Keys To Optimal Wound Dressing Selection

These expert panelists offer advice on choosing antimicrobial or conventional dressings, the use of antiseptics in wounds, and what emerging dressings show promise.

Q:

What kind of antimicrobial dressings do you use?

A:

Lawrence Karlock, DPM, keeps it simple and limits his choices to four or five different dressings depending on the wound type, drainage and depth of the wound.

“As you know, we have multiple choices in what we shall apply to a wound, which invariably leads us to the conclusion that one product is not necessarily better than another,” says Dr. Karlock. Kazu Suzuki, DPM, CWS, adds, “As there are hundreds of wound dressings are available today, I believe it is perfectly fine for clinicians to have a few favorites that worked the best in their hands.”

Dr. Suzuki uses several antimicrobial dressings depending on the wound location, the size and depth of wounds as well as the expected drainage amount. For the foam dressings category, he cites RTD Wound Dressings (Keneric Healthcare) as well as Mepilex Ag foam dressings (Mölnlycke Health Care), saying the main difference is the latter is adherent with silicone adhesive. Dr. Suzuki notes the RTD dressing is very thick and cushions the wound bed nicely. He adds that the RTD dressing is also very absorbent and works well for many highly draining wounds (i.e., venous leg ulcers) as well as for diabetic foot ulcers.

For large and highly draining wounds, Dr. Suzuki likes the Cutimed Sorbact (BSN Medical) contact layer, a green plastic mesh that is non-adherent and bacteriostatic, to be used along with Jobst Comprifore multilayer compression bandage (BSN Medical). He also uses various Medihoney antimicrobial gel dressings (Derma Sciences) when he wants gradual and gentle autolytic debridement of wounds for in-house patients in the hospital setting.

Generally speaking, for a wound that is draining excessively, Dr. Karlock will use an alginate, usually a silver-based product. If the wound has minimal drainage and has a red, beefy granular base, he prefers Bactroban ointment, adding that it does not seem to macerate like some of the hydrogels can.

Eric Lullove, DPM, will use Iodosorb (Smith and Nephew) and Hydrofera Blue Classic/Hydrofera Blue Ready (Hollister Wound Care). In the presence of most bacteria, he says the need to kill bacteria and prevent quorum sensing is most important initially when treating wounds. Dr. Lullove says Iodosorb will act as a true bacteriocide and the use of Hydrofera Blue Classic and Ready allows him to utilize collagen dressings without the dressing causing a cytotoxic response to the wound bed.

If a wound is somewhat macerated, Dr. Karlock prefers an iodine-based product, Iodosorb, or the “good, old-fashioned, cheap, by the gallon” topical Betadine. He acknowledges misconceptions about how Betadine may be toxic to a wound. However, Dr. Karlock cites a study that notes “Iodine is an effective antiseptic agent that shows neither the purported harmful effects nor a delay of the wound-healing process, particularly in chronic and burn wounds.”¹ In a grossly contaminated, foul-smelling infected wound, Dr. Karlock will sometimes use one-quarter strength Dakin’s solution, calling it “an old-fashioned remedy.”

“In 21 years of practice, I really cannot say that one product stands out above the rest that would make me exclusively use it for a wound,” says Dr. Karlock.

Q:

What is your thought process in choosing antimicrobial dressings versus conventional dressings?

A:

As Dr. Suzuki notes, the conventional wisdom says a clean wound just needs a sterile dressing and does not require antimicrobial dressings. While he believes antimicrobial dressings would be worth the cost of paying a few dollars more in comparison to conventional dressings, he says there is a lack of good clinical evidence to show a decrease in infection by using antimicrobial dressings. Dr. Suzuki has observed a few cases in which a clean wound suddenly became infected after he stopped using an antimicrobial dressing. Based on that, he advocates using antimicrobial wound dressings whenever possible and feasible.

Dr. Karlock does not see a huge difference when using topical antibiotic dressings versus hydrogels for a wound.

“Certainly, we all rely upon and think that topical antimicrobials will help decontaminate a wound, but I am not sure it is true,” notes Dr. Karlock.

If there is an infection within a wound, he says systemic antibiotics are the mainstay as opposed to any topicals. Dr. Karlock has also “played around” with honey-based wound products, noting they seem to do “as good of a job as any other product.”

In most cases, once wounds are under inflammatory control, Dr. Lullove advises conventional dressings are most appropriate. However, in the presence of initially treating a chronic or even an acute wound, he argues the need to control the inflammatory cycle is most important. This is where antimicrobial dressings play a large role in the management of matrix metalloproteinases and bacterial bioburden, according to Dr. Lullove. He notes that to underutilize antimicrobial dressings early in the wound management cycle is to allow the wound to become more chronic and other treatment modalities will fail as a result.

Q:

Do you use any antiseptic for wounds?

A:

Dr. Lullove uses buffered sodium hypochlorous acid wound washes such as Vashe (SteadMed Medical) for treatment of all wounds, including surgical incisions. As he notes, the soaking of buffered hypochlorous solutions on wounds during the treatment regimen allows for the 30 second to five minute kill time to eliminate nosocomial bacteria. Unfortunately, he says those solutions do not replace the need for surgical debridement or hydrosurgical debridement methods to remove biofilm.

Dr. Suzuki has been using Puracyn (Innovacyn) antimicrobial hypochlorous acid solution on a daily basis for the past year, and has also been using Puracyn hydrogel for the past few months. He has found that Puracyn controls wound odor nicely and a yet-to-be published study shows that switching from normal saline irrigation to hypochlorous solution in his wound care center reduced the infection rate and oral antibiotics prescribed.

Dr. Karlock notes Betadine decontaminates the wound and is not detrimental to wound healing. He prefers Betadine for any macerated tissue as many neuropathic wounds will have a macerated hyperkeratotic halo around the wound.

Q:

Are there any new dressings you have used recently that have helped facilitate good outcomes?

A:  

Dr. Suzuki praises the use of V.A.C. Ulta with VeraFlo (KCI/Acelity), a negative pressure wound therapy system that allows continuous or intermittent irrigation of wounds. He says this is a rather complicated system that is only indicated for the acute care setting in the hospital. He cites data showing the irrigation controls wound infection more effectively than conventional negative pressure wound therapy.² Dr. Suzuki adds that the data also shows the V.A.C. Ulta with VeraFlo reduces the length of stay in the hospital for some of the more complicated and infected wounds, such as diabetic foot ulcers with deep infection. Dr. Suzuki also uses various skin substitute grafts in addition to conventional wound dressings to facilitate the wound closure rate.

Dr. Lullove posits that dressing technologies have not changed much and understanding the wound healing cycle and controlling the inflammatory stage of wounds are key to getting better outcomes. After clearing out the bioburden in the wound, he has mostly used the Endoform Dermal Template (Hollister Wound Care) and Hydrofera Blue Ready as twice-weekly dressings. As he explains, the use of the anti-protease treatment of Endoform and the antimicrobial treatment of Hydrofera Blue  Ready allow for the complete management of the wound from inflammation to proliferation and eventually wound closure.

Dr. Karlock will use a variety of skin substitutes to try to expedite closure of wounds, ranging from living keratinocyte products to placenta-based membrane products. In addition, he says some of the collagen-based topicals do play a role in treating some chronic wounds.

Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and is in private practice in Austintown, Ohio. He is the Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio.

Dr. Lullove is in private practice in Boca Raton and Delray Beach, Fla. He is a staff physician at West Boca Medical Center in Boca Raton. Dr. Lullove is a Fellow of the American College of Certified Wound Specialists.

Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo.

References
1. Vermeulen H, Westerbos ST, Ubbink DT. Benefit and harm of iodine in wound care: a systematic review. J Hosp Infect. 2010; 76(3):191–9.
2. Kim PJ, Attinger C, Steinberg JS, et al. The impact of negative pressure wound therapy with instillation compared to negative pressure wound therapy: a retrospective historical cohort controlled study. Plast Reconstr Surg. 2014; 133(3):709–16.