Download New Wound Dressing Techniques to Accelerate Healing

New Wound Dressing
Techniques to
Accelerate Healing
Christopher H. Moon, MD*
Thomas G. Crabtree, MD, FACS
Address
*Department of Surgery, Tripler Army Medical Center, Tripler, HI 96859, USA.
E-mail: [email protected]
Current Treatment Options in Infectious Diseases 2003, 5:251–260
Current Science Inc. ISSN 1523-3820
Copyright © 2003 by Current Science Inc.
Opinion statement
The purpose of dressing a wound is to promote an optimal healing environment by
providing pain relief, protection from trauma and infection, a moist environment,
and removal of debris. By simultaneously maximizing the patient’s nutritional status
and providing meticulous wound care, most wounds will heal appropriately. A simple
occlusive dressing consisting of an antibacterial ointment (nonadherent and absorbent layers) and securing tape is normally all that is needed for acute and sutured
wounds to heal. For more complex chronic wounds and burns, treatment should be
tailored uniquely to the patient’s situation.
Introduction
Wounds can be divided into two types: acute and
chronic. They can heal primarily, secondarily, or by
delayed primary closure. Healing by primary intention
involves the surgical apposition of the wound edges,
usually with sutures. The healing process is hastened
and scarring is usually minimized by allowing direct
contact. However, when the wound is contaminated,
primary closure results in infection. Delayed primary
closure closes the wound surgically after allowing
time to pass. The wound has the capacity to clear the
contamination and begin healing after direct surgical
closure when time is allowed for the inflammatory
process and angiogenesis to begin. Wounds healing by
secondary intention are usually not amenable to
surgical closure. As a result, the wound is left to
granulate and epithelialize from the wound bed and
edges. Numerous dressing products were developed
during the past few years to accelerate this type of
healing process.
In 1962, Winter [1] noticed a shortened epithelialization time for occluded pig wounds versus wounds
left open to air. Cho and Lo [2••] report that occlusive
dressings increase re-epithelialization rates by 30% to
50% and collagen synthesis by 20% to 60% compared
to wounds exposed to air. They do this by providing an
optimal healing environment that exposes the wound
continuously to the surrounding fluid of proteinases,
chemotactic factors, complements, and growth factors.
An electrical gradient that may stimulate fibroblast and
epithelial cell migration is maintained. In addition,
o c c l u s i ve d r e s s i n g s p r ov i d e a p hys i c a l b a r r i e r
against further trauma to the wound. Pain is decreased
by maintaining a moist environment. The use of nonadherent dressing prevents the stripping of the newly
formed epithelial layer. This environment simultaneously stimulates the growth of bacteria and shifts the
usual flora to more gram-negative organisms; however,
studies show that the incidence of clinical infection,
demonstrated by cellulitis and lymphangitis, remains
the same. Infection should not be diagnosed on wound
culture only, but on clinical signs of warmth, erythema,
local tenderness, and edema. Thus, wound colonization
should be differentiated from wound infection.
The management of a wound begins by identifying
the overall well-being of the patient. Dressings and the
various topical medications are a small part of healing a
wound. The key to successful wound healing is meticulous wound care and the optimization of the body’s
wound-healing capacity. Impairments to wound
healing such as malnutrition, edema, bacterial contami-
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Skin and Skin Structure Infections
nation, ischemia, and immunosuppression must be
minimized. Wound healing is anabolic; protein,
vitamin, and mineral intake must be adequate.
When these factors are controlled, attention can be
focused on the local aspects of the wound. The first step
for acute and chronic wounds is to adequately clean
and debride the wound of all foreign bodies, fibrinous
exudates, and devitalized tissue that impede healing
and serve as a nidus for infection. Irrigation with
normal saline should be adequate for acute wounds.
Kaye [3•] reports that antiseptics such as providineiodine are toxic to fibroblasts and epithelial cells and
should not be used on open wounds. Sharp mechanical
debridement may be necessary to expose viable tissue
for large areas of fibrinous exudates or eschar. Chemical
debridement is useful for those areas that are difficult to
access by sharp debridement. When debridement is
complete, dressings can be applied.
The occlusive dressing is divided into a hydrating
layer (antibiotic ointments or petrolatum jelly), a nonadherent contact layer, an absorbent and cushioning
layer (gauze), and a securing layer (tape or wrap).
A simple occlusive dressing composed of Polysporin
ointment (bacitracin zinc, polymyxin B sulfate [Pfizer,
New York, NY]), a nonadherent Telfa dressing (The
Kendall Company, Mansfield, MA), and an absorbent
layer of gauze secured with hypoallergic tape such as
Hypafix (Smith and Nephew, London, UK) usually
suffices for acute and sutured wounds. Alternatively,
a polymer film such as Opsite (Smith and Nephew,
London, UK) or Tegaderm (3M Pharmaceuticals,
St. Paul, MN) provides occlusiveness and fixation. They
are semipermeable to water vapors and oxygen but
impermeable to liquids. Thus, a nonadherent Telfa, an
absorbable gauze dressing, and Tegaderm on a sterile
postoperative wound or a layer of Polysporin, absorbable gauze, and Tegaderm is appropriate. Although it is
controversial whether topical antibiotics are effective
prophylaxis of infection in superficial wounds, studies
indicate that application of topical antibiotic ointment
helps maintain a moist wound environment, decreases
bacterial counts, and prevents dressing adherence to the
wound site. Systemic antibiotics have no role in
the management of wounds unless there is evidence of
cellulitis or sepsis. For superficial burns treated on an
outpatient basis, silver sulfadiazine can be used instead
of Polysporin. Occlusive dressings should be applied
within 2 hours of wounding and left on for at least
24 hours for optimal healing to occur for acute wounds.
At Tripler Army Medical Center, the dressing is removed
after 24 to 48 hours. Occlusive dressings should never
be used on clinically infected wounds. Dressing changes
can be performed once or twice daily if using the topical
ointment and Telfa dressing. The wound should be
cleaned gently with saline or tap water, but antiseptics
should not be used. If other types of occlusives are used,
the timing of the dressing changes will vary between
1 to 7 days, depending on the wound characteristics.
An early attempt to switch from antibiotic ointment
to petrolatum helps minimize hypersensitivity to the
antibiotics. Smoking delays healing and should be
strongly discouraged.
Small and simple lacerations and wounds that
require few epidermal sutures may be alternatively
apposed with tissue adhesives consisting of octyl-2cyanoacrylate, such as Dermabond (Ethicon Inc.,
Cornelia, GA). When Dermabond is used, there is no
need for topical agents and fluid contact can be
immediate. Arpey and Whitaker [4] report that there
is little need for additional wound care. Dermabond
gradually falls off as the wound heals.
Chronic wounds are defined as wounds that fail
to heal after 3 months. Venous stasis ulcers, diabetic
ulcers, pressure ulcers, and ischemic ulcers are the most
common. Many of the new dressing products on the
market are aimed at healing these wounds. The plethora
of options for treating chronic ulcerations cannot be
discussed adequately in this article. However, many of
the dressing options that attempt to heal venous stasis
ulcers are a variation on the classic paste compression
bandage Unna’s boot. Ladin [5] reports that there is
some evidence to suggest that products such as
Regranex (Ortho-McNeil Pharmaceutical, Raritan, NJ)
may be effective in healing clean-based lower extremity
diabetic ulcers. However, most evidence suggests that
the use of these adjuncts is no better than meticulous
wound care. The definitive treatment for these wounds
is optimization of the wound bed for closure. However,
overall patient and local wound conditions often
prevent using this option. These wounds can sometimes
have large amounts of exudates that require frequent
debridement. Alginates, foams, and other absorptives
can be used in this situation. Because chronic wounds
heal by slightly different mechanisms than those of
acute wounds, experimentation with growth factors are
being investigated. Regranex and Procuren (Curative
Health Services, Inc., Hauppauge, NY) are the only
medications approved by the US Food and Drug
Administration (FDA). More studies are needed to
determine the benefit of growth factors.
The most significant wound-healing device of the
past few years may be the wound VAC (vacuum-assisted
closure). The VAC accelerates the healing of chronic
wounds. The machine uses a closed foam dressing
system connected to an adjustable vacuum device that
exposes a wound to negative pressure. Theoretically,
experimentally, and practically, this allows increased
tissue perfusion while decreasing wound debris and
lowering bacterial count.
Initial wound hypoxia is important for fibroblast
proliferation and angiogenesis; however, continued
hypoxia at the wound site delays wound healing. As a
New Wound Dressing Techniques to Accelerate Healing Moon and Crabtree
result, if an occlusive dressing is applied to an ischemic
wound, healing is severely impaired. Hyperbaric
therapy has become popular to help accelerate healing
of chronic ischemic wounds such as those associated
with chronic venous insufficiency and other wounds
that are not amenable to revascularization surgery.
Because of increasing technologic advances in
creating skin substitutes, it is important to mention
burns briefly. Most small partial-thickness burns can be
managed on an outpatient basis using the occlusive
dressing techniques described earlier. However,
larger wounds that are not autografted, allografted,
or xenografted can be managed with cellular wound
dressings such as Integra (Johnson & Johnson, New
Brunswick, NJ), TransCyte (Smith and Nephew,
London, UK), and Apligraf (Organogenesis Inc.,
Canton, MA). These materials are not skin equivalents
because they lack hair follicles, glands, nerves, and
blood vessels. However, they try to mimic closely the
protective and healing function of the epidermis and
dermis. Some become permanently incorporated into
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the wound and others are temporary. Kearney [6]
reports that a few, such as Apligraf, have been used on
chronic ulcers with limited success.
In conclusion, few of the hundreds of dressing
adjuncts on the market accelerate wound healing. In
most cases, the use of these adjuncts is no better than
the standard treatment of optimizing the patient’s
nutritional status, meticulous wound care, and maintaining a moist wound environment. The use of negative pressure dressings (wound VAC) seems especially
promising for chronic wounds. The future of fullthickness burns and problematic nonhealing chronic
wounds is not in adjuncts that aid in the body’s reparative process but in adjuncts that aid in the body’s
regenerative process.
ACKNOWLEDGMENTS
The views expressed in this abstract/manuscript are
those of the author(s) and do not reflect the official
policy or position of the Department of the Army,
Department of Defense, or the US Government.
Treatment
Lifestyle factors and prevention
• Meticulous wound care includes adequate cleansing, debridement, edema
control, and prevention of ischemia, in addition to maintaining a moist
wound environment and keeping the bacteria count as low as possible [7•].
• Impairments to wound healing include malnutrition, obesity, edema,
bacterial contamination, and ischemia [8].
• Maximize nutritional status [9]:
– Maintain serum protein (albumin > 3.0).
– Vitamin A: Topical or systemic; fat soluble. 25,000 IU orally four
times a day or 200,000 IU ointment three times daily. Necessary
for fibroplasia, collagen cross-linking, and epithelialization.
– Vitamin C: Necessary as cofactor for hydroxylation of proline and
lysine in collagen synthesis and cross-linking. No set recommended
daily allowance. May reverse glucocorticoid inhibition.
– Essential fatty acids.
– Zinc: Important cofactor; necessary for normal lymphocyte function
and resistance to infection.
– Copper: Cofactor of lysyl oxidase; necessary for collagen cross-linking.
• There is no evidence to support the idea that megadoses of vitamins and
minerals will accelerate healing. Excessive fat-soluble vitamin ingestion
can lead to problems (ie, vitamin A).
Procedures
• Debridement (sharp, chemical, mechanical-washing, whirlpools, water
irrigation) to clear fibrinous exudates and devitalized tissue that impedes
healing and serves as a nidus for infection.
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• Chemical debridement:
– Collagenase: Used directly on chronic wound bed. Removed with
saline irrigation. If left on for prolonged periods, it may damage new
epithelium. Conforms to irregular contours on wound and is useful
for debriding areas not amenable to sharp mechanical debridement.
– Streptokinase/streptodornase: Debridement equivalent to zinc oxide/
gauze at 8 weeks.
– Trypsin: No more effective than mechanical gauze debridement.
– Papain/urea: Measurable debridement in 4 days.
– Maggots: Renewed interest. Useful for removing necrotic tissue while
leaving healthy tissue intact. Especially useful when antibacterialresistant pathogens are present [10].
Topical agents
Antiseptics
Chlorhexidine, providine-iodine, alcohol, hydrogen peroxide, triclosan
Indications Because of tissue toxicity, no use in the management of open wounds.
Antibacterials
Bacitracin, mupirocin, silver sulfadiazine, neomycin, polymyxin, honey inhibine [3•]
Indications Used as prophylaxis of infection at epidermis and superficial dermis. Ointment
matrix serves to maintain moist wound environment. Burns (silver nitrate
compresses, chlorhexidine gluconate, mafenide acetate cream 0.5%, providoneiodine, nitrafurazone, silver sulfadiazine).
Application Concurrent with each dressing change.
Contraindications Allergic reactions.
Complications Usually without risk of systemic toxicity. Local adverse effects include contact
dermatitis (ie, neomycin is as high as 34%). Application of silver sulfadiazine has
been associated with neutropenia in a small number of patients.
Special points Use is controversial. Bacitracin zinc is extremely popular because of low cost, low
toxicity, and low allergic contact dermatitis. Relatively safe; topical antibiotics
have low systemic absorption.
Cost effectiveness Inexpensive. A 15-g tube of bacitracin costs $0.59.
Growth factors
• Regulates cell proliferation, migration, and secretion.
CT-102 (Procuren; Curative Health Services, Inc., Hauppauge, NY)
Indications Chronic wounds.
Composition Autologous platelets are extracted and activated. Resulting supernatant-containing
platelet-derived growth factors reapplied to the wound.
Application Directly on healthy granulating wound bed, secured with occlusive dressing.
Change dressing twice daily but apply growth factor for 12 hours only.
Contraindications If patient cannot tolerate autotransfusion. Malignancy.
Complications Transfusion-related.
Special points Available only through wound centers operated by Curative Health Services
of Hauppauge, NY.
Cost effectiveness Expensive. Specific amount contracted to each health center.
New Wound Dressing Techniques to Accelerate Healing Moon and Crabtree
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Becaplermin (Regranex; Ortho-McNeil Pharmaceutical, Raritan, NJ) [5]
Indications Clean based diabetic wounds up to 5 cm2. Approved by the FDA for clean diabetic
forefoot ulcers only.
Composition Recombinant platelet-derived growth factor.
Application Directly on healthy granulating wound bed. Secured with occlusive dressing.
Change dressing twice daily but apply growth factor for 12 hours only. Continue
for 20 weeks or until wound has healed.
Contraindications Hypersensitivity to materials. Malignancy.
Complications Nonhealing.
Special points All studies conducted with meticulous wound care. Wounds healed 4 to 6 weeks
faster. Rate of recurrence is significant; approximately 30% at 3 months.
Cost effectiveness A 30-g tube costs approximately $300 to $400.
Dressings
• No dressing is effective if basic wound care is not adhered to.
• Occlusive.
Polymer films
Bioclusive (Johnson & Johnson, New Brunswick, NJ), Polyskin II (The Kendall Company, Mansfield, MA), Opsite
(Smith and Nephew, London, UK), Tegaderm (3M Pharmaceuticals, St. Paul, MN)
Indications Acute partial- or full-thickness wounds with minimal exudates. Nondraining
primarily closed wounds. Good for catheter sites, first- and second-degree burns,
grade 1 decubitus ulcers, graft donor sites.
Composition Semiocclusive/semipermeable polyurethane or copolyester, approximately
0.2 mm thick.
Application Directly over the wound with a layer of gauze or antibiotic ointment underneath.
Contraindications Hypersensitivity to the adhesive backing.
Complications Sometimes difficult to apply because of adhesive backing and must adhere to 1
to 2 cm on healthy skin. Not good for wounds with large exudates or serous fluid.
May strip new epithelium in adhesive backing allowed to come in contact with
wound base.
Special points Elastic and transparent; allows continuous inspection of the wound. Permeable
to gases and water vapor but impermeable to bacteria and liquids.
Cost effectiveness Relatively inexpensive. The cost is a few dollars per package of sheets.
Polymer foams
Allevyn (Smith and Nephew, London, UK ), Flexzan (Bertek Pharmaceuticals, Morgantown, WV),
Lyofoam (Acme United Corp, Fairfield, CT), Sof-Foam (Johnson & Johnson, New Brunswick, NJ)
Indications Acute or chronic partial-thickness wounds with large exudates that require
mechanical debridement. Good for chronic venous stasis ulcers and deep
cavity wounds.
Composition Hydrophilic or hydrophobic, semiocclusive. Bilaminate. High absorbency.
Polyurethane or gel film coated.
Application Place on wound bed with or without antibacterial ointment or hydrogel. Then
secure in place with tape. Once exudates are minimal, create occlusive dressing.
Contraindications Hypersensitivity to materials.
Complications Opaque. Cannot be applied to dry wounds. Must be changed at least every 3 days
or it could be incorporated into the wound.
Special points Permeable to fluids and gases. Nonadherent, thus requires a securing layer.
Can be form fitted.
Cost effectiveness A 4 × 4 inch sheet of Allevyn costs $3.
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Skin and Skin Structure Infections
Hydrogels
Carrasyn (Carrington Laboratories, Inc., Irving, TX), Intrasite (Smith and Nephew, London, UK),
Lamin (ProCyte Corporation, Redmond, WA), Nu-gel (Johnson & Johnson, New Brunswick, NJ),
Vigilon (Bard Home Health, Murray Hill, NJ)
Indications Acute or chronic partial-thickness wound with minimal exudates. Good for
dermabrasion, superficial burns, and chronic ulcers with decreased exudates.
Composition 80% to 99% water. Cross-linked polymers (polyethleneoxide, polyvinyl pyrrolidone,
acrylamide).
Application Applied onto wound bed usually in conjunction with a topical antibiotic.
Then securing layer applied.
Contraindications Hypersensitivity to materials.
Complications Poor barrier protection against bacteria. Selects gram-negative bacteria colonization.
Special points Semitransparent. Can absorb significant fluid volume without significant increase
in size. Semipermeable to fluids and vapors. Nonadherent to wound base. Requires
a securing layer. Substantial pain relief because of cooling effect of materials.
Frequent dressing changes required every 1 to 3 days, depending on amount
of exudates.
Cost effectiveness Inexpensive. Nu-gel costs $2 to $4 per 30-g tube.
Hydrocolloids
Comfeel (Coloplast, Humlebaek, Denmark), Cutinova (Beiersdorf-Jobst, Hamburg, Germany),
DuoDERM (ConvaTec, Princeton, NJ), Intrasite (Smith and Nephew, London, UK), Replicare
(Smith and Nephew, London, UK), Hyprapad (Beiersdorf-Jobst, Hamburg, Germany)
Indications Acute or chronic partial- or full-thickness wounds. Good for stage 1 to 3 decubitus
ulcers and chronic venous stasis ulcers. Also used for plaque psoriasis, bullous
disorders, burns, and dermabrasions.
Composition Hydrophilic colloidal particles in an adhesive mass. Outer polyurethane foam,
middle gelling agent such as sodium carboxymethyl cellulose, and an inner
adhesive layer.
Application Can be applied directly to wound. Perform dressing changes every 3 to 7 days.
Saline irrigation cleans colloidal layer.
Contraindications Hypersensitivity to materials. Cannot be used over eschars or over exposed tendons.
Complications New epithelium may still be removed by the adhesive backing if gelling agent is
not completely transformed to viscous layer. May overhydrate the wound to cause
macerations. Gel is odiferous and can be confused with purulent discharge.
Special points Impermeable to liquids and vapors. Can be cut and shaped without the need for a
securing layer. Absorbs moderate wound exudates forming a viscous, colloidal layer
that prevents wound adherence to the adhesive. Impregnated enzymes chemically
debride wound.
Cost effectiveness DuoDERM costs $10 per 4 × 4 inch sheet and $20 per 10 × 10 inch sheet.
Alginates
Algosteril (Johnson & Johnson, New Brunswick, NJ), AlgiSite (Smith and Nephew, London, UK),
Kaltostat (ConvaTec, Princeton, NJ), Sorbsan (Bertek Pharmaceuticals, Morgantown, WV)
Indications Acute postoperative wounds that require hemostasis. Good for wounds with
moderate exudate, chronic ulcers, partial- and full-thickness burns, split-thickness
skin grafts.
Composition Polysaccharide dressing derived from seaweed. Packaged as twisted fibers or
nonwoven mats.
Application Directly on wound bed and secured with a fixation layer. Can be left for 7 days or
when wound is soaked. Saline irrigation used to remove gel during dressing changes.
Contraindications Hypersensitivity to materials. Thyroid abnormalities.
New Wound Dressing Techniques to Accelerate Healing Moon and Crabtree
257
Complications Secondary dressing layer must be used to prevent dessication. May be odiferous
and can be confused with purulent discharge. New epithelial layer can be stripped
if the gel is allowed to dessicate and is removed.
Special points Forms an alginate gel when combined with wound exudate, creating an occlusive,
nonadherent, moist environment. A securing layer must be applied. Hemostatic.
Cost effectiveness AlgiSite costs $20 to $30 per 4 × 4 inch sheet.
Impregnates
Aquaphor-Gauze (Beiersdorf Jobst, Hamburg, Germany), Adaptic (Johnson & Johnson, New Brunswick, NJ),
Biobrane (Bertek Pharmaceuticals, Morgantown, WV), Scarlet Red (The Kendall Company, Mansfield, MA),
Xeroform (The Kendall Company)
Indications Acute or chronic partial-thickness wounds with minimal to moderate exudate.
Good for burns and split-thickness donor sites.
Composition Fine mesh gauze impregnated with moisturizing, antibacterial, or bactericidal
compounds. Nonadherent.
Application Direct contact with wound bed.
Contraindications Hypersensitivity to materials.
Complications Sometimes adheres through fibrous bonds, which damages re-epithelialization and
delays healing. Increased infection rate compared to other occlusive dressings.
Will not adhere to full-thickness wounds.
Special points Does not contain adhesive, but sometimes adheres to wound site by creating
fibrous bonds.
Cost effectiveness Biobrane is expensive. All others inexpensive. Adaptic costs less than $1 per 3 × 3
inch sheet. Scarlet Red costs $10 to $15 dollars for 12 sheets (5 x 9 inch).
Absorptive powders and pastes
Cutinova (Smith and Nephew, London, UK), Polywic (Ferris Manufacturing Corp., Burr Ridge, IL), Bard Absorption
Dressing (Bard Home Health, Murray Hill, NJ), DuoDERM Granules (ConvaTec, Princeton, NJ)
Indications Chronic full-thickness wounds with large exudates.
Composition Starch, copolymers, or colloidal hydrophilic particles. Can absorb up to 100 times
their weight in fluid.
Application Placed directly on the wound bed. Securing layer must be applied.
Contraindications Hypersensitivity to materials.
Complications Has potential to macerate tissue if left on too long.
Special points High absorbancy. Fibrinolytic.
Cost effectiveness Cutinova costs $15 to $20 for a 6 × 8 inch box of three.
Skin substitutes, synthetic/biosynthetic
Integra (Johnson & Johnson, New Brunswick, NJ)
Indications Bovine collagen, shark cartilage; matrix used for partial- and full-thickness burns.
Special points Two-layer membrane. Top layer is a peelable silicone layer-simulating epidermis.
Bottom layer is absorbed by the body and becomes permanently incorporated into
the wound. Cell free.
Dermagraft (Smith and Nephew, London, UK)
Indications Nonimmunogenic neonatal fibroblast on polyglactin mesh. Used for burns.
Special points Has been used experimentally with diabetic foot ulcers.
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OrCel (Ortec International, New York, NY)
Indications Fibroblasts layered onto bovine collagen matrix. Used for burns and
epidermolysis bullosa.
TransCyte (Smith and Nephew, London, UK)
Indications Shipped frozen for use on partial- and full-thickness burns.
Composition Dual layer, synthetic epidermal layer with dead fibroblasts layered onto a
nylon mesh.
Standard procedure Temporary covering; trim away as wound heals.
Skin substitutes, biological
Apligraf (Organogenesis Inc., Canton, MA)
Composition Dermis-like matrix from cultured heterogenous human foreskins and bovine
collagen type 1. Has epidermal and dermal components.
Indications Used for diabetic venous ulcers and burns.
Special points Permanently applied. Body absorbs matrix. Short shelf-life.
Cost effectiveness High cost. $1000 per 7-cm circle.
Mediskin I (Brennan Medical Inc., St. Paul, MN)
Composition Porcine xenograft.
Contraindications Contraindicated in patients with pork allergies.
Special points Adjunct to granulating tissue. Occlusive biological dressing that may be left on
wound for 7 to 10 days without wound care. Can become malodorous. Must be
secured in place with sutures. Applied until granulating bed develops, then other
occlusive methods should be used.
Oasis (Cook Biotech, West Lafayette, IN)
Composition Porcine, small-intestine submucosal dressing.
Special points Longer shelf-life because it is dehydrated. Rehydrate when needed. A secondary
dressing is needed to prevent desiccation.
Alloderm (LifeCell Corp., Branchburg, NJ)
Composition Allogenic human dermal matrix. Preserved by freeze-drying. Cell free. Biological
and synthetic matrix, may have cells.
Indications Partial- and full-thickness burns. Some diabetic and venous stasis ulcers. Most used
as a temporary measure until definitive treatment with autograft [11].
Application Directly on wound.
Contraindications Hypersensitivity reactions.
Complications Materials are made from animal and human products that may transmit diseases and
cause hypersensitivity reactions. Polymyositis/dermatomyositis are rarely seen.
Special points Not very efficacious on chronic wounds.
Cost effectiveness Cost variable but all are relatively expensive and range from $50 to $500.
New Wound Dressing Techniques to Accelerate Healing Moon and Crabtree
259
Other treatments
Tissue glue
Dermabond (Ethicon Inc., Cornelia, GA)
Indications Small, simple lacerations and wounds that require 5-0 or smaller epidermal sutures.
Composition Octyl-2-cynaoacrylate.
Application If deep dermal sutures are required, place topically with epidermis apposed evenly
after dermal sutures are placed.
Contraindications Large wounds and lacerations. Infected wounds. Hypersensitivity to material.
Mucosal surfaces or mucocutaneous junction (oral cavity, lips).
Complications If wound becomes infected, glue is difficult to remove and does not allow for
wound exploration without removal of glue.
Special points Requires no further wound care. Application is not painful in contrast to sutures.
Cost effectiveness More expensive than sutures.
Hyperbaric therapy
• Raises PO2 tension in chronic ischemic wounds. Increased usage with
diabetic foot ulcers and irradiated wounds.
Wound vacuum-assisted closure
Indications Constantly evolving. Used for chronic ulcers, pressure sores, sternal wound
breakdown, skin graft dressing, and flap salvage [12].
Composition Special wound vacuum pump. Silastic hose. Foam. Transparent film.
Application Fit and apply wound form into wound cavity, cover with air-tight transparent film,
connect to low-suction vacuum machine through a silastic hose. Empty effluent
container as needed. Change foam every 2 to 7 days as needed.
Contraindications Malignancy in wounds. Exposed vessels. Fistulas.
Complications Some wounds fail to close. Skin irritation at site where foam overlies normal tissue.
Hypersensitivity to components such as polyurethane sponge or adhesive to
transparent film.
Special points Monitor patients carefully if anticoagulated or if patient has wound that
drains copiously.
Cost effectiveness The vacuum pump costs $67.50 per day to rent. The dressings cost $25 to
$40 per change.
Emerging therapies
• Growth factors: Topical epidermal growth factor, fibroblast growth factors
used in conjunction with split-thickness skin grafts. Granulocyte colonystimulating factor used in chronic wounds. Interleukin 1 used in infected
wounds. Transforming growth factor used for neovascularization, reepithelialization, reduced scar formation, and increased collagen deposition. Vascular endothelial growth factor promotes angiogenesis.
• Skin equivalents: From embryonic stem cells.
• Proteinase inhibitors: Used to improve healing in chronic ulcers.
• Gene therapy: Provide important relevant healing genes directly to
wound site.
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Skin and Skin Structure Infections
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as:
•
Of importance
•• Of major importance
1.
Winter GD: Formation of the scab and rate of epithlialisation of superficial wounds in the skin of the
young domestic pig. Nature 1962, 193:293–294.
2.•• Cho CY, Lo JS: Excision and repair: dressing the part.
Dermatol Clin 1998, 16:25–47.
This study provides a general overview on wound healing
and dressings.
3.• Kaye ET: Topical antibacterial agents. Infect Dis Clin
North Am 2000, 14:321–339.
This is a fairly comprehensive report on the use of topical
antibiotics, antiseptics, and wound healing.
4. Arpey CJ, Whitaker DC: Postsurgical wound management. Dermatol Clin 2001, 19:787–797.
5. Ladin D: Becaplermin gel (PDGF-BB) as topical
wound therapy. Plast Reconstr Surg 2000,
105:1230–1231.
6. Kearney JN: Clinical evaluation of skin substitutes.
Burns 2001, 27:545–551.
7.• Thomas DR, Kamel HK: Wound management in postacute care. Clin Geriatr Med 2000, 16:783–804.
This article discusses chronic wound management.
8. Harding KG, Morris HL, Patel GK: Healing chronic
wounds. BMJ 2002, 324:160–163.
9. Reynolds TM: The future of nutrition and wound healing. J Tissue Viability 2001, 11:5–13.
10. Natarajan S, Williamson D, Stiltz A, et al.: Advances in
wound care and healing technology. Am J Clin Dermatol 2000, 1:269–275.
11. Balasuramani M, Kumar TR, Babu M: Skin substitutes:
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12. Hopf HW, Humphrey LM, Puzziferri N, et al.: Adjuncts
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