Complex and hard-to-heal chronic wounds impact millions of people globally. In the United States, care for these types of wounds exceeds $25 billion annually.¹ Wound healing naturally progresses through the overlapping phases of hemostasis, inflammation, proliferation, and remodeling. With chronic and complex wounds, the natural biological healing process stalls in the inflammatory phase, thereby preventing both the proliferative phase and further advancement toward wound closure.

These types of wounds often contain microbial, biochemical, and cellular abnormalities that prevent or slow the progression of healing. Debridement can be used to remove necrotic, damaged, infected, or otherwise devitalized tissue and/or foreign debris that may impair healing. Debriding a wound exposes the healthy underlying tissue and allows granulation and re-epithelialization to occur.² Debridement can also be used to manage biofilm and prevent wound infection. There are multiple types of debridement, including sharp (surgical), biological, enzymatic, mechanical, and autolytic debridement. Clinicians can choose from any of these debridement methods (or a combination of methods) based on what is most appropriate for a given patient or wound. The selection of the method often depends on the wound characteristics, patient comorbidities, pain limitations, health needs, time considerations, caregiver skills, and treatment setting.¹

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Mechanics of Enzymatic Debridement

Enzymatic debridement is often used in conjunction with sharp debridement. It is a topical treatment that uses naturally occurring proteolytic enzymes or proteinases, which can aid in the wound repair process. These enzymes remove devitalized tissue by digesting and dissolving the non-viable tissue and thus chemically liquefying non-viable tissues within the wound bed. Proteinase activity in chronic wounds debrides the wound, and it also facilitates cell migration necessary for epithelialization, further contributing to the healing process.¹ This process helps the wound move from the inflammatory phase of healing to the proliferative phase.

Historical Perspectives of Enzymatic Debridement

The use of plant-based enzymes for treating burn wounds goes back to ancient times. In modern medicine, plant-based enzymes were first used in 1940 to remove eschar tissue through debridement. Bacterial enzymes were introduced approximately a decade later. Initially, these therapies were marketed based on positive responses for debriding burn wounds with less pain than other options.³

Enzymatic Debridement and Other Therapies

Today, enzymatic debridement is used for far more applications than debridement of burns, including pressure injuries, diabetic foot ulcers, and other complex and chronic wounds.⁴ Enzymes may be used to debride both adherent slough and eschar, and they may be used in cases when alternative methods such as surgical or sharp debridement are not feasible because of bleeding disorders or other considerations.⁵

Enzymatic debridement is commonly used in care settings or facilities where surgical or sharp debridement is not an option. It is also sometimes used with a short course (one week) before considering surgical or sharp debridement. This strategy can help a clinician determine the potential of a more conservative approach before moving forward with surgical or sharp debridement.¹ In other instances, clinicians will employ surgical or sharp debridement initially, with the expectation that follow-up debridement will be necessary. Maintenance debridement in this manner is commonly accomplished by using enzymatic agents for debridement.¹ This strategy can result in greater efficacy and optimize wound healing conditions.

Conclusion

Enzymatic debridement has many different applications and is less painful than traditional sharp debridement. Although enzymatic debridement may not be appropriate for every patient, It should be considered for patients receiving palliative care and those with a low pain tolerance, as well as for maintenance between sequential sharp debridement procedures.

References

1. McCallon SK, Weir D, Lantis JC 2nd. Optimizing wound bed preparation with collagenase enzymatic debridement. J Am Coll Clin Wound Spec. 2015;6(1-2):14-23.

2. Madhok BM, Vowden K, Vowden P. New techniques for wound debridement. Int Wound J. 2013;10:247-251.

3. Heitzmann W, Fuhs PC, Schiefer JL. Historical perspectives on the development of current standards of care for enzymatic debridement. Medicina (Kaunas). 2020;56(12):706.

4. Patry J, Blanchette V. Enzymatic debridement with collagenase in wounds and ulcers: a systematic review and meta-analysis. Int Wound J. 2017;14:1055-1065.

5. Ramundo J, Gray M. Enzymatic wound debridement. J Wound Ostomy Continence Nurs. 2008;35(3):273-280.