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Let's Be Frank

Wound Dressing Selection Is More Than a Choice

The use of dressings to treat chronic wounds dates back to ancient times. But as we all well know that time does not truly heal all wounds, and certainly not chronic wounds, we also know that not all dressings heal all wounds. It’s what we do with the wound during the time that we have that is of upmost importance. 

The Egyptians used honey, grease, and lint. The Greeks wrote that for an obstinate ulcer, sweet wine and a lot of patience “should be enough.”1 Fast forward to present time and we are faced with thousands of dressing choices, and the likelihood of a patient’s wound to heal will be impacted by the choice of dressing(s) that we utilize in the wound clinic. 

Much like the practice of wound care itself, dressings have evolved and become more advanced, and the science behind some of them is quite interesting. But how should we as wound care clinicians sift through all the available options and make the best choice for the patient? 

Remember that patients may quickly grow wearier and more anxious each time they need to try a different dressing, so selecting the correct dressing from the outset will play a big role in the provider-patient relationship. We should never use the dressings “dartboard” approach to wound healing, which unfortunately seems like a common practice today.

What prevents us from choosing the best dressing every time, anyway? Let’s try to simplify this complex topic by acknowledging the elephant in the room. Wound care providers across the country today continue to report the inappropriate use of specific dressings, such as wet-to-dry dressings. This continues to be a challenge for frontline clinicians. 

It is understood in the literature that the right dressing improves healing time, pain, infection rates, and costs to the patient and the provider when compared to a wet-to-dry dressing. In the early 1960s, moist wound healing demonstrated how wounds can heal faster as opposed to being placed in a dry environment.2 At the time, dressings were moving from a passive to an active role in wound healing. 

The goal of any ideal dressing is to be comfortable and user-friendly, reduce pain, provide a moist wound environment and autolytic debridement, serve as a thermal insulator and barrier against bacteria, and protect the periwound skin at a cost-effective rate. Today, as previously noted, some dressings have an active role while others have a biologic role, a role for which most clinicians do not comprehend the science involved. Understanding the science for these types of products can help with the selection process.

Finding the Right Dressing for a Specific Phase of Wound Healing

Determining the phase of wound healing can help to determine the proper use of dressings and other interventions that are based on patient-centered goals. Each overlapping cascade of events occurring during the inflammatory, proliferative, and maturation phases will have specific wound and periwound characteristics. 

Wounds in the inflammatory phase will often have a large amount of exudate, no granulation tissue present, necrotic/nonviable tissue, and (possibly) periwound induration, edema, redness, warmth, and purulence. A wound in the proliferative phase will have minimal exudate, granulation tissue formation, and no periwound inflammatory markers. The maturation phase will indicate wound closure while it continues to completely resolve. Each phase will have different dressing needs, but the goal continues to be proper moisture balance after the causative factor is promptly addressed.  

The wet-to-dry dressing “controversy” continues even though it has been reported that such dressings are not standard of care.3 Wet-to-dry dressings do not guarantee the best wound environment or the right amount of moisture balance. Despite its general description as a “mechanical debrider” dressing, a wet-to-dry dressing usually is not an effective form because it’s nonselective and does not foster an appropriate wound environment. The Centers for Medicare and Medicaid Services’ guidance to surveyors in long-term care states that the use of wet-to-dry dressings may be appropriate in limited circumstances, giving some evidence that this dressing can be the exception, not the standard, depending on the purpose.4 

The ‘Why’ Behind the Dressing 

The main evidence behind any dressing selection should be that the provider can describe the “why” and purpose of using that specific dressing above all others. There is always a gamble to consider when assuming that a specific dressing will work for a specific wound. And when patients present with a nonhealing wound that was previously treated in another care setting, it is not wise, in this author’s opinion, to expect different results by continuing to use the same dressing.

Quite often, this author is asked to recommend dressings, and when consulted there is a “Dressing Cook Book” of sorts that is advisable. The hypothetical introduction describes dressing selection based on patient assessment, defined current phase of healing, wound assessment, periwound assessment, and wound bed preparation. By knowing the overall picture of the patient’s current health status, wound causative factor, objective wound/periwound characteristics, and appropriate testing to determine vascular status and presence/absence of infection, the three elements of wound bed preparation consisting of debridement, bacteria balance, and exudate management will lead to proper interventions and dressing selection.

Dressing selection will be based on the assessment results as well as achieving adequate wound bed moisture balance. In this said “cook book,” each chapter contains a different product category outlining the purpose, variations, indications, contraindication, and clinical pearls. The different categories are listed as such: gauze, contact layers, composite, transparent film, hydrocolloid, hydrogel, foams, calcium alginates, hydrofibers, super absorbents, negative pressure wound devices, compression, honey, antimicrobials, antiseptics, collagens, fillers, and cellular tissue products.

As time elapses, ongoing reassessments will allow proper selection and use of specific dressings. Remember to follow the product manufacturer’s guidelines, facility policies, and best practice guidelines when selecting products.  

Overcoming the Barriers to Healing

Often, clinicians will encounter problems when selecting a dressing from a specific category. Consider this working list of barriers encountered when selecting dressings:

  1. Inadequate patient, wound, and periwound assessment
  2. Not addressing the causative factor
  3. Utilizing advanced products without wound care basics
  4. Limited product selection based on facility formulary
  5. Inappropriate dressing orders
  6. Not applying the product as it was intended  
  7. Dressing not matching wound characteristics
  8. Cost 
  9. Lack of product reimbursement
  10. Clinician incompetence
  11. Combining non-complementary product categories
  12. Not following manufacturer’s product guidelines
  13. Poor preparation of the wound bed 
  14. Poor understanding of the science behind each product
  15. Inadequate and untimely reassessment to determine product effectiveness

The Dressing ‘Recipe’

As the wound progresses or regresses through the phases of healing, the dressing should match the wound characteristics. Dressings play a small part in the overall plan of care for each wound for each patient. Inappropriately selecting dressings can increase the cost of caring for each patient, thus delaying wound resolution. A comprehensive assessment is needed when determining which dressing to apply. Addressing the wound’s causative factor, and removing factors that delay healing concurrently while matching the dressing to the assessment, are effective ways to select a dressing. Proper education for patients, families, and clinicians is also imperative to use dressings appropriately. 

As an example, when assessing the wound and periwound areas, the causative factor will have certain similarities, such as specific location and wound and periwound characteristics. Combining the wound/periwound assessment with subjective evaluation and objective testing will help to verify the true nature of the wound/ulcer leading to proper interventions. After proper interventions are selected, the dressing can complement the overall goal for said wound. For example, a venous ulcer typically may be found around the “gaiter” area with shallow wound beds and increased drainage. Noting the periwound area will help to identify an inflammatory process, such as stasis dermatitis or lipodermatosclerosis or infection (such as cellulitis or erysipelas). Together, subjective information will most likely indicate that the patient has a history of longstanding activities, trauma, and/or swelling while objective testing can rule out an arterial component and a deep vein thrombosis, thus concentrating on the actual venous culprit. Once this is information is gathered, the dressing category is matched to the collected assessment data. 

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

Let's Be Frank
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Frank Aviles Jr., PT, CWS, FACCWS, CLT
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References

1. Shah JB. The history of wound care. J Am Col Certif Wound Spec. 2011;3(3):65-66.

2. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-294.

3. Ovington LG. Hanging wet to dry dressings out to dry. Home Healthc Nurse. 2001; 19(8):477–483.

4. Fleck C. Why “wet to dry”? J Am Col Certif Wound Spec. 2009;1(4):109-113.

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