Basic principles of wound management

Basic principles of wound management

Authors
David G. Armstrong, DPM, MD, PhD
Andrew J Meyr, DPM
Section Editors
Hilary Sanfey, MD
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Tue Jan 31 00:00:00 GMT 2012. | This topic last updated: Mon Oct 10
00:00:00 GMT 2011.

INTRODUCTION — A wound is a disruption of the normal structure and function of the skin and skin
architecture [1]. An acute wound has normal wound physiology and healing is anticipated to progress
through the normal stages of wound healing, whereas a chronic wound is defined as one that is
physiologically impaired [2,3].

To ensure proper healing, the wound bed needs to be well vascularized, free of devitalized tissue, clear of
infection and moist. Wound dressings should eliminate dead space, control exudate, prevent bacterial
overgrowth, ensure proper fluid balance, be cost-efficient, and be manageable for the patient and/or
nursing staff. Wounds that demonstrate progressive healing as evidenced by granulation tissue and
epithelialization can undergo closure or coverage.

Many topical agents and alternative therapies are available that are meant to improve the wound healing
environment and, although data are lacking to support any definitive recommendations, some may be
useful under specific circumstances.

The basic principles and available options for the management of various wounds will be reviewed. The
efficacy of wound management strategies for the treatment of specific wounds is discussed in individual
topic reviews:

 (See "Management of diabetic foot lesions".)

 (See "Medical management of lower extremity chronic venous disease", section on 'Ulcer care'.)
 (See "Treatment of pressure ulcers", section on 'Ulcer treatment by stage'.)
 (See "Treatment of lower extremity critical limb ischemia".)
 (See "Overview and management strategies for the combined burn trauma patient".)

MEDICAL CARE

Role of antibiotics — Antibiotic therapy is not indicated for all wounds, and should only be reserved for
wounds that appear clinically infected. There is no published evidence to support antibiotic therapy as
“prophylaxis” in non-infected chronic wounds, or to improve the healing potential of wounds without clinical
evidence of infection. Clinical signs of infection that warrant antibiotic therapy include local (cellulitis,
lymphangitic streaking, purulence, malodor, gangrene, exposed bone, etc) and systemic (fever, chills,
nausea, hypotension, hyperglycemia, leukocytosis, confusion) symptoms [4]. (See "Cellulitis and
erysipelas" and "Management of severe sepsis and septic shock in adults".)

Control of blood sugar — Although there is no overwhelming clinical evidence in support of short-term

glycemic control as directly affecting wound healing potential or preventing infection [4,5], we make
glycemic control a priority in our practice when treating wounds and infection. (See "Susceptibility to
infections in persons with diabetes mellitus".)

Patients at risk for the development of chronic wounds often have comorbid conditions associated with
immunocompromised states (eg diabetes), and may not have classic systemic signs of infection such as
fever and leukocytosis on initial presentation. In these patients, hyperglycemia may be a more sensitive
measure of infection.

WOUND DEBRIDEMENT — Wounds that have devitalized tissue, contamination or residual suture material
require debridement prior to further wound management. Acute traumatic wounds may have irregular
devitalized edges or foreign material within the wound, and surgical wounds that have dehisced may have
an infected exudate, bowel contamination or necrotic muscle or fascia. These materials impede the body’s
attempt to heal by stimulating the production of abnormal metalloproteases and consuming the local
resources necessary for healing.

Characteristics of chronic wounds that prevent an adequate cellular response to wound-healing stimuli
include accumulation of devitalized tissue, decreased angiogenesis, hyperkeratotic tissue, exudate, and
biofilm formation (ie, bacterial overgrowth on the surface of the wound) [6]. These wounds need repeated
debridement to restore an optimal wound healing environment.

Wound bed preparation facilitates ordered restoration and regeneration of damaged tissue and may
enhance the function of specialized wound care products and advanced biologic tissue substitutes [7].

Irrigation — Irrigation with warm, isotonic (normal) saline should be a routine part of wound management
[1]. Irrigation is important for decreasing bacterial load and removing loose material [8,9]. The addition of
dilute iodine or other antiseptic solutions (eg, chlorhexidine and hydrogen peroxide) is generally
unnecessary. These solutions have minimal action against bacteria and could potentially impede wound
healing through toxic effects on normal tissue [10-12]. (See 'Antiseptics and antimicrobials' below.)

Low pressure irrigation (eg, <15 pounds per square inch [psi]) is usually adequate to remove material from
the surface of most wounds [13]. Decreased bacterial load has been documented clinically with the use of
pulsed irrigation in lower extremity chronic wounds [14]. Higher pressure irrigators may cause local tissue
damage by dissecting loose connective tissue and increasing tissue edema.

Bacteria do not appear to accompany the irrigation fluid into adjacent tissues in animal studies even at
higher pressure levels [15]. In an experimental model, high-pressure irrigation decreased bacterial levels
more than bulb irrigation (average reduction, 70 versus 44 percent) with no increase in the rate of
bacteremia [16]. For highly contaminated wounds, the benefits of reducing bacterial load may outweigh the
risk of adjacent tissue damage associated with the use of higher irrigating pressures.

Surgical — Sharp excisional debridement uses a scalpel or other sharp instruments (eg, scissors, or
curette) to remove devitalized tissue (picture 1) and accumulated debris (biofilm). Sharp excisional
debridement of chronic wounds decreases bacterial load and stimulates contraction and wound
epithelialization [17]. Surgical debridement is the most appropriate choice for removing large areas of
necrotic tissue and is indicated whenever there is any evidence of infection (cellulitis, sepsis). Surgical
debridement is also indicated in the management of chronic non-healing wounds to remove infection,
handle undermined wound edges, or obtain deep tissue for culture and pathology [18-20].

In patients with active infection, antibiotic therapy should be targeted and determined by wound culture
and sensitivity to decrease the development of bacterial resistance [21,22]. (See "Cellulitis and
erysipelas" and "Cellulitis and erysipelas", section on 'Antibiotics'.)

In patients with chronic critical limb ischemia, surgical debridement must be coupled with revascularization
in order to be successful [23]. (See "Treatment of lower extremity critical limb ischemia".)

Enzymatic — Enzymatic debridement involves applying exogenous enzymatic agents to the wound. Many
products are commercially available, but results of clinical studies are mixed and their use remains
controversial [24]. Ulcer healing rates are not improved with the use of most topical agents, including
debriding enzymes [25]. However, collagenase may promote endothelial cell and keratinocyte migration,
thereby stimulating angiogenesis and epithelialization as its mechanism of action, rather than functioning
as a strict debridement agent [26]. It also remains a good option in patients who require debridement but
are not surgical candidates.

Biologic — An alternative method of wound debridement uses the larvae of the green bottle fly (Lucilia
sericata, Lucilia cuprina) [27,28]. Larval therapy can be used as a bridge between debridement procedures,
or for debridement of chronic wounds when surgical debridement is not available or cannot be performed.

Maggot therapy has been used in the treatment of pressure ulcers [29,30], chronic venous ulceration [31],
diabetic ulcers [27], and other acute and chronic wounds [32]. The larvae secrete proteolytic enzymes that
liquefy necrotic tissue which is subsequently ingested while leaving healthy tissue intact. Basic and clinical
research suggests that larval therapy has additional benefits, including antimicrobial action and stimulation
of wound healing [28,31,33]. However, randomized trials have not found consistent reductions in the time
to wound healing compared with standard wound therapy (eg, debridement, hydrogel, moist dressings)
[34,35]. Larval therapy appears to be at least equivalent to hydrogel in terms of cost [35,36].

Dressing changes include the application of a perimeter dressing and a cover dressing of chiffon that helps
direct the larvae into the wound and limits their migration (movie 1). Larvae are generally changed every
48 to 72 hours. The larvae can be applied within a prefabricated “biobag,” (picture 2) which is commercially
available outside the United States, that facilitates application and dressing change [37-40]. Randomized
trials comparing “free range” with “biobag” contained larvae in the debridement of wounds have not been
performed.

A main disadvantage of larval therapy relates to negative perceptions about its use by patients and staff.
One concern among patients is the possibility that the larvae can escape the dressing, although this rarely
occurs. Although one study identified that about 50 percent of patients indicated they would prefer
conventional wound therapy over maggot therapy, 89 percent of the patients randomly assigned to larval
therapy said they would undergo larval treatment again [41]. Pain associated with larval therapy may limit
its use in about 20 percent of patients [42].

TOPICAL THERAPY

Growth factors — Growth factors important for wound healing include platelet derived growth factor
(PDGF), fibroblast growth factor (FGF) and granulocyte-macrophage colony stimulating factor (GM-CSF).
(See "Wound healing and risk factors for non-healing".)
Recombinant human growth factors have been developed and are being actively investigated for the
treatment of chronic ulcers, mostly those affecting the lower extremity.

 Platelet-derived growth factor – Becaplermin is a platelet-derived growth factor (PDGF) gel

preparation that promotes cellular proliferation and angiogenesis, and thereby improves wound
healing [43]. It is approved for use in the United States as an adjuvant therapy for the treatment
of diabetic foot ulcers and is the only pharmacological agent approved for treatment of chronic
wounds. The growth factor is delivered in a topical aqueous-based
sodium carboxymethylcellulose gel. It is indicated for non-infected diabetic foot ulcers that extend
into the subcutaneous tissue and have an adequate vascular supply [44]. A black box warning
mentions a concern for malignancy; however, the overall malignancy risk is believed to be low.
Malignancy complications of this therapy may reflect usage of the agent in multiple courses of
treatment, and possible selective transformation of wounds already at risk [45]. A post-marketing
study found an increased rate of mortality secondary to malignancy in patients treated with three
or more tubes of becaplermin (3.9 versus 0.9 per 1000 person years) compared with controls
[46,47].(See "Management of diabetic foot lesions", section on 'Growth factors'.)
 Epidermal growth factor – In a study of chronic venous ulcers, topical application of human
recombinant epidermal growth factor was associated with a greater reduction in ulcer size (7
versus 3 percent reduction) and higher ulcer healing rate (35 versus 11 percent) compared with
placebo, but these differences were not statistically significant [48]. Epithelialization was not
significantly affected.
 Granulocyte-macrophage colony stimulating factor – Intradermal injections of granulocyte-
macrophage colony stimulating factor (GM-CSF) promote healing of chronic leg ulcers, including
venous ulcers [49,50]. A trial that randomly assigned 60 patients with venous ulcers to four
weekly injections with GM-CSF 200 mcg, 400 mcg, or placebo found significantly higher rates of
healing at 13 weeks in the GM-CSF group (57, 61, and 19 percent, respectively) [50]. GM-CSF
has been used in various types of chronic wounds to promote healing [51]. (See "Medical
management of lower extremity chronic venous disease", section on 'Ulcer care'.)

Antiseptics and antimicrobials — Most topically-applied antiseptic and antimicrobial products are

irritating, partially cytotoxic leading to delayed healing and can cause contact sensitization. However, two
of these agents may be associated with potential benefits in select populations:

Cadexomer iodine (eg, Iodosorb) is an antimicrobial that reduces bacterial load within the wound and
stimulates healing by providing a moist wound environment [52]. Cadexomer iodine is bacteriocidal to all
gram-positive and gram-negative bacteria. For topical preparations, there is some evidence to suggest that
Cadexomer iodine generates higher healing rates than standard care.

Silver is toxic to bacteria. Silver sulfadiazine (eg, Silvadene) is a topical antiseptic cream shown to decrease
the incidence of sepsis in the treatment of cutaneous wounds, including partial thickness wounds, chronic
wounds, skin graft donor sites, and burns. Silver impregnated dressings have not demonstrated significant
benefits. A systematic review identified three trials that treated 847 participants with various silver-
containing dressings [53]. One trial compared silver-containing foam (Contreet) with hydrocellular foam
(Allevyn™) in patients with leg ulcers. The second compared a silver-containing alginate (Silvercel®) with
an alginate alone (Algosteril®). The third trial compared a silver-containing foam dressing (Contreet) with
best local practice in patients with chronic wounds. Silver-containing foam dressings were not found to
significantly improve ulcer healing at four weeks compared with non-silver-containing dressings for best
local practices. Nevertheless, silver dressings are used by many clinicians to decrease the heavy bacterial
surface contamination [54].
WOUND DRESSINGS — When a suitable dressing is applied to a wound and changed appropriately, the
dressing can have a significant impact on the speed of wound healing, wound strength and function of the
repaired skin, and cosmetic appearance of the resulting scar. No single dressing is perfect for all wounds;
rather, a clinician should evaluate individual wounds and choose the best dressing on a case by case basis.
In addition, wounds must be continually monitored, as their characteristics and dressing requirements
change over time [55].

There is little clinical evidence to aid in the choice between the different types of wound dressings.
Consensus opinion supports the following general principles for chronic wound management [56]:

 Hydrogels for the debridement stage

 Foam and low-adherence dressings for the granulation stage
 Hydrocolloid and low-adherence dressings for the epithelialization stage.

For all intents and purposes, dressings are best suited to manage the moisture level in and around the
wound. Although some may have additional benefits in terms of local antimicrobial effects, odor control, or
mild debridement ability, these are secondary benefits [57].

Dressings are typically changed once a day or every other day to avoid disturbing the wound healing
environment. Because some dressings may impede some aspects of wound healing, they should be used
with caution. As examples, alginate dressings with high calcium content may impede epithelialization by
triggering premature terminal differentiation of keratinocytes [56], and silver-impregnated dressings are
cytotoxic and should not be used in the absence of significant infection. (See 'Antiseptics and
antimicrobials' above and 'Alginates' below.)

The advantages and disadvantages of the various dressing types are discussed below. (See 'Common
dressings' below.)

Importance of moisture — For much of the history of medicine, it was believed that wounds should not
be occluded but left exposed to the air. However, an important study in a pig model showed that moist
wounds healed more rapidly compared with wounds that dried out [58]. Similar results have been obtained
in humans [59-61].

Occluded wounds heal up to 40 percent more rapidly than non-occluded wounds [59]. This is thought to be
due, in part, to easier migration of epidermal cells in the moist environment created by the dressing [60].
Another mechanism for improved wound healing may be the exposure of the wound to its own fluid [62].
Acute wound fluid is rich in metalloproteinases, platelet-derived growth factor, and basic fibroblast growth
factor, which interact with one another and with other cytokines to stimulate healing [63]. On the other
hand, the effect of chronic wound fluid on healing may not be beneficial. Chronic wound fluid is very
different from acute wound fluid and contains persistently elevated levels of inflammatory cytokines which
may inhibit proliferation of fibroblasts [64-66]. Excessive peri-wound edema and induration contributes to
the development of chronic wound fluid and should be managed to minimize this effect. (See"Wound
healing and risk factors for non-healing", section on 'Phases of wound healing'.)

In addition to faster wound healing, wounds treated with occlusive dressings are associated with less
prominent scar formation [67]. One study of porcine skin found an acceleration in the inflammatory and
proliferative phases of healing when wounds were covered with an occlusive dressing as opposed to dry
gauze [68]. This “acceleration” through the wound phases may prevent the development of a chronic
wound state which is typically arrested in the inflammatory phase of healing. Wounds that have a greater
amount of inflammation tend to result in more significant scars, and thus the decreased inflammation and
proliferation seen with wound occlusion may also decrease the appearance of the scar.

An ideal dressing is one that has the following characteristics:

 Absorbs excessive wound fluid while maintaining a moist environment

 Protects the wound from further mechanical or caustic damage
 Prevents bacterial invasion or proliferation
 Conforms to the wound shape and eliminates dead space
 Debrides necrotic tissue
 Does not macerate the surrounding viable tissue
 Achieves hemostasis and minimizes edema through compression
 Does not shed fibers or compounds that could cause a foreign body or hypersensitivity reaction
 Eliminates pain during and between dressing changes
 Minimizes dressing changes
 Is inexpensive, readily available, and has a long shelf life
 Is transparent in order to monitor wound appearance without disrupting dressing

In most cases, a dressing with all of these characteristics is not available, and a clinician must decide which
of these is most important in the case of a particular wound. The moisture content of a wound bed must be
kept in balance for both acute and chronic wounds. The area should be moist enough to promote healing,
but excess exudate must be absorbed away from the wound to prevent maceration of the healthy tissue.

Common dressings — Although dressings can be categorized based upon many characteristics, it is most
useful to classify dressings by their water-retaining abilities because the primary goal of a dressing is the
maintenance of moisture in the wound environment. As such, dressings are classified as open, semi-open
or semi-occlusive.

Open dressings include, primarily, gauze which is typically moistened with saline before placing it into the
wound. Gauze bandages are available in multiple sizes including 2 x 2 inch and 4 x 4 inch square dressings
and in 3 or 4 inch rolls (eg, Kerlix™). Thicker absorbent pads (eg, ABD pads) are used to cover the gauze
dressings. For managing large wounds, self adhesive straps (Montgomery straps) can be used to hold a
bulky dressing in place. As discussed above, dried gauze dressings are discouraged. Wet-to-moist gauze
dressings are useful for packing large soft-tissue defects until wound closure or coverage can be performed.
Gauze dressings are inexpensive but often require frequent dressing changes.

Semi-open dressings typically consist of fine mesh gauze impregnated with petroleum, paraffin wax, or
other ointment and have product names such as Xeroform™, Adaptic, Jelonet™, and Sofra Tulle. This initial
layer is covered by a secondary dressing of absorbent gauze and padding, then finally a third layer of tape
or other method of adhesive. Benefits of semi-open dressings include their minimum expense and their
ease of application. The main disadvantage of this type of dressing is that it does not maintain a moisture-
rich environment or provide good exudate control. Fluid is permitted to seep through the first layer and is
collected in the second layer, allowing for both desiccation of the wound bed and maceration of the
surrounding tissue in contact with the secondary layer. Other disadvantages include the bulk of the
dressing, its awkwardness when applied to certain areas, and the need for frequent changing.

Semi-occlusive dressings come in a wide variety of occlusive properties, absorptive capacities,

conformability and bacteriostatic activity. Semi-occlusive dressings include films, foams, alginates,
hydrocolloids and hydrogels and are discussed below.
Films — Polymer films are transparent sheets of synthetic self-adhesive dressing that are permeable to
gases such as water vapor and oxygen but impermeable to larger molecules including proteins and
bacteria. This property enables insensible water loss to evaporate, traps wound fluid enzymes within the
dressing, and prevents bacterial invasion. These dressings are sometimes known as synthetic adhesive
moisture-vapor-permeable dressings, and include Tegaderm™, Cutifilm®, Blisterfilm™, and Bioclusive.
Transparent film dressings were found to provide the fastest healing rates, lowest infection rates, and to be
the most cost-effective method for dressing split-thickness skin graft donor sites in a review of 33
published studies [69]. 

Advantages of these dressings include their ability to maintain moisture, encourage rapid re-epithelization,
and their transparency and self-adhesive properties. Disadvantages of film dressings include limited
absorptive capacity and they are not appropriate for moderately to heavily exudative wounds. If they are
allowed to remain in place over a wound with heavy exudates, the surrounding skin is likely to become
macerated. In addition, if the wound dries out, film dressings may adhere to the wound and be painful and
damaging to remove.

Foams — Foam dressings can be thought of as film dressings with the addition of absorbency. They consist
of two layers, a hydrophilic silicone or polyurethane-based foam that lies against the wound surface, and a
hydrophobic, gas permeable backing to prevent leakage and bacterial contamination. Some foams require a
secondary adhesive dressing. Foams are marketed under names such as Allevyn™, Adhesive, Lyofoam, and
Spyrosorb.

Advantages of foams include their high absorptive capacity and the fact that they conform to the shape of
the wound and can be used to pack cavities. Disadvantages of foams include the opacity of the dressings
and the fact that they may need to be changed each day. Foam dressings may not be appropriate on
minimally exudative wounds, as they may cause desiccation.

One small trial compared foams to films as dressings for skin tears in institutionalized adults and found that
more complete healing occurred in the group using foams [70].

Alginates — Natural complex polysaccharides from various types of algae form the basis of alginate
dressings. Their activity as dressings is unique because they are insoluble in water, but in the sodium-rich
wound fluid environment these complexes exchange calcium ions for sodium ions and form an amorphous
gel that packs and covers the wound. Alginates come in various forms including ribbons, beads, and pads.
Their absorptive capacity ranges depending upon the type of polysaccharide used. In general, these
dressings are more appropriate for moderately to heavily exudative wounds.

Advantages of alginates include augmentation of hemostasis [71,72], they can be used for wound packing,
most can be washed away with normal saline in order to minimize pain during dressing changes, and they
can stay in place for several days. Disadvantages of alginates are that they require a secondary dressing
that must be removed in order to monitor the wound, they can be too drying on a minimally exudative
wound, and they have an unpleasant odor.

In a trial of 77 patients, patients with diabetic foot wounds were randomly assigned to alginate or
petroleum gauze dressings [73]. Patients treated with alginates were found to have significantly superior
granulation tissue coverage at four weeks of treatment, significantly less pain, and fewer dressing changes
than the petroleum gauze group. 
Hydrocolloids — Hydrocolloid dressings usually consist of a gel or foam on a carrier of self-adhesive
polyurethane film. The colloid composition of this dressing traps exudate and creates a moist environment.
Bacteria and debris are also trapped, and washed away with dressing changes in a gentle, painless form of
mechanical debridement. Another advantage of hydrocolloids is the ability to use them for packing wounds.
Disadvantages include malodor and the potential need for daily dressing changes, and allergic contact
dermatitis has been reported [74]. Hydrocolloid products include DuoDERM®, Tegasorb™, J and J Ulcer
Dressing, and Comfeel®.

Cadexomer iodine is a type of hydrocolloid in which iodine is dispersed and slowly released after it comes in
contact with wound fluid. The concentration of iodine released is low and does not cause tissue damage
[75]. A multi-center trial found that over a 12-week period, Cadexomer iodine paste was more cost-
effective than non-iodinated hydrocolloid dressing or paraffin gauze dressing in patients with exudating
venous ulcers [76]. A systematic review found some evidence that topical application of Cadexomer iodine
enhanced venous ulcer healing rates compared with standard care (with and without compression) [25].
The treatment regimen was complex and it is unclear if the results are generalizable to most clinical
settings. Iodine-induced hyperthyroidism has been documented with use of Cadexomer iodine for leg ulcers
[77]. (See 'Antiseptics and antimicrobials' above.)

Hydrogels — Hydrogels are a matrix of various types of synthetic polymers with >95 percent water
formed into sheets, gels, or foams that are usually sandwiched between two sheets of removable film. The
inner layer is placed against the wound, and the outer layer can be removed to make the dressing
permeable to fluid. Sometimes a secondary adhesive dressing is needed. These unique matrices can absorb
or donate water depending upon the hydration state of the tissue that surrounds them. Hydrogel products
include Intrasite Gel™, Vigilon®, Carrington Gel, and Elastogel.

Hydrogels are most useful for dry wounds. They initially lower the temperature of the wound environment
they cover, which provides cooling pain relief for some patients [78]. As a disadvantage, although there
have been no reports of increased wound infection, hydrogels have been found to selectively permit gram-
negative bacteria to proliferate [79].

Hydroactive — Hydroactive, the most recently developed synthetic dressing, is a polyurethane matrix that
combines the properties of a gel and a foam. Hydroactive selectively absorbs excess water while leaving
growth factors and other proteins behind [80].

A randomized trial compared hydroactive dressings with two different hydrocolloids and found the
hydroactive dressing to be equally effective at promoting ulcer healing and alleviating ulcer-associated pain
after 12 weeks of treatment [81]. Another study found hydroactive dressings combined with enzymatic
debridement to be more cost-efficient than gauze alone in dressing pressure ulcers and venous stasis ulcers
[82].

WOUND PACKING — Wounds with large soft-tissue defects may have an area of dead space between the
surface of intact healthy skin and the wound base. These wounds are described as tunneled or undermined.
Undermining is defined as extension of the wound under intact skin edges such that the wound measures
larger at its base than is appreciated at the skin surface.
When describing and documenting undermined wounds, it is important to accurately measure the depth of
undermining in centimeters and location of undermining using clock formation as a guide (12:00, 6:00,
etc.). The presence of necrotic tissue indicates the need for surgical debridement to decrease bacterial
burden and prevent sequelae of infection [21].

Although there have been no specific trials comparing packed versus unpacked wounds, wound packing is
considered standard care [83]. Traditional gauze dressings are often used to pack wounds associated with
significant dead space or undermining to aid in continuing debridement of devitalized tissue from the
wound bed. The gauze is moistened with normal saline or tap water and placed into the wound and covered
with dry layers of gauze. As the moistened gauze dries, it adheres to surface tissues, which are then
removed when the dressing is changed. Dressing changes should be frequent enough that the gauze does
not dry out completely, which can be two to three times daily. A disadvantage of gauze dressings is that
they can also remove developing granulation tissue, resulting in reinjury. Thus, these dressings are
discontinued when the necrotic tissue has been removed and granulation is occurring. An alternative to
gauze dressing for managing wounds with significant dead space is negative pressure wound therapy.
(See 'Negative pressure wound therapy' below.)

Many of the materials that are used as topical dressings for wounds (foams, alginates, hydrogels) can be
molded into the shape of the wound and are useful for wound packing. As with their use in dressing
wounds, there is little consensus over what constitutes the best material for wound packing. (See 'Wound
dressings' above.)

Wound dressing changes associated with large defects can be managed without repeated applications of
tape to the skin by using Montgomery straps (picture 1).

WOUND CLOSURE — Primary closure refers to the suture or staple closure of acute surgical or traumatic
wounds after appropriate wound preparation (figure 1 and picture 3). (See "Minor wound preparation and
irrigation" and "Closure of skin wounds with sutures" and "Closure of minor skin wounds with staples".)

Delayed primary closure achieves skin edge apposition following an interval of wound management.
Delayed closure in abdominal wounds, chest wounds, and surgical wounds without evidence of infection is
widely accepted (figure 1) [84]. However, a chronic wound should never be closed primarily. In contrast,
delayed closure or coverage of chronic wounds is accepted.

Negative pressure wound therapy — Negative pressure wound therapy enhances wound healing by
reducing edema surrounding the wound, stimulating circulation, and increasing the rate of granulation
tissue formation [85-88]. The technique involves the application of a controlled subatmospheric pressure to
a wound covered with a foam dressing. Negative pressure wound therapy is useful to manage large defects
until closure can be performed. It has also been used with modest success in the treatment of pressure
ulcers [89-91], and diabetic wounds [88,92]. (See "Negative pressure wound therapy".)

WOUND COVERAGE

Skin grafts — Split-thickness and full-thickness skin grafts are the most basic biologic dressings and
consist of skin taken from a donor site and grafted onto a wound on the same patient. Skin grafts are used
for wound closure, to prevent fluid and electrolyte loss, and reduce bacterial burden and infection. Skin
transplanted from one location to another on the same individual is termed an autogenous graft or
autograft.
Skin grafts are classified as either split-thickness or full-thickness, depending upon the amount of dermis
included in the graft. A partial or split-thickness skin graft contains a variable thickness of dermis, while a
full-thickness skin graft contains the entire dermis. The characteristics of normal skin are maintained with a
thicker dermal component. However, thicker grafts require a more robust wound bed due to the greater
amount of tissue that needs to be revascularized. The choice between full- and split-thickness skin grafting
depends upon the condition of the wound, location, size, and need for cosmesis [93].

Full-thickness skin grafts — Full-thickness grafts contain the epidermis and dermis, and thus retain
more of the characteristics of normal skin, including color, texture, and thickness, when compared with
split-thickness grafts. Full-thickness skin grafts are limited to relatively small, uncontaminated, well-
vascularized wounds. The skin used for full-thickness skin grafts is obtained from areas of redundant and
pliable skin such as the groin, lateral thigh, lower abdomen, or lateral chest. Donor sites are usually closed
primarily. The main disadvantages of full-thickness grafts include limited availability of donor skin and the
potential for fluid accumulation beneath the graft. 

Split-thickness skin grafts — Split-thickness skin grafts are commonly used tissue for wound coverage.
A split-thickness skin graft includes the epidermis and a variable amount of dermis ranging between 0.008
to 0.012 inches (picture 4). Split-thickness skin grafts are further categorized as thin (0.005 to 0.012
inches), intermediate (0.012 to 0.018 inches), or thick (0.018 to 0.030 inches) based upon the thickness of
graft harvested.

Compared with full thickness skin grafts, split-thickness skin grafts tolerate a less-than-ideal wound bed
and have a broader range of applications. They can be used to resurface large wounds, line cavities,
resurface mucosal deficits, close donor sites of flaps, and resurface muscle flaps. They also are used to
achieve temporary closure of wounds created by the removal of lesions that require pathologic examination
prior to definitive reconstruction.

Split thickness skin grafts can be meshed to provide coverage of a greater surface area at the recipient
site, with expansion ratios generally ranging from 1:1 to 6:1. Split-thickness skin graft donor sites heal
spontaneously with cells supplied by the remaining epidermal appendages. Donor sites can be re-harvested
once healing is complete.

Split-thickness grafts have disadvantages that need to be considered. Split-thickness grafts are more
fragile, especially when placed over areas with little underlying soft tissue bulk for support. They contract
more during healing, do not grow with the individual, and tend to be smoother and shinier than normal skin
because of the absence of skin appendages in the graft. They also tend to be abnormally pigmented, either
pale or white, or alternatively, hyperpigmented, particularly in darker-skinned individuals. For these
reasons, split thickness skin grafts are more widely used for control of infection and prevention of
fluid/electrolyte loss rather than cosmesis [93].

Skin equivalents — Human skin equivalent is a biologic dressing composed of a bilayered living-skin
construct that contains an outer layer of live allogenic human keratinocytes and a second layer of live
allogeneic fibroblasts on type 1 collagen dispersed in a dermal layer matrix. Both cell layers are grown from
human infant foreskin. Human skin equivalent looks and feels like human skin and is a potent stimulator of
wound healing.

Skin equivalents can be used when traditional dressings have failed or are deemed inappropriate. One
study has suggested that advanced biologics should be used when chronic wounds fail to heal at an
appropriate rate of closure, (ie, 55 percent reduction in wound area within four weeks of treatment) [94].
Human skin equivalent is ideal for the treatment for chronic ulcers because additional cells and growth
factors are added to a deficient wound-healing environment. Accelerated wound healing reduces the risk of
wound infection.

These dressings are categorized based on the layer of skin from which they are derived:

 Dermal skin equivalents are composed of dermal elements such as collagen and fibroblasts, which
prevent wound contraction and provide greater stability [95]. Dermal skin substitutes include
AlloDerm®, which is made of decellularized allogenic dermal component, Integra™, which is a
bovine collagen-based dermal matrix, and Dermagraft-TC™, which is a nylon mesh embedded
with human fibroblast. Each of these has been used successfully for treating burn wounds [96-
98].
 Composite skin equivalents use epidermal and dermal elements. Apligraf® consists of bovine
collagen and allogenic fibroblast and epidermal cells. Apligraf® combined with compression
therapy has been found to improve healing of venous stasis ulcers compared with compression
therapy alone [99]. Clinical rejection has not been reported.
 Human skin equivalents have also been studied in patients with diabetes [100-103]. In one study of
208 patients with noninfected neuropathic ulcers, weekly application of Graftskin for four weeks
improved the rate of complete wound healing compared with usual care (56 versus 38 percent)
[100].

ADJUNCTIVE THERAPIES

Hyperbaric oxygen therapy — Hyperbaric oxygen therapy has been shown, in vitro, to have effects on
wound healing [104]. Endothelial progenitor cells play an important role in wound healing because they
participate in the formation of new blood vessels in areas of hypoxia [105]. Although hyperoxia induced by
hyperbaric oxygen effectively improves endothelial progenitor cells’ mobilization, therapy is not targeted to
the wound site. Serious adverse events can be associated with hyperbaric oxygen therapy including
seizures and pneumothorax. (See "Hyperbaric oxygen therapy", section on 'Mechanisms of action'.)

When indicated, hyperbaric oxygen therapy is accomplished in a specialized chamber that allows for patient
monitoring. Chamber pressure is typically maintained between 2.5 and 3.0 atmospheres of pressured
oxygen or air. Therapy for nonhealing wounds generally consists of daily sessions of 1.5 to 2 hours for 20
to 40 days [104]. The mechanisms and technique of hyperbaric oxygen therapy are discussed in detail
elsewhere. (See "Hyperbaric oxygen therapy" and "Hyperbaric oxygen therapy", section on 'Technique'.)

Hyperbaric oxygen has been used as an adjunct to wound care in the therapy of acute and chronic wounds
[106-111]. Most studies are observational and the few available trials are limited by small sample size and
low quality [112-114]. A systematic review concluded that, although hyperbaric oxygen may benefit some
types of wounds (eg, diabetic ulcers), there is insufficient evidence to support routine use [115].

 Acute injury – Hyperbaric oxygen therapy may be of value in patients with extensive soft tissue
injury. A systematic review identified three trials evaluating the use of hyperbaric oxygen therapy
in acute surgical and traumatic wounds [116]. Due to the small numbers of included patients and
 heterogeneity of patients treated, a metaanalysis could not be performed. The authors also noted
a potential risk for bias. In one of the trials, 36 patients with crush injuries were randomly
assigned to a 90 minute twice daily hyperbaric oxygen treatment or sham treatments for a total
of six days postoperatively [117]. The group treated with hyperbaric oxygen had significantly
more complete healing (17 versus 10 patients) and required fewer skin flaps, grafts, vascular
surgery, or amputation (1 versus 6 patients). (See "Surgical management of severe extremity
injury", section on 'Soft tissue debridement/coverage'.)
 Fasciotomy wounds – Animal models of reperfusion following release of acute extremity
compartment syndromes suggest that the hyperbaric oxygen therapy may be beneficial.
(See "Patient management following extremity fasciotomy", section on 'Hyperbaric oxygen'.)
 Thermal injury – A systematic review of hyperbaric oxygen therapy in burn wounds found only two
high quality trials and concluded that there was insufficient evidence to support the use of HBO
following thermal injury [118]. The treatment of burn wounds is discussed in detail elsewhere.
(See"Local treatment of burns: Topical antimicrobial agents and dressings".)
 Chronic ulcers – Hyperbaric oxygen therapy has been used as an adjunct in the management of
chronic, nonhealing wounds and ulcers due to venous insufficiency, diabetes, and peripheral
artery disease. Support for hyperbaric oxygen therapy for venous or pressure ulcers, and wounds
related to chronic ischemia (peripheral artery disease), is lacking. Although hyperbaric oxygen
therapy has been associated with more rapid ulcer healing in patients with diabetes, the
indications for hyperbaric oxygen in the treatment of nonhealing diabetic foot ulcers remains
uncertain. Hyperbaric oxygen therapy for the management of diabetic foot ulceration is discussed
in detail elsewhere. (See "Medical management of lower extremity chronic venous disease",
section on 'Ulcer care' and "Management of diabetic foot lesions", section on 'Hyperbaric oxygen
therapy'.)
 Compromised skin grafts and flaps – Hyperbaric oxygen therapy may improve the survival of skin
grafts and reconstructive flaps that have compromised blood flow, thereby preventing tissue
breakdown and the development of wounds. Patients who require skin grafting or reconstructive
flaps in areas with local vascular compromise, previous radiation therapy, or in sites of previous
graft failure may benefit from prophylactic therapy. (See "Principles of grafts and flaps for
reconstructive surgery", section on 'Vascular compromise' and "Hyperbaric oxygen therapy",
section on 'Radiation injury'.)

Other therapies — A variety of other therapies, such as therapeutic ultrasound [119], electrical
stimulation [120-124] and electromagnetic therapy [125], have been investigated primarily for the
treatment of pressure ulcers [126-130]. The treatment of pressure ulcers is discussed in detail elsewhere.
(See"Treatment of pressure ulcers", section on 'Adjunctive therapies'.)

MANAGEMENT OF SPECIFIC WOUNDS

 Simple laceration – Simple traumatic lacerations may be cleaned and closed primarily with either
staples or sutures. (See "Minor wound preparation and irrigation" and "Closure of skin wounds
with sutures" and "Closure of minor skin wounds with staples".)
 Complicated laceration – Following cleansing of the wound and debridement, an attempt is often
made to close more complicated lacerations. It is not uncommon for the irregular skin edges or
skin at sites where lacerations meet to break down. Plastic surgery techniques may be needed to
provide an acceptable cosmetic and functional result. (See "Z-plasty".)
 Large tissue defect – Large tissue defects can result from traumatic wounds or the need to remove
devitalized tissue due to infection (eg, Fournier’s gangrene). Once the debridement is completed,
the wound can be packed open with wet to moist saline gauze dressings or using negative
pressure wound therapy until the wound bed allows for skin graft or flap closure [88]. (See "Z-
plasty".)
  Burns – Burn wound care depends on many factors including the depth of the burn and anatomic
locations. (See "Emergency care of moderate and severe thermal burns in adults", section on
'Wound management' and "Principles of burn reconstruction: Overview of surgical procedures".)
 Pressure ulcers – The treatment of pressure ulcers depends upon the stage of the ulcer.
(See "Treatment of pressure ulcers", section on 'Ulcer treatment by stage'.)
 Diabetic foot ulcer – The management of diabetic foot ulcers varies depending on the grade of ulcer.
(See "Management of diabetic foot lesions".)
 Venous ulcer – The mainstay of treatment for venous ulcerations is compression. (See "Medical
management of lower extremity chronic venous disease", section on 'Ulcer care'.)
 Ischemic ulcerations and gangrene – The presence of ischemia influences the timing of debridement
and definitive intervention. When faced with wet gangrene or abscess, the wound should be
debrided immediately regardless of the need for revascularization. The dressing choice depends
upon the level of anticipated drainage and size of the wound. Dead space is usually managed with
gauze packing. If revascularization is required, the leg should be performed as soon as possible
thereafter.

However, if dry gangrene without cellulitis is present, the limb should be revascularized first. The
primary goal for the dressing is to protect a wound, thereby reducing the risk for infection or
trauma. To accomplish this, the wound is wrapped with a bulky dry gauze bandage, lightly
wrapped so as not to aggravate the level ischemia. Following revascularization, the wound is
monitored closely for signs of healing or instability that indicate a need for debridement.

SUMMARY AND RECOMMENDATIONS

 For optimal wound healing, the wound bed needs to be well vascularized, free of devitalized tissue,
clear of infection and moist. (See'Introduction' above.)
 Wound dressings should be chosen to eliminate dead space, control exudate, prevent bacterial
overgrowth, ensure proper fluid balance, be cost-efficient, and be manageable for the patient or
nursing staff. (See 'Wound packing' above and 'Wound dressings' above.)
 We suggest sharp surgical debridement over nonsurgical methods for the initial debridement of
devitalized tissue associated with acute and chronic wounds or ulcers (Grade 2C). (See 'Wound
debridement' above.)
 Topical agents such as antiseptics and antimicrobial agents can be used to control locally heavy
contamination. Significant improvements in rates of wound healing have not been found and
tissue toxicity may be a significant disadvantage. (See 'Antiseptics and antimicrobials' above.)
 Recombinant human growth factors, including platelet derived growth factor, epidermal growth
factor and granulocyte macrophage colony stimulating factor, have been used to stimulate healing
in impaired wounds. Of these, only platelet derived growth factor has shown consistent
improvement in healing diabetic neuropathic ulcers. (See 'Growth factors' above.)
 For deep wounds, negative pressure wound therapy may be beneficial in protecting the wound and
reducing the complexity and depth of the defect. Negative pressure wound therapy is frequently
used to manage complex wounds prior to definitive closure. (See 'Negative pressure wound
therapy' above.)
 Following wound bed preparation, acute wounds can often be closed primarily. Chronic wounds that
demonstrate progressive healing as evidenced by granulation tissue and epithelialization along the
wound edges can undergo delayed closure or coverage with skin grafts or human skin
equivalents. (See'Wound closure' above and 'Wound coverage' above.)
 Many other therapies have been tried for the purpose of enhancing wound healing and include
hyperbaric oxygen therapy, and wound stimulation using ultrasound, electrical and
electromagnetic energy. No significant benefits to these therapies have been identified.
(See 'Adjunctive therapies' above.)