Chronic wounds are any types of wounds that have failed to heal in 90 days. Identifying the cause of a chronic wound is most important in the healing process. We as clinicians must help bolster advanced wound care by sharing advances in education in evidence-based treatment, prevention, and wound assessment.¹ A wound must go through hemostasis, inflammation, proliferation, and remodeling, along with various cellular contributions. The scaffolding of the extracellular matrix is what provides the elasticity and tensile strength to the skin structure. Various proteins such as collagen, fibronectins, elastins, and laminins make up this vital matrix to aid and complete the process of wound closure. We see extracellular matrix damage mostly in our geriatric population.¹

10 Key Essentials of Chronic Wound Management

Chronic wound management must be gauged by assessing the patient as a whole. A thorough history and physical examination, nutrition, pain level, wound assessment, compliance, self-care abilities, insurance payer, and education are all essentials of a chronic wound management plan of care. Identifying the etiology is most important, but it not always possible. Therefore, optimizing wound healing with wound bed preparation (optimal moist environment and bioburden control) and advanced wound care dressings is most effective. Following are 10 key components of effective chronic wound management:¹

1. Wound etiology
2. Wound assessment
3. Wound bed preparation
4. Wound depth and exudate amount
5. Dressing wear time
6. Nutrition level
7. Pain level
8. Patient compliance, self-abilities, lifestyle changes
9. Patient and caregiver education
10. Payer source (reimbursement, financial)

Moist Wound Healing and the Effect on Biofilm Formation

Moist wound healing has been shown to reduce healing time.^3,4 Controlling exudate and bacteria is most effective. Keeping an even moisture balance of the wound bed is vital in the healing progress. Moist wound healing increases the speed of the proliferative phase and decreases the intensity and length of the inflammatory phase. Autolytic debridement is also provided with moist wound healing, in return increasing synthesis of collagen and fibroblast proliferation. Less scarring and less pain have also been proven with moist wound healing.² A common myth is that leaving a wound "open to air" will help it heal.

We now know that using an optimal moist wound bed environment increases healing time, reduces infection, lessens necrosis and inflammation, and enhances newly regenerated epidermis.⁴ However, not all wounds are appropriate for moist wound healing. Dry, stable, and intact necrotic type wounds caused by ischemia and or neuropathy should be monitored and kept dry. We can support moist wound healing by using advanced wound care dressings that donate moisture. Examples are hydrogel filler, honey gel, oil emulsion, and petrolatum gauze dressings. Devitalized tissues (slough and eschar) harbor bacteria and slow down the wound healing process.

Most chronic wounds are considered contaminated with biofilm. Biofilms are another culprit that impede wound healing progress. Most, if not all, ulcers develop a biofilm over time. The protective polysaccharide matrix is produced by bacteria. Bioactive wound care dressings can include tissue-engineered products derived from artificial sources or natural tissues (e.g., hyaluronic acid, elastin, silicone, chitosan, alginates, collagen, antimicrobials, skin equivalents, growth factors, cell-free matrices, and cell-containing matrices).¹

What Is the Difference Between Wet-to-Dry and Wet-to-Moist Dressings? Wet-to-dry: This type of dressing is used to remove drainage and dead tissue from wounds. Deep wounds with undermining and tunneling need to be packed loosely. Without packing, the space may close off to form a pocket and not heal. This type of dressing is to be changed every 4 to 6 hours.⁵ Wet-to-moist: This type of dressing is used to keep the wound moist. This type of dressing is used to remove drainage and dead tissue from wounds. Deep wounds with undermining and tunneling need to be packed loosely. Without packing, the space may close off to form a pocket and not heal. This type of dressing is to be changed daily.

Disadvantages of Wet-to-Dry Dressings

• Clinicians moisten the dressing with normal saline during removal. This defeats the purpose of non-selective debridement.
• These dressings are labor intensive, repeating every 4 to 6 hours.
• The wound bed temperature is cooled.
• The dressings are painful when removed.
• Desiccation of viable tissue occurs.
• Infection rates are increased.
• Dressing particles are retained.
• Bioburden can embed up to 60 layers of gauze.

Other Considerations for Dressing Application

The following factors also need to be taken into account when selecting wound care dressings for application⁶:

• Dressing compatibility: Does the use of viscous materials block the absorptive properties of the dressing? Do the properties of the dressing interfere with or deactivate collagenase or antimicrobial products?
• Ointment or cream thickness: Did you check for the correct dosage to ensure efficacy and prevent potential periwound maceration?
• Wear time of medicated dressing: Are you changing the dressing often enough to ensure consistent mechanism of action, wicking, or absorption?
• Cleanser compatibility: Is the dressing compatible with the cleansers you are using on the wound (to avoid cytotoxicity or deactivation of certain bioactive products)?
• Dressing size: If using a dressing larger than the wound, have you ensured that the periwound skin is protected from maceration? Can the dressing you chose be cut to fit the wound?
• Packing dead space: Have you ensured that the dressing will be entirely retrievable from the dead space (woven not to leave fibers, counting individual pieces, leaving a tail)?
• Clean wound bed: Have you ensured that any devitalized tissue that may block the mechanism of action of your dressing has been removed from the wound?

Conclusion

We all want good outcomes for our patients. We must work toward expanding our knowledge of advanced wound care and share it with other health care clinicians and providers. Chronic wounds can lead to infection and even death. We must strive to help prevent and promote faster wound healing outcomes. We can do this with careful assessment and involving the patient and caregiver in the plan of care.

References

1. Carver C. Bioactive Wound Care Dressings. WoundSource. 2016. Available at: http://www.woundsource.com/blog/future-bioactive-wound-care-dressings. Accessed March 20, 2018.

2. Meyers B. Wound Management: Principles and Practice. 2nd ed. Upper Saddle River, NJ_ Pearson Prentice Hall; 2008:124–125

3. Winter G. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293–4.

4. Field FK, Kerstein MD. Overview of wound healing in a moist environment. Am J Surg. 1994;167(1A):2S-6S.

5. Carver C. Alternatives to Wet to Dry Dressings. WoundSource. 2016. Available at: http://www.woundsource.com/blog/alternatives-wet-dry-wound-care-dressin…. Accessed March 20, 2018.

6. Carver C. 8 Questions to Ask When Choosing a Wound Care Dressing. WoundSource. 2015. Available at: http://www.woundsource.com/blog/8-questions-ask-when-choosing-wound-car…. Accessed March 20, 2018.