OfficialreprintfromUpToDate

www.uptodate.com2016UpToDate

Basicprinciplesofwoundmanagement

Authors: DavidGArmstrong,DPM,MD,PhD,AndrewJMeyr,DPM
SectionEditors: HilarySanfey,MD,JohnFEidt,MD,JosephLMills,Sr,MD,EduardoBruera,MD
DeputyEditor: KathrynACollins,MD,PhD,FACS

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Sep2016.|Thistopiclastupdated:Apr28,2016.

INTRODUCTIONAwoundisadisruptionofthenormalstructureandfunctionoftheskinandskinarchitecture
[1].Anacutewoundhasnormalwoundphysiologyandhealingisanticipatedtoprogressthroughthenormal
stagesofwoundhealing,whereasachronicwoundisdefinedasonethatisphysiologicallyimpaired[2,3].

Toensureproperhealing,thewoundbedneedstobewellvascularized,freeofdevitalizedtissue,clearof
infection,andmoist.Wounddressingsshouldeliminatedeadspace,controlexudate,preventbacterial
overgrowth,ensureproperfluidbalance,becostefficient,andbemanageableforthepatientand/ornursingstaff.
Woundsthatdemonstrateprogressivehealingasevidencedbygranulationtissueandepithelializationcan
undergoclosureorcoverage.Allwoundsarecolonizedwithmicrobeshowever,notallwoundsareinfected[4,5].

Manytopicalagentsandalternativetherapiesareavailablethataremeanttoimprovethewoundhealing
environmentand,althoughdataarelackingtosupportanydefinitiverecommendations,somemaybeuseful
underspecificcircumstances[6,7].

Thebasicprinciplesandavailableoptionsforthemanagementofvariouswoundswillbereviewed.Theefficacy
ofwoundmanagementstrategiesforthetreatmentofspecificwoundsisdiscussedinindividualtopicreviews:

(See"Managementofdiabeticfootulcers".)

(See"Medicalmanagementoflowerextremitychronicvenousdisease",sectionon'Ulcercare'.)

(See"Clinicalstagingandmanagementofpressureinducedinjury",sectionon'Woundmanagement'.)

(See"Treatmentofchroniclowerextremitycriticallimbischemia".)

(See"Overviewandmanagementstrategiesforthecombinedburntraumapatient".)

MEDICALCARE

RoleofantibioticsAllwoundsarecolonizedwithmicrobeshowever,notallwoundsareinfected[4,5].Thus,
antibiotictherapyisnotindicatedforallwounds,andshouldbereservedforwoundsthatappearclinicallyinfected
[8].Thereisnopublishedevidencetosupportantibiotictherapyasprophylaxisinnoninfectedchronicwounds,
ortoimprovethehealingpotentialofwoundswithoutclinicalevidenceofinfection.Clinicalsignsofinfectionthat
warrantantibiotictherapyincludelocal(cellulitis,lymphangiticstreaking,purulence,malodor,wetgangrene,
osteomyelitis,etc)andsystemic(fever,chills,nausea,hypotension,hyperglycemia,leukocytosis,confusion)
symptoms[9,10].(See"Cellulitisanderysipelas"and"Evaluationandmanagementofsuspectedsepsisand
septicshockinadults".)

ControlofbloodsugarAlthoughthereisnooverwhelmingclinicalevidenceinsupportofshorttermglycemic
controlasdirectlyaffectingwoundhealingpotentialorpreventinginfection[11,12],mostcliniciansmakeglycemic
controlaprioritywhentreatingwoundsandinfection.(See"Susceptibilitytoinfectionsinpersonswithdiabetes
mellitus".)

Patientsatriskforthedevelopmentofchronicwoundsoftenhavecomorbidconditionsassociatedwith
immunocompromisedstates(egdiabetes),andmaynothaveclassicsystemicsignsofinfectionsuchasfever
andleukocytosisoninitialpresentation[13].Inthesepatients,hyperglycemiamaybeamoresensitivemeasure
ofinfection.

WOUNDDEBRIDEMENTWoundsthathavedevitalizedtissue,contamination,orresidualsuturematerial
requiredebridementpriortofurtherwoundmanagement.Acutetraumaticwoundsmayhaveirregulardevitalized
edgesorforeignmaterialwithinthewound,andsurgicalwoundsthathavedehiscedmayhaveaninfected
exudate,bowelcontamination,ornecroticmuscleorfascia.Thesematerialsimpedethebodysattempttohealby
stimulatingtheproductionofabnormalmetalloproteasesandconsumingthelocalresourcesnecessaryfor
healing.

Characteristicsofchronicwoundsthatpreventanadequatecellularresponsetowoundhealingstimuliinclude
accumulationofdevitalizedtissue,decreasedangiogenesis,hyperkeratotictissue,exudate,andbiofilmformation
(ie,bacterialovergrowthonthesurfaceofthewound)[14].Thesewoundsneedplannedserialdebridementto
restoreanoptimalwoundhealingenvironment.

Woundbedpreparationfacilitatesorderedrestorationandregenerationofdamagedtissue,andmayenhance
thefunctionofspecializedwoundcareproductsandadvancedbiologictissuesubstitutes[15,16].

IrrigationIrrigationisimportantfordecreasingbacterialloadandremovingloosematerial,andshouldbea
partofroutinewoundmanagement[1,17,18].Warm,isotonic(normal)salineistypicallyusedhowever,
systematicreviewshavefoundnosignificantdifferencesinratesofinfectionfortapwatercomparedwithsaline
forwoundcleansing[19,20].Theadditionofdiluteiodineorotherantisepticsolutions(eg,chlorhexidineand
hydrogenperoxide)isgenerallyunnecessary.Thesesolutionshaveminimalactionagainstbacteriaandcould
potentiallyimpedewoundhealingthroughtoxiceffectsonnormaltissue[2123].(See'Antisepticsand
antimicrobialagents'below.)

Lowpressureirrigation(eg,<15poundspersquareinch[psi])isusuallyadequatetoremovematerialfromthe
surfaceofmostwounds.Decreasedbacterialloadhasbeendocumentedclinicallywiththeuseofpulsed
irrigationinlowerextremitychronicwounds[24].Bacteriadonotappeartoaccompanytheirrigationfluidinto
adjacenttissuesinanimalstudiesevenathigherpressurelevels[25].Inanexperimentalmodel,highpressure
irrigationdecreasedbacteriallevelsmorethanbulbirrigation(averagereduction,70versus44percent)withno
increaseintherateofbacteremia[26].Forhighlycontaminatedwounds,thebenefitsofreducingbacterialload
mayoutweightheriskofspeculativeadjacenttissuedamageassociatedwiththeuseofhigherirrigating
pressures.Althoughhigherpressureirrigatorsmayleadtolocaltissuedamageandincreasedtissueedema,
therearenospecificdataavailabletosuggestaspecificcutoffpressureabovewhichtissuedamageorimpaired,
ratherthanimproved,woundhealingwilloccur.

SurgicalSharpexcisionaldebridementusesascalpelorothersharpinstruments(eg,scissorsorcurette)to
removedevitalizedtissueandaccumulateddebris(biofilm).Sharpexcisionaldebridementofchronicwounds
decreasesbacterialloadandstimulatescontractionandwoundepithelialization[27].Surgicaldebridementisthe
mostappropriatechoiceforremovinglargeareasofnecrotictissueandisindicatedwheneverthereisany
evidenceofinfection(cellulitis,sepsis).Surgicaldebridementisalsoindicatedinthemanagementofchronic
nonhealingwoundstoremoveinfection,handleunderminedwoundedges,orobtaindeeptissueforcultureand
pathology[2830].Serialsurgicaldebridementinaclinicalsetting,whenappropriate,appearstobeassociated
withanincreasedlikelihoodofhealing[29,31].
Inpatientswithactiveinfection,antibiotictherapyshouldbetargetedanddeterminedbywoundcultureand
sensitivitytodecreasethedevelopmentofbacterialresistance[32,33].(See"Cellulitisanderysipelas"and
"Cellulitisanderysipelas",sectionon'Antibiotics'.)

Inpatientswithchroniccriticallimbischemia,surgicaldebridementmustbecoupledwithrevascularizationin
ordertobesuccessful[34].(See"Treatmentofchroniclowerextremitycriticallimbischemia".)

EnzymaticEnzymaticdebridementinvolvesapplyingexogenousenzymaticagentstothewound.Many
productsarecommerciallyavailable(table1),butresultsofclinicalstudiesaremixedandtheiruseremains
controversial[35].Ulcerhealingratesarenotimprovedwiththeuseofmosttopicalagents,includingdebriding
enzymes[36].However,collagenasemaypromoteendothelialcellandkeratinocytemigration,therebystimulating
angiogenesisandepithelializationasitsmechanismofaction,ratherthanfunctioningasastrictdebridement
agent[37].Italsoremainsagoodoptioninpatientswhorequiredebridementbutarenotsurgicalcandidates.

BiologicAnadditionalmethodofwounddebridementusesthelarvaeoftheAustraliansheepblowfly(Lucilia
[Phaenicia]cuprina)orgreenbottlefly(Lucilia[Phaenicia]sericata,MedicalMaggots,MonarchLabs,Irvine,CA)
[38,39].Maggottherapycanbeusedasabridgebetweendebridementprocedures,orfordebridementofchronic
woundswhensurgicaldebridementisnotavailableorcannotbeperformed[40].Maggottherapymayalso
reducethedurationofantibiotictherapyinsomepatients[41].

Maggottherapyhasbeenusedinthetreatmentofpressureulcers[42,43],chronicvenousulceration[4447],
diabeticulcers[38,48],andotheracuteandchronicwounds[49].Thelarvaesecreteproteolyticenzymesthat
liquefynecrotictissuewhichissubsequentlyingestedwhileleavinghealthytissueintact.Basicandclinical
researchsuggeststhatmaggottherapyhasadditionalbenefits,includingantimicrobialactionandstimulationof
woundhealing[39,44,50,51].However,randomizedtrialshavenotfoundconsistentreductionsinthetimeto
woundhealingcomparedwithstandardwoundtherapy(eg,debridement,hydrogel,moistdressings)[52,53].
maggottherapyappearstobeatleastequivalenttohydrogelintermsofcost[53,54].

Dressingchangesincludetheapplicationofaperimeterdressingandacoverdressingofmesh(chiffon)that
helpsdirectthelarvaeintothewoundandlimitstheirmigration(movie1).Larvaearegenerallychangedevery48
to72hours.Onestudythatevaluatedmaggottherapyinchronicvenouswoundsfoundnoadvantageto
continuingmaggottherapybeyondoneweek[45].Patientswererandomlyassignedtomaggottherapy(n=58)
orconventionaltreatment(n=61).Thedifferenceinthesloughpercentagewassignificantlyincreasedinthe
maggottherapygroupcomparedwiththecontrolgroupsatday8(67versus55percent),butnotat15or30
days.

Thelarvaecanalsobeappliedwithinaprefabricatedbiobag(picture1),commerciallyavailableoutsidethe
UnitedStates,thatfacilitatesapplicationanddressingchange[5558].Randomizedtrialscomparingfreerange
withbiobagcontainedlarvaeinthedebridementofwoundshavenotbeenperformed.

Amaindisadvantageofmaggottherapyrelatestonegativeperceptionsaboutitsusebypatientsandstaff.One
concernamongpatientsisthepossibilitythatthelarvaecanescapethedressing,althoughthisrarelyoccurs.
Althoughonestudyidentifiedthatabout50percentofpatientsindicatedtheywouldpreferconventionalwound
therapyovermaggottherapy,89percentofthepatientsrandomlyassignedtomaggottherapysaidtheywould
undergolarvaltreatmentagain[59].Painassociatedwithmaggottherapymaylimititsuseinabout20percentof
patients[60].

TOPICALTHERAPY

GrowthfactorsGrowthfactorsimportantforwoundhealingincludeplateletderivedgrowthfactor(PDGF),
fibroblastgrowthfactor(FGF)andgranulocytemacrophagecolonystimulatingfactor(GMCSF).(See"Wound
healingandriskfactorsfornonhealing".)
Recombinanthumangrowthfactorshavebeendevelopedandarebeingactivelyinvestigatedforthetreatmentof
chroniculcers,mostlythoseaffectingthelowerextremity.

PlateletderivedgrowthfactorBecaplerminisaplateletderivedgrowthfactor(PDGF)gelpreparationthat
promotescellularproliferationandangiogenesis,andtherebyimproveswoundhealing[61].Itisapprovedfor
useintheUnitedStatesasanadjuvanttherapyforthetreatmentofdiabeticfootulcersandistheonly
pharmacologicalagentapprovedfortreatmentofchronicwounds.Thegrowthfactorisdeliveredinatopical
aqueousbasedsodiumcarboxymethylcellulosegel.Itisindicatedfornoninfecteddiabeticfootulcersthat
extendintothesubcutaneoustissueandhaveanadequatevascularsupply[62].Ablackboxwarning
mentionsaconcernformalignancyhowever,theoverallmalignancyriskisbelievedtobelow.Malignancy
complicationsofthistherapymayreflectusageoftheagentinmultiplecoursesoftreatment,andpossible
selectivetransformationofwoundsalreadyatrisk[63].Apostmarketingstudyfoundanincreasedrateof
mortalitysecondarytomalignancyinpatientstreatedwiththreeormoretubesofbecaplermin(3.9versus0.9
per1000personyears)comparedwithcontrols[64,65].(See"Managementofdiabeticfootulcers",section
on'Growthfactors'.)

EpidermalgrowthfactorInastudyofchronicvenousulcers,topicalapplicationofhumanrecombinant
epidermalgrowthfactorwasassociatedwithagreaterreductioninulcersize(7versus3percentreduction)
andhigherulcerhealingrate(35versus11percent)comparedwithplacebo,butthesedifferenceswerenot
statisticallysignificant[66].Epithelializationwasnotsignificantlyaffected.

GranulocytemacrophagecolonystimulatingfactorIntradermalinjectionsofgranulocytemacrophage
colonystimulatingfactor(GMCSF)promotehealingofchroniclegulcers,includingvenousulcers[67,68].A
trialthatrandomlyassigned60patientswithvenousulcerstofourweeklyinjectionswithGMCSF200mcg,
400mcg,orplacebofoundsignificantlyhigherratesofhealingat13weeksintheGMCSFgroup(57,61,
and19percent,respectively)[68].GMCSFhasbeenusedinvarioustypesofchronicwoundstopromote
healing[69].(See"Medicalmanagementoflowerextremitychronicvenousdisease",sectionon'Ulcercare'.)

AntisepticsandantimicrobialagentsMosttopicallyappliedantisepticandantimicrobialproductsare
irritating,partiallycytotoxicleadingtodelayedhealing,andcancausecontactsensitization.However,twoofthese
agentsmaybeassociatedwithpotentialbenefitsinselectpopulations:

IodinebasedCadexomeriodine(eg,Iodosorb)isanantimicrobialthatreducesbacterialloadwithinthe
woundandstimulateshealingbyprovidingamoistwoundenvironment[70].Cadexomeriodineisbacteriocidalto
allgrampositiveandgramnegativebacteria.Fortopicalpreparations,thereissomeevidencetosuggestthat
Cadexomeriodinegenerateshigherhealingratesthanstandardcare.

SilverbasedAlthoughsilveristoxictobacteria,silvercontainingdressingshavenotdemonstrated
significantbenefits[7173].Asystematicreviewevaluatingtopicalsilverininfectedwoundsidentifiedthreetrials
thattreated847participantswithvarioussilvercontainingdressings[74].Onetrialcomparedsilvercontaining
foam(Contreet)withhydrocellularfoam(Allevyn)inpatientswithlegulcers.Thesecondcomparedasilver
containingalginate(Silvercel)withanalginatealone(Algosteril).Thethirdtrialcomparedasilvercontainingfoam
dressing(Contreet)withbestlocalpracticeinpatientswithchronicwounds.Silvercontainingfoamdressings
werenotfoundtosignificantlyimproveulcerhealingatfourweekscomparedwithnonsilvercontainingdressings
forbestlocalpractices.Nevertheless,silverdressingsareusedbymanyclinicianstodecreasetheheavy
bacterialsurfacecontamination[75].

HoneyHoneyhasbeenusedsinceancienttimesforthemanagementofwounds.Honeyhasbroad
spectrumantimicrobialactivityduetoitshighosmolarity,andhighconcentrationofhydrogenperoxide[76].
Medicalgradehoneyproductsarenowavailableasagel,paste,andimpregnatedintoadhesive,alginate,and
colloiddressings[77,78].Basedupontheresultsofsystematicreviewsevaluatinghoneytoaidhealingina
varietyofwounds,thereareinsufficientdatatoprovideanyrecommendationsfortheroutineuseofhoneyforall
woundtypesspecificwoundtypes,suchasburns,maybenefit,whereasothers,suchaschronicvenousulcers,
maynot[7985].

BetablockersKeratinocyteshavebetaadrenergicreceptors,andbetablockersmayinfluencetheiractivity
andincreasetherateofmaturationandmigration.Theuseofsystemicbetablockershasbeenstudiedinburn
patients[86],andseveralcasestudieshavepresentedtheuseoftopicaltimololinchronicwounds[8789].

Timololisatopicallyappliedbetablockerwithsomelimitedevidencethatitpromoteskeratinocytemigrationand
epithelializationofchronicwounds,whichhavebeenunresponsivetostandardwoundinterventions.

WOUNDDRESSINGSWhenasuitabledressingisappliedtoawoundandchangedappropriately,the
dressingcanhaveasignificantimpactonthespeedofwoundhealing,woundstrengthandfunctionofthe
repairedskin,andcosmeticappearanceoftheresultingscar.Nosingledressingisperfectforallwoundsrather,
aclinicianshouldevaluateindividualwoundsandchoosethebestdressingonacasebycasebasis.Examplesof
differingtypesofwoundsandpotentialdressingsaregiveninthetable(table2andtable3).Inaddition,wounds
mustbecontinuallymonitored,astheircharacteristicsanddressingrequirementschangeovertime[90].

Thereislittleclinicalevidencetoaidinthechoicebetweenthedifferenttypesofwounddressings.Consensus
opinionsupportsthefollowinggeneralprinciplesforchronicwoundmanagement[91]:

Hydrogelsforthedebridementstage

Foamandlowadherencedressingsforthegranulationstage

Hydrocolloidandlowadherencedressingsfortheepithelializationstage.

Forallintentsandpurposes,dressingsarebestsuitedtomanagethemoisturelevelinandaroundthewound.
Althoughsomemayhaveadditionalbenefitsintermsoflocalantimicrobialeffects,reducedpainonchange,odor
control,antiinflammatoryormilddebridementability,thesearesecondarybenefits[92].

Dressingsaretypicallychangedonceadayoreveryotherdaytoavoiddisturbingthewoundhealing
environment.Becausesomedressingsmayimpedesomeaspectsofwoundhealing,theyshouldbeusedwith
caution.Asexamples,alginatedressingswithhighcalciumcontentmayimpedeepithelializationbytriggering
prematureterminaldifferentiationofkeratinocytes[91],andsilvercontainingdressingsarecytotoxicandshould
notbeusedintheabsenceofsignificantinfection.(See'Antisepticsandantimicrobialagents'aboveand
'Alginates'below.)

Theadvantagesanddisadvantagesofthevariousdressingtypesarediscussedbelow.(See'Commondressings'
below.)

ImportanceofmoistureFormuchofthehistoryofmedicine,itwasbelievedthatwoundsshouldnotbe
occludedbutleftexposedtotheair.However,animportantstudyinapigmodelshowedthatmoistwounds
healedmorerapidlycomparedwithwoundsthatdriedout[93].Similarresultshavebeenobtainedinhumans[94
96].

Occludedwoundshealupto40percentmorerapidlythannonoccludedwounds[94].Thisisthoughttobedue,
inpart,toeasiermigrationofepidermalcellsinthemoistenvironmentcreatedbythedressing[95].Another
mechanismforimprovedwoundhealingmaybetheexposureofthewoundtoitsownfluid[97].Acutewound
fluidisrichinplateletderivedgrowthfactor,basicfibroblastgrowthfactor,andhasabalanceofmetalloproteases
servingamatrixcustodialfunction[98].Theseinteractwithoneanotherandwithothercytokinestostimulate
healing[99].Ontheotherhand,theeffectofchronicwoundfluidonhealingmaynotbebeneficial.Chronicwound
fluidisverydifferentfromacutewoundfluidandcontainspersistentlyelevatedlevelsofinflammatorycytokines
whichmayinhibitproliferationoffibroblasts[100102].Excessiveperiwoundedemaandindurationcontributesto
thedevelopmentofchronicwoundfluidandshouldbemanagedtominimizethiseffect.(See"Woundhealingand
riskfactorsfornonhealing",sectionon'Phasesofwoundhealing'.)

Inadditiontofasterwoundhealing,woundstreatedwithocclusivedressingsareassociatedwithlessprominent
scarformation[103].Onestudyofporcineskinfoundanaccelerationintheinflammatoryandproliferativephases
ofhealingwhenwoundswerecoveredwithanocclusivedressingasopposedtodrygauze[104].This
accelerationthroughthewoundphasesmaypreventthedevelopmentofachronicwoundstatewhichis
typicallyarrestedintheinflammatoryphaseofhealing.Woundsthathaveagreateramountofinflammationtend
toresultinmoresignificantscars,andthusthedecreasedinflammationandproliferationseenwithwound
occlusionmayalsodecreasetheappearanceofthescar.

Anidealdressingisonethathasthefollowingcharacteristics(table2):

Absorbsexcessivewoundfluidwhilemaintainingamoistenvironment
Protectsthewoundfromfurthermechanicalorcausticdamage
Preventsbacterialinvasionorproliferation
Conformstothewoundshapeandeliminatesdeadspace
Debridesnecrotictissue
Doesnotmaceratethesurroundingviabletissue
Achieveshemostasisandminimizesedemathroughcompression
Doesnotshedfibersorcompoundsthatcouldcauseaforeignbodyorhypersensitivityreaction
Eliminatespainduringandbetweendressingchanges
Minimizesdressingchanges
Isinexpensive,readilyavailable,andhasalongshelflife
Istransparentinordertomonitorwoundappearancewithoutdisruptingdressing

Inmostcases,adressingwithallofthesecharacteristicsisnotavailable,andaclinicianmustdecidewhichof
theseismostimportantinthecaseofaparticularwound.Themoisturecontentofawoundbedmustbekeptin
balanceforbothacuteandchronicwounds.Theareashouldbemoistenoughtopromotehealing,butexcess
exudatemustbeabsorbedawayfromthewoundtopreventmacerationofthehealthytissue.

CommondressingsAlthoughdressingscanbecategorizedbaseduponmanycharacteristics(table2),itis
mostusefultoclassifydressingsbytheirwaterretainingabilitiesbecausetheprimarygoalofadressingisthe
maintenanceofmoistureinthewoundenvironment.Assuch,dressingsareclassifiedasopen,semiopenor
semiocclusive.

Opendressingsinclude,primarily,gauze,whichistypicallymoistenedwithsalinebeforeplacingitintothewound.
Gauzebandagesareavailableinmultiplesizes,including2x2inchand4x4inchsquaredressingsandin3or4
inchrolls(eg,Kerlix).Thickerabsorbentpads(eg,ABDpads)areusedtocoverthegauzedressings.For
managinglargewounds,selfadhesivestraps(Montgomerystraps)canbeusedtoholdabulkydressinginplace.
Asdiscussedabove,driedgauzedressingsarediscouraged.Wettomoistgauzedressingsareusefulfor
packinglargesofttissuedefectsuntilwoundclosureorcoveragecanbeperformed.Gauzedressingsare
inexpensivebutoftenrequirefrequentdressingchanges.

Semiopendressingstypicallyconsistoffinemeshgauzeimpregnatedwithpetroleum,paraffinwax,orother
ointment,andhaveproductnamessuchasXeroform,Adaptic,Jelonet,andSofraTulle.Thisinitiallayeris
coveredbyasecondarydressingofabsorbentgauzeandpadding,thenfinallyathirdlayeroftapeorother
methodofadhesive.Benefitsofsemiopendressingsincludetheirminimumexpenseandtheireaseof
application.Themaindisadvantageofthistypeofdressingisthatitdoesnotmaintainamoisturerich
environmentorprovidegoodexudatecontrol.Fluidispermittedtoseepthroughthefirstlayerandiscollectedin
thesecondlayer,allowingforbothdesiccationofthewoundbedandmacerationofthesurroundingtissuein
contactwiththesecondarylayer.Otherdisadvantagesincludethebulkofthedressing,itsawkwardnesswhen
appliedtocertainareas,andtheneedforfrequentchanging.

Semiocclusivedressingscomeinawidevarietyofocclusiveproperties,absorptivecapacities,conformability,
andbacteriostaticactivity.Semiocclusivedressingsincludefilms,foams,alginates,hydrocolloids,andhydrogels,
andarediscussedbelow.

FilmsPolymerfilmsaretransparentsheetsofsyntheticselfadhesivedressingthatarepermeabletogases
suchaswatervaporandoxygenbutimpermeabletolargermoleculesincludingproteinsandbacteria.This
propertyenablesinsensiblewaterlosstoevaporate,trapswoundfluidenzymeswithinthedressing,andprevents
bacterialinvasion.Thesedressingsaresometimesknownassyntheticadhesivemoisturevaporpermeable
dressings,andincludeTegaderm,Cutifilm,Blisterfilm,andBioclusive.Transparentfilmdressingswerefoundto
providethefastesthealingrates,lowestinfectionrates,andtobethemostcosteffectivemethodfordressing
splitthicknessskingraftdonorsitesinareviewof33publishedstudies[105].

Advantagesofthesedressingsincludetheirabilitytomaintainmoisture,encouragerapidreepithelization,and
theirtransparencyandselfadhesiveproperties.Disadvantagesoffilmdressingsincludelimitedabsorptive
capacity,andtheyarenotappropriateformoderatelytoheavilyexudativewounds.Iftheyareallowedtoremain
inplaceoverawoundwithheavyexudates,thesurroundingskinislikelytobecomemacerated.Inaddition,ifthe
wounddriesout,filmdressingsmayadheretothewoundandbepainfulanddamagingtoremove.

FoamsFoamdressingscanbethoughtofasfilmdressingswiththeadditionofabsorbency.Theyconsistof
twolayers,ahydrophilicsiliconeorpolyurethanebasedfoamthatliesagainstthewoundsurface,anda
hydrophobic,gaspermeablebackingtopreventleakageandbacterialcontamination.Somefoamsrequirea
secondaryadhesivedressing.FoamsaremarketedundernamessuchasAllevyn,Adhesive,Lyofoam,and
Spyrosorb.

Advantagesoffoamsincludetheirhighabsorptivecapacityandthefactthattheyconformtotheshapeofthe
woundandcanbeusedtopackcavities.Disadvantagesoffoamsincludetheopacityofthedressingsandthe
factthattheymayneedtobechangedeachday.Foamdressingsmaynotbeappropriateonminimallyexudative
wounds,astheymaycausedesiccation.

Onesmalltrialcomparedfoamstofilmsasdressingsforskintearsininstitutionalizedadultsandfoundthatmore
completehealingoccurredinthegroupusingfoams[106].

AlginatesNaturalcomplexpolysaccharidesfromvarioustypesofalgaeformthebasisofalginate
dressings.Theiractivityasdressingsisuniquebecausetheyareinsolubleinwater,butinthesodiumrichwound
fluidenvironmentthesecomplexesexchangecalciumionsforsodiumionsandformanamorphousgelthatpacks
andcoversthewound.Alginatescomeinvariousformsincludingribbons,beads,andpads.Theirabsorptive
capacityrangesdependinguponthetypeofpolysaccharideused.Ingeneral,thesedressingsaremore
appropriateformoderatelytoheavilyexudativewounds.

Advantagesofalginatesincludeaugmentationofhemostasis[107,108],theycanbeusedforwoundpacking,
mostcanbewashedawaywithnormalsalineinordertominimizepainduringdressingchanges,andtheycan
stayinplaceforseveraldays.Disadvantagesofalginatesarethattheyrequireasecondarydressingthatmustbe
removedinordertomonitorthewound,theycanbetoodryingonaminimallyexudativewound,andtheyhave
anunpleasantodor.
Inatrialof77patients,patientswithdiabeticfootwoundswererandomlyassignedtoalginateorpetroleumgauze
dressings[109].Patientstreatedwithalginateswerefoundtohavesignificantlysuperiorgranulationtissue
coverageatfourweeksoftreatment,significantlylesspain,andfewerdressingchangesthanthepetroleum
gauzegroup.

HydrocolloidsHydrocolloiddressingsusuallyconsistofagelorfoamonacarrierofselfadhesive
polyurethanefilm.Thecolloidcompositionofthisdressingtrapsexudateandcreatesamoistenvironment.
Bacteriaanddebrisarealsotrapped,andwashedawaywithdressingchangesinagentle,painlessformof
mechanicaldebridement.Anotheradvantageofhydrocolloidsistheabilitytousethemforpackingwounds.
Disadvantagesincludemalodorandthepotentialneedfordailydressingchanges,andallergiccontactdermatitis
hasbeenreported[110].HydrocolloidproductsincludeDuoDERM,Tegasorb,JandJUlcerDressing,and
Comfeel.

Cadexomeriodineisatypeofhydrocolloidinwhichiodineisdispersedandslowlyreleasedafteritcomesin
contactwithwoundfluid.Theconcentrationofiodinereleasedislowanddoesnotcausetissuedamage[111].A
multicentertrialfoundthatovera12weekperiod,Cadexomeriodinepastewasmorecosteffectivethannon
iodinatedhydrocolloiddressingorparaffingauzedressinginpatientswithexudatingvenousulcers[112].A
systematicreviewfoundsomeevidencethattopicalapplicationofCadexomeriodineenhancedvenousulcer
healingratescomparedwithstandardcare(withandwithoutcompression)[36].Thetreatmentregimenwas
complexanditisuncleariftheresultsaregeneralizabletomostclinicalsettings.Iodineinducedhyperthyroidism
hasbeendocumentedwithuseofCadexomeriodineforlegulcers[113].(See'Antisepticsandantimicrobial
agents'above.)

HydrogelsHydrogelsareamatrixofvarioustypesofsyntheticpolymerswith>95percentwaterformed
intosheets,gels,orfoamsthatareusuallysandwichedbetweentwosheetsofremovablefilm.Theinnerlayeris
placedagainstthewound,andtheouterlayercanberemovedtomakethedressingpermeabletofluid.
Sometimesasecondaryadhesivedressingisneeded.Theseuniquematricescanabsorbordonatewater
dependinguponthehydrationstateofthetissuethatsurroundsthem.HydrogelproductsincludeIntrasiteGel,
Vigilon,CarringtonGel,andElastogel.

Hydrogelsaremostusefulfordrywounds.Theyinitiallylowerthetemperatureofthewoundenvironmentthey
cover,whichprovidescoolingpainreliefforsomepatients[114].Asadisadvantage,althoughtherehavebeenno
reportsofincreasedwoundinfection,hydrogelshavebeenfoundtoselectivelypermitgramnegativebacteriato
proliferate[115].

HydroactiveHydroactive,themostrecentlydevelopedsyntheticdressing,isapolyurethanematrixthat
combinesthepropertiesofagelandafoam.Hydroactiveselectivelyabsorbsexcesswaterwhileleavinggrowth
factorsandotherproteinsbehind[116].

Arandomizedtrialcomparedhydroactivedressingswithtwodifferenthydrocolloidsandfoundthehydroactive
dressingtobeequallyeffectiveatpromotingulcerhealingandalleviatingulcerassociatedpainafter12weeksof
treatment[117].Anotherstudyfoundhydroactivedressingscombinedwithenzymaticdebridementtobemore
costefficientthangauzealoneindressingpressureulcersandvenousstasisulcers[118].

WOUNDPACKINGWoundswithlargesofttissuedefectsmayhaveanareaofdeadspacebetweenthe
surfaceofintacthealthyskinandthewoundbase.Thesewoundsaredescribedastunneledorundermined.
Underminingisdefinedasextensionofthewoundunderintactskinedgessuchthatthewoundmeasureslarger
atitsbasethanisappreciatedattheskinsurface.
Whendescribinganddocumentingunderminedwounds,itisimportanttoaccuratelymeasurethedepthof
underminingincentimetersandlocationofunderminingusingclockformationasaguide(12:00,6:00,etc.).The
presenceofnecrotictissueindicatestheneedforsurgicaldebridementtodecreasebacterialburdenandprevent
sequelaeofinfection[32].

Althoughtherehavebeennospecifictrialscomparingpackedversusunpackedwounds,woundpackingis
consideredstandardcare[119].Traditionalgauzedressingsareoftenusedtopackwoundsassociatedwith
significantdeadspaceorunderminingtoaidincontinuingdebridementofdevitalizedtissuefromthewoundbed.
Thegauzeismoistenedwithnormalsalineortapwaterandplacedintothewoundandcoveredwithdrylayersof
gauze.Asthemoistenedgauzedries,itadherestosurfacetissues,whicharethenremovedwhenthedressingis
changed.Dressingchangesshouldbefrequentenoughthatthegauzedoesnotdryoutcompletely,whichcanbe
twotothreetimesdaily.Adisadvantageofgauzedressingsisthattheycanalsoremovedevelopinggranulation
tissue,resultinginreinjury.Thus,thesedressingsarediscontinuedwhenthenecrotictissuehasbeenremoved
andgranulationisoccurring.Analternativetogauzedressingformanagingwoundswithsignificantdeadspaceis
negativepressurewoundtherapy.(See'Negativepressurewoundtherapy'below.)

Manyofthematerialsthatareusedastopicaldressingsforwounds(foams,alginates,hydrogels)canbemolded
intotheshapeofthewoundandareusefulforwoundpacking.Aswiththeiruseindressingwounds,thereislittle
consensusoverwhatconstitutesthebestmaterialforwoundpacking.(See'Wounddressings'above.)

Wounddressingchangesassociatedwithlargedefectscanbemanagedwithoutrepeatedapplicationsoftapeto
theskinbyusingMontgomerystraps(picture2).

WOUNDCLOSUREPrimaryclosurereferstothesutureorstapleclosureofacutesurgicalortraumatic
woundsafterappropriatewoundpreparation(figure1andfigure2).(See"Minorwoundpreparationand
irrigation"and"Closureofskinwoundswithsutures"and"Closureofminorskinwoundswithstaples".)

Delayedprimaryclosureachievesskinedgeappositionfollowinganintervalofwoundmanagement.Delayed
closureinabdominalwounds,chestwounds,andsurgicalwoundswithoutevidenceofinfectioniswidelyaccepted
(figure1)[120].However,achronicwoundshouldneverbeclosedprimarily.Incontrast,delayedclosureor
coverageofchronicwoundsisaccepted.

NegativepressurewoundtherapyNegativepressurewoundtherapyenhanceswoundhealingbyreducing
edemasurroundingthewound,stimulatingcirculation,andincreasingtherateofgranulationtissueformation
[121124].Thetechniqueinvolvestheapplicationofacontrolledsubatmosphericpressuretoawoundcovered
withafoamdressing.Negativepressurewoundtherapyisusefultomanagelargedefectsuntilclosurecanbe
performed.Ithasalsobeenusedwithmodestsuccessinthetreatmentofpressureulcers[125127],anddiabetic
wounds[124,128].(See"Negativepressurewoundtherapy".)

WOUNDCOVERAGE

SkingraftsSplitthicknessandfullthicknessskingraftsarethemostbasicbiologicdressingsandconsistof
skintakenfromadonorsiteandgraftedontoawoundonthesamepatient.Skingraftsareusedforwound
closure,topreventfluidandelectrolyteloss,andreducebacterialburdenandinfection.Skintransplantedfrom
onelocationtoanotheronthesameindividualistermedanautogenousgraftorautograft.

Skingraftsareclassifiedaseithersplitthicknessorfullthickness,dependingupontheamountofdermisincluded
inthegraft.Apartialorsplitthicknessskingraftcontainsavariablethicknessofdermis,whileafullthicknessskin
graftcontainstheentiredermis.Thecharacteristicsofnormalskinaremaintainedwithathickerdermal
component.However,thickergraftsrequireamorerobustwoundbedduetothegreateramountoftissuethat
needstoberevascularized.Thechoicebetweenfullandsplitthicknessskingraftingdependsuponthecondition
ofthewound,location,size,andneedforcosmesis[129,130].

FullthicknessskingraftsFullthicknessgraftscontaintheepidermisanddermis,andthusretainmoreof
thecharacteristicsofnormalskin,includingcolor,texture,andthickness,whencomparedwithsplitthickness
grafts.Fullthicknessskingraftsarelimitedtorelativelysmall,uncontaminated,wellvascularizedwounds.The
skinusedforfullthicknessskingraftsisobtainedfromareasofredundantandpliableskinsuchasthegroin,
lateralthigh,lowerabdomen,orlateralchest.Donorsitesareusuallyclosedprimarily.Themaindisadvantagesof
fullthicknessgraftsincludelimitedavailabilityofdonorskinandthepotentialforfluidaccumulationbeneaththe
graft.

SplitthicknessskingraftsSplitthicknessskingraftsarecommonlyusedtissueforwoundcoverage.A
splitthicknessskingraftincludestheepidermisandavariableamountofdermisrangingbetween0.008to0.012
inches(picture3).Splitthicknessskingraftsarefurthercategorizedasthin(0.005to0.012inches),intermediate
(0.012to0.018inches),orthick(0.018to0.030inches)baseduponthethicknessofgraftharvested.

Comparedwithfullthicknessskingrafts,splitthicknessskingraftstoleratealessthanidealwoundbedandhave
abroaderrangeofapplications.Theycanbeusedtoresurfacelargewounds,linecavities,resurfacemucosal
deficits,closedonorsitesofflaps,andresurfacemuscleflaps.Theyalsoareusedtoachievetemporaryclosure
ofwoundscreatedbytheremovaloflesionsthatrequirepathologicexaminationpriortodefinitivereconstruction.
Splitthicknessskingraftshavebeenusedsuccessfullyintreatinglargechronicwounds,includingthoseonthe
legandsoleofthefoot,providedtheareacanbeprotectedagainstchronicverticalandshearstresses.

Splitthicknessskingraftscanbemeshedtoprovidecoverageofagreatersurfaceareaattherecipientsite,with
expansionratiosgenerallyrangingfrom1:1to6:1.Splitthicknessskingraftdonorsiteshealspontaneouslywith
cellssuppliedbytheremainingepidermalappendages.Donorsitescanbereharvestedoncehealingis
complete.

Splitthicknessgraftshavedisadvantagesthatneedtobeconsidered.Splitthicknessgraftsaremorefragile,
especiallywhenplacedoverareaswithlittleunderlyingsofttissuebulkforsupport.Theycontractmoreduring
healing,donotgrowwiththeindividual,andtendtobesmootherandshinierthannormalskinbecauseofthe
absenceofskinappendagesinthegraft.Theyalsotendtobeabnormallypigmented,eitherpaleorwhite,or
alternatively,hyperpigmented,particularlyindarkerskinnedindividuals.Forthesereasons,splitthicknessskin
graftsaremorewidelyusedforcontrolofinfectionandpreventionoffluid/electrolytelossratherthancosmesis
[129,131].

Biologic(cellbaseddressings)Biologiccellbaseddressingsarecomposedofalivecellconstructthat
containsatleastonelayerofliveallogeniccells.

Cellbaseddressingscanbeusedwhentraditionaldressingshavefailedoraredeemedinappropriate[132].One
studysuggestedthatadvancedbiologicsshouldbeusedwhenchronicwoundsfailtohealatanappropriaterate
ofclosure,(ie,55percentreductioninwoundareawithinfourweeksoftreatment)[133].Cellbaseddressingsare
idealforthetreatmentofchroniculcersbecauseadditionalcellsandgrowthfactorsareaddedtoadeficient
woundhealingenvironment.Acceleratedwoundhealingreducestheriskofwoundinfection.

Cellbasedtherapiesmayuseepidermalanddermalelements.Othertherapiesfocusondermalelementssuch
ascollagenandfibroblasts,whichpreventwoundcontractionandprovidegreaterstability[134].Apligraf
combinedwithcompressiontherapyhasbeenfoundtoimprovehealingofvenousstasisulcerscomparedwith
compressiontherapy[135].Clinicalrejectionhasnotbeenreported.Cellbasedtherapieshavealsobeenstudied
inpatientswithdiabetes[136139].Inonestudyof208patientswithnoninfectedneuropathiculcers,weekly
applicationofGraftskinforfourweeksimprovedtherateofcompletewoundhealingcomparedwithusualcare
(56versus38percent)[136].OtherstudieshaveshownDermagrafttobesuperiortostandardcareinthehealing
ofdiabeticfootulcers[140,141].

Acellularmatricesserveasascaffold,whichmayassistinformingsomeofthestructure,components,and
signalingmechanismtoassistinhealingandregeneration.SomeoftheseincludeAlloDerm,whichismadeof
decellularizedallogenicdermalcomponent,andIntegra,whichisabovinecollagenbaseddermalmatrix.These
beenusedsuccessfullyfortreatingburnwounds[142145].

ADJUNCTIVETHERAPIES

HyperbaricoxygentherapyHyperbaricoxygentherapy(HBOT)hasbeenshown,invitro,tohaveeffectson
woundhealing[146].Endothelialprogenitorcellsplayanimportantroleinwoundhealingbecausethey
participateintheformationofnewbloodvesselsinareasofhypoxia[147].AlthoughhyperoxiainducedbyHBOT
effectivelyimprovesendothelialprogenitorcellsmobilization,therapyisnottargetedtothewoundsite.Serious
adverseeventscanbeassociatedwithHBOTincludingseizuresandpneumothorax.(See"Hyperbaricoxygen
therapy",sectionon'Mechanismsofaction'.)

Whenindicated,HBOTisaccomplishedinaspecializedchamberthatallowsforpatientmonitoring.Chamber
pressureistypicallymaintainedbetween2.5and3.0atmospheresofpressuredoxygenorair.Therapyfor
nonhealingwoundsgenerallyconsistsofdailysessionsof1.5to2hoursfor20to40days[146].The
mechanismsandtechniqueofHBOTarediscussedindetailelsewhere.(See"Hyperbaricoxygentherapy"and
"Hyperbaricoxygentherapy",sectionon'Technique'.)

HBOThasbeenusedasanadjuncttowoundcareinthetherapyofacuteandchronicwounds[148153].Most
studiesareobservationalandthefewavailabletrialsarelimitedbysmallsamplesizeandlowquality[154156].
Systematicreviewshaveconcludedthat,althoughhyperbaricoxygenmaybenefitsometypesofwounds(eg,
diabeticulcers),thereisinsufficientevidencetosupportroutineuse[157,158].Furthermore,althoughanumber
ofseriesandrandomizedtrialsofvarioussizesandqualityhavesuggesteditsutility,laterworkshavesuggested
thatHBOTmaynothavesignificantbenefitintreatmentofdiabeticfootulcerhealingandlimbsalvage[159].
(See"Overviewoftreatmentofchronicwounds",sectionon'Hyperbaricoxygentherapy'.)

HBOTmaybeofvalueinpatientswithextensivesofttissueinjury.Asystematicreviewidentifiedthreetrials
evaluatingtheuseofHBOTinacutesurgicalandtraumaticwounds[160].Duetothesmallnumbersofincluded
patientsandheterogeneityofpatientstreated,ametaanalysiscouldnotbeperformed.Theauthorsalsonoteda
potentialriskforbias.Inoneofthetrials,36patientswithcrushinjurieswererandomlyassignedtoa90minute
twicedailyHBOTorshamtreatmentsforatotalofsixdayspostoperatively[161].Thegrouptreatedwith
hyperbaricoxygenhadsignificantlymorecompletehealing(17versus10patients)andrequiredfewerskinflaps,
grafts,vascularsurgery,oramputation(1versus6patients).(See"Surgicalmanagementofsevereextremity
injury",sectionon'Softtissuedebridement/coverage'.)

Animalmodelsofreperfusionfollowingreleaseofacuteextremitycompartmentsyndromessuggestthatthe
HBOTmaybebeneficial.(See"Patientmanagementfollowingextremityfasciotomy",sectionon'Hyperbaric
oxygen'.)

AsystematicreviewofHBOTinburnwoundsfoundonlytwohighqualitytrialsandconcludedthattherewas
insufficientevidencetosupporttheuseofHBOfollowingthermalinjury[162].Thetreatmentofburnwoundsis
discussedindetailelsewhere.(See"Localtreatmentofburns:Topicalantimicrobialagentsanddressings".)

HBOTmayimprovethesurvivalofskingraftsandreconstructiveflapsthathavecompromisedbloodflow,thereby
preventingtissuebreakdownandthedevelopmentofwounds.Patientswhorequireskingraftingorreconstructive
flapsinareaswithlocalvascularcompromise,previousradiationtherapy,orinsitesofpreviousgraftfailuremay
benefitfromprophylactictherapy.(See"Principlesofgraftsandflapsforreconstructivesurgery",sectionon
'Vascularcompromise'and"Hyperbaricoxygentherapy",sectionon'Radiationinjury'.)

OthertherapiesAvarietyofothertherapies,suchaslowfrequencyultrasound[163,164],electrical
stimulation[165168],electromagnetictherapy[169],andphototherapy[170],havebeeninvestigatedprimarily
forthetreatmentofpressureulcersorchronicvenouswounds[171175].Thetreatmentofpressureulcersand
chronicvenouswoundsarediscussedindetailelsewhere.(See"Clinicalstagingandmanagementofpressure
inducedinjury"and"Medicalmanagementoflowerextremitychronicvenousdisease",sectionon'Ulcercare'.)

MANAGEMENTOFSPECIFICWOUNDS

Acutewounds

SimplelacerationSimpletraumaticlacerationsmaybecleanedandclosedprimarilywitheitherstaplesor
sutures.(See"Minorwoundpreparationandirrigation"and"Closureofskinwoundswithsutures"and
"Closureofminorskinwoundswithstaples".)

ComplicatedlacerationFollowingcleansingofthewoundanddebridement,anattemptisoftenmadeto
closemorecomplicatedlacerations.Itisnotuncommonfortheirregularskinedgesorskinatsiteswhere
lacerationsmeettobreakdown.Plasticsurgerytechniquesmaybeneededtoprovideanacceptable
cosmeticandfunctionalresult.(See"Zplasty".)

LargetissuedefectLargetissuedefectscanresultfromtraumaticwoundsortheneedtoremove
devitalizedtissueduetoinfection(eg,Fourniersgangrene).Oncethedebridementiscompleted,thewound
canbepackedopenwithwettomoistsalinegauzedressingsorusingnegativepressurewoundtherapyuntil
thewoundbedallowsforskingraftorflapclosure[124].

BurnsBurnwoundcaredependsonmanyfactorsincludingthedepthoftheburnandanatomiclocations.
(See"Emergencycareofmoderateandseverethermalburnsinadults",sectionon'Woundmanagement'
and"Principlesofburnreconstruction:Overviewofsurgicalprocedures".)

PostoperativesurgicalincisionPostoperativesurgicalincisions(clean,cleancontaminated)aretypically
coveredwithadrydressingthatisheldinplacewithanadhesive(eg,tape,Tegaderm).Theinitial
postoperativedressingcanberemovedwithin48hours,providedthewoundhasremaineddry.Thetiming
withwhichthepatientcanresumebathing/showeringisnotwelldefined[176].Atrialrandomlyassigned444
patientsundergoingproceduresclassifiedascleanorcleancontaminated(thyroidsurgery,thoracoscopic
surgery,openherniarepair,excisionofaskintumor)toshowering48hoursaftersurgeryornoshowering
[177].Thewoundwasleftuncoveredforthosewhowereallowedtoshower,butcoveredwithdailydressing
changesforthosenotallowedtoshower.Nosignificantdifferencewasfoundfortherateofsurgicalsite
infectionbetweenthegroups(1.8versus2.7percent).

ChronicwoundsThemanagementofchronicwounds(eg,pressureulcers,diabeticfootulcers,ischemic
ulcerationsandgangrene,atypicalandmalignancyassociatedwoundsarereviewedseparately.(See"Overview
oftreatmentofchronicwounds".)

SUMMARYANDRECOMMENDATIONS

Foroptimalwoundhealing,thewoundbedneedstobewellvascularized,freeofdevitalizedtissue,clearof
infection,andmoist.(See'Introduction'above.)

Wounddressingsshouldbechosenbasedupontheirabilitytomanagedeadspace,controlexudate,reduce
painduringdressingchanges(asapplicable),preventbacterialovergrowth,ensureproperfluidbalance,be
 costefficient,andbemanageableforthepatientornursingstaff.(See'Woundpacking'aboveand'Wound
dressings'above.)

Wesuggestsharpsurgicaldebridementovernonsurgicalmethodsfortheinitialdebridementofdevitalized
tissueassociatedwithacuteandchronicwoundsorulcerswhenpossible(Grade2C).(See'Wound
debridement'above.)

Topicalagentssuchasantisepticsandantimicrobialagentscanbeusedtocontrollocallyheavy
contamination.Significantimprovementsinratesofwoundhealinghavenotbeenfoundandtissuetoxicity
maybeasignificantdisadvantage.(See'Antisepticsandantimicrobialagents'above.)

Fordeepwounds,negativepressurewoundtherapymayprotectthewoundandreducethecomplexityand
depthofthedefect.Negativepressurewoundtherapyisfrequentlyusedtomanagecomplexwoundspriorto
definitiveclosure.(See'Negativepressurewoundtherapy'above.)

Followingwoundbedpreparation,acutewoundscanoftenbeclosedprimarily.Chronicwoundsthat
demonstrateprogressivehealingasevidencedbygranulationtissueandepithelializationalongthewound
edgescanundergodelayedclosureorcoveragewithskingraftsorbioengineeredtissues.(See'Wound
closure'aboveand'Woundcoverage'above.)

Manyothertherapieshavebeenusedwiththeaimofenhancingwoundhealingandincludehyperbaric
oxygentherapy,andwoundstimulationusingultrasound,electrical,andelectromagneticenergy.Someof
thesetherapieshaveshownamarginalbenefitinrandomizedstudies,andmaybeusefulasadjunctsfor
woundhealing.(See'Adjunctivetherapies'above.)

ACKNOWLEDGMENTWearesaddenedbythedeathofJAndrewBillings,MD,whopassedawayin
September2015.UpToDatewishestoacknowledgeDr.Billings'manycontributionstopalliativecare,inparticular,
hisworkasourEditorinChiefandSectionEditorforNonPainSymptoms:AssessmentandManagement.

UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

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Topic15912Version21.0
GRAPHICS

Enzymaticdebridingagents

Enzyme
Agent Advantages Disadvantages Precautions
source

Collagenase Strainof Approvedbythe Effectiveness Moistwound

Clostridium UnitedStatesFDAfor comparedwithother environmentrequired
histolyticum thedebridementof formsofdebridement foractivation
chronicwoundsand maybequestionable Topicalsilverdressings
burns Prescriptionbased significantlyinhibit
Selectiveforcollagen uponwoundarea collagenaseactivity
Generallypainfree Highcost
delivery Relativelyslowacting
Maybecombinedwith
avarietyofother
topicaldressings

Papain Papaya Providesrelatively Notreadilyavailablein Agentisoften

"aggressive"enzymatic theUnitedStates combinedwitha
debridement Nonselective(ie,will chlorophyllcomplex
Generallypainfree cleaveanyprotein thatcausesgreen
delivery containingcysteine) wounddiscoloration
Maybecombinedwith Relativelyslowacting followingapplication
avarietyofother Needtoavoidadjacent
topicaldressings healthytissues

Bromolain Pineapple Relativelyrapidacting Removalfrombaseof Evidenceofefficacyis

Selectivefornon woundrequiredafter basedonacute
viabletissue severalhours woundsorburns,not
Inhibitsplatelet chronicwounds
functionbutis
reversible

FDA:FoodandDrugAdministration.

Datafrom:
1.RamundoJ,GrayM.Collagenaseforenzymaticdebridement:asystematicreview.JWoundOstomyContinenceNurs
200936:S4.
2.KravitzSR,McGuireJ,ZinszerK.Managementofskinulcers:understandingthemechanismandselectionof
enzymaticdebridingagents.AdvSkinWoundCare200821:72.

Graphic85776Version3.0
Treatmentofnecrotictissuewithmaggots

(A)Infectionofnecroticskinassociatedwithulceratedcancer.
(B)Aftertreatmentwithmaggots.
(C)Maggotsinateabag.

CourtesyofMichaelJDixon,MD.

Graphic67885Version3.0
Propertiesofdressings

Type Actions Indications/use Precautions/contraindications

Alginates/CMC* Absorbfluid. Moderatetohighexuding Donotuseondry/necroticwounds.

Promoteautolytic wounds. Usewithcautiononfriabletissue
debridement. Specialcavity (maycausebleeding).
Moisturecontrol. presentationsintheform Donotpackcavitywoundstightly.
Conformabilityto ofropeorribbon.
woundbed. Combinedpresentation
withsilverfor
antimicrobialactivity.

Foams Absorbfluid. Moderatetohighexuding Donotuseondry/necroticwounds

Moisturecontrol. wounds. orthosewithminimalexudate.
Conformabilityto Specialcavity
woundbed. presentationsintheform
ofstripsorribbon.
Lowadherentversions
availableforpatientswith
fragileskin.
Combinedpresentation
withsilverorPHMBfor
antimicrobialactivity.

Honey Rehydratewoundbed. Sloughy,lowtomoderate Maycause'drawing'pain(osmotic

Promoteautolytic exudingwounds. effect).
debridement. Criticallycolonized Knownsensitivity.
Antimicrobialaction. woundsorclinicalsigns
ofinfection.

Hydrocolloids Absorbfluid. Clean,lowtomoderate Donotuseondry/necroticwounds

Promoteautolytic exudingwounds. orhighexudingwounds.
debridement. Combinedpresentation Mayencourageovergranulation.
withsilverfor Maycausemaceration.
antimicrobialactivity.

Hydrogels Rehydratewoundbed. Dry/lowtomoderate Donotuseonhighlyexuding

Moisturecontrol. exudingwounds. woundsorwhereanaerobicinfection
Promoteautolytic Combinedpresentation issuspected.
debridement. withsilverfor Maycausemaceration.
Cooling. antimicrobialactivity.

Iodine Antimicrobialaction. Criticallycolonized Donotuseondrynecrotictissue.

woundsorclinicalsigns Knownsensitivitytoiodine.
ofinfection. Shorttermuserecommended(riskof
Lowtohighexuding systemicabsorption).
wounds.

Lowadherent Protectnewtissue Lowtohighexuding Maydryoutifleftinplacefortoo

woundcontact growth. wounds. long.
layer(silicone) Atraumaticto Useascontactlayeron Knownsensitivitytosilicone.
periwoundskin. superficiallowexuding
Conformabletobody wounds.
contours.

PHMB Antimicrobialaction. Lowtohighexuding Donotuseondry/necroticwounds.

wounds. Knownsensitivity.
Criticallycolonized
woundsorclinicalsigns
 ofinfection.
Mayrequiresecondary
dressing.

Odorcontrol Odorabsorption. Malodorouswounds Donotuseondrywounds.

(eg,activated (duetoexcessexudate).
charcoal) Mayrequireantimicrobial
ifduetoincreased
bioburden.

Protease Activeorpassive Cleanwoundsthatare Donotuseondrywoundsorthose

modulating controlofwound notprogressingdespite withleatheryeschar.
proteaselevels. correctionofunderlying
causes,exclusionof
infectionandoptimal
woundcare.

Silver Antimicrobialaction. Criticallycolonized Somemaycausediscoloration.

woundsorclinicalsigns Knownsensitivity.
ofinfection. Discontinueafter2weeksifno
Lowtohighexuding improvementandreevaluate.
wounds.
Combinedpresentation
withfoamand
alginates/CMCfor
increasedabsorbency.
Alsoinpasteform.

Polyurethane Moisturecontrol. Primarydressingover Donotuseonpatientswith

film Breathablebacterial superficiallowexuding fragile/compromisedperiwoundskin.
barrier. wounds. Donotuseonmoderatetohigh
Transparent(allow Secondarydressingover exudingwounds.
visualizationof alginateorhydrogelfor
wound). rehydrationofwound
bed.

Othermoreadvanceddressings(eg,collagenandbioengineeredtissueproducts)maybeconsideredforwoundsthat
arehardtoheal [1].

CMC:carboxymethylcellulosePHMB:polyhexamethylenebiguanide.
*WounddressingsmaycontainalginatesorCMConlyalginatesmayalsobecombinedwithCMC.

Reference:
1.InternationalConsensus.Acellularmatricesforthetreatmentofwounds.Anexpertworkinggroupreview.Wounds
International2010.Availableathttp://woundsinternational.com(AccessedonMarch2013).
Reproducedwithpermissionfrom:McCardleJ,ChadwickP,EdmondsM,etal.InternationalBestPracticeGuidelines:
WoundManagementinDiabeticFootUlcers.WoundsInternational,2013.Copyright2013SchofieldHealthcareMediaLTD.
Availablefrom:www.woundsinternational.com.

Graphic60931Version4.0
Woundmanagementdressingguide

Typeof Treatmentoptions
Therapeutic Roleof
tissueinthe Woundbed Secondary
goal dressing Primarydressing
wound preparation dressing

Necrotic, Remove Hydrationof Surgicalor Hydrogel Polyurethane

black,dry devitalized woundbed mechanical Honey filmdressing
tissue Promote debridement
Donotattempt autolytic
debridementif debridement
vascular
insufficiency
suspected
Keepdryand
referfor
vascular
assessment

Sloughy, Removeslough Rehydrate Surgicalor Hydrogel Polyurethane

yellow, Provideclean woundbed mechanical Honey filmdressing
brown,black woundbedfor Control debridement Lowadherent
orgrey granulation moisture if (silicone)
Drytolow tissue balance appropriate dressing
exudate Promote Wound
autolytic cleansing
debridement (consider
antiseptic
wound
cleansing
solution)

Sloughy, Removeslough Absorb Surgicalor Absorbentdressing Retention

yellow, Provideclean excessfluid mechanical (alginate/CMC/foam) bandageor
brown,black woundbedfor Protect debridement Fordeepwounds, polyurethane
orgrey granulation periwound if usecavitystrips, filmdressing
Moderateto tissue skinto appropriate ropeorribbon
highexudate Exudate prevent Wound versions
management maceration cleansing
Promote (consider
autolytic antiseptic
debridement wound
cleansing
solution)
Consider
barrier
products

Granulating, Promote Maintain Wound Hydrogel Padand/or

clean,red granulation moisture cleansing Lowadherent retention
Drytolow Providehealthy balance (silicone)dressing bandage
exudate woundbedfor Protectnew Fordeepwounds Avoid
epithelialization tissue usecavitystrips, bandages
growth ropeorribbon thatmay
versions cause
occlusion
and
Granulating, Exudate Maintain Wound Absorbentdressing maceration
clean,red management moisture cleansing (alginate/CMC/foam)
 Moderateto Providehealthy balance Consider Lowadherent Tapesshould
highexudate woundbedfor Protectnew barrier (silicone)dressing beusedwith
epithelialization tissue products Fordeepwounds, cautiondue
growth usecavitystrips, toallergy
ropeorribbon potentialand
versions secondary
complications
Epithelializing, Promote Protectnew Hydrocolloid(thin)
red,pink epithelialization tissue Polyurethanefilm
Notolow andwound growth dressing
exudate maturation Lowadherent
(contraction) (silicone)dressing

Infected Reduce Antimicrobial Wound Antimicrobial

Lowtohigh bacterialload action cleansing dressing
exudate Exudate Moistwound (consider
management healing antiseptic
Odorcontrol Odor wound
absorption cleansing
solution)
Consider
barrier
products

Thepurposeofthistableistoprovideguidanceaboutappropriatedressingsandshouldbeusedinconjunctionwith
clinicaljudgementandlocalprotocols.Wherewoundscontainmixedtissuetypes,itisimportanttoconsiderthe
predominantfactorsaffectinghealingandaddressaccordingly.Whereinfectionissuspected,itisimportantto
regularlyinspectthewoundandtochangethedressingfrequently.Wounddressingsshouldbeusedincombination
withappropriatewoundbedpreparation,systemicantibiotictherapy,pressureoffloading,anddiabeticcontrol.

CMC:carboxymethylcellulose.

Reproducedwithpermissionfrom:McCardleJ,ChadwickP,EdmondsM,etal.InternationalBestPracticeGuidelines:
WoundManagementinDiabeticFootUlcers.WoundsInternational,2013.Copyright2013SchofieldHealthcareMediaLTD.
Availablefrom:www.woundsinternational.com.

Graphic101893Version2.0
Montgomerystraps

Montgomerystrapsmakeitpossibletocareforawoundwithoutremovingadhesivestripswith
eachdressingchange.

Reproducedwithpermissionfrom:TaylorCR,LillisC,LeMoneP,LynnP.FundamentalsofNursing:
TheArtAndScienceOfNursingCare,SixthEdition.Philadelphia:LippincottWilliams&Wilkins,2008.
Copyright2008LippincottWilliams&Wilkins.

Graphic69031Version1.0
Typesofwoundhealing

Reproducedwithpermissionfrom:SmeltzerSC,HinkleJL,CheeverKH.Brunnerand
Suddarth'sTextbookofMedicalSurgicalNursing,12thEdition.Philadelphia:Lippincott
Williams&Wilkins,2009.Copyright2009LippincottWilliams&Wilkins.

Graphic53921Version1.0
Healingbyprimaryandsecondaryintention

Reproducedwithpermissionfrom:McConnellTH.TheNatureOfDisease:PathologyfortheHealth
Professions,Philadelphia:LippincottWilliams&Wilkins,2007.Copyright2007Lippincott
Williams&Wilkins.

Graphic62583Version2.0
Harvestedsplitthicknessskingraft,meshed

Thesplitthicknessskingrafthasbeenmeshed.Notetheaperturesfortissue
expansion.

CourtesyofJorgeLeonVillapalos,MD,FRCS.

Graphic77019Version1.0
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aneurysm].Consultant/AdvisoryBoards:GoreBypassSummit[Veinbypass(PTFEgraftsandendografts)].
OtherFinancialInterest:ElsevierRutherford[Vascularsurgery(RutherfordandComprehensiveVascularand
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