Bandaging / Dressings

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If you were to ask an average person,
even the average health care worker,
what we should do with a wound, 
applying a bandage is probably going
to be the first answer mentioned. 

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And it's not a bad answer, as dressings
certainly play a role in wound care. 

 

• We need to keep the wound clean
  and protect it from the dangers of
  the outside world. 

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• We need to protect the wound from
  mechanical pressure and abrasion
  that can further damage the wound
  and prevent it from healing. 

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• In addition, specialized dressings can
  be used for moisture balance. 
  
  For example, hydrogels and hydrocolloid
  dressings can add moisture to wounds
  that are too dry (near right). 
  
  And alginates and foams can absorb
  liquid from wounds that are too wet
  (far right).

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There are also dressings with silver, iodine,

and honey that claim antimicrobial effects. 

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And one can add antibiotic ointments and

creams into the dressing, in the effort to

fight infection, provide nutrition to the
wound, or otherwise assist the wound in

healing. 

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Even more specialized, there are dressings

made from the same biological materials

cells use in healing. 

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There are even bandages with living cells

built into them. 

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As you might imagine, the more specialized the dressing, the more expensive it may be.  And given the fact that many dressings are changed multiple times per week, it means we spend billions on wound care dressings.

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Wound dressings are big business.

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One could argue that dressing changes is the central pillar of our provincial health plan's prescribed treatment protocol.  Because dressing changes are not overly difficult to perform, it's something our provincial health plans cover.

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While dressings are important in wound care, the question, however, is whether dressings should be the central thrust of our wound care strategy.  Do the dressings actually do what they claim to do?  And are fancy dressings worth the resources we invest?

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What's Most Important in Wound Care?

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In the wound care world, there is an expression that it's not so
much what you put on a wound that counts, it's what you take
off.  

 

In other words, it probably doesn't matter all that much what
dressing or topical medicinal agent is applied to the wound. 

 

What matters most is:

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1) Taking off the dead cells (slough) on and around the wound
    to unburden the wound, (debridement, a technique discussed
    in greater detail here), and

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2) Removing the pressure and shear forces that cause the wound (something called offloading, and discussed in greater
  detail here). 

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Why Do You Say That Dressings Don't Matter So Much?

 

 

It's not that dressings are unimportant.  It's just that, given what we

spend on wound care dressings, if you're looking for unbiased clinical
evidence for the use of a specific dressing, there may not be as much

evidence as you'd think. 

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In 2016, two well-known researchers in Britain examined papers

produced between 2006 and 2014 on the various products available

to apply to wounds. 

 

They looked at 5,632 articles and selected the 207 best articles that met
predefined criteria. 

 

In reviewing the evidence found in those, they found in the best of these
papers, they concluded that "few published studies were of high quality,
and the majority were susceptible to bias." 

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Game FL, Jeffcoate WJ. Dressings and Diabetic Foot Ulcers:
A Current Review of the Evidence  
Plast Reconstr Surg. 2016 Sep;138(3 Suppl):158S-64S.

 

 

In other words,  the UK researchers couldn't find a lot of scientific
evidence to support the use of most of the fancier dressings we apply to
the foot.  Hence, the UK government pays for inexpensive, non-adherent
dressings, but little in the way of the higher-priced dressings on the market. 

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This is very much in line with other independent findings. 

 

 

 

Cochrane is a UK-based organization that aims to organize medical research in order to make evidence-based choices on health care interventions.  To maintain an independent, unbiased perspective, they don't accept corporate funding.  So there is no financial interest in reporting their conclusions one way or the other.

 

Cochrane has also reviewed the evidence on common dressings used in wound care.  Here are several of their conclusions, regarding various dressing choices.

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Regarding Hydrocolloid dressings to promote foot ulcer healing in people with
diabetes when compared with other dressing types, the author's conclude: 
"Currently there is no research evidence to suggest that any type of hydrocolloid
wound dressing is more effective in healing diabetic foot ulcers than other types
of dressing or a topical cream containing plant extracts. Decision makers may wish
to consider aspects such as dressing cost and the wound management properties
offered by each dressing type e.g. exudate management."

 

Dumville JC, Deshpande S, O'Meara S, Speak K.
Hydrocolloid dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews August 6, 2013, Issue 8.
Art. No.: CD009099. DOI: 10.1002/14651858.CD009099.pub3

 

 

 

 

Regarding Alginate dressings for healing foot ulcers in people with diabetes mellitus, the author's conclude:  "Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management."

 

Dumville JC, O'Meara S, Deshpande S, Speak K.
Alginate dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews
June 25, 2013, Issue 6. Art. No.: CD009110.

DOI: 10.1002/14651858.CD009110.pub3

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Regarding Foam dressings for healing foot ulcers in people with diabetes,
the author's conclude:  "Currently there is no research evidence to suggest
that foam wound dressings are more effective in healing foot ulcers in people
with diabetes than other types of dressing however all trials in this field are
very small. Decision makers may wish to consider aspects such as dressing
cost and the wound management properties offered by each dressing type
e.g. exudate management."

 

Dumville JC, Deshpande S, O'Meara S, Speak K.
Foam dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews
June 6, 2013, Issue 6. Art. No.: CD009111.

DOI: 10.1002/14651858.CD009111.pub3

 

 

 

 

Regarding Hydrogel dressings to promote diabetic foot ulcer healing, the author's conclude:  "There is some evidence to suggest that hydrogel dressings are more effective in healing (lower grade) diabetic foot ulcers than basic wound contact dressings however this finding is uncertain due to risk of bias in the original studies. There is currently no research evidence to suggest that hydrogel is more effective than larval therapy or platelet-derived growth factors in healing diabetic foot ulcers, nor that one brand of hydrogel is more effective than another in ulcer healing. No RCTs comparing hydrogel dressings with other advanced dressing types were found."

Dumville JC, O'Meara S, Deshpande S, Speak K.
Hydrogel dressings for healing diabetic foot ulcers.
Cochrane Database of Systematic Reviews
July 12, 2013, Issue 7. Art. No.: CD009101. DOI: 10.1002/14651858.CD009101.pub3

 

  

 

Regarding silver-based wound dressings and topical agents containing silver for
treating diabetic foot ulcers, Cochrane has produced two recent statements. 

 

In the 2006 paper, the author's conclude:  "Despite the widespread
use of dressings and topical agents containing silver for the treatment of diabetic

foot ulcers, no randomised trials or controlled clinical trials exist that evaluate

their clinical effectiveness. Trials are needed to determine clinical and cost-

effectiveness and long term outcomes including adverse events."

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Bergin S, Wraight P. Silver based wound dressings and topical agents for
treating diabetic foot ulcers.
Cochrane Database of Systematic Reviews
January 5, 2006, Issue 1. Art. No.: CD005082.

DOI: 10.1002/14651858.CD005082.pub2

 

 

The updated 2010 review concludes:  "There is insufficient evidence to establish
whether silver-containing dressings or topical agents promote wound healing or
prevent wound infection; some poor quality evidence for SSD suggests the
opposite."

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Storm-Versloot MN, Vos CG, Ubbink DT, Vermeulen H.
Topical silver for preventing wound infection.
Cochrane Database of Systematic Reviews
March 17 2010, Issue 3. Art. No.: CD006478. DOI: 10.1002/14651858.CD006478.pub2

 

Regarding Honey as a topical treatment for acute and chronic wounds, the author's conclude: "It is difficult to draw overall conclusions regarding the effects of honey as a topical treatment for wounds due to the heterogeneous nature of the patient populations and comparators studied and the mostly low quality of the evidence. The quality of the evidence was mainly downgraded for risk of bias and imprecision. Honey appears to heal partial thickness burns more quickly than conventional treatment (which included polyurethane film, paraffin gauze, soframycin-impregnated gauze, sterile linen and leaving the burns exposed) and infected post-operative wounds more quickly than antiseptics and gauze. Beyond these comparisons any evidence for differences in the effects of honey and comparators is of low or very low quality and does not form a robust basis for decision making."

 

Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N.
Honey as a topical treatment for wounds.
Cochrane Database of Systematic Reviews
March 6, 2015, Issue 3. Art. No.: CD005083. DOI: 10.1002/14651858.CD005083.pub4

 

Regarding Aloe vera for treating acute and chronic wounds, the author's conclude:  "There is currently an absence of high quality clinical trial evidence to support the use of Aloe vera topical agents or Aloe vera dressings as treatments for acute and chronic wounds."

 

Dat AD, Poon F, Pham KBT, Doust J.
Aloe vera for treating acute and chronic wounds.
Cochrane Database of Systematic Reviews
February 15, 2012, Issue 2. Art. No.: CD008762. DOI: 10.1002/14651858.CD008762.pub2

 

 

And regarding dressing as a whole to treat foot ulcers in people with diabetes, the author's conclude:  "There is currently no robust evidence for differences between wound dressings for any outcome in foot ulcers in people with diabetes (treated in any setting). Practitioners may want to consider the unit cost of dressings, their management properties and patient preference when choosing dressings."

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Wu L, Norman G, Dumville JC, O'Meara S, Bell-Syer SEM.
Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews.
Cochrane Database of Systematic Reviews
July 14, 2015, Issue 7. Art. No.: CD010471. DOI: 10.1002/14651858.CD010471.pub2

 

 

 

These statements are in line with our personal experience.

 

 

 

Why Do You Say Debridement Helps Wounds Heal?

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We discuss debridement here.

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In 2010, Cochrane reviewed the concept of various forms of debriding diabetic wounds. In that review, they state, "Debridement is widely regarded as an effective intervention to speed up ulcer healing."  However, their conclusions are a bit vague. "More research is needed to evaluate the effects of a range of widely used debridement methods and of debridement per se."

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Edwards  J, Stapley  S. Debridement of diabetic foot ulcers.
Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD003556.

DOI: 10.1002/14651858.CD003556.pub2.

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However, there are other studies that do suggest debridement works.  

 

In fact, in 2013 a huge retrospective study was performed, looking at data between 2008 and 2012 compiled from 525 wound care clinics.  

 

312,744 wounds in 154,664 individual patients were treated, and the efficacy of debridement was assessed.

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The authors found that healing time was 21 days if debridement was performed weekly.  Healing time was three times slower (64 days) if debridement was performed every two weeks, and slower still (76 days) if debridement was performed every three weeks.  

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Wilcox JR, Carter MJ, Covington S Frequency of debridements and time to heal: a retrospective cohort study of 312,744 wounds
JAMA Dermatol. 2013; 149(12):1441

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Given the huge number of wounds examined across hundreds of wound care facilities, the evidence is rather compelling that regular debridement performed weekly is highly effective in helping wounds heal.  

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Other authors agree. 

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"Debridement should be carried out in all chronic wounds to remove surface debris and necrotic tissues." 

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Kleopatra Alexiadou K, Doupis J.  Management of Diabetic Foot Ulcers  
Diabetes Ther. 2012 Dec; 3(1): 4. Published online 2012 Apr 20.

doi: 10.1007/s13300-012-0004-9 PMCID: PMC3508111 PMID: 22529027

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"Maintenance debridement is a proactive way to "jump-start" the wound and keep it in a healing mode, even when traditional debridement may not appear necessary because of a seemingly "healthy" wound bed."
 

Falanga V(1), Brem H, Ennis WJ, Wolcott R, Gould LJ, Ayello EA.
Maintenance debridement in the treatment of difficult-to-heal chronic wounds.
Recommendations of an expert panel.  

Ostomy Wound Manage. 2008 Jun;Suppl:2-13; quiz 14-5.

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"Debridement remains an important adjunct to good wound care, but questions of what type, how much, and how often it should be performed remain unresolved."

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Steed DL    Debridement   Am J Surg. 2004 May;187(5A):71S-74S.

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Our results suggest that frequent debridement of DFUs and VLUs may increase wound healing rates and rates of closure, though there is not enough evidence to definitively conclude a significant effect. Future clinical research in wound care should focus on the relationship between serial surgical wound debridement and improved wound healing outcomes as demonstrated in this study.

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Cardinal M, Eisenbud DE, Armstrong DG, Zelen C, Driver V, Attinger C, Phillips T, Harding K. 
Serial surgical debridement: a retrospective study on clinical outcomes in chronic lower extremity wounds.
Wound Repair Regen. 2009 May-Jun;17(3):306-11. doi: 10.1111/j.1524-475X.2009.00485.x.

 

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In a study at the University of Pittsburgh, 118 patients were treated with and without debridement.  The patients undergoing debridement healed faster.  The authors concluded, "Wound debridement is a vital adjunct in the care of patients with chronic diabetic foot ulcers."

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Steed DL, Donohoe D, Webster MW, Lindsley L.  Effect of extensive debridement
and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group.

J Am Coll Surg. 1996 Jul;183(1):61-4.

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Why Do You Say Offloading Is Important in Wound Care?

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There's quite a bit of evidence that offloading is of the utmost importance in treating wounds, achieving closure rates of up to 90% within 6-8 weeks.  Here are three studies:

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Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VP III, Drury DA, Rose SJ: Total contact casting in treatment of diabetic plantar ulcers: controlled clinical trial. Diabetes Care 12:384–388, 1989

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Caravaggi C, Faglia E, De Giglio R, Mantero M, Quarantiello A, Sommariva E, Gino M, Pritelli C, Morabito A: Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care 23:1746–1751, 2000

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Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB: Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 24:1019–1022, 2001

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It is unfortunate that this is not the primary emphasis of our provincial health plans. 

 

For the most part, provincial plans do not pay for offloading devices, and most medical personnel have little training in biomechanics. 

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And most wounds in a hospital are not regularly debrided because few physicians are trained in either debridement, and even fewer are interested in actually doing so.   

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But there are lots of people who can put a bandage on a wound.  So this is what's emphasized.

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So how do manufacturers of special wound care dressings make claims that don't have a lot of evidence?

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Most people involved in wound care know what works--debridement and offloading.  So most of the research produced by the manufacturers of dressings produce papers explaining the purported effect of the dressing, and make conclusions that the evidence shows their dressing works when combined with debridement and offloading.  

 

In other words, the study is often performed with a new wound care product--a dressing or cream of some sort--used in combination with debridement and offloading.  They will frequently conclude that when the researchers used this new product in combination with debridement and offloading, they had a 90% closure rate within just two months. 

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The suggestion is then that clinicians should use that new wound care product.  

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What's not mentioned is that debridement and offloading work most of the time at that rate, with or without the fancy, expensive dressing.
 

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So what should we be putting on wounds?

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It is the position of the Medical Alliance for the Preservation of the Lower Extremity (MAPLE) that dressings' primary role is to keep the wound clean and protect it from mechanical forces like pressure and shear that can cause further damage.  This can often be done with simple, non-adherent dressings.

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In some wounds, specialized dressings can be useful to remove excessive moisture from a draining wound, or to hydrate a dry wound. 

 

Other dressings and medications may be appropriate in some cases, but they are probably indicated much less frequently.

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What matters most in treating uninfected wounds, however, is offloading and debridement. 

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When infection is present, antibiotics become the single most important treatment.  And if an infection is present, delivering an antibiotic via IV or orally is more efficacious than applying an antimicrobial dressing.  

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Our provincial governments should focus funding upon debridement and offloading.

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