Journal of Athletic Training 2008;43(6):600–607

g by the National Athletic Trainers’ Association, Inc

www.nata.org/jat
original research

Occlusive Dressings and the Healing of

Standardized Abrasions
Joel W. Beam, EdD, LAT, ATC
University of North Florida, Jacksonville, FL
Context: Acute skin trauma during sport participation, Main Outcome Measure(s): Wound contraction, color (chro-
resulting in partial-thickness abrasions, is common. The matic red), and luminance.
limited investigations focusing on the acute wound environ- Results: A day-by-dressing interaction was found for wound
ment and dressing techniques and the subsequent lack of contraction, color, and luminance. Post hoc testing indicated
evidence-based standards complicate clinical wound care that the film and hydrocolloid dressings produced greater wound
decisions. contraction than the hydrogel and no dressing on days 7 and 10.
Objective: To examine the effects of occlusive dressings on Film, hydrogel, and hydrocolloid dressings also resulted in
healing of standardized, partial-thickness abrasions. greater wound contraction than the control on day 14.
Design: Controlled, counterbalanced, repeated-measures Hydrocolloid dressings produced smaller measures of color
design. and greater measures of luminance than no dressing on day 7.
Setting: University laboratory. Film, hydrogel, and hydrocolloid dressings also resulted in
Patients or Other Participants: Sixteen healthy women (n smaller measures of color and greater measures of luminance
5 10) and men (n 5 6). compared with no dressing on days 10 and 14.
Intervention(s): Four standardized, partial-thickness abra- Conclusions: When compared with the control (no dress-
sions were inflicted. Film, hydrogel, and hydrocolloid occlusive ing), the film, hydrogel, and hydrocolloid occlusive dressings
dressings and no dressing (control) were applied. Participants were associated with a faster healing rate of partial-thickness
returned on postwound days 1, 3, 5, 7, 10, and 14 for digital abrasions across time measured by wound contraction, color,
imaging. Wound healing time was measured by change in and luminance. Overall, these data indicate that occlusive
wound contraction (cm2) and change in wound color dressings were more effective in healing than no dressing was.
(chromatic red) and luminance in red, green, and blue color Key Words: wound management, skin trauma, moist envi-
values. ronment

Key Points
N Partial-thickness abrasions treated with film, hydrogel, and hydrocolloid occlusive dressings healed more quickly, as
measured by wound contraction, color, and luminance, than those receiving no dressing.
N Additional studies are needed to determine the practicality, cost-effectiveness, and compliance level when occlusive
dressings are used in the clinical setting.

P
artial-thickness abrasions often are sustained during influence the clinical outcomes.9 Additionally, few stan-
participation in athletic and recreational activities. dardized protocols in the literature describe specific
The selection and use of appropriate dressing methods to examine acute wound healing.10,11 Therefore,
techniques in the management of these wounds is my purpose was to examine the effects of occlusive
paramount for an orderly and timely healing process to dressings on measures of wound healing in standardized,
occur. However, a limited number of authors1,2 have partial-thickness abrasions. Specifically, I adapted a
examined acute wounds and dressing techniques to guide semiautomatic digital imaging processing method to
clinical decisions. Current practice by athletic trainers may examine the effects of film, hydrogel, and hydrocolloid
consist of not covering abrasions or using nonocclusive occlusive dressings and no dressing (control) on healing
dressings (ie, sterile gauze, adhesive strips, or patches).3 time, measured by change in wound contraction, wound
These techniques likely impede the healing process by color (chromatic red), and luminance. I hypothesized that
cooling and drying the tissue, as well as increasing the risk the occlusive dressings would produce greater rates of
of cross-contamination and bacterial colonization from healing (greater wound contraction and luminance and
Staphylococcus and Streptococcus pathogens.4,5 lower color) when compared with the control.
Past investigators6–8 researching the effects of dressings
on healing rates have traditionally focused on the chronic METHODS
wound environment. Although these findings are vital to
understanding the effects of various dressings, factors such
Design and Setting
as underlying pathologic conditions associated with the
chronic wound environment, as well as various wound I used a controlled, counterbalanced, repeated-measures
sizes, depths, locations, and mechanisms of injury, can design to compare the effects of 3 occlusive dressings and

600 Volume 43 N Number 6 N December 2008

no dressing on the healing of partial-thickness abrasions BlisterFilm was removed and a 10-minute ice massage was
across time. The independent variables were dressing applied over the area to desensitize the skin and allow it to
(BlisterFilm, a transparent film dressing [Covidien, Mans- be abraded more easily. I then cleansed the lateral lower leg
field, MA]; Curagel, a hydrogel dressing [Covidien]; Ultec, with a Betadine surgical scrub (Purdue Pharma LLP,
a hydrocolloid dressing [Covidien]; and no dressing Stamford, CT) and dried the area with sterile gauze pads.
[control]) and time (postwound days 1, 3, 5, 7, 10, and A 21 3 10-cm template made of 0.15-mm clear vinyl was
14). The dependent variables were change in surface area of constructed for each participant before wound infliction.
the wound (wound contraction) and change in wound color Four circles (2.25 cm in diameter) were cut in the template
and luminance. Wound contraction was measured as and spaced 4 cm apart. The template was cleansed with
relative surface area in square centimeters and reflects the isopropyl alcohol and secured to the nonkicking lateral
drawing together of the wound perimeter. Wound color lower leg with Cover-Roll (BSN-Jobst, Inc, Charlotte,
(chromatic red) and luminance were recorded in red, green, NC). The 4 circular holes allowed the skin of the lower leg
and blue color values. Chromatic red represents the change to protrude through the template.
in the color of the wound from a bright red to pale pink as A weighted (3.70-kg) ‘‘sanding sled’’ (24.5 3 8.5 cm)
healing occurs.12 Luminance indicates the change in the with an attached handle was constructed to ensure
consistency of the wound colors from heterogeneous to consistent contact and downward pressure over the
homogeneous over time.12 A counterbalanced technique template and circular holes during infliction. A 24.5 3
for dressing application was used to control for structural 8.5-cm piece of 60-grit autoclaved SandBlaster sandpaper
and physiologic differences of the lower leg that might have (3M, St Paul, MN) was attached to the sled. The sled was
affected the healing rate. All procedures and data centered on the most proximal hole in the template,
collection were performed in a research laboratory. contacting the protruding skin, and pulled in a medial-to-
lateral (1 pass) and then lateral-to-medial (1 pass) direction
Participants to the beat of a metronome (60 beats per minute) for 80
passes. I used pilot testing to establish the number of passes
Ten healthy women (age 5 22.20 6 1.81 years, height 5
to achieve appropriate wound depth. Appropriate wound
165.86 6 6.55 cm, mass 5 66.90 6 14.22 kg) and 6 healthy
depth was defined as even bleeding from the circular
men (age 5 21.50 6 0.55 years, height 5 180.34 6 2.77 cm,
wound, indicating removal of the epidermis, extending
mass 5 86.94 6 11.29 kg) volunteered for the study. All
partially into the dermis. This procedure was repeated on
participants completed a preparticipation questionnaire to
the next distal wound and continued until all wounds were
determine eligibility for the study. They were excluded if
inflicted. After infliction of the 4 wounds, the template and
they reported ever having diabetes mellitus, peripheral
sandpaper were removed and discarded using Occupational
vascular disease, deep venous thrombosis, bleeding or
Safety and Health Administration guidelines.14 I used
clotting disorders, dermatitis, excessive scarring, cancer,
direct pressure with sterile gauze pads to control bleeding
systemic bacterial infection, immune suppression, hyper-
of each abrasion.
tension, cardiac disease, or hypersensitivity to pain or
allergies to latex, polyurethane, gelatin, pectin, or lidocaine Each abrasion was cleansed by irrigation with warm tap
or prilocaine anesthetic cream. Each volunteer read and water through a 35-mL syringe and 19-gauge hub blunt
completed an informed consent form approved by the needle, and the periwound tissues were dried by patting the
university’s institutional review board, which also ap- area with sterile gauze. In accord with the assigned group, I
proved the study, and had any questions answered before applied the dressings following manufacturer’s instructions
data collection. The reported nonkicking leg served as the in a proximal-to-distal direction on the lower leg. No
test limb. dressing or medication was applied to the control wound
throughout the study. Each participant was provided with
prepackaged or precut replacement dressings to use if any
Testing Procedures fell off or lost their barrier capability between wound-
Wound-Infliction Protocol. The partial-thickness wound imaging days. Volunteers also were given precut strips of
model for this study was adapted from Claus et al1 and Cover-Roll to use if the edges of any dressing began to
Hopkins et al13 and further developed through pilot testing. loosen. Wound care instructions and guidelines for
Occupational Safety and Health Administration guidelines14 identifying signs of infection, including contact informa-
were followed during all procedures, and a physician was on tion for the principal investigator, were given to each
call during the wound-infliction procedure. person. Participants were instructed to continue their
Twenty-four hours before wound infliction, each partic- normal daily activities, including showering, bathing, and
ipant shaved the lower part of the nonkicking leg with a physical activity (excluding aquatics) during the study
disposable razor to prevent any irritation. Two hours period. They were provided with PowerFlex (Andover
before infliction, volunteers reported to the laboratory. Coated Products, Salisbury, MA) to protect the dressings
Each participant was placed in a seated position with the during showering and bathing.
nonkicking leg extended on a table, parallel to the surface. Wound-Imaging Protocol. Digital imaging of the wound
I applied an anesthetic ointment (Hi?Tech Lidocaine and surface was performed on postwound days 1, 3, 5, 7, 10,
Prilocaine Cream [2.5% lidocaine and 2.5% prilocaine]; and 14 within a 1- to 2-hour window based on the time of
Hi?Tech Pharmacal Co, Inc, Amityville, NY) to a 21 3 10- wound infliction. The imaging procedure began at the most
cm area on the lateral lower leg and covered this area with proximal wound on the lower leg with removal of the
BlisterFilm. During the 2 hours, volunteers were allowed dressing. I irrigated the wound with warm tap water
to continue their daily activities, excluding bathing, through a 35-mL syringe and 19-gauge hub blunt needle
showering, and all physical activity. After 2 hours, the until all exudate, eschar, and dressing residue were

Journal of Athletic Training 601

 darkest portion of red color for perimeter measurements.
Area measurements represented the selected wound area
and bounding box automatically calculated by Photo-
shop. The rectangular box was calculated from the
maximum height and width points of the selected wound
area. The box was measured in pixels and then converted
to square centimeters. If no differences in the colors were
detected visually, the wound was considered fully
contracted or healed. After the wound perimeter was
traced manually, the selected portion of the image
(wound area) was used to automatically calculate red,
green, and blue color values. When the wound was
considered fully contracted, the largest portion of the
original wound was selected (approximately 49 000 pixels
5 4.75 cm2) and used for red, green, and blue color
Figure 1. Digital image of abrasions on day 1. values. Wound color (chromatic red) and luminance were
calculated from the color values of the defined wound
area. The wound width and height measurements and red,
removed from the wound bed and perimeter. If necessary,
green, and blue color values were entered into Microsoft
sterile tweezers were used to remove loose eschar from the
Excel 2003 (Microsoft Corp, Redmond, WA). Wound
wound perimeter. I avoided direct contact with the wound
area was calculated using the formula of width 3 height.
bed and did not observe damage to the tissues (bleeding) Chromatic red and luminance were calculated using the
with irrigation. Sterile gauze pads were used to dry and following computations adapted from Hansen et al15:
remove dressing residue from the periwound tissues. I
continued this procedure with the next distal wound until r ~ ð100 | RÞ=ðR z G z BÞ ð1Þ
all 4 wounds were cleansed and periwound tissues dried.
The participant was placed with the involved leg in a
parallel position directly over the base of a Kaiser RS-2XA L ~ ðR z G z BÞ=3 ð2Þ
camera stand with a RB-218-HF Lighting Unit (Kaiser
Fototechnik; GmbH & Co, Buchen, Germany) equipped with where R 5 red, G 5 green, B 5 blue, r 5 chromatic red,
two 18-W Dulux fluorescent lamps and reflectors. A Nikon and L 5 luminance.
DX1 camera with a manual 60-mm lens (Nikon Corp, Intrarater (test-retest) reliability using the intraclass
Chiyoda-ku, Tokyo, Japan) was mounted 45 cm perpendic- correlation model (3,1) was calculated to determine the
ular to the lower leg on the stand. A 142 3 40-mm QPCard 101 consistency of wound contraction, chromatic red, and
reference card (QPCard AB, Goteborg, Sweden) with neutral luminance measurements.16 I randomly selected 5 partic-
white, gray, and black patches was used to calibrate color ipants and analyzed all images (720) during 1 session and
values. Starting at the most proximal wound, the reference again during a second session 45 days later. All images
card was placed on a nonadherent TELFA pad (Covidien) were analyzed following the same format. Measurement
next to the wound on the periwound tissues. A label was recording was blinded with the use of new data sheets. The
placed on the periwound tissues to identify the volunteer, day, intraclass correlation coefficient (ICC) was .97 (SEM 5
and wound and image number. Three digital images (3008 3 0.164 cm2) for wound contraction, .83 (SEM 5 0.408) for
1960 pixels, tagged image file format) with standardized chromatic red, and .94 (SEM 5 0.231) for luminance.
camera settings (International Organization for Standardiza-
tion 200 and f-stop 6.3) were recorded of each wound, for a Statistical Analysis
total of 12 images per session (Figure 1). Manual focus on the
center of the original wound area was performed with the first Data from postwound days 1, 3, 5, 7, 10, and 14 were
image and remained consistent for the next 2 images. The used in the analysis. The mean of the 3 images for wound
lighting unit and ambient lighting remained consistent for all contraction, color (chromatic red), and luminance were
participants. This procedure was continued with the next used for the data analysis. A 4 3 6 repeated-measures
distal wound until all images were recorded. I reapplied the analysis of variance (dressing by time) was used to compare
dressings in the same order as previously assigned. the dressings (film, hydrogel, and hydrocolloid) and
control with the change in wound contraction, color, and
Data Reduction and Processing luminance over time, respectively. I performed a Tukey
post hoc test for comparisons. Alpha level was set a priori
The images were entered into Adobe Photoshop CS2 at #.05 for all analyses. The data were analyzed using the
(Adobe Systems, Inc, San Jose, CA) for semiautomatic SPSS statistical software package (version 15.0; SPSS Inc,
analysis. Each image was adjusted for color using the Chicago, IL).
reference card in the image. Wound area was determined
by tracing the wound perimeter with the mouse cursor (9 RESULTS
pixels, round diameter, single-tipped brush). Wound
perimeter was defined as visual differences between the
Wound Contraction, Color, and Luminance
colors of red and pale pink in each image. Each image
was viewed at 100% size (5 895 680 pixels) to analyze the Means and SDs for wound area, color, and luminance
color differences. I traced the outside border of the are presented in the Table. Additionally, only the clinically

602 Volume 43 N Number 6 N December 2008

 a
Table. Wound Area, Chromatic Red, and Luminance by Dressing Over Time (Mean 6 SD) (n = 16)
Dressing
Day Measure Film Hydrogel Hydrocolloid Control
1 Wound area 8.52 6 1.01 9.26 6 1.10 8.67 6 1.14 8.60 6 1.57
Chromatic red 54.30 6 7.53 47.62 6 3.16 61.16 6 10.97 58.19 6 12.57
Luminance 131.19 6 15.51 150.99 6 12.98 118.51 6 20.40 120.19 6 25.97
3 Wound area 8.21 6 1.09 8.84 6 1.14 8.14 6 1.18 8.38 6 1.68
Chromatic red 68.52 6 11.35 57.23 6 8.94 69.86 6 8.91 67.40 6 8.78
Luminance 100.46 6 21.64 125.11 6 23.66 97.46 6 18.78 98.39 6 15.16
5 Wound area 6.89 6 1.56 8.59 6 1.06 6.83 6 1.78 7.75 6 1.56
Chromatic red 63.06 6 9.44 59.59 6 6.07 58.80 6 6.33 63.88 6 7.95
Luminance 109.36 6 18.73 115.62 6 14.49 117.58 6 19.75 106.55 6 16.21
7 Wound area 4.67 6 1.69 7.53 6 1.40 4.21 6 2.63 6.71 6 1.56
Chromatic red 55.75 6 8.27 56.88 6 4.69 52.05 6 5.04 58.81 6 7.31
Luminance 126.07 6 22.15 119.32 6 12.41 133.68 6 16.83 116.27 6 14.48
10 Wound area 2.24 6 2.26 4.17 6 2.75 1.11 6 1.95 5.02 6 1.74
Chromatic red 50.52 6 7.90 50.73 6 5.08 48.30 6 6.51 61.40 6 8.91
Luminance 137.59 6 24.22 136.29 6 18.54 145.53 6 19.07 111.71 6 18.57
14 Wound area 0.94 6 1.31 0.98 6 1.75 0.17 6 .52 3.21 6 1.59
Chromatic red 47.33 6 5.08 44.65 6 2.18 44.99 6 2.38 57.03 6 11.64
Luminance 143.57 6 18.73 151.89 6 12.43 152.22 6 13.44 119.91 6 20.79
a
Area (cm2); chromatic red 5 (100 3 red)/(red + green + blue); luminance 5 (red + green + blue)/3.

meaningful results for the day-by-dressing interaction are 14. The F, HG, and HC demonstrated greater contraction
presented and discussed. than C on day 14. The associated Cohen d values for day 7
Area. A day-by-dressing interaction effect was noted for comparisons were 1.05 (F versus C), 1.54 (F versus HG),
wound contraction (F15,225 5 9.486, P , .001). The Tukey 0.97 (HC versus C), and 1.33 (HC versus HG). For day 10,
honestly significant difference test (mean significant Cohen d values were 1.16 (F versus C), 0.65 (F versus HG),
difference [MSD] 5 1.44) revealed that the film (F) and 1.79 (HC versus C [day 10]), 0.98 (HC versus C [day 14]),
hydrocolloid (HC) dressings produced greater wound and 1.08 (HC versus HG). For day 14, Cohen d values were
contraction than the hydrogel (HG) dressing and control 1.31, 1.12, and 2.18 for F, HG, and HC versus C,
(C) on days 7 and 10 (the Table and Figure 2). On day 10, respectively. Overall, the HC produced the greatest amount
the HC also produced greater contraction than C on day of wound contraction (0.17 6 0.52 cm2) compared with the

Figure 2. Mean wound areas (cm2) for dressings and control over time. Differences were demonstrated as follows: a between film and
hydrogel, b between film and control, c between hydrocolloid and hydrogel, d between hydrocolloid and control, e between film
f g h i
and hydrogel, between film and control, between hydrocolloid and hydrogel, between hydrocolloid and control, between hydrocolloid
j k l
and control (day 14), between hydrogel and control, between film and control, and between hydrocolloid and control.

Journal of Athletic Training 603

 a
Figure 3. Mean wound color (chromatic red) for dressings and control over time. Differences were demonstrated as follows: between
hydrocolloid and control (day 10), b between hydrogel and control, c between film and control, d between hydrocolloid and control,
e
between hydrocolloid and control (day 14), f between hydrogel and control, g between film and control, and h between hydrocolloid
and control.

F (0.94 6 1.31 cm2) and HG (0.98 6 1.75 cm2) dressings HC versus C, respectively. Overall, the HC dressing
and C (3.21 6 1.59 cm2). produced the greatest measure of luminance (152.22 6
Color. A day-by-dressing interaction effect was demon- 13.44) compared with the HG (151.89 6 12.43) and F (143.57
strated for chromatic red (F15,225 5 6.42, P , .001). The 6 18.73) dressings and C (119.91 6 20.79).
Tukey test (MSD 5 8.39) revealed that the HC dressing
was associated with a lower measure of chromatic red on DISCUSSION
day 7 compared with C on day 10 (the Table and Figure 3).
The F, HG, and HC displayed lower measures of The results support the hypothesis that occlusive dressings
chromatic red than C on days 10 and 14. On day 10, the were more effective than no dressing in the healing of partial-
HC also produced a lower measure of chromatic red than thickness abrasions measured by wound contraction, color,
C on day 14. The associated Cohen d value for the day 7 and luminance. I observed differences between the dressings
comparison was 1.08 (HC versus C [day 10]). For day 10, and control on days 7, 10, and 14. The film, hydrogel, and
Cohen d values were 1.08 (F versus C), 1.23 (HG versus C), hydrocolloid produced greater rates of contraction and
1.41 (HC versus C [day 10]), and 0.77 (HC versus C [day measures of luminance and lower measures of color than no
14]). For day 14, Cohen d values were 0.9, 1.23, and 1.19 dressing (Figures 2 through 4). These findings correspond to
for F, HG, and HC versus C, respectively. Overall, the HG the greatest amount of healing with each of these measures,
dressing produced the lowest measure of chromatic red greater wound contraction and luminance and less color.
(44.65 6 2.18) compared with the HC (44.99 6 2.38) and F Between dressings, the film and hydrocolloid produced
(47.33 6 5.08) dressings and C (57.03 6 11.64). greater contraction than the hydrogel on days 7 and 10.
Luminance. A day-by-dressing interaction effect was Overall, the findings suggest that hydrocolloid dressings were
noted for luminance (F15,225 5 9.41, P , .001). The Tukey most effective in the healing of partial-thickness abrasions in
test (MSD 5 16.65) revealed that the HC produced a greater this study.
measure of luminance on day 7 compared with C on days 7 Since the early 1960s, authors have demonstrated that
and 10 (the Table and Figure 4). The F, HG, and HC occlusive dressings are beneficial to the healing process in
resulted in greater measures of luminance than C on days 10 various wounds, but the exact mechanisms are not entirely
and 14. On day 10, the F and HC also produced greater known. Occlusive dressings maintain an environment
measures of luminance compared with C on day 14. The conducive to healing by trapping moisture next to the
associated Cohen d values for the day 7 comparisons were wound bed, producing a moist wound environment.17
0.93 (HC versus C [day 7]) and 1.03 (HC versus C [day 10]). Occlusive dressings and a moist wound environment may
For day 10, Cohen d values were 1.0 (F versus C [day 10]), enhance fibroblast and keratinocyte proliferation and
0.65 (F versus C [day 14]), 1.11 (HG versus C), 1.5 (HC migration,17–21 the inflammatory response,22 and autolytic
versus C [day 10]), and 1.07 (HC versus C [day 14]). For day debridement6; stimulate angiogenesis23,24; increase collagen
14, Cohen d values were 1.0, 1.56, and 1.54 for F, HG, and synthesis25; provide thermal insulation4,5; prevent tissue

604 Volume 43 N Number 6 N December 2008

Figure 4. Mean wound luminance for dressings and control over time. Differences were demonstrated as follows: a between hydrocolloid
and control, b between hydrocolloid and control (day 10), c between hydrogel and control, d between film and control, e between film and
control (day 14), f between hydrocolloid and control, g between hydrocolloid and control (day 14), h between hydrogel and control,
i j
between film and control, and between hydrocolloid and control.

necrosis and wound desiccation7; lower rates of cross- cost-effective and less labor intensive, and can be changed
contamination and infection5; and reduce levels of pain.4 In without interrupting the healing process.4
comparison, nonocclusive dressings can promote tissue The goal in selecting and using a dressing is to create an
desiccation and increase the risk of infection, delaying the environment that allows for maximum activity of enzy-
normal healing process.4,5 matic and cellular systems to promote healing.5 Although
The finding of an increased rate of healing with occlusive film, hydrogel, and hydrocolloid dressings are indicated for
dressings is consistent with past investigations and supports partial-thickness abrasions, I found that hydrocolloid was
the use of these dressings by athletic trainers in the the most effective. This could be due to the ability of
management of acute abrasions.1,6,7,17–25 Although film, hydrocolloids to manage greater amounts of exudate,
hydrogel, and hydrocolloid occlusive dressings vary in their provide greater insulation and protection to the wound bed
construction and purpose, each provides advantages over based on the thickness of the dressing, and melt within the
nonocclusive dressings (ie, sterile gauze, adhesive strips, or wound bed to produce a more effective moist healing
patches) or no dressing. Occlusive dressings increase rates of environment.4 Hydrocolloids increase the rate of healing
re-epithelialization21 between 30% and 45% and heal acute and allow earlier return to athletic and recreational
wounds an average of 3 to 4 days faster20 than nonocclusive activities. The ability of hydrocolloids to remain on the
dressings do. Partial-thickness abrasions extend through the wound bed during normal daily and athletic activities for
epidermis and possibly the superficial dermis and typically up to 7 days increases patient compliance and decreases the
heal through a reparative process of re-epithelialization, frequency of dressing changes compared with nonocclusive
normally completed within 7 to 14 days.26 I did not observe dressings. Perhaps most important, hydrocolloids can
full contraction in any wounds before day 7. On day 7, there lessen the amount of time and the degree to which the
were 3 (18%) wounds under the hydrocolloid and 1 (6%) wound is susceptible to cross-contamination and infection.
under the film that were healed or fully contracted. On day The emergence of methicillin-resistant Staphylococcus
10, there were 9 (56%) wounds under the hydrocolloid, 7 aureus (MRSA) in the athletic population and the reported
(43%) under the film, and 2 (12%) under the hydrogel that risk factors of direct contact with an infected individual
were healed. On day 14, there were 14 (87%), 11 (68%), and and the presence of skin trauma (eg, abrasions) encourage
10 (62%) wounds under the hydrocolloid, hydrogel, and film, the use of hydrocolloids for abrasions.27 Prevention
respectively, that were healed. Over the 14-day study period, guidelines in the literature to address these risk factors
no control wounds achieved full contraction. Occlusive include proper cleansing of a wound and application of a
dressings are permeable, semipermeable, or impermeable to dressing to protect and guard against the introduction of
water, water vapor, and oxygen, but each provides a physical bacteria into the wound.27,28 Hydrocolloid dressings
barrier against cross-contamination and infection from provide a physical, impermeable barrier from the external
external microorganisms.4 The dressings protect the wound environment and protect the wound bed against penetra-
bed from further trauma, increase patient compliance, are tion of microorganisms. However, the dressings should not

Journal of Athletic Training 605

be used on clinically infected wounds (more than 105 computer imaging systems and software are medically
organisms per gram of tissue).4 The use of hydrocolloid sound and cost-effective to use in assessing these measures.
dressings may prevent or lessen the transmission of Others31 have stated that fully automatic computerized
pathogens such as MRSA. Additional research is needed assessment systems are not essential due to the variability
to determine their effectiveness in reducing transmission of in wound assessments caused by the absence of consistent
Staphylococcus and Streptococcus pathogens and to char- measurement factors. Semiautomatic assessments similar
acterize the risk factors of direct contact and skin trauma in to the methods in this study are common and appear
athletic settings. clinically relevant in wound-healing investigations. Semi-
Past authors8,9 examining the effects of occlusive automatic methods are used with other computerized
dressings have used animal models as well as chronic photogrammetry systems and have demonstrated accept-
wounds when examining measures of healing. The differ- able psychometric properties in past investigations.32 The
ences in healing among species, wound size and depth, results of this study demonstrate high reliability with
location, and mechanism of injury can significantly affect semiautomatic assessment of wound contraction, chromat-
the clinical outcomes of these studies.8,9 These differences ic red, and luminance (ICC 5 0.97, 0.83, and 0.94,
and the limited number of investigations with acute respectively). From these values, it appears these measure-
wounds1,2 make comparisons among studies difficult. To ments could provide researchers with an accurate, cost-
investigate the effects of dressings on wound healing, it effective method to assess acute wound healing. This
appears that if standardized wounds were inflicted, the investigation is one of the few to use a standardized wound
differences in healing could be attributed to the interven- model and semiautomatic processing method to examine
tion, rather than wound variability.13 Several authors healing rates among occlusive dressings.
developed a superficial wound model for use with human
subjects (forearm) that controls for wound variability.1,13 Limitations
Claus et al1 found that film and hydrocolloid dressings
reduced the area of standardized abrasions more effectively The wound model used in this study is limited to partial-
than adhesive strips or no dressing over a 10-day period. thickness abrasions on the lateral lower leg. Rates of
The model in this study was similar and included healing may differ for other areas of the body. The
standardized abrasions to allow comparisons among the occlusive dressings are limited to films, hydrogels, and
dressings. The data and previous work from Claus et al1 hydrocolloids. These dressings are widely available to
are a start in the controlled investigation of the effects of athletic trainers, and recommendations for use based on
dressings on abrasions. wound characteristics (eg, color, amount of exudate) are
Accurate assessment of wound characteristics over time is remarkably similar among manufacturers. Wound area
essential to determine the progression of healing and the measurements (width 3 height) used in the analysis
effectiveness of interventions.29,30 However, few protocols in represented the relative size of the wound rather than the
the literature describe the terminology, methods, or specific specific shape of the wound. This method was found to be
variables to monitor.10,11 Numerous changes occur within reliable and reproducible to examine wound contraction
the wound bed as healing progresses, and measures such as over time. Blinded assessment was not performed with
changes in wound size and color, formation of exudate, and digital imaging of wound healing. Upon removal, each
development of slough or eschar can be observed subjective- dressing left signs on the skin indicating its presence,
ly. In previous work, wound area, color, and luminance have resulting in the inability to assess in a truly blinded
been objectively assessed to investigate the effectiveness of fashion.33 It should be noted that the objective nature of
various dressings1,12,15,31 and laser therapy13 on healing. the semiautomatic assessment method likely decreased this
These characteristics have been described as important and effect on the results. Variations among the participants
clinically relevant indicators of wound healing. New growth with regard to tissue elasticity may have caused differences
of epithelium decreases the area of a partial-thickness in the amount of tissue that protruded through the holes of
abrasion over time as epithelium migrates across the wound the template during wound infliction.13
bed from the edges and reservoirs in hair and sweat and scent The removal of the dressings at days 1, 3, 5, 7, 10, and 14
glands.10,31 The wound color changes from bright red, for imaging may have interrupted the healing process.
indicating granulation tissue, to pale pink as cellular and However, this assessment is a more objective measure of
chemical activities slow, causing a decrease in the measure of healing.2 The dressings in this study are designed to remain
chromatic red as healing progresses.12,13 Consistency in the on the wound bed from 3 to 7 consecutive days in the absence
color of the wound, initially heterogeneous, becomes more of leakage or signs of infection. To lessen interruption of
homogeneous over time with healing, resulting in an increase healing, I performed cleansing, digital imaging, and redress-
in the measure of luminance.12,13 In contrast to Hopkins et ing of the wounds in a 20- to 30-minute window. Although
al,13 who investigated laser therapy and healing, I found more clinically relevant, using the measure of days to
differences in chromatic red and luminance, indicating complete healing (when dressings can be removed without
healing of the wounds. These results and those of oth- trauma and pain) introduces the health care provider’s error
ers1,12,15,31 appear to support the use of wound contraction, and bias resulting from skill and experience in dressing
color, and luminance as quantitative measures of healing in removal.2 The wounds inflicted in this study were partial
future studies. thickness in depth and were healed by the progression of
Wound area, color, and luminance have been document- epithelium from the wound edges and reservoirs of
ed with ruler-based assessment, wound tracing, stereo- epithelium. Some authors12 have suggested that these
photogrammetry, and automatic and semiautomatic com- wounds demonstrate minimal contraction and that area is
puterized systems. Some15 have suggested that existing not a relevant measure of healing.

606 Volume 43 N Number 6 N December 2008

CONCLUSIONS 14. US Department of Labor, Occupational Safety & Health Administration.
Bloodborne pathogens and needlestick prevention OSHA standards.
Film, hydrogel, and hydrocolloid occlusive dressings http://www.osha.gov/SLTC/bloodbornepathogens/standards.html. Ac-
demonstrated a faster rate of healing of standardized, cessed September 5, 2006.
partial-thickness abrasions of the lateral lower leg on 15. Hansen GL, Sparrow EM, Kokate JY, Leland KJ, Iaizzo PA. Wound
postwound days 7, 10, and 14 compared with no dressing. status evaluation using color image processing. IEEE Trans Med
Overall, hydrocolloid dressings are recommended in the Imaging. 1997;16(1):78–86.
management of these wounds. These assessment methods 16. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater
and data are a focused start in the development of reliability. Psychol Bull. 1979;86(2):420–428.
evidence-based guidelines for athletic trainers to improve 17. Winter GD. Formation of the scab and the rate of epithelization of
superficial wounds in the skin of the young domestic pig. Nature.
health care services to various populations. Future
1962;193:293–294.
investigators should continue to examine the effect of 18. Alper JC, Tibbetts LL, Sarazen AA Jr. The in vitro response of
occlusive dressings on measures of healing, infection, and fibroblasts to the fluid that accumulates under a vapor-permeable
pain with standardized acute wounds to determine the membrane. J Invest Dermatol. 1985;84(6):513–515.
most appropriate dressing for healthy populations. Addi- 19. Katz MH, Alvarez AF, Kirsner RS, Eaglstein WH, Falanga V.
tional studies are needed to determine the practicality (use Human wound fluid from acute wounds stimulates fibroblast and
in competitive athletes), cost-effectiveness (supply costs, endothelial cell growth. J Am Acad Dermatol. 1991;25(6, pt 1):
personnel time, and follow-up), and level of compliance 1054–1058.
with the use of occlusive dressings in the clinical setting. 20. Madden MR, Nolan E, Finkelstein JL, et al. Comparison of an
occlusive and a semi-occlusive dressing and the effect of the wound
exudate upon keratinocyte proliferation. J Trauma. 1989;29(7):924–930.
ACKNOWLEDGMENTS 21. Eaglstein WH, Mertz PM. New method for assessing epidermal
I thank Matt Diohep of Covidien (Mansfield, MA) for wound healing: the effects of triamcinolone acetonide and poly-
donating dressings used in this study. ethelene film occlusion. J Invest Dermatol. 1978;71(6):382–384.
22. Rovee D, Kurowsky C, Labun J, Downes A. Effect of local wound
environment on epidermal healing. In: Maibaich H, Rovee D, eds.
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Joel W. Beam, EdD, LAT, ATC, contributed to conception and design; acquisition and analysis and interpretation of the data; and
drafting, critical revision, and final approval of the article.
Address correspondence to Joel W. Beam, EdD, LAT, ATC, University of North Florida, Brooks College of Health, Athletic Training &
Physical Therapy Department, 1 UNF Drive, Jacksonville, FL 32224. Address e-mail to [email protected].

Journal of Athletic Training 607