Traditionally, we've been told that wounds should be kept clean and dry, and the scab formation is a good sign that the wound is healing, but what if this theory is fundamentally flawed?
Dry wound healing, with its emphasis on scab formation, may hinder the overall speed of healing. The scab, while protective, can act as a physical barrier, limiting the movement of essential cells involved in tissue repair, hence re-epithelialization is slowed down.
Scab formation and excessive dryness can also contribute to heightened scar formation. In some instances, the lack of moisture may cause the wound to contract excessively, resulting in larger and more prominent scars.
If dry wound healing is not the best way to manage most superficial wounds, what would be the alternative practice for wound healing?
Moist wound healing, on the other hand, has gained prominence in recent years as a preferred approach in wound care, and for good reason. This method involves maintaining a controlled, moist environment around a wound during the healing process.
The theory of Moist Wound Healing was first introduced by Dr. George D Winter in 1962 when he discovered that superficial wounds healed 2 times faster in a moist environment compared to a dry environment.[1] This practice is further supported by subsequent studies and generally adopted by professionals nowadays.
Here are several reasons why moist wound healing is the preferred approach:
Promotes optimal tissue regeneration - epidermal cells can move smoothly across the surface of the wound for re-epithelialization in a moist environment.
Promotes autolysis of necrotic tissue in the wound - moist environment allows endogenous proteolytic enzymes to break down dead tissue. This can contribute to a cleaner wound bed and faster healing.
Reduces scarring.
Minimizes pain and discomfort.
Prevent tissue dehydration and death.
When to Consider for Moist Wound Healing:
Chronic Wounds
Pressure Ulcers
Surgical Wounds
Superficial Wounds
Wounds in aesthetically sensitive areas
How to Create Moist Wound Environment?
The key to creating a moist wound healing environment is to choose the right type of dressings.
How to choose wound dressings? To determine the right type of dressings, assessing the wound types and the level of exudate (fluid drainage) of the wound is important.
Level 1 Moist Wound Healing : Wound care for dry wounds or wounds with minimal exudates - Hydrogels
Hydrogels, are gel-based dressings that provide moisture to rehydrate the dry wound bed.
Hydrogels also:
soften the necrotic tissue (dead tissue) to achieve the effect of natural and painless debridement of dead tissues (autolytic debridement).
has a cooling effect when applied to the wound to help alleviate pain and discomfort, providing relief to the patient.
Hydrogels are indicated for dry wound and minimally draining wounds such as:
Pressure Ulcers
Deep cavity wounds
Surgical wounds
Wounds with necrotic tissue or slough
Infected wounds under medical supervision*
Radiation dermatitis
Minor burns
Examples of hydrogels available are Duoderm Gel, Intrasite Gel, Cavidagel Ag and Hyzo Gel.
Level 2 Moist Wound Healing : Wound care for wounds with low to moderate exudates - Hydrocolloids
Hydrocolloids are occlusive or semi-occlusive dressings that consist of a gel-forming material, typically a combination of gelatin, pectin, and carboxymethylcellulose. Hydrocolloids absorb exudate to form a hydrated gel over the wound, maintaining a controlled level of moisture around the wound which is conducive to healing.
It is self-adhesive and has a backing that adheres to the skin, also called ‘artificial skin’. This helps create a seal around the wound, preventing leakage and protecting against external contaminants. However, the dressing needs to be changed when it becomes less adhesive with the overloading of the exudates.
Hydrocolloid dressings are flexible and conform easily to the contours of the wound bed.
Similar to hydrogel dressings, hydrocolloid dressings support autolytic debridement of slough and dead tissues and speed up wound healing.
Hydrocolloid dressings are indicated for lightly to moderately exuding wounds such as:
Pressure ulcers
Partial thickness wounds
Surgical wounds
Diabetic foot ulcers
Wounds with necrotic tissue or slough
Minor burns
Hydrocolloid dressings are NOT recommended for:
Infected wounds due to the semi-occlusive nature of the dressing
Moderate to highly exudating wounds - Reports showed hypergranulation with prolonged use of hydrocolloids in moderate to highly exudating wounds, hence assessing the wound tissue from time to time is important when applying hydrocolloids in the long term to prevent hypergranulation.
How to use hydrocolloid dressings correctly?
The frequency to change hydrocolloid dressing is every 3 to 7 days, however, if the exudates start to leak, it's time to change the dressings.
Cut the dressings 1-2 inches larger than the wound for a secured seal.
Monitor for peri-wound maceration.
Examples of hydrocolloids dressings available in Malaysia are Adventa OxyMax, Duoderm CGF, Duoderm Extra Thin.
Level 3 Moist Wound Healing : Wound Care for Heavily Exudating Wounds - Alginate Dressings & Foam Dressings
Alginate Dressings
Alginate dressings are highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibres derived from brown seaweed or kelp.
Alginate dressings can absorb up to 20 times their weight of exudate, turning it into a gel-like consistency. This helps to maintain a moist wound environment while preventing pooling of excess fluids.
Alginates are available in sheet form or spun into ropes form. In rope form, they are also great for filling small, draining wound cavities.
Alginate dressings are indicated for moderately or heavily exuding wounds such as:
Stage III - IV Pressure Ulcers
Surgical wounds
Diabetic foot ulcers
Tunneling wounds
Donor sites
Infected wounds - for alginate dressings that contain silver to provide antimicrobial action
Alginate dressings also provide hemostasis (stop bleeding) for postoperative wounds with minimal bleeding.
Alginate dressings are NOT recommended for:
Lightly exuding wounds - it's important to reserve alginate dressings only to moderate to heavily exuding wounds as using of alginate dressings on wound with minimal exudate will dry out the wound bed.
Dry eschar
Third degree burn
Wounds with heavy bleeding
How to use Alginate dressings correctly?
Change alginate dressings every 1 to 3 days, although it may stay up to 7 days depending on the condition of the wound. Change frequently enough to prevent saturation of the outer dressing and leakage of drainage onto surrounding skin, which can cause maceration.
Use secondary dressing to keep alginate dressings in place.
Make sure to irrigate the wound thoroughly to remove all of the alginate before applying a new dressing.
Examples of alginate dressings are KALTOSTAT®Alginate Calcium Sodium Dressing, KALTOSTAT® Alginate Rope, Oxymax Silver Alginate Dressing, Almedico Silver Calcium Alginate Dressing.
Level 3 Moist Wound Healing : Wound Care for Heavily Exudating Wounds - Foam Dressings
Foam dressings are made from polyurethane base, laminated with a semi-occlusive film backing. Foam dressings are:
highly absorbent
promotes autolytic debridement of wounds.
provide a cushioning effect, making them suitable for protecting intact skin over bony prominences and friction areas.
They are available in pad, sheet, or other shapes with adhesive borders with transparent film coating which conform well to the contours of the wound, eg. foam dressing designed to contour to the sacral and heel area for prevention and treatment of bedsores.
Foam dressings may be impregnated or layered in combination with other materials such as enzyme deriders or ionic silver for antibacterial function.
Foam dressings are indicated for moderately to heavily exuding wounds such as:
Stage II - IV pressure ulcers
Surgical wounds
Infected ulcers - for foam dressings with ionic silver for antibacterial purpose
Foam dressings are NOT Recommended for:
Dry or non-draining wounds unless used for prevention or protection.
Third degree burns
Necrotic wounds
Hard eschar
How to use Foam dressings correctly?
Foam dressing can be left in place for up to 4 to 7 days, however, it should be changed when saturated with exudates.
For non-adherent foam dressing, may require secondary dressing to keep it in place.
Monitor for peri-wound maceration.
Examples are Convatec Aquacel Foam Dressing, Convatec Aquacel Ag Foam Adhesive Sacral, Allevyn Foam Dressing, Allevyn Gentle Border Heel , 3M™ Tegaderm™ High Performance Foam Adhesive Dressings etc.
Moist Wound Healing by Medicated Honey Dressings
Medical grade honey dressings contain Manuka honey which has been proven to support moist wound healing.
The high sugar content of honey results in the osmotic effect and provides an optimal moist environment for wound healing.
Other than that, medicated honey dressings is antibacterial due to the low pH of 3.2 to 4.5, high sugar content, and low water content of honey creating an unfavorable environment for bacterial growth and reproduction.
With this, it also helps to reduce wound odour caused by bacterias.
Besides, anti-inflammatory action of medicated honey reduces edema and exudates, which can subsequently improve wound healing.
More importantly, medicated honey dressings provides autolytic debridement of slough and eschar as the proteolytic enzymes and immune cells contained in the extracellular fluids can be drawn from deeper tissues of the wound to the surface by osmotic actions facilitated by the honey. Honey also produces hydrogen peroxide through the enzyme glucose oxidase which is thought to contribute to the debridement process.
Medicated honey dressings is indicated for partial- and full-thickness wounds :
Stage II - IV Pressure Ulcers
Diabetic foot ulcers
Surgical wounds
Malodorous wounds
Superficial wounds
Donor sites
First- and second- degree burns (superficial and partial-thickness)
How often to change medicated honey dressings?
The frequency of dressing changes depends on how rapidly the honey is diluted by the wound fluid, which normally can be left on the wound for up to 3-7 days.
Examples of medicated honey dressings available are MEDIHONEY 80% Active Leptostermum Honey Gel, Activon 100% Medical Grade Manuka Honey Gel.
In short, moist wound healing is useful in certain chronic wounds such as pressure ulcers, diabetic foot ulcers, and surgical incisions as a moist environment promotes autolytic debridement of slough and necrotic tissue, reducing scarring and promoting wound healing.
The factor of wound types and level of exudates need to be taken into account for choosing the most compatible wound dressings for the wound itself.
However, the moist environment can also be double-edged sword when it comes to certain wounds that would only be deteriorated in moist environment.
When Not to Use Moist Wound Healing?
Gangrene wounds - Dry gangrene may progress to wet gangrene as the moist environment may promote bacterial growth, for example gangrenous diabetic foot ulcer.
Ischemic or neuropathic ulcers
Wounds for patients undergoing palliative care should be assessed by doctor for wound management
There is no such one-size-fits-all methodology in wound care, it's crucial to consult with a healthcare professional to determine the most appropriate approach for a specific wound. Each case is unique, and a tailored treatment plan based on the individual characteristics of the wound is essential for optimal healing outcomes.
Article by : Pharmacist Goh Khang Phing
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References:
Winter, G. D. (1962, January 1). Formation of the Scab and the Rate of Epithelization of Superficial Wounds in the Skin of the Young Domestic Pig. Nature. https://doi.org/10.1038/193293a0
Junker, J. P., Kamel, R. A., Caterson, E. J., & Eriksson, E. (2013, September 1). Clinical Impact Upon Wound Healing and Inflammation in Moist, Wet, and Dry Environments. Advances in Wound Care. https://doi.org/10.1089/wound.2012.0412
Nuutila, K., & Eriksson, E. (2021, December 1). Moist Wound Healing with Commonly Available Dressings. Advances in Wound Care. https://doi.org/10.1089/wound.2020.1232
Rajendran, S. (2018, September 20). Advanced Textiles for Wound Care. Woodhead Publishing.
Weller, C. (2009, January 1). Interactive dressings and their role in moist wound management. Elsevier eBooks. https://doi.org/10.1533/9781845696306.1.97
Kirwan, H., & Pignataro, R. M. (2016, January 1). The Skin and Wound Healing. Elsevier eBooks. https://doi.org/10.1016/b978-0-323-31072-7.00002-6
Kapoor, N., & Yadav, R. (2021, January 1). Manuka honey: A promising wound dressing material for the chronic nonhealing discharging wounds: A retrospective study. National Journal of Maxillofacial Surgery. https://doi.org/10.4103/njms.njms_154_20
Yılmaz, A., & Aygin, D. (2020, June 1). HONEY DRESSING IN WOUND TREATMENT: A SYSTEMATIC REVIEW. Complementary Therapies in Medicine. https://doi.org/10.1016/j.ctim.2020.102388
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