Basic principles of wound management

Authors:
David G Armstrong, DPM, MD, PhD
Andrew J Meyr, DPM
Section Editors:
John F Eidt, MD
Joseph L Mills, Sr, MD
Eduardo Bruera, MD
Russell S Berman, MD
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review
process is complete.
Literature review current through: Aug 2020. | This topic last updated: Jun 12, 2020.

INTRODUCTIONA wound is a disruption of the normal structure and function of the

skin and soft tissue architecture [1]. An acute wound demonstrates normal
physiology, and healing is anticipated to progress through the expected stages of
wound healing, whereas a chronic wound is defined as one that is physiologically
impaired [2,3].

To ensure proper healing through the expected stages, the wound bed needs to be well
vascularized, free of devitalized tissue, clear of infection, and moist. Wound dressings
might help facilitate this process if they 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. All wounds are colonized with microbes; however, not all wounds are
infected [4,5].

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 [6,7].

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 ulcers".)

●(See "Medical management of lower extremity chronic venous disease", section on

'Ulcer care'.)

●(See "Clinical staging and management of pressure-induced skin and soft tissue
injury", section on 'Wound management'.)

●(See "Treatment of chronic limb-threatening ischemia".)

●(See "Overview of inpatient management of the adult trauma patient", section on
'Introduction'.)

MEDICAL CARE

Role of antibiotics — All wounds are expected to be colonized with microbes;

however, not all wounds with microbes are infected [4,5]. Thus, antibiotic therapy is
not indicated for all wounds and should be reserved for wounds that appear clinically
infected [8]. There is no published evidence to support antibiotic therapy as
"prophylaxis" in noninfected chronic wounds, or to improve the healing potential of
wounds without clinical evidence of infection. Clinical signs of wound infection that
might warrant antibiotic therapy include local (cellulitis, lymphangitic streaking,
purulence, malodor, wet gangrene, osteomyelitis) and systemic (fever, chills, nausea,
hypotension, hyperglycemia, leukocytosis, change in mental status) symptoms [9,10].
(See "Evaluation and management of suspected sepsis and septic shock in adults" and
"Cellulitis and skin abscess in adults: Treatment".)

Control of blood sugar — Most clinicians make glycemic control a priority when

treating wounds, although there is no overwhelming clinical evidence in support of
short-term glycemic control as directly affecting wound healing potential [11,12].
(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 [13]. In these patients, hyperglycemia may be a more sensitive measure
of infection.

WOUND DEBRIDEMENTWounds 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) [14]. The majority of wounds often require
planned serial debridement to restore an optimal wound healing environment [15]. For
those minority of patients where serial debridement may not be tolerated, enzymatic
or biologic (larval) debridement might be helpful to potentially increase "antibiotic-
free days" while reducing treatment complexity [16-19]. These interventions may also
be of benefit in the time interval between serial debridements.

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 [20,21].
Irrigation — Irrigation with fluid is important for decreasing the bacterial load and
removing loose material, and should be a part of routine wound management
[1,22,23]. Low-pressure irrigation (eg, <15 pounds per square inch [psi]) can be
performed in any setting using a syringe or bulb, whereas high-pressure irrigation (eg,
pulsed lavage) is typically performed in the operative setting using a commercial
device.

Low-pressure irrigation is usually adequate to remove material from the surface of

most wounds. Decreased bacterial load has been documented with the use of pulsed
irrigation in lower extremity chronic wounds [24]. Bacteria do not appear to
accompany the irrigation fluid into adjacent tissues in animal studies, even at higher
pressure levels [25]. 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 [26]. For highly contaminated wounds, the
benefits of reducing bacterial load may outweigh the risk of speculative adjacent
tissue damage associated with the use of higher irrigating pressures. Although higher-
pressure irrigators may lead to local tissue damage and increased tissue edema, there
are no specific data available to suggest a specific cutoff pressure above which tissue
damage or impaired, rather than improved, wound healing will occur.

There is no high-level evidence to support the use of any particular additive to the
irrigant, nor any particular additive over another. The act of irrigation and the volume
of irrigant probably provides the positive benefits. Warm, isotonic (normal) saline is
typically used; however, systematic reviews have found no significant differences in
rates of infection for tap water compared with saline for wound cleansing [27,28]. The
addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine, hydrogen
peroxide, sodium hypochlorite) is generally unnecessary. Such additives have
minimal action against bacteria, and some, but not all, may impede wound healing
[29-31]. (See 'Antiseptics and antimicrobial agents' below.)

Surgical — Sharp excisional debridement uses a scalpel or other sharp instruments

(eg, scissors or curette) to remove devitalized tissue and accumulated debris (biofilm).
Sharp excisional debridement of chronic wounds decreases bacterial load and
stimulates contraction and wound epithelialization [32]. 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 nonhealing wounds to remove infected
tissue, handle undermined wound edges, or obtain deep tissue for culture and
pathology [15,33,34]. Serial surgical debridement in a clinical setting, when
appropriate, appears to be associated with an increased likelihood of healing [15,35].

In patients with active infection, antibiotic therapy should be targeted and determined
by wound culture and sensitivity to decrease the development of bacterial resistance
[36,37]. (See "Cellulitis and skin abscess in adults: Treatment".)

In patients with chronic critical limb ischemia, surgical debridement must be coupled
with revascularization in order to be successful [38]. (See "Treatment of chronic limb-
threatening ischemia".)
Enzymatic — Enzymatic debridement involves applying exogenous enzymatic agents
to the wound. Many products are commercially available (table 1), but results of
clinical studies are mixed and their use remains controversial [39]. Ulcer healing rates
are not improved with the use of most topical agents, including debriding enzymes
[40]. 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 [41]. It also remains a good
option in patients who require debridement but are not surgical candidates.

Biologic — An additional method of wound debridement uses the larvae of the

Australian sheep blow fly (Lucilia [Phaenicia] cuprina) or green bottle fly (Lucilia
[Phaenicia] sericata, Medical Maggots) [42,43]. Maggot 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 [44]. Maggot therapy
may also reduce the duration of antibiotic therapy in some patients [16].

Maggot therapy has been used in the treatment of pressure ulcers [45,46], chronic
venous ulceration [47-50], diabetic ulcers [42,51], and other acute and chronic
wounds [52]. The larvae secrete proteolytic enzymes that liquefy necrotic tissue,
which is subsequently ingested while leaving healthy tissue intact. Basic and clinical
research suggests that maggot therapy has additional benefits, including antimicrobial
action and stimulation of wound healing [43,47,53,54]. However, randomized trials
have not found consistent reductions in the time to wound healing compared with
standard wound therapy (eg, debridement, hydrogel, moist dressings) [55,56]. Maggot
therapy appears to be at least equivalent to hydrogel in terms of cost [56,57].

Dressing changes include the application of a perimeter dressing and a cover dressing
of mesh (chiffon) that helps direct the larvae into the wound and limits their migration
(movie 1). Larvae are generally changed every 48 to 72 hours. One study that
evaluated maggot therapy in chronic venous wounds found no advantage to
continuing maggot therapy beyond one week [48]. Patients were randomly assigned to
maggot therapy (n = 58) or conventional treatment (n = 61). The difference in the
slough percentage was significantly increased in the maggot therapy group compared
with the control groups at day 8 (67 versus 55 percent), but not at 15 or 30 days.

The larvae can also be applied within a prefabricated "biobag" (picture 1),
commercially available outside the United States, that facilitates application and
dressing change [58-61]. Randomized trials comparing "free range" with "biobag"-
contained larvae in the debridement of wounds have not been performed.

A main disadvantage of maggot 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
approximately 50 percent of patients indicated they would prefer conventional wound
therapy over maggot therapy, 89 percent of the patients randomly assigned to maggot
therapy said they would undergo larval treatment again [62]. Perceived pain or
discomfort with the dressings associated with maggot therapy may limit its use in
approximately 20 percent of patients [63].
WOUND PACKINGWounds 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
superior direction is defined as 12:00, or distally on the plantar aspect of the foot. The
presence of necrotic tissue indicates the need for surgical debridement to decrease
bacterial burden and prevent sequelae of infection [36].

Although there have been no specific trials comparing packed versus unpacked
wounds, wound packing is considered a basic standard care [64]. Packing wounds
associated with significant dead space or undermining is important to reduce
physiological dead space and to absorb exudate/seroma collection, and reduce the risk
for infection. Packing can also be an effective temporary dressing technique between
planned serial debridements.

A traditional gauze dressing is often used to pack wounds 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 all 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' below.)

Wound dressing changes associated with large defects can be managed without
repeated applications of tape to the skin by using Montgomery straps (picture 2).

TOPICAL THERAPYAfter appropriately addressing debridement of necrotic tissue,

pressure offloading, infection, and ischemia, there are a number of adjunctive
therapies that may be helpful to augment wound healing.

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), amongst others. (See "Basic
principles of wound 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. As with other therapies, isolated growth factors applied in the absence of
good-quality debridement, infection control, and offloading when indicated are likely
to be ineffective in promoting healing [33,65].

●Platelet-derived growth factor – Becaplermin is a PDGF gel preparation that

promotes cellular proliferation and angiogenesis and thereby improves wound healing
[66]. 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
the treatment of chronic wounds. The growth factor is delivered in a topical aqueous-
based sodium carboxymethylcellulose gel. It is indicated for noninfected diabetic foot
ulcers that extend into the subcutaneous tissue and have an adequate vascular supply
[67]. 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 [68]. 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 [69,70]. (See "Management of diabetic foot ulcers", 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 [71]. Epithelialization was not significantly affected.

●Granulocyte-macrophage colony stimulating factor – Intradermal injections of GM-

CSF promote healing of chronic leg ulcers, including venous ulcers [72,73]. 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) [73]. GM-CSF
has been used in various types of chronic wounds to promote healing [74]. (See
"Medical management of lower extremity chronic venous disease", section on 'Ulcer
care'.)

Antiseptics and antimicrobial agents — Some topical antimicrobials may be

associated with potential benefits in selected patient populations. The properties of
some broadly used agents are reviewed briefly below; others are reviewed separately
(table 2). (See "Topical agents and dressings for local burn wound care".)

Iodine-based — Cadexomer iodine (eg, Iodosorb) is an antimicrobial that reduces

bacterial load within the wound and stimulates healing by providing a moist wound
environment [75]. 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, but should likely
only be considered for use on a short-term basis.

Silver-based — Although silver is toxic to bacteria, silver-containing dressings have

not demonstrated significant benefits in comparison with other topical wound
dressings [76-78]. A systematic review evaluating topical silver in infected wounds
identified three trials that treated 847 participants with various silver-containing
dressings [79]. 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 [80].

Honey — Honey has been used since ancient times for the management of wounds.
Honey has broad-spectrum antimicrobial activity due to its high osmolarity and high
concentration of hydrogen peroxide [81]. Medical-grade honey products are now
available as a gel, paste, and impregnated into adhesive, alginate, and colloid
dressings [82,83]. Based upon the results of systematic reviews evaluating honey to
aid healing in a variety of wounds, there are insufficient data to provide any
recommendations for the routine use of honey for all wound types; specific wound
types, such as burns, may benefit, whereas others, such as chronic venous ulcers, may
not [84-90].

Beta blockers — Keratinocytes have beta-adrenergic receptors, and beta blockers may

influence their activity and increase the rate of maturation and migration. The use of
systemic beta blockers has been studied in burn patients [91], and several case studies
have presented the use of topical timolol in chronic wounds [92-94].

Timolol is a topically applied beta blocker with some limited evidence that it
promotes keratinocyte migration and epithelialization of chronic wounds, which have
been unresponsive to standard wound interventions.

WOUND DRESSINGSWhen a suitable dressing is applied to a wound and changed

appropriately, the dressing can arguably 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. Examples of differing types of wounds and potential dressings are
given in the tables (table 3 and table 4). In addition, wounds must be continually
monitored as their characteristics and dressing requirements change over time [95].

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 [96], but similar principles may be used for acute wound
management:

●Hydrogels for the debridement stage

●Low-adherent dressings that maintain moisture balance for the granulation stage

●Low-adherent dressings for the epithelialization stage

For acute and chronic wound dressing selection, the degree of drainage/moisture
should help guide the clinician in terms of dressing selection. A relatively moist
wound bed is clearly beneficial for healing, while excessive moisture is detrimental,
leading to maceration. The ideal dressing for a given wound would wick away excess
drainage while maintaining an appropriate level of moisture. Although some dressings
may have additional benefits in terms of local antimicrobial effects, reduced pain on
change, odor control, and anti-inflammatory or mild debridement ability, these are
secondary benefits [97].

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 [96], and highly silver-containing dressings
are potentially cytotoxic and should not be used in the absence of significant
infection. (See 'Antiseptics and antimicrobial agents' 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 [98]. Similar results have been obtained in humans [99-101].

Occluded wounds heal up to 40 percent more rapidly than nonoccluded wounds [99].
This is thought to be due, in part, to easier migration of epidermal cells in the moist
environment created by the dressing [100]. Another mechanism for improved wound
healing may be the exposure of the wound to its own fluid [102]. Acute wound fluid
is rich in platelet-derived growth factor, basic fibroblast growth factor, and has a
balance of metalloproteases serving a matrix custodial function [103]. These interact
with one another and with other cytokines to stimulate healing [104]. 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 that may inhibit proliferation of fibroblasts
[105-107]. Excessive periwound edema and induration contributes to the development
of chronic wound fluid and should be managed to minimize this effect. (See "Basic
principles of wound healing", section on 'Wound healing'.)

In addition to faster wound healing, wounds treated with occlusive dressings are
associated with less prominent scar formation [108]. 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 [109]. 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 (table 3):

●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 (table 3), 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. Thicker
absorbent pads are used to cover the gauze dressings. For managing large wounds,
self-adhesive 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 [110].

Advantages of these dressings include their ability to maintain moisture, encourage

rapid reepithelization, 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 [111].

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 [112,113], 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 [114]. 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 [115].
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 [116]. A multicenter 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 [117]. 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) [40]. 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 [118]. (See 'Antiseptics and antimicrobial agents' 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
[119]. 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 [120].

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 [121].

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 [122]. 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 [123].

WOUND CLOSUREPrimary closure refers to the direct apposition of skin edges of

acute surgical or traumatic wounds after appropriate wound preparation with sutures
and/or staples (figure 1 and figure 2). (See "Minor wound preparation and irrigation"
and "Closure of minor skin wounds with sutures" and "Closure of minor skin wounds
with staples".)

This might be contrasted with delayed primary closure, where skin edge apposition
occurs following an interval of wound management. In other words, the wound is
purposefully left open for a period of time, and then the edges are directly apposed
with sutures and/or staples. Although delayed, this still represents primary closure as
the skin edges are brought into direct apposition by external means. For abdominal
wounds, chest wounds, and surgical wounds without evidence of infection, delayed
closure is widely accepted (figure 1) [124]. However, while a chronic wound should
never be closed primarily, delayed closure or coverage of chronic wounds is
acceptable.

Another option still is healing by secondary intention (figure 1). This is where a
wound is purposefully left open and fills in with granulation tissue and eventually
epithelization over a period of time. At no point are the skin edges brought together
by external means. The process of healing by secondary intention might be assisted by
the use of negative pressure wound therapy.

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 [125-128]. 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 [129-131] and diabetic wounds [128,132]. (See
"Negative pressure wound therapy".)

WOUND COVERAGESplit-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 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. With
full-thickness grafts, 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 [133,134]. (See "Skin autografting", section on 'Split-
thickness skin grafting' and "Skin autografting", section on 'Full-thickness skin
grafting'.)

Biologic cell-based dressings are composed of a live-cell construct that contains at

least one layer of live allogenic cells. Skin substitutes can be used when traditional
dressings have failed or are deemed inappropriate [135]. One study suggested their
use when a chronic wound fails to heal at an appropriate rate of closure (ie, 55 percent
reduction in wound area within four weeks of treatment) [136]. Skin substitutes are
ideal for the treatment of 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. (See "Skin substitutes".)

For larger wounds or loss of multiple tissue components (skin, subcutaneous tissue,
muscle), a tissue flap may be required to provide adequate wound coverage. (See
"Overview of flaps for soft tissue reconstruction".)

ADJUNCTIVE THERAPIES

Hyperbaric oxygen therapy — Hyperbaric oxygen therapy (HBOT) has been

demonstrated to have positive effects on wound healing in vitro in many situations
[137]. Endothelial progenitor cells play an important role in wound healing because
they participate in the formation of new blood vessels in areas of hypoxia [138].
Although hyperoxia induced by HBOT effectively improves endothelial progenitor
cells' mobilization, therapy is not targeted to the wound site. (See "Hyperbaric oxygen
therapy", section on 'Mechanisms of action'.)

Although HBOT has been used as an adjunct to wound care in the treatment of a
variety of acute and chronic wounds [139-144], the specific indications are relatively
unclear. Most studies are observational, and the few available trials are limited by
small sample size and low quality [145-147]. Systematic reviews have concluded that,
although hyperbaric oxygen may benefit some types of wounds (eg, diabetic ulcers),
there is insufficient evidence to support routine use [148-150]. It is reasonable to
conclude that HBOT might be considered in situations of chronic wounds that have
not responded to conventional interventions, in relatively ischemic states where
revascularization is not an option, and in the setting of subacute osteonecrosis not
amenable to surgical excision. (See "Overview of treatment of chronic wounds",
section on 'Hyperbaric oxygen therapy'.)
●HBOT may be of value in patients with extensive soft tissue injury. A systematic
review identified three trials evaluating the use of HBOT in acute surgical and
traumatic wounds [151]. In one of the trials, 36 patients with crush injuries were
randomly assigned to a 90 minute twice daily HBOT or sham treatments for a total of
six days postoperatively [152]. 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 lower extremity injury", section on 'Wound care and coverage'
and "Patient management following extremity fasciotomy", section on 'Hyperbaric
oxygen'.)

●A systematic review of HBOT 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 [153]. The treatment of burn wounds is discussed in detail
elsewhere. (See "Topical agents and dressings for local burn wound care".)

●HBOT 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 "Hyperbaric oxygen therapy",
section on 'Radiation injury'.)

When indicated, HBOT 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 [137]. The mechanisms
and technique of HBOT are discussed in detail elsewhere. Serious adverse events can
be associated with HBOT, including seizures and pneumothorax. (See "Hyperbaric
oxygen therapy" and "Hyperbaric oxygen therapy", section on 'Technique'.)

Other therapies — A variety of other therapies, such as low-frequency ultrasound

[154,155], electrical stimulation [156-159], electromagnetic therapy [160], and
phototherapy [161], have been investigated primarily for the treatment of pressure
ulcers or chronic venous wounds [162-166]. The treatment of pressure ulcers and
chronic venous wounds are discussed in detail elsewhere. (See "Clinical staging and
management of pressure-induced skin and soft tissue injury" and "Medical
management of lower extremity chronic venous disease", section on 'Ulcer care'.)

MANAGEMENT OF SPECIFIC WOUNDS

Acute 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 minor 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 (eg, stellate, contiguous,
intersecting). 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 [128]. (See 'Wound packing' above and 'Negative
pressure wound therapy' above.)

●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 "Overview of surgical procedures
used in the management of burn injuries".)

●Postoperative surgical incision – Postoperative surgical incisions (clean, clean-

contaminated) are typically covered with a dry dressing that is held in place with an
adhesive (eg, tape, Tegaderm). The initial postoperative dressing can be removed
within 48 hours, provided the wound has remained dry. The timing with which the
patient can resume bathing/showering is not well defined [167,168].

Chronic wounds — The management of chronic wounds (eg, pressure ulcers, diabetic

foot ulcers, ischemic ulcerations and gangrene, atypical and malignancy-associated
wounds) is reviewed separately. (See "Overview of treatment of chronic wounds".)

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored

guidelines from selected countries and regions around the world are provided
separately. (See "Society guideline links: Chronic wound management".)

SUMMARY AND RECOMMENDATIONS

●For optimal wound healing, the wound bed should be well vascularized, free of
devitalized tissue, clear of infection, and moist. (See 'Introduction' above.)

●Wound dressings should be chosen based upon their ability to manage dead space,
control exudate, reduce pain during dressing changes (as applicable), 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
when feasible (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 antimicrobial agents' above.)
●For deep wounds, negative pressure wound therapy may protect the wound and
reduce 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 bioengineered tissues. (See 'Wound closure' above and
'Wound coverage' above.)

●Many other therapies have been used with the aim of enhancing wound healing and
include hyperbaric oxygen therapy, and wound stimulation using ultrasound,
electrical, and electromagnetic energy. Some of these therapies have shown a
marginal benefit in randomized studies and may be useful as adjuncts for wound
healing. (See 'Adjunctive therapies' above.)

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