Wound Dressings and Management

from AFP > 2014 > September > Ulcer dressings and management

The most common chronic wounds seen in practice are:

• leg ulcers (venous, arterial, mixed)
• pressure wounds
• skin tears.

Skin Tears

Definition:

• Skin tears are the most common wound type in the elderly population.
• If not treated properly, they can become chronic wounds with significant physical, psychological, and economic impacts.

Age-Related Skin Changes:

• Loss of hair follicles
• Reduction in sebaceous glands (less natural moisture)
• Decreased receptors
• Reduced blood supply
• Decreased sweat glands
• Result: Thinner, more brittle skin that is prone to injury.

Prevention:

• Identify at-risk patients.
• Moisturizing: A study in Western Australia showed a 50% reduction in skin tears and significant cost savings by applying a moisturizing lotion twice daily.

Management:

1. Assess the Damage:
   • Replace the flap: If possible, carefully reposition the skin flap.
   • Adhesive strips: Apply without tension to hold the flap in place.
   • Dressing: Use a silicone foam dressing.
   • Compression bandage: Cover with one or two layers of tubular compression bandages for mild pressure.
2. Review and Redress:
   • Initial review: After 3 days.
   • Redressing interval: Every 5-7 days until healed.

Venous Leg Ulcers (VLUs)

• Prevalence: An estimated 400,000 Australians affected.
• Primary Cause: Chronic venous insufficiency (CVI).
• Management: Primarily in primary care or community settings with varying effectiveness.
• Cost: Over $2 billion per year in healthcare costs (2010).
• Recurrence: Expected to rise due to aging population, diabetes, and obesity.
• Pathophysiology:
  • Breakdown of venous circulation in the leg.
  • Inability of leg veins to effectively push blood, due to faulty bicuspid valves.
  • Increased venous pressure leads to pitting oedema.
  • Oedema affects skin perfusion, leading to ulcers after trauma.
• Development Area: Commonly in the lower one-third of the leg (gaiter area).
• Appearance:
  • Irregular shape.
  • Skin staining around the ulcer due to haemosiderin deposition.
  • Pitting oedema usually present.
  • Skin changes such as eczema or atrophy blanche.
• Risk Factors:
  • History of obesity.
  • Past deep vein thrombosis (DVT).
  • Poor mobility leading to venous stasis.
• Treatment:
  • Surgery in some cases.
  • Mainstay: Graduated compression therapy (30-40 mmHg at the ankle).
  • Essential to exclude arterial involvement (ankle brachial index or ultrasonography).
  • Encourage lower limb exercise.
  • Address occupational factors (e.g., long periods of standing).
• Other Causes of Oedema:
  • Organ failure.
  • Lymph disease.
  • Medications (e.g., calcium channel blockers).
• Lymphoedema:
  • Caused by reduced lymph vessel function.
  • Results in oedema, increasing risk of ulcer development.
  • Associated with minor trauma and hyperkeratotic skin.

Arterial Ulcers

• Cause: Occlusion of arterial blood supply, commonly due to atheroma (thickening).
• Pathophysiology:
  • Skin death follows arterial occlusion unless gradual enough for collateral blood supply.
  • Ischaemic pain, particularly at night.
• Appearance:
  • Sharply defined edges, ‘punched out’ appearance.
  • Base often covered with slough, may expose tendons.
  • Common sites: below ankles, foot, or toes; may also appear on other body areas.
  • Skin: shiny and friable.
• Associated Symptoms:
  • History of intermittent claudication.
  • Dependent foot: dusky when dependent, white when elevated.
  • Peripheral vascular disease signs: lower ankle-brachial pressure index, weak/absent pulses, poor capillary refill.
• Risk Factors:
  • Poorly controlled diabetes.
  • Smoking.
• Treatment:
  • Surgical interventions: angioplasty, stenting, bypass grafting, amputation.
  • Pain management: adequate analgesia for severe ischaemic pain.
  • No compression therapy, even with associated venous disease.

Mixed Ulcers (Venous/Arterial):

• 15-20% of leg ulcers are of mixed aetiology.
• Challenges in healing due to oedema, cellulitis, thrombophlebitis, rheumatoid diseases, bedridden patients, malnourishment in elderly.
• Key: Determine predominant cause (venous or arterial) and treat accordingly.
• Graduated compression may be contraindicated depending on arterial involvement.

Pressure Ulcers

• Preventability: Most preventable of all chronic wounds.
• At-Risk Populations:
  • Bedridden patients (e.g., due to stroke, spinal injury, multiple sclerosis, dementia).
• Causes:
  • Direct pressure.
  • Friction.
  • Shear injuries.
• Pathophysiology:
  • Decreased capillary blood flow to skin/tissue over bony prominences.
  • Reduced oxygen and nutrient supply.
  • Inadequate excretion of waste products.
• Types of Injury:
  • Friction: Top layers of skin worn away by rubbing against external surfaces (e.g., ill-fitting footwear, bed linen).
    • Manifestations: Blisters, tissue oedema, open pressure wounds.
  • Shear: Skin remains in place while underlying bone and tissue move, damaging microvasculature.
• Management:
  • Remove all pressure from the wound.
  • Increase nutrition.
  • Use of topical or cavity products depending on wound size and depth.

Factors Affecting Healing

• Intrinsic Factors:
  • Health Status: Good arterial and venous circulation, anemia affects oxygen transport.
  • Immune Function: Normal function cleanses wound, reduced function increases infection risk.
  • Comorbidities: Diabetes, rheumatoid arthritis, other diseases.
  • Age-Related Changes: Loss of hair follicles, sebaceous glands, receptors; reduced blood supply, increased fragility, dryness, thinning.
• Extrinsic Factors:
  • Mechanical Stress: Pressure, friction, shearing forces.
  • Debris: Slough, necrotic tissue, eschar, scab, dressing residue, sutures.
  • Dessication: Dry wound surface leads to cell death.
  • Maceration: Excess moisture retards healing, damages peri-skin.
  • Temperature: Optimal healing at 37ºC.
  • Nutrition: Balanced diet (proteins, carbohydrates, fats, fluids).
  • Infection: Chemical stress, topical agents (e.g., antiseptics).
  • Smoking.
  • Drugs: Steroids, non-steroidal anti-inflammatory drugs.

Intrinsic factors	Extrinsic factors
Health status Good arterial and venous circulation: anaemia impairs oxygen transport	Mechanical stress Pressure Friction Shearing forces
Immune function Normal immune function helps to cleanse the wound Reduced function increases the risk of infection	Debris Slough Necrotic tissue Eschar Scab Dressing residue Sutures
Comorbidities Diabetes Rheumatoid arthritis Other diseases	Dessication Drying of the wound surface results in death of surface cells
Age-related changes to skin Loss of hair follicles, sebaceous glands, receptors Reduced blood supply Increased fragility Dryness Thinning	Maceration Excess moisture retards healing and damages the peri-skin Optimal temperature 37ºCTemperature
Nutrition Balanced diet including proteins (particularly for the amino acid arginine), carbohydrates, fats and fluids promotes healing	Infection Chemical stress may have an adverse effect on the wound and cells Topical agents (eg antiseptics) Smoking20 Drugs (eg steroids and non-steroidal anti-inflammatory drugs)21–23

Wound Management

• Concept: Based on Wound Bed Preparation (WBP) interventions.
  • Focus Areas: Debridement, bacterial balance, exudate management, local tissue.
  • TIME Principles:
    • Tissue
    • Inflammation/Infection
    • Moisture
    • Edge/Epithelialisation
  • Developed by the World Union of Wound Healing Societies.
• Guidelines: Therapeutic guidelines: Ulcer and wound management uses this approach for best practice and evidence-based care.
• Dressing Misconception:
  • Focus should not be solely on the dressing.
  • Address underlying causes of the wound.
  • Identify and manage factors affecting healing.
  • Select dressings based on function (e.g., exudate management, debriding, cavity filling).
• Wound Management Products:
  • Passive Dressings:
    • Traditional ‘plug and conceal’ products like gauze, lint, non-stick, and tulle dressings.
    • Limited use as primary dressings; useful as secondary dressings.
  • Interactive Dressings:
    • Control the wound micro-environment.
    • Combine with exudate to form hydrophilic gel or use semipermeable membranes.
    • May stimulate the healing process.
    • Types:
      • Film dressings.
      • Hydroactive dressings.
      • Hydrocolloid dressings.
      • Hydrogel dressings.
      • Foam dressings.
      • Alginate absorbent fibre dressings.
    • Choice depends on wound type, depth, exudate level, and bacterial presence.
• Bandages:
  • Historical use: Ancient practice with evolving techniques and materials.
  • Recent developments: Increased variety in the past 15 years.
  • Functions:
    • Retention: Keeping a dressing in place.
    • Musculoskeletal Support: Supporting an injured joint.
    • Compression: Assisting venous return from the lower leg.
  • Consider what is best and most cost-effective for the patient when choosing and applying bandages.
• Ongoing Care for Healed Venous Ulcers:
  • Consider use of compression stockings for life.