Hydro-responsive wound dressings for treating hard-to-heal wounds: a narrative review of the clinical evidence

A break in skin integrity must be repaired as quickly as possible to avoid excess blood and fluid loss, and to minimise the onset of infection. Hard-to-heal wounds, in which the progression of the wound healing response is compromised, present several challenges to healing (for example, the presence of devitalised tissue acting as a physical barrier to healing and as a focus for bacterial contamination with the potential for subsequent infection). The objective of this article is to present, as a narrative review, the clinical evidence supporting the use of a unique hydro-responsive wound dressing (HydroClean, HRWD1, PAUL HARTMANN AG, Germany). The dressing provides a simple treatment option to address a number of clinical challenges clinicians must overcome in order to facilitate wound healing progression. These studies demonstrated that this product supported successful debridement/cleansing of a wide variety of wounds, including hard-to-heal wounds, enabled wound bed preparation, and lead to positive healing outcomes, including in wounds that previously had failed to heal. The simplicity of using HRWD1 as a single dressing can help clinicians overcome a variety of challenges when treating both acute and hard-to-heal wounds, which, with the benefit of proven patient outcomes, could make it an ideal choice for a first-line treatment.

Management of complex wounds treatment with a hydrofiber dressing in a public hospital in Bogota (Colombia)

Objective. To evaluate the efficacy of the use of a last generation hydrofiber dressing with silver, for the treatment of complex wounds that are difficult to heal.Materials and research methods. A prospective observational case-follow-up study was carried out, which included patients with acute or chronic wounds that were difficult to heal, treated in the plastic surgery service of a public hospital in Bogota-Colombia, who underwent healing with hydrofiber dressings reinforced, with silver ions, benzethonium chloride and EDTA (Aquacel Agplus®, ConvaTec). The wound was monitored, evaluating infection control, exudate and biofilm, as well as the number of required dressings and the time required for the complete closure of the wound.Research results. A total of 55 patients were included, with a median age of 44 years. In all cases, a follow-up was carried out until the definitive closure of the wound. At the end of the study, it was observed that, in 35 (63.6 %) patients, the wounds evolved to complete closure by second intention in an average of 59.3 days, requiring 12.5 dressings. 20 (36.4 %) patients had adequate wound bed preparation for definitive surgical coverage with grafts, flaps or dermal substitutes, in an average of 31.4 days, requiring 6.5 dressings on average.33 (60.0 %) wounds were infected and adequate infection control was achieved on average with 5 dressings. A decrease in the direct and indirect signs of biofilm was achieved after 6 dressings.Conclusion. The results show that the dressing studied is effective to control exudate, infection and biofilm, as well as to prepare the bed for a definitive surgical coverage.

Development and integration of a wound cleansing pathway into clinical practice

Wound bed preparation has come into sharper focus over the past decade, with strategies identified to improve wound condition. This article focuses on implementing a wound cleansing policy and measuring, through audits, how this change affected rates of wound infection. From 2016 onwards, the Skin Integrity Team at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust took steps to revise and improve wound care practices. This resulted in the introduction of a wound cleansing pathway incorporating a surfactant-based cleanser in place of saline, with subsequent staff training and other changes made to practice. This study details the steps taken to implement the new pathway, which brought a reduction in wound infections of 84.3% between 2017 and 2019.

Use of a flowable wound matrix to treat lower limb vascular ulcers

Objectives: This study is aimed at assessing the safety and effectiveness of an advanced flowable wound matrix (FWM) in the treatment of hard-to-heal vascular leg ulcers that often involve deep structures, are irregular and/or tunnelled or excavated. Methods: Records of patients seen at our Vascular Surgery Unit, at the University of Campania ‘Luigi Vanvitelli’, for hard-to-heal vascular leg ulcers between January 2018 and January 2020 were retrospectively reviewed. For each wound aetiology, area and complications were recorded and evaluated. Every patient received one or more applications of FWM and was followed up. Results: A total of 22 patients (18 female/four male), mean age 63±8.5 years, were treated. The initial wound area ranged from 4–58cm2. After wound bed preparation, FWM was applied. Treatment was well tolerated and effective—rate of complications was low, graft take was very satisfactory, and no graft loss, rejection or superimposed infections were observed. Healing time was short: 85% of ulcers healed after 12 weeks. Most importantly, there was a decrease in the rate and level of amputations as compared with standard wound care. Conclusions: The data presented indicate that FWM is an option for the treatment of hard-to-heal vascular leg ulcers, particularly for those with an irregular cavity. Declaration of interest: The authors have no conflicts of interest.

Wound bed preparation with hypochlorous acid oxidising solution and standard of care: a prospective case series

Objective: This prospective case series aims to evaluate the clinical impact of a hypochlorous acid oxidising solution (AOS) in association with usual standard of care (SoC) on wound bed preparation (WBP) in patients with hard-to-heal ulcers of various aetiologies. The AOS (Nexodyn, APR Applied Pharma Research S.A., Switzerland) comprises three main features: highly pure and stabilised hypochlorous acid, acidic pH and high reduction–oxidation potential. Method: Between February 2015 and February 2017, patients who met the inclusion criteria were treated with AOS and usual SoC. Data collection ran for 70 days: T0–T70. A baseline assessment was undertaken at T0; parameters assessed at fortnightly visits included: WBP score, area and depth of ulcer, duration, pain, Bates–Jensen score and infection status. Results: A total of 60 patients took part in the study. By T70, 68.3% of wounds had healed or improved and a significant wound size reduction of 21% was observed (p<0.001), despite a mean wound duration of 20.6 months. All wounds were free of local infection and cellulitis; 10% were colonised. WBP scores improved, while Bates–Jensen and pain scores fell significantly over time. Conclusion: This evaluation suggests that AOS might represent a valuable therapeutic addition for an optimal WBP in the routine management of hard-to-heal ulcers of different aetiologies. Declaration of interest: ER worked as a consultant for APR Applied Pharma Research S.A. The authors have no other conflicts of interest.

Frequency of sharp wound debridement in the management of diabetes-related foot ulcers: exploring current practice

Background Conservative sharp wound debridement (CSWD) is fundamental to wound bed preparation. Evidence-based practice guidelines strongly recommend frequent CSWD of diabetes-related foot ulcers (DFU) based on expert opinion and observational studies which suggest that more frequent debridement is associated with better healing outcomes. Aim To document current practice with regards to CSWD of DFU and whether this is performed at every visit, how often and what factors determine debridement frequency. Method Survey data were collected and managed using REDCap electronic data tools, a secure, web-based application. The survey was distributed through podiatry managers and relevant clinical networks between October 2017 and February 2018. Results One hundred clinicians opened the survey and seventy-five surveys were completed by n = 53 NSW Health (Australia) employed podiatrists (representing 41% of all NSW Health podiatrists), 11 privately practicing podiatrists, and 11 nurses. Most (n = 47) worked in metropolitan areas versus regional/remote (n = 28). CSWD was the most frequently used debridement method, performed at every visit by most (84%) of podiatrists. Callus, slough and infection presence were the top 3 most important determinants of frequency, with staff time (a limiting factor) ranking 4th. Regional/remote podiatrists practiced less frequent debridement compared with those in metropolitan areas (debridement every 2 weeks or less = 71% regional podiatrists versus 45% metropolitan podiatrists) (p = 0.024). Conclusion and clinical implications CSWD was the predominant form of debridement used with debridement occurring at every treatment visit for most of the clinicians surveyed. Debridement frequency was determined by clinical wound indications and staffing resources, with regional/remote podiatrists providing debridement less often than their metropolitan colleagues.

The Evidence for Antimicrobial and Hard to Infect Regenerative Matrices

Preparation of the wound bed is a key step in the use of cell- and tissue-based therapy (CTP). In particular, good pre-application debridement is an essential component of CTP. However, there are many situations in which the wound bed is not adequately debrided, including trauma, burn, and in cases of chronic wounds with significant biofilm. In the setting of inadequate wound bed preparation, the use of a CTP that has either added or intrinsic antimicrobial properties is attractive. Some CTPs include added antimicrobial agents such as PHMB or silver, while others have intrinsic antimicrobial components, such as Omega 3 fatty acids. In addition, some wound-covering dressings are completely synthetic, and therefore simply do not become infected. A full understanding of the basic science and clinical data supporting the use of these therapies is important for the advanced wound care practitioner.

Utility of Porcine-Derived Xenograft as an Adjunct to Split-Thickness Skin Grafting in Lower-Extremity Wounds

Objective Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds. Methods Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected. Results There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P30 = .818; 82.2% versus 80.9%, P60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P30 = .902; 1.2 cm2 versus 1.1 cm2, P60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group. Conclusions Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.