Care Lexicon – A Series to Collect – Treatment Options for Wounds in Various Stages, Part 6

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MCIF 1/2015
The Management of Granulating and Epithelising Wounds

Described in the following article are treatment options, materials and techniques that have been developed for use in the treatment of wounds in their various stages. This article makes no claim to be an exhaustive review of the subject but is intended to provide examples of each treatment option only.

Granulating Wounds

Granulation tissue is well perfused with a granular structure, a deep red colour and a moist shiny appearance that is accompanied by decreasing exudation. This immature new tissue is rich in cells and highly vascular but is still very susceptible. In order to avoid tissue lesions and irritation, the dressings applied during this stage need to be such that they can protect the wound for longer periods. They must also not adhere to the wound, must provide optimal preservation of the warmth and moisture level and protect the wound from drying out.

Hypergranulation as Possible Complication

2_Hypergranu-lationIn some instances, hypergranulation can occur. In such cases there is overgrowth of excess granulation tissue in the wound so that it extends above the height of the surrounding healthy tissue. Hypergranulation tissue (also known as ‘proud flesh’) has a spongy, foam-like, very soft consistency, is easily damaged, bleeds readily and prevents epithelisation. Mechanical abrasion of hypergranulation tissue is often sufficient to encourage the subsequent development of healthier granulation tissue. Alternatively, it is also possible to change the wound management strategy from moist-warm to conventional-dry. Too much moisture and warmth can promote the growth of hypergranulation tissue. In other words, it is advisable to employ a form of dressing that will ensure the wound is drier, such as compresses and wound protection mesh in place of polyurethane foam or hydrocolloid dressings. The use of slight compression may also prove to be of benefit. Wound management concepts that recommend the use of silver nitrate (Höllenstein caustic pencil) or the topical application of tannic acid, cortisone creams or hypersomolar saline are now considered obsolete.

The following groups of products can be used for the local management of granulating wounds: Fine-pored polyurethane foam dressings/hydropolymer dressings, hydrocapillary dressings, hydrocolloid dressings, hydrogel dressings and transparent hydroactive dressings.

Polyurethane Foam Dressings/ Hydropolymer Dressings (Fine-pored Foams)

Structure and composition:

  • These consist of a fine-pored polyurethane foam with/without adhesive borders
  • The adhesive borders may be made of thin hydrocolloid films, silicone-coated films or other materials
  • Some come with superabsorbent materials to collect large volumes of exudate
  • There are also special forms designed for attachment to areas such as the heel or the sacral region

Characteristics:

  • Hydropolymer dressings expand when they come into contact with wound exudate and thus continue to line the wound; no residues remain in the wound
  • Pathogens and excess wound exudate are retained within the structure of the fine-pored foam
  • High absorption capacity; however, if pressure is applied, various quantities of the absorbed exudate may be released
  • Promote granulation: matrix for new tissue growth
  • Cushioning effect
  • Available in forms for dressing wounds and as cavity foam dressings for the tamponade of wound pockets

Indications:

  • Moderately to extensively exudating wounds (depending on dressing characteristics)
  • For the packing (as cavity foam) of clean, granulating, deep exudating wounds and pockets

Contraindications:

  • Dry wounds
  • Third- and fourth-degree burns, bite wounds, fungal infections
  • Should not be applied as primary dressings directly to exposed bone, tendons or cartilage
  • Known hypersensitivity to the product or any of its constituents

Potential complications:

  • Allergic reactions
  • Hypergranulation
  • Maceration of the wound margins/surrounding tissue
  • Tissue damage as a result of excessive tamponade

Instructions for use:

  • Ensure the dressing extends for some 2 cm beyond the margins of the wound
  • Some products should not be cut to size as this impairs the absorbent structure
  • If pores become blocked, some products are not able to adequately absorb more viscous wound exudate
  • Carefully pack deep/undermining wounds with cavity products; bear in mind that, depending on the product used, it will swell to a greater or lesser extent so that it is advisable to fill the wound to approx. 50 –75% only
  • Shave and remove hairs before applying products with adhesive borders; these will adhere to dry and non-oily skin only
  • Some products will require a secondary dressing
  • Duration of application: up to 7 days (depending on extent of exudation and wound status)

3_Erschöpfter Polyurethanschaumverband 4_Gesättigter Polyurethanschaumverband

Example dressing products: Advazorb, Advazorb Silfix/Silflo (Advancis Medical Deutschland), aktivmed foam dressing with adhesive border/non-adhesive/heel (aktivmed GmbH), Allevyn foam dressing adhesive/non-adhesive, Allevyn plus adhesive, Allevyn foam dressing heel non-adhesive, Allevyn plus Sacrum, Allevyn Tracheostomy/Sacrum, Allevyn compression, Allevyn Gentle/Gentle Border/Gentle Border Heel/Gentle Border Multisite/Gentle Border Sacrum/Gentle Border Lite, Allevyn Life, Allevyn Thin, Cutinova hydro (Smith & Nephew), Aquacel foam ­(Convatec), Askina Foam, Askina ThinSite, Askina Heel, Askina Transorbent/Transorbent Sacrum/Transorbent Border, Askina Tracheo, Askina Touch, Askina DresSil/DresSil Sacrum (B.Braun), Biatain self-adhesive/non-adhesive, Biatain gentle adhesive, Biatain sacrum/heel, Biatain silicone/silicone Lite (Coloplast), Kendall foam dressing, Kendall Plus foam dressing, Kendall Island, Kendall foam dressing fenestrated (Covidien), Cutimed Siltec, Cutimed Siltec Plus, Cutimed Siltec B/Siltec Heel 3D/Siltec L (BSNmedical), Decutastar Foam-A, Decutastar Foam-pur (ADL), DracoFoam, DracoFoam adhesive, DracoFoam adhesive sensitive, DracoFoam heel (Dr. Ausbüttel & Co. GmbH), Kliniderm Foam Silicone / Foam Silicone Border/ Foam Silicone Lite/Foam Silicone Lite Border (SastoMed GmbH), Mepilex, Mepilex border, Mepilex lite, Mepilex border lite, Mepilex Transfer (Mölnlycke Health Care GmbH), NOBASPONGE, NOBASPONGE – Plus (NOBA), PermaFoam, PermaFoam Comfort, PermaFoam sacral, PermaFoam tracheostomy, PermaFoam concave, HydroTac, Hydro Tac comfort, Hydro Tac sacral (HARTMANN), Protek (Trusetal), PolyMem, PolyMem Max, PolyMem Shapes Sacral, PolyMem Shapes Oval (MediSet GmbH), PROTEK (distributor: Trusetal), ROGG-Foam (ROGG Verbandstoffe), sorbion aquafoam (sorbion GmbH & Co. KG), Suprasorb P self-adhesive, Suprasorb P non-adhesive, Suprasorb P silicone, Suprasorb P sacrum (Lohmann & Rauscher), Tegaderm Foam, Tegaderm Foam Adhesive, Tegaderm Silicone Foam (3M Medica), TEXTUS biofix (biocell), Tielle, Tielle Lite, Tielle Max, Tielle Plus (Acelity), UrgoCell, UrgoCell Non-Adhesive/Contact/Adhesive Contact/ Lite/ Non Adhesive/Heel contact, UrgoTül Foam Border (Urgo), Versiva XC (ConvaTec)

Fine-pored foam/hydropolymer dressings for use in wound tamponade: Allevyn Cavity and Allevyn Plus Cavity (Smith & Nephew), Askina Foam Cavity (B.Braun), Biatain cavity (Coloplast), Cutimed Cavity (BSNmedical), DELTAfoam stripe (DELTAmedicare GmbH), NOBASPONGE without cover layer (NOBA), PermaFoam cavity (HARTMANN), PolyMem WIC (MediSet GmbH), Tielle packing (Acelity)

Hydrocapillary dressings: This form of dressing has already been described in Part 5 of this Care Lexicon (issue 4, 2014).

Hydrocolloid Dressings

Structure and composition:

  • These consist of a water-resistant polymer matrix that contains hydrophilic particles (made of cellulose derivatives, pectin and gelatin) designed to absorb exudate
  • The outer layer is made of semipermeable polyurethane film
  • The matrix consists of elastomers with adhesives
  • The dressings have a thickness of 0.5 – 2.5 mm
  • In some cases, they have a thinner margin or an additional adhesive border made of adhesive webbing material
  • There are also special forms designed for attachment to areas such as the heel or the sacral region

Characteristics:

  • Promote granulation
  • Prevent contamination of the wound and are water-resistant
  • Promote the lysis of superficial coatings
  • Absorb excessive wound exudate and form a gel

Indications:

  • Mildly to moderately exudating, granulating and epithelising wounds (depending on the thickness of the dressing)
  • Wounds healing by primary intention

Contraindications:

  • Clinically infected wounds, deep fungal infections, osteomyelitis
  • Exposed cartilage, bone, muscles
  • Third- and fourth-degree burns
  • Tumour wounds
  • Ischaemic ulcers
  • Known hypersensitivity to the product or any of its constituents

Potential complications:

  • Maceration of surrounding skin, hypergranulation
  • Dermal irritation, allergic reactions
  • Incorrect assessment leading to exacerbation of infection
  • Dressing too small for wound→ exudate soon escapes from edges

Instructions for use:

  • Should be applied/modelled into place at body temperature
  • Form a yellow, malodorous gel that should not be confused with pus; however, lavage of the wound is advisable when the dressing is removed
  • Ensure that the dressing extends at least 2 – 3 cm beyond the wound margins
  • The wound margin/surrounding tissue must be dry and non-oily; remove any hairs present by shaving
  • Can be worn by the patient while showering
  • Duration of application: until the gel bubble that forms comes close to the edge of the dressing; 7 days maximum

5_Erschöpfter HydrokolloidverbandExample dressing products: aktivmed hydrocolloid wound dressings (aktivmed GmbH), Algoplaque Border/Sacrum/Film (URGO), Askina Hydro, Askina Biofilm Transparent (B.Braun), Comfeel Plus/Plus transparent/ Plus sacrum/Plus pressure-relieving dressing/Plus contoured dressing (Cololplast), Cutimed Hydro B/Hydro L (BSNmedical), Decutastar hydrocolloid (ADL), DracoHydro, DracoHydro thin/ultra (Dr.Ausbüttel & Co. GmbH), GoTa-DERM (Gothaplast), Hydrocoll, Hydrocoll concave/thin/sacral (HARTMANN), Klinion Kliniderm Hydro Thin/Hydro S (Klinion), NU-DERM Border, NU-DERM Border Sacrum/Border Elbow/Border Heel/Border Thin (Acelity), NOBACOLLOID, NOBACOLLOID transparent (NOBA), Replicare, Replicare thin/Ultra (Smith & Nephew), Restore (Hollister), ROGG hydrocolloid (ROGG Verbandstoffe), Suprasorb H Standard, Suprasorb H thin/sacrum/border (Lohmann & Rauscher), Tegaderm™ Hydrocolloid, Tegaderm™ Hydrocolloid Thin (3M Medica), Traumasive (Hexal-Pharma GmbH), Ultec Pro, Ultec Pro sacral, Ultec Pro Border (Covidien), Varihesive E, Varihesive E Border, Varihesive Extra thin, Varihesive Signal (ConvaTec)

 

Transparent Hydroactive Dressings (Tegaderm Absorbent)

Structure and composition:

  • Consists of an adaptable acrylic wound pad enclosed between two layers of a transparent adhesive film

Characteristics:

  • 6_Gute Wundbeobachtung duch Transparenten Hydroaktivverband möglichThe adhesive layer that comes into contact with the wound is perforated so that the pad can absorb wound exudate
  • The wound status can be readily monitored because of the transparency of the dressing
  • The non-perforated other layer of adhesive film is semi-permeable i.e. it allows the passage of water vapour but is impermeable for bacteria, viruses and fluids
  • The smooth surface and thin profile provide for good adhesion in regions subject to high shear stress (will not roll up)

Indications:

  • Superficial, mildly to moderately exudating wounds (e.g. grade 2 pressure ulcers as defined in the EPUAP guidelines)
  • Abrasion injuries, skin graft donor sites, second-degree burns
  • As secondary dressings, e.g. over alginate dressings

Contraindications:

  • Known hypersensitivity to the product or any of its constituents
  • Clinically infected wounds

Potential complications:

  • In rare cases: irritation (rash), maceration of the surrounding skin, hypergranulation ⇒ in such cases, obtain medical advice

Instructions for use:

  • May not be cut to size
  • Duration of application: can be left in place considerably longer than 7 days depending on volume of exudate

Example dressing products: 3M™ Tegaderm ™ Absorbent (3M Medica)

Hydrogel Dressings

Structure and composition:

  • Consist of a semi-occlusive film to which hydrogel has been applied
  • Contain 15 – 95% water, with gelatin, polysaccharides, polymers of methacrylate esters, polyacrylamide polymers and polyelectrolyte complexes
  • Available with/without adhesive border

Characteristics:

  • 7_Gute Wundbeobach-tung durch Hydrogelkom-presse möglichWounds can be readily observed due to transparency of dressing
  • Cooling effect alleviates pain
  • Help moisten dry wounds and keep wounds at risk of drying moist
  • Some cushioning effect
  • Promote granulation
  • Promote autolytic debridement

Indications:

  • Mildly to moderately exudating wounds in the granulation and epithelisation phase
  • Superficial, clean abrasion wounds and superficial second-degree burns
  • Clean wounds at risk of drying out

Contraindications:

  • Clinically infected wounds, fungal infections
  • Extensively exudating or bleeding wounds
  • Third- and fourth-degree burns
  • Known hypersensitivity to the product or any of its constituents

Potential complications:

  • Allergic and intolerance reactions
  • Maceration of the surrounding skin, hypergranulation
  • Patients with ulcers of arterial aetiology will often find the initial cooling effect to be painful

Instructions for use:

  • Wounds can be readily monitored thanks to the transparency of the dressing
  • Ensure the dressing extends for at least 2 cm beyond the wound margins
  • The product must be replaced if it becomes opaque
  • Duration of application: 3 – 7 days depending on product (see package leaflet)

Example dressing products: AQUAFLO (Covidien), Elasto-Gel (Velo Medizinprodukte Gmbh), Geliperm, Geliperm comfort (Geistlich Pharma), GLYCOcell (Medi-Globe GmbH), GoTac (Gothaplast), Hydrosorb, Hydrosorb comfort (HARTMANN), NOBAGEL (NOBA), Suprasorb G gel compression dressing (Lohmann & Rauscher)

Epithelising Wounds

8_Fortschreitende Epithelisierung mit restlicher GranulationIn the epithelisation phase, a wound produces little exudate and contracts as a new layer of skin forms over the wound, moving inwards from the margins. Epithelial tissue is very sensitive and has a (bright) pink to whitish colouration. At this stage, the objective of management is to maintain a moist climate within the wound in order to stimulate the migration of epithelial cells across the wound surface; at the same time, the wound dressing must not adhere to the sensitive new tissue and must not promote the drying of the wound. Emphasis should be placed on protecting the wound over the long term and ensuring that dressing replacement is as non-aggressive and atraumatic as possible.

The following product groups can be used for the local management of epithelising wounds: The thin or lite variants of polyurethane foam dressings, thin or transparent hydrocolloid dressings, transparent hydroactive dressings, hydrogel dressings and semipermeable transparent film dressings.

Polyurethane foam dressings, hydrocolloid dressings, hydrogel dressings, transparent hydroactive dressings: See ‘Granulating wounds’

Semipermeable Transparent Film Dressings

Structure and composition:

  • 9_ Wundauflage mit semipermeablen Transparentfolien-streifen fixiertMade of semipermeable (i.e. allow water vapour and oxygen to pass) polyurethane films
  • Are often coated with hypoallergenic polyacrylate adhesives

Characteristics:

  • Protect against secondary infections (pathogen barrier)
  • Wounds can be readily monitored thanks to the transparency of the dressing
  • Do not absorb exudate

Indications:

  • Dry wounds healing by primary intention
  • Epithelising wounds
  • Skin graft donor wounds
  • For the additional stabilisation of other wound dressings or as secondary dressing over other dressings (such as alginates and hydrogels in gel form)
  • As surgical covering; for the fixation of cannulas and i.v. catheters
  • As an occlusive dressing over topical local anaesthetics, e.g. Emla® cream
  • Can be worn while showering

Contraindications:

  • Known hypersensitivity to the product or any of its constituents
  • Necrotic wounds
  • Deep undermining wounds
  • Clinically infected wounds

Potential complications:

  • Can adhere excessively to dry skin → may thus cause damage on removal from parchment skin
  • Can form a moist chamber on double adhesion
  • Allergic reactions

Instructions for use:

  • Promote the independence and mobility of patients ⇒ can shower while wearing the dressing
  • Atraumatic removal of the film; gradually stretch the film in parallel to the skin; to avoid exerting a shear force on the skin, support the skin underneath the film by pressing down with the hand
  • Will not adhere to moist skin (incontinent/heavily sweating patients)
  • Remove hair by shaving prior to application
  • Duration of application: 1– 7 days

Example sterile film dressing products: Askina Derm (B. Braun), Bioclusive Select (Acelity), BLISTERFILM (Covidien), Hydrofilm (HARTMANN), Leukomed T (BSNmedical), Mepore Film, Mepitel Film (Mölnlycke), NOBADERM (NOBA), OpSite Flexigrid (Smith & Nephew), Optiskin Film (URGO), POLYSKIN II (Covidien), ROGG Film exakt (ROGG Verbandstoffe), Suprasorb F sterile film dressing (Lohmann & Rauscher), Tegaderm transparent film dressing (3M Medica)

Semipermeable non-sterile rolled transparent film dressings: Cutiroll (Trusetal), Fixomull® transparent (BSNmedical), Hydrofilm Roll (Hartmann), Mepore Film Roll (Mölnlycke), OpSiteflexifix, OPSITE Flexifix Gentle (with silicone coating) (Smith & Nephew), Optiskin Film Roll (URGO), Suprasorb F Roll (Lohmann & Rauscher), Tegaderm Roll (3M Medica), XTRATA® Perme-Roll (mediset) is a hypoallergenic product that contains no latex and does not use polyacrylate adhesive

 

The following general guidelines should always be followed irrespective of the materials or technique employed: Prior to commencing wound treatment, the cause of the wound must first be determined. The required wound dressing should then be selected on the basis of clinical and cost criteria and the effect it is likely to have on the quality of life of the patient.