Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article Title: Using the Entropic Wound Cycle as the Basic for Making Effective Treatment Choices

Authors: Mcguire, J, Sebag JA, Solnik, J

Journal: WoundSource

Reviewed by: Cindy H. Duong, class of 2021, Temple University School of Podiatric Medicine

Introduction: Use of the Entropic Wound Cycle

According to the article by Sheehan et al., an ideal wound dressing should maintain humidity, be of stable material, not contaminate, be non-allergic and non-toxic, not be expensive, protect from trauma and bacteria, and require few changes.¹ However, an ideal wound dressing protocol for all wound types has yet to be made. When selecting a proper wound dressing, it is necessary to consider the wound and periwound conditions, the patient's state of health, cost restraints, psychosocial issues, and ways to prevent biofilm formation, which may interfere with healing. Chronic wounds have an entropic wound cycle, with entropic meaning "to decline into disorder." If there is a perpetually inflamed state caused by bioburden, inflammatory cytokines, and/or cell signaling molecular destruction, the wound has a <50% chance of healing completely. Patients most susceptible to lack of healing are at risk of progressing to chronic wounds.

They are those who present with physical, economic, or psychosocial challenges and those with underlying medical conditions such as diabetes, smoking, or immune deficiencies. If skin is not properly maintained, patients can unintentionally cause skin breakdown and form wounds resulting from trauma, pressure, or infection; thus, patients must be well educated by the clinician. The "Golden Month" of wound healing is the four weeks after a wound appears, when treatments can reverse the entropic wound cycle and allow 50% of wounds to heal.¹ Therapy involves five phases, which include maintaining a moist wound bed, preventing biofilm development, using offloading devices, assessing vascular conditions, controlling glycemic levels, providing nutritional support, and limiting any aggravating factors.

Using the Entropic Wound Cycle as the Basic for Making Effective Treatment Choices
 

Steps of the Entropic Wound Cycle

1: Initial interventions—debridement, moist wound healing, offloading

Aggressive debridement creates a new, clean wound bed for initial treatment. Debridement can be surgical (most aggressive and selective form) or mechanical, enzymatic, autolytic, and biosurgical (non-selective forms). Enzymatic and autolytic debridement (micro-debridement) may be used along with surgical debridement (macro-debridement). Dressings control fluid levels based on viscosity and amount of exudate. Types of dressings for debridement range from occlusive dressings to enhance autolytic debridement to hydrophilic dressings that increase fluid movement within the wound bed. Dressings that provide a moist wound environment, such as hydrogels, improve rates of epithelialization and granulation.² Offloading devices such as depth shoes with molded inserts prevent the forming of diabetic foot ulcers.

2: Delayed wound healing

In this phase, wound dressings should control both biofilm formation and inflammation in the wound and periwound. More aggressive therapy (such as more frequent debridements and use of a total contact cast) and improved patient education are vital.

3: Deteriorating wound strategies—biofilms

Systemic topical antibiotics are not recommended because of the risk of bacterial resistance. Control of biofilm can be improved with dressings that incorporate antibiotics, such as Manuka honey or foam that releases a moist iodine gas. As suggested by Regulski et al., multiple strategies may be used to manage wound biofilms.³

4: Deteriorating wound strategies—inflammation

Copious drainage must be controlled by dressings that can hold large volumes of exudate. Combination, hydroconductive, or high-moisture vapor dressings hold or move large amounts of fluids into the dressing. When these dressings fail, utilization of negative pressure wound therapy can help control drainage and obtain a healthy wound bed.

5: Deteriorating wound strategies—extracellular matrix loss

Collagen dressings act as sacrificial substrates during inflammation and extracellular matrix replacement when inflammation recedes. This is because collagen becomes a target for inflammatory cytokines and redirects them to the dressing instead of the wound. Hyaluronic acid dressings and topical antioxidants may also improve healing. Growth factors such as becaplermin may be given to patients with poor healing. Cellular and/or tissue-based products for wounds and mesenchymal stem cells have shown remarkable results, but they also have a high failure cost.

Conclusion

Wounds heal quickly when all conditions have been perfectly met. It is the responsibility of the entire health professional team to ensure there is a balance in the patient's medical management, offloading, perfusion, moisture, compliance, biofilm prevention, and cellular proliferation.

References

1. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4 week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003;26(6):1879-1882.

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. Regulski M, Jacobstein DA, Petranto RD, Migliori VJ, Nair G, Pfeiffer D. A retrospective analysis of a human cellular repair matrix for the treatment of chronic wounds. Ostomy Wound Manage. 2013;59(12):38-43.

About the Author

Cindy H. Duong is currently a second-year podiatric medical student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia. Cindy graduated Temple University in 2017 with a Bachelor of Science in Biology. She is currently a TUSPM student ambassador, President of the Dermatology Club, and Chair of the Boards Committee for the Class of 2021. She is also an editor for Hallux Magazine, an online magazine run by podiatric medical students from all nine schools. Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.