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DRESSINGS

Overview

  • Topic with little exposure in medical school syllabus

  • This page aims to outline types and uses of dressings, but availability of these dressings will vary between centres

  • Very highly relevant in all specialties as wounds are encountered in trauma, cancers, pressure ulcers, diabetic ulcers, chemotherapy extravasation, etc

  • Plastic surgery involves a significant volume of soft tissue injury and reconstruction, and will frequently be consulted regarding dressings. Therefore a knowledge of a wide variety of specialised dressings is important​

  • Other specialties/ departments who are high stakeholders in dressings include tissue viability nurses (TVN) and podiatry/ vascular surgery

  • The aim of local wound management is to provide the optimum environment for the natural healing process to occur

  • Types:

    • Low adherent dressings​

    • Semipermeable films

    • Hydrogels

    • Alginates

    • Foam dressings

    • Antimicrobial dressings

Overview

The ideal dressing

  • Capable of maintaining a high humidity at the wound site while removing excess exudate

  • Free of particles and toxic wound contaminants

  • Non-toxic and non-allergenic

  • Capable of protecting the wound from further trauma

  • Can be removed without causing trauma to the wound

  • Impermeable to bacteria

  • Thermally insulating

  • Will allow gaseous exchange

  • Comfortable and conformable

  • Require only infrequent changes

  • Cost effective

  • Long shelf life

The ideal dressing

Low adherent/ soft polymer dressings

  • Cheap and widely available

  • Allows exudate to pass through a secondary dressing while maintaining a moist wound bed

  • Manufactured in the form of tulles

    • Open weave cloth soaked in soft paraffin or chlorhexidine​

    • Textiles

    • Multilayered or perforated plastic silms

  • Designed to reduce adherence at the wound bed​

  • Useful for patients with sensitive or fragile skin

  • Examples:

    • Tulles - Bactigras, Jelonet, Paranet, Paratulle, Tullegras, Unitulle, Urgotul​

    • Textiles - Atrauman, Mepilex, Mepitel, NA Dressing, NA Ultra, Tegapore, Tricotex

Low adherent/ soft polymer dressings

Semipermeable films

  • Sterile plastic sheets of polyurethane coated with hypoallergenic acrylic adhesive

  • Transparent primary wound cover

  • Able to conform to any shape and do not require extra taping

  • Impermeable to fluids and bacteria

  • Permeable to air (oxygen and carbon dioxide) and water vapour

  • Provides autolytic debridement of eschar

  • Flexible and good for wounds on "difficult" anatomical sites

  • Unable to cope with large amounts of exudate

    • Not for infected or heavily exudating wounds​

  • May cause skin maceration

  • No cushioning

  • Examples: Bioclusive, Mefolm, OpSite Flexigrid, OpSite Plus, Tegaderm

Semipermeable films

Hydrocolloids

  • Sodium carboxymethylcellulose, gelatin, pectin, elastomers and adhesives bonded to a carrier of semipermeable film or a foam sheet to produce a flat, occlusive, adhesive dressing

  • Permeable to water vapour

  • Impermeable to bacteria

  • Has properties of wound debridement and absorbs wound exudates

  • Promotes moist wound healing

  • Forms a gel on the wound surface that may be mistaken for infection

  • Not indicated for neuropathic ulcers or highly exudating wounds

  • Examples:

    • Sheets: Alione, CombiDERM, CombiDERM N, Comfeel, Comfeel Plus, Cutinova Thin, DuoDERM Extra Thin, Granuflex, Tegasorb, Tegasorb Thin​

    • Paste: GranuGel Paste

    • Hydrofibre: Aquacel (Hydrofibre), Versiva

Hydrocolloids

Hydrogels

  • Insoluble polymers with up to 96% water content enabling them to donate water molecules to the wound surface and maintain a moist environment at the wound bed

  • Polymers have ability to absorb a degree of wound exudate

  • Transmits moisture vapour and oxygen

  • Bacterial and fluid permeability is dependent on the type of secondary dressing

  • Promote wound debridement by rehydration of non-viable tissue, facilitating autolysis

  • Standard form of management for slought or necrotic wounds

  • Not indicated for wounds producing high levels of exudate or gangrenous tissue

  • May cause maceration

  • Examples: Aquaform, Intrasite, GranuGel, Nu-Gel, Purilon, Sterigel

Hydrogels

Alginates

  • Produced from the naturally occurring calcium and sodium salts of alginic acid found in a family of brown seaweed (Phaeophyceae)

  • Rich in mannuronic acid or guluronic acid

    • Relative amount of each influences the amount of exudate absorbed ​

  • Partly dissolve on contact with wound fluid to form a hydrophilic gel 

  • Can absorb 15-20 times their weight of fluid

    • Suitable for highly exudating wounds​

  • Adheres to the healing wound surface​

    • Painful and damaging to healthy tissue on removal​

  • Examples​: Algisite, Algosteril, Kaltostat, Melgisorb, SeaSorb, Sorbsan, Sorbsan SA, Tegagen, Urgosorb​​

Alginates

Foam dressings

  • Manufactured from either polyurethane or silicone foam

  • Transmits moisture vapour and oxygen and provide thermal insulation to the wound bed

  • Highly absorbent and able to contain exudate

  • Protects area around wound from further damage

  • Examples:

    • Adhesive sheets​: Allevyn Adhesive, Allevyn Lite Island, Allevyn Thin, Allevyn Plus Adhesive, Biatain Adhesive, Lyofoam Extra Adhesive, Tielle Plus, Tielle Lite, Tielle

    • Non-adhesive sheets: Allevyn, Allevyn Lite, Lyofoam, Lyofoam Extra

    • For cavities: Allevyn Cavity, Allevyn Plus Cavity, Cavi-Care

Foam dressings

Tissue engineered skin substitutes

  • Human skin or dermal equivalent has two types of engineered substitues available

    • First mimics the layer of skin composed of keratinocytes and fibroblast on collagen matrix​ (cell-containing matrix)

    • Second contains only dermal elemets with fibroblast on collagen matrix (acellular matrix)

  • Secret and stimulate wound growth factors

  • Suitable for diabetic foot ulcers and venous leg ulcer

  • Examples: Apligraf, Alloderm, Integra, Laserskin, Biobrane, Bioseed, Hyalograft3-DTM

Tissue engineered skin substitutes

Antimicrobial dressings

  • For local wound infection, antimicrobial dressings can be used to reduce the level of bacteria at the wound surface but will not eliminate a spreading infection

  • Antimicrobial agents:

    • Silver in ionic or nanocrystalline form

    • Iodine as povidone-iodine (polyvinylpyrrolidone-iodine complex) or cadexomer iodine

    • Honey

    • Chlorhexidine

  • Examples: Acticoat, Actisorb Silver 200, Aquacel Ag, Arglaes, Avance, Inadine, Iodoflex, Iodosorb, Metrotop Gel

Antimicrobial dressings

Simple algorithm for dressings selection

  • This is a simplified guide for wounds based on appearance, but it is not all encompassing

    • Some wounds can be exceptionally complex

    • Departmental guidelines should be adhered to where available

  • Non-infected wounds:

    • Pink (epitheliasing)​

      • Low exudate - low adherence dressings, semipermeable films, soft polymer dressings, hydrocolloid dressing​

      • Moderate exudate - soft polymer dressings, foam dressings, alginate dressings

    • Red (granulating)​

      • Low exudate​ - low adherence dressing, soft polymer dressings, hydrocolloid dressings, foam dressings

      • Moderate exudate - hydrocolloid dressings, foam dressings, alginate dressings

      • Heavy exudate - hydrocolloid dressings, alginate dressings, foam dressings

    • Yellow (Sloughy, granulating)​

      • Low exudate - hydrocolloid dressings, hydrogel dressings

      • Moderate exudate - hydrocolloid dressings, alginate dressings

      • Heavy exudate - alginate dressings, capillary-acting dressings, hydrocolloid-firbous dressings

    • Black (Necrotic, eschar)

      • Low exudate - hydrocolloid dressings​, hydrogel dressings

      • Moderate exudate - hydrocolloid dressings, foam dressings, hydrocolloid-fibrous dressings

  • Wounds with signs of infection​​

    • Consider systemic antibacterials if appropriate​

    • For malodourous  wounds, consider mechanical or autolytic debridement

    • Low exudate - honey dressings, low adherence dressings, iodine dressings, hydrocolloid dressings​​

    • Moderate exudate - hydrocolloid dressings, foam dressings, alginate dressings, honey dressings, iodine dressings

    • Heavy exudate - hydrocolloid dressings, foam dressings, alginate dressings

Simple algorithm for dressings selection

Unwanted effects of dressings

  • Skin maceration

    • Use highly absorbent dressings

    • More frequent dressing changes

    • Protect ​nearby wound with emollients or barrier films

  • Allergic reactions

    • Avoid causative dressings​

    • Topical steroids

Unwanted effects of dressings

References

  1. Jones V, Grey JE, Harding KG. Wound dressings. BMJ. 2006:332;777-780.

  2. Dhivya S, Padma VV, Santhini E. Wound dressings - a review. BioMedicine. 2015:5(4);24-28.

  3. BNF NICE. Wound management products and elasticated garments. Link: https://bnf.nice.org.uk/wound-management/

References
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