A large, randomized, controlled trial is currently underway, and this data 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, despite 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 infections, patients at risk for infection, and patients with malodorous wounds. These products differ from topical antibiotics in that they are actual dressings that may or may not require a secondary dressing. 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 iodine and 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 technology to control bacterial burden in the wound. These dressings contain silver ions with broad-spectrum activity against many organisms, including methicillinresistant staphylococcus aureus and vancomycinresistant enterococci.39, 40 Silver ions kill bacteria rapidly and remain nontoxic to human cells. In addition to reducing bacterial counts in wounds, these dressings may have a positive effect on wound healing by decreasing proteolytic activity, specifically matrix metalloproteinase activity, and by reducing inflammation.41 Silver dressings are available in a variety 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,

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

31

Mansfield, Massachusetts), is available as woven gauze rolls or sponges that contain 0.2% polyhexamethylene biguanide, an antimicrobial commonly used in products such as contact lens solutions and baby wipes. Kerlix AMD is used to decrease bacterial colonization within the dressing and reduce bacterial penetration through the dressing. Unpublished studies have demonstrated the dressings ability to achieve the latter, as well as maintain epithelialization rates similar to saline-moistened gauze. Since this gauze dressing may dry out readily, a moist wound environment can be maintained by periodically 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 patients should be treated primarily with systemic antibiotic therapy.

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 prescription No 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 surgical closure 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

Reimbursement
The majority of the dressings reviewed in this article, whether used as primary or secondary dressings, are reimbursed by Medicare and most insurance companies.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. Clinicians should work with local suppliers who are willing to provide Medicare and insurance billing for patients. In addition, a knowledgeable supplier can assist clinicians with daily to weekly dressing use guidelines, or this information can be accessed on the Internet.

infection, debriding nonviable tissue, and addressing systemic factors that affect wound healing.

References 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 characteristics of an ideal dressing. These characteristics include maintenance of a moist wound environment, absorption of excess exudate, elimination of dead space, prevention of harm to the wound, and the provision 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 attaining 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
1. CHO CY, LO JS: Dressing the part. Dermatol Clin 16: 25, 1998. 2. TURNER TD: The Development of Wound Management Products, in Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 2nd Ed, ed by D Krasner, D Kane, p 124, Health Management Publications, Wayne, PA, 1997. 3. OVINGTON LG: The well-dressed wound: an overview of dressing types. Wounds 10 (suppl A): 1A, 1998. 4. WINTER GD: Formation of the scab and the rate of epithelialization of superficial wounds in the skin of young domestic pigs. Nature 193: 293, 1962. 5. HINMAN CD, MAIBACH HI: Effect of air exposure and occlusion on experimental human skin wounds. Nature 200: 377, 1963. 6. BOLTON LL, MONTE K, PIRONE LA: Moisture and healing: beyond the jargon. Ostomy Wound Mgmt 46 (suppl 1A): 51S, 2000. 7. FIELD CK, KERSTEIN MD: Overview of wound healing in a moist environment. Am J Surg 167 (suppl 1A): 2S, 1994.

32

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

8. KANNON GA, GARRETT AB: Moist wound healing with occlusive dressings. Dermatol Surg 21: 583, 1995. 9. HUTCHINSON JJ, MCGUCKIN M: Occlusive dressings: a microbiologic and clinical review. Am J Infect Contr 18: 257, 1990. 10. BOLTON LL, JOHNSON CL, VAN RIJSWIJK L: Occlusive dressings: therapeutic agents and effects on drug delivery. Clin Dermatol 9: 573, 1992. 11. MERTZ PM, OVINGTON LG: Wound healing microbiology. Dermatol Clin 11: 739, 1993. 12. R OLSTAD BS, O VINGTON LG, H ARRIS A: Principles of Wound Management, in Acute and Chronic Wounds: Nursing Management, 2nd Ed, ed by RA Bryant, p 85, Mosby, St Louis, 2000. 13. WU P, NELSON EA, REID WH, ET AL: Water vapour transmission rates in burns and chronic leg ulcers: influence of wound dressings and comparison with in vitro evaluation. Biomaterials 17: 1373, 1996. 14. S ILVERMAN RA, L ENDER J, E LMETS CA: Effects of occlusive and semiocclusive dressings on the return of barrier function to transepidermal water loss in standardized human wounds. J Am Acad Dermatol 20: 755, 1989. 15. BERGSTROM N, BENNETT MA, CARLSON CE, ET AL: Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. AHCPR publication 95-0652. US Dept of Health and Human Services, Agency for Health Care Policy and Research, Rockville, MD, 1994. 16. HARDING KG, BALE S: Wound care: putting theory into practice in the United Kingdom, in Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 2nd Ed, ed by D Krasner, D Kane, p 115, Health Management Publications, Wayne, PA, 1997. 17. R ODEHEAVER G: Controversies in topical wound management. Wounds 1: 19, 1989. 18. OWENS N: Use of pressure dressings in the treatment of burns and other wounds. Surg Clin North Am 23: 1354, 1943. 19. C OLEBROOK L, L OND MB, H OOD AM: Infection through soaked dressings. Lancet ii: 682, 1948. 20. MERKLE LEIBY D, LOTT G: Topical wound product ingredient guide. Ostomy Wound Mgmt 7: 42, 1997. 21. PALAMAND S, BRENDEN RA, REED AM: Intelligent wound dressings and their physical characteristics. Wounds 3: 149, 1991. 22. W U P, F ISHER AC, F OO PP, ET AL : In vitro assessment of water vapour transmission of synthetic wound dressings. Biomaterials 16: 171, 1995. 23. S MITH AND N EPHEW WEB SITE . Available at: http://www. snwmd.com/iv/mvtr.htm. Accessed October 10, 2000. 24. SASSEVILLE D, TENNSTEDT D, LACHAPELLE JM: Allergic contact dermatitis from hydrocolloid dressings. Am J Contact Dermat 8: 236, 1997. 25. F ALANGA V: Venous ulceration. J Dermatol Surg Oncol 19: 764, 1993. 26. Q IN Y, G ILDING DK: Alginate fibres and wound dressings. Med Device Technol 7: 32, 1996. 27. L ORENZETTI OJ, F ORTENBERRY B, B USBY E, ET AL : Influ-

28.

29. 30.

31. 32.

33. 34. 35.

36. 37.

38.

39.

40.

41. 42.

ence of microcrystalline collagen on wound healing. Proc Soc Exp Biol Med 140: 896, 1972. K OLENIK SA, M C G OVERN TW, L EFFELL DJ: Use of lyophilized bovine collagen matrix in postoperative wound healing. Dermatol Surg 25: 303, 1999. PURNA SK, BABU M: Collagen based dressings: a review. Burns 26: 54, 2000. S ILVER 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. P ONDER RB, K RASNER D: Gauzes and related dressings. Ostomy Wound Mgmt 39: 48, 1993. W EIR DM, B OHANAN BG, H OCKENBROCHT GP, ET AL : Improved wound packing and debridement: evaluation of a new fabric sponge. Wounds 4: 216, 1992. L AWRENCE JC: Dressings and wound infection. Am J Surg 167 (suppl 1A): 21S, 1994. CONVATEC WEB SITE. Available at: http://www.convatec. com. Accessed October 25, 2001. E DMONDS ME, F OSTER AVM, W ILSON S, D OXFORD M, ET AL : The management of indolent neuropathic ulceration of the diabetic foot with Hyalofill. Oral abstract presented at the 13th Annual Symposium on Advanced Wound Care, April 3, 2000, 2000; Dallas, TX. COOK GROUP WEB SITE. Available at: http://www.cooksis. com/technology.html. Accessed October 25, 2001. H OLLOWAY GA, J OHANSEN KH, B ARNES RW, ET AL : Multicenter trial of cadexomer iodine to treat venous stasis ulcer. West J Med 151: 35, 1989. DANIELSEN L, CHERRY GW, HARDING K, ET AL: Cadexomer iodine in ulcers colonised by pseudomonas aeruginosa. J Wound Care 6: 169, 1997. W RIGHT JB, H ANSEN DL, B URRELL RE: The comparative efficacy of two antimicrobial barrier dressings: in vitro examination of two controlled release silver dressings. Wounds 10: 179, 1998. WRIGHT JB, LAM K, BURRELL RE: Wound management in an era of increasing bacterial antibiotic resistance: a role for topical silver treatment. Am J Infect Control 26: 572, 1998. D EMLING RH, D E S ANTI L: The role of silver in wound healing. Wounds 13 (suppl A): 4, 2001. S CHAUM K: Steps to reimbursement success for 2000. Step 3: write orders to justify medical necessity. Adv Skin Wound Care 13 (4 pt 1): 150, 2000.

Additional References
Advances in Skin and Wound Care: 1999 Directory, Springhouse 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 Information, Williston, VT, 2001 (www.woundsource.com).

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

33