CME-Article

Submitted: 27.12.2013
Accepted: 13.3.2014
Joachim Dissemond has served as consultant and/or paid speaker for and/or
participated in clinical trials sponsored by
companies including 3M , B. Braun, BSN,
Coloplast, Convatec, Draco, Har tmann AG,

DOI: 10.1111/ddg.12351

Modern wound care practical aspects

of non-interventional topical treatment
of patients with chronic wounds

KCI, Lohmann & Rauscher, Medoderm,

Sastomed, Systagenix, UCB and Urgo.
Matthias Augustin has ser ved as consultant
and/or paid speaker for and/or participated
in clinical trials sponsored by companies
that manufacture drugs used for the treatment of psoriasis including Abbott, Almirall,
Amgen, Biogen Idec, Celgene, Centocor,
Janssen-Cilag, Leo, Medac, MSD (formerly
Esse x, Schering-Plough), Novar tis, Pfizer
(formerly Wyeth). Sabine Eming has been
advisor to Paul Har tmann AG. Tobias George has received honoraria for lectures
from Urgo and Lohmann & Rauscher. Hauke

Joachimhas
Dissemond1
Matthias
Schumann
been advisor to,Birken
AG.

Augustin2,
Sabine
A. Markus
Eming3
,
Thomas
Horn, Sigrid
Karrer,
Stcker
TobiasnoGoerge4,
Thomas
declare
conflict of interest.

Horn5,
Sigrid Karrer6 , Hauke Schumann7, Markus Stcker8, for
the working group for wound
healing (AGW ) of the German
Society of Dermatology (DDG)

(1) Cl inic for Dermatology, Univer sity

Hospital Essen, Germany
(2) Institute for Health Services
Research i n Der matology and
Healthcare (IVDP), Uni versity Medical
Center, Hamburg- Eppendorf
(3) Department of Dermatology,
Allgemeine
Universit y of Cologne, Cologne,
Dermatologie und Venerologie, University
Hospital
GermanyMnster, Germany
(5)
Clinic
policlinic for Dermatology,
(4)
Klinik and
frand
Hautkrankheiten,
Venereology
Allergology, Helios
Klinikum Krefeld, Germany
(6) Department of Dermatology,

Summar y
The treatment of patient s with chronic wounds is becoming increasingly complex. It
was therefore the aim of the members of the working group for wound healing (AGW)
of the German Society of Dermatology (DDG) to report on the currently relevant aspects of non-interventional, topical wound treatment for daily prac tice.
Beside necessar y procedures, such as wound cleansing and dbridement, we describe commonly
used wound dressings, their indications and practical use. Modern antiseptics, which
are currently used in wound therapy, usually contain polyhexanide or octenidine.
Physic al methods, such as negative-pressure treatment, are also interesting options.
It is always impor tant to objectify and adequately treat pain symptoms which often
affect these patients. Mod ern moist wound therapy may promote healing, reduce
complicati ons, and improve the qualit y of life in patients with chronic wounds. Together with the improvement of the underlying c auses, moder n wound therapy is an
important aspect in the overall treatment regime for patients with chronic woun ds.

Introduction

Germany
Germany
(8) Depar tment of Dermatology,
(7)
Department ofBochum,
Dermatology,
Ruhr-University
Germany.

Physiological wound healing is a complex pro cess. The primary goal of this t emporally and regionally cont rolled series of events is to restore tissue integrity and func tion. In regard to the skin, the wound healing process encompasses a time period
which depends on many factors and which may b e divided into several con secutive
phases [1]. There is still no standard ized, accepted consensus on the definition of
ch ronic wounds. Along with du rat ion, there are problems owing to the h ighly variable factors related to the pat hophysiology. Most cu rrent classifications are based
only on time. In the following, chronic refers to wounds which have persisted for
more t han eight weeks [2].

Freiburg
University Hospital,
Section Editor
Pr of. Dr. Jan C. Simon, Leipzig
Conflict of interest

Even if there is scant scientific evidence on the effectiveness of wound care

products in accelerating the healing of chronic wounds, there is consensus
among experts in the field concerning the use of modern wound care products,
especially in regard to improving quality of life [2]. New discoveries in topical

Universit y Hospi tal Regensbur g,

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Chronic wounds are presently defined

as those which have per sisted for more
than eight weeks.

wound care have made the treatment of patients w ith chronic wounds more
complex. Thus it was the aim of the working group for wound healing (AGW)
of the German Society of Dermatology (DDG) to present a review article on the
current, relevant aspects of topical, non-interventional wound care for use in
daily practice.

Modern wound care

Today it is gen erally accepted that

proper wound car e should aim to
create a moist wound milieu.

Before treatment of any patient wit h a ch ronic wound b egins, the relevant underlying factors should be diagnosed and, whenever possible, t reated. Wound healing
may be promoted by topical wound care. The concept of moist wound care was
pioneered by George D. Winter. In pre clinic al studies done in 1962, he showed that
a moist wound milieu promoted wound healing [3].

Wound cleansing
At the beginning of wound therapy, it is often necessary to perform dbridement, or at least to cleanse the wound. In addition to necrotic areas, fibrin,
crusts, or dressing remnants must also be removed [4]. For wounds that are
to be cleansed when changing the wound dressing, Ringer solution or physiological saline solution are the cleansers of choice. Sterility is no longer
ensured once the container has been opened. Solutions which do not contain
preservatives must be used immediately. For practical purposes, it is often
more feasible to use cleansing solutions which contain preservatives, such as
polyhexanide, or which are completely used up in a single dressing change.
Care should be taken to ensure that the solution has been warmed to body
temperature [5].
The use of tap water is st rongly debated among experts [6]. T he German law
on the prevention of in fection, and t he recommendations of the Commission for
Hospital Hygiene and Infection Prevention (KRINKO) of the Robert Koch Institute (RKI), have unequivocally stated that only sterile cleansing liquids may be used
for wound care. T he use of tap water is only permissible in Germany if filters with
a maximum pore size of 0.2 m are used [7].
Patients rarely pu rchase such filters, given their expense. Yet, for doctors
offices and wound clinics, they represent a viable alternative if one wishes to continue using tap water.

Dbridement
Dbridement should be as radic al as necessary, but as gentle as possible. Tre atment
of chronic wounds often begins with mechanical dbridement. Mechanical dbridement using sterile compresses is often su fficient for removal of loosely adherent
coatings, such as fibrin.
For painfu l wounds, in partic ular, one t herapy option is to use a monofilament
fiber product, which involves minimal pain. Firmly adherent coatings and necrotic
areas usually have to be removed surgically. Other alternative s include biosurgical
dbridement with medicinal larvae or physical dbridement with ultrasound, plasma, or laser. These methods are usually only of fered by specialized wound care
centers. In out patient care, especially, autolytic techniques, such as hydrogels and
proteolytic enzymes are used. For effect ive dbridement , it is imperat ive to plan the
necessary pain therapy in advance and to discuss it with the patient [4, 8].

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Table 1 Requirements for modern wound dressings.

Reasonable cost
Conforms to body contours
Atraumatic dressing changes
Absorption of wound exudate (also with compression therapy)
Permeable to oxygen, water vapor, and car bon dioxide
Simple and complete removal
Easy to apply
Mechanical protection
May be cut to size, or available in a variety of shapes and sizes
Protection against microorganisms
Sterile packaging
Prevention of dehydration
Contains hypoallergenic materials
Contains non-toxic mater ials
Thermal insulation

Materials for modern wound care

In everyday practice, dressings are recommended as part of modern moist wound care
for most chronic wound patients. No single dressing is optimal for all wound types
(Table 1). In Germany, there are currently more than 1,000 different medical products
for use in chronic wounds, and many manufacturers have their own declarations. This
makes the steadily growing market for such products increasingly difficult to navigate
(Figure 1). The following discussion focuses on only a few, widely used types of wound
care products and briefly discusses their presumed modes of action [913].

Activated carbon
Activated carbon wound care dressings are made up of fibers consisting of carbonized
cellulose products. The compresses reduce odors and absorb
endotoxins, and t hey
also have bactericidal properties. They are thus esp ecially suitable for foul-smelling
wounds and ulc erated tumors.
T he dressings are placed in the wound and fi xed in place with compresses.
Some of the products available cannot be cut to siz e, as th is would leave activated
carbon in the wound. For wounds with only a limited amount of exudate, the dressing should be moistened regularly. For wounds with a large amount of exudate,
an absorbent secondary dressing should be used and the su rrounding area should
be protec ted against maceration, as currently activated carbon dressings can only
absorb a small amount of moist ure. The d ressing should be changed every 13 days.

Alginate
Alginate products consist of a loose d ressing structure made up of fibers which are
composed of red or brown algae. Af ter contact with sod ium salts present in the
blood or in wou nd secretions, t he alginate fibers absorb t he secretions to form a

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Figure 1 Phase- and exud ate-depend ent use of wound products for the treatment of patients with chronic wounds.

moist hydrophilic gel; bacteria and det ritus are enclosed in the gel structure. The
speed and amount of gel formation depend on the amou nt of exudate absorbed and
the fiber weave. Alginates are capable of absorbing up to 20 times their own weight.
Depending on the product, calcium, zinc, or manganese is supplied to the wound
milieu. Alginates are used for deep, jagged, or heavily exuding wounds,
either for
wou nd cleansing or to promote granulation. Given that alginates also have hemostinstanc e, following
atic effects, they are also suitable for achieving hemostasis, for
surgical dbridement.
Depend ing on the type of wound and the amount of exudate, either dry or
moist alginate is applied. Compresses may be placed in deep wou nds and po cket
wounds; tamponade may also be used. For heavily exudative wounds, it is advisable
to use an absorbent secondary d ressing for example a superabsorber. For clinically
infected wounds, the dressing should be changed daily. For all other wounds, a new
dressing should be placed every 25 days, depending on t he amou nt of exudate.

Biosurgery
Biosurgery refers here to the treatment of wounds wit h med ical grade maggots.
Species that are suitable for use in biosurgery include larvae belonging to the Lucilia
sericata (gold fly), as they are capable of performing highly selective dbridement .
Biosurgical dbridement does not cause bleed ing, and is associated with minimal or no pain. Fly larvae have the potential for lysis of bacteria, includ ing me thicillin-resistant Staphylococcu s au reus (MRSA). The larvae are placed direc tly on

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t he wound. If free-roaming larvae are used, a cage must be built around the wound
using t he net that comes wit h the larvae and gel strips or stoma paste. Nowadays,
fly larvae are more common; these come contained in a BioBag. Depending on the
wound shape, the bag should be moved every day, as it is only ef fective on the area
over which it is directly placed. Highly absorbent compresses should be used as a
secondary dressing. The dressing should be changed after 35 days.

Chitosan
Chitosan is a biopolymer that is derived from chitin. It is available in wound dressings or as a spray. It is believed to promote various aspec ts of wound healing,
given its positively charged surface. Chitosan products may be used in all phase s of
wound t reat ment, af ter adequate dbridement has been performed. They may also
be used for achieving hemostasis af ter surgical dbridement .
T he wound dressing shou ld be c ut to size before being plac ed on the wou nd.
W hen using the spray, it must be allowed to dry for at least 90 seconds before
applying t he secondary dressing. Depending on the type of product, the dressing
should be changed every 13 days.

Honey
Honey wound care preparations come in tubes or as impregnated dressings.
The osmotic effect, leading to wound dehydration, and low pH values, as well
as the release of small amounts of hydrogen peroxide and methylglyoxal, explain its antimicrobial properties as well as the often severe pain reported during
treatment.
G ive n that honey is a natural product, its effectiveness varies dep ending on
the source of the produc t and the proc essing method s u sed. Honey-based produc ts are u sed for wounds with a small amount of exudate for osmotic dbride ment and elimination of bac teria. The se products should be applied to the
wound only, tak ing c are to avoid th e su rrounding area. How often to change the
d ressing depends on how quick ly the honey is diluted by the exudate. Honey is
water-soluble and can be washed off during dressing changes, which are done
every 13 days.

Hyaluronic acid
Hyaluronic acid wound dressings are available as gel, fiber compresses, microgranules, and sprays; hyalu ronic acid products may also be used for tamponade. Hyaluron ic acid forms a hydrophilic gel upon contact with wound exudate.
Products contain ing hyaluronic acid are often used for wounds w ith a large amount
of exudate to promote granulation and for wound cleansing.
may be applied in its dry form, or combined with Ringer solution; gel formation is absolutely essential for the release of hyaluronic acid. The wound should
be covered with a secondary dressing. The dressing should be changed after
13 days.

Hydrofiber dressings
Hydrofibers or aqua fibers are composed of sodiu m carboxyl cellulose. F luid absorpt ion occ urs vertically on ly; no fluid should be released horizont ally. This is

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intended to avoid maceration about the wound margins. Hydrofiber dre ssings can
rapidly absorb up to 40 times their weight in ex ud ate.
After absorbing the wound exudate, the fibers rapidly transform into a firm,
transparent gel. Hydrofiber products may be used for wounds with a large amount of
exudate to promote granulation and for wound cleansing. The hydrofiber dressing is
placed on the wound and may ex tend over the wound margin. The wound should be
covered with a secondary dressing. The dressing should be changed after 13 days.

Hydrogel dressings
Hydrogels are preparations that contain up to 95 % water, along w ith organic additives such as pectin and starch , or gelling agents. Generally, a tube or syringe is
used to plac e the gel in the wound. Hydrogel sheet s, which are placed on semi-permeable fi lms, are available for wou nd therapy. Hydrogels can provide moisture to
the wou nd as well as absorb excess wound exudate. They are especially suitable for
dry wounds to facilit ate autolyt ic dbridement .
Hydrogels may also be combined with various other dressing materials, in order
to keep these or other structures (such as exposed tendons) moist. The hydrogel
sheets are applied in 35 mm thick layers, and are then covered with impregnated
gauze or semi-permeable film dressings. The dressing is changed every day for dbridement; during the granulation phase, the dressing should be changed every 23 days.

Hydrocolloid dressings
Hydrocolloid dressings are made of a polyurethane film or foam, on which there
is a self-adhesive mass made of elastomers and adhesives, with particles that are
capable of swelling to absorb large amounts of exudate (such as gelatin, carboxymethyl cellulose, or pectin). As it absorbs the wound exudate, the hydrocolloid mass liquefies to form a viscous gel. Hydrocolloids are used mainly for superficial wounds, with little exudate, to promote granulation or epithelization.
Self-adhesive hydrocolloid dressings may also be applied without a second ary
dressing; these conform to body contours. The dressing should extend 2 3 cm
beyond the wou nd margin to ensure that it adheres suf ficiently without leading
to mac eration of intact skin. Depending on the amount of exudate, hyd rocolloid
dressings may be left on the wound for 35 days.

Impregnated gauze
Impregnated gauze dre ssings are fiber nets which are coated with oint ments, hydrocolloid, silver, or silicone. The impregnation prevents the dressing from sticking
to the wound base. This type of dressing is primarily used for acute wounds, temporary coverage of chronic wounds, and to prevent the adhesion of other dressing
materials. For chronic wounds, impregnated gauz e is generally unsu itable for use
as the sole wou nd dressing.
Depending on the wound and the product , the dressing should be changed
af ter 17 days.

Collagen
Collagen wound care pro duct s are currently available in fleece, powder, or sponge
form. Different mechanisms of action have been described, especially conc erning
modificat ion of t he pro-inflammatory wound milieu through protease binding.

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Collagen may be used for the promotion of granulation and epitheliz ation,
especially in previously stagnant wou nd healing. Due to t heir hemostatic propert ies, t hey are also used after surgical dbridement. T hey are applied as a dry or
moist dre ssing to the wound surface , extending to the wou nd margin. A secondary
d ressing should be placed over the collagen dressing. Depending on t he product
used, the dressing should be changed after 15 days. Most of t he collagen w ill have
be en absorbed by the time of the d ressing change; it is usually only necessary to
rinse of f any remain ing re sidue.

Foam
Foam dressings are made of non-irritating polyurethane foam. T he surfaces
may be coated for example, with silicone or heat-treated. Foams may be used
for moderately or strongly exuding wounds to promote granulation and epithelization. If the dressing does not come with adhesive border or an additional
superabsorber, it may be cut to size; the wound dressing should extend at least
2 cm over the wound margin. The dressing should be in direct contact with the
wou nd be d.
Depending on t he amount of exudate, the wou nd dressing shou ld b e changed
after 17 days.

Silver
Wound products may contain silver in the form of silver ions, elementary silver, nanocrystalline silver, or anorganic silver complexes. Silver ions are either
firmly attached to the dressing materials or they are released after contact with
wound exudate. Silver ions form complexes w ith bacterial proteins, which lead
to damage of the cell membrane, enzymes, or DNA, and irreversibly damage the
bacteria.
Wound d ressings cont aining silver are often used in patients with infected
wounds. Depending on wh ich materials t he silver is attached to, the size of the
d ressing may be modifie d to fit the individual wound. I n wounds with litt le exudate, the dressing should be moistened regularly. Depend ing on the product, the
d ressing should be changed after 17 days.

Polyacrylate super-absorbers
Polyacrylate super- absorbers consist of neutralized , cross-linked polyacrylic acid
molecules. They can absorb up to 100 times their own weight and store the exudate
in their polymer structure.
Polyacrylate super-absorbers inhibit excessive protease activity and normalize
t he wound micromilieu. They thus support wound cleansing and t he formation of
granulation tissue. Depending on the amount of exudate , the dressing should be
changed af ter 13 days.

Proteolytic enzymes
Proteolytic enzymes enable selective dbridement, which may be accomplished
without pain or ble eding. They are safe, quick and easy to apply. Yet treatment
can t ake a very long time. If the wound margin is not protected, maceration of the
surrounding area may occ ur. At present, an ointment with collagenase, and a gel
with streptodornase/streptokinase are available.

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The preparations are applied, af ter mechanical wound cleansing, in 25 mm

layers. They should be covered with non- adhesive dressings. Depending on the
chosen preparation, the wound dressing should be changed after 1224 hours.

Other products
There are many other products which do not clearly belong to one of the aforementioned groups. Of particular interest are advanced wound care products which
are also de clared as wound (kick)starters. These are a new, highly diverse group
of therapies for use in wound treatment. Their primary aim is to ac tively in fluence
the wound milieu.
By interacting wit h the wound, they are intended to alter the wound milieu or
wou nd surface. Advanced wound care products are used in chron ic wounds which,
despite optimal, cau sal therapy, remain hard-to-heal.
The aim of products containing collagen and cellulose (PromogranTM ;
Systagenix), nano-oligosaccharide factor (NOSF, UrgoStartT M; Urgo), or polyhydrated ionogens (PHI-5, TegadermT M Matrix; 3M), is to directly reduce matrix
metalloproteinases (MM Ps) [14, 15]. A test procedure is also currently offered
(WoundchekT M; Systagenix) for detecting increased levels of various proteases
(increased protease activity [EPA]). Currently used grow th factors include platelet-derived grow th factor (PDGF), which is available as a gel (RegranexTM ;
Janssen-Cilag) for the treatment of diabetic foot syndrome, as well as epidermal
growth factor (EGF), which comes in a wound dressing (NeodermT M; Trimedicales) [16]. Another new, innovative product uses porcine hemoglobin in the
form of a spray (G ranuloxT M; Sastomed), which may be applied directly to the
wound surface, along with conventional wound products. The spray is supposed to transport oxygen from the air into the wound, and is thus suitable for
all types of hypoxic wounds [17]. There is also a paste, containing modified
starch (poloxamer) that is intended to reduce wound pH levels (CadexomerTM ;
Smith&Nephew) [18]. Other products contain, e.g., the extracellular matrix protein (ECM) amelogenin (XelmaTM ; Mlnlycke) [19], coagulation factor
XIII (FibrogramminT M; CSL Behring) [20], the analgesic ibuprofen (Biatain
IbuTM ;

Many of the underlying ideas, and t he therapeutic approaches, relat ed to these

wou nd care products are very interesting. One may expect that, in the futu re, more
solid recommendations for their targe ted use may become available. At present,
there is still lacking scientific dat a and high qualit y and controlled clin ical t rials
are requ ired to proof their clinical effectiveness[1113].

Contact allergens in wound therapies

The current lit erat ure contains several report s of an increased incide nce of cont act
sensit ization in patients w ith ch ronic wounds, compared to t he normal population. In pat ients with chronic venous leg ulcers, contac t sensitization rates of up
to 80 % have been c ited. The most commonly identified contact allergens among
these patients are wool wax alcohols (18 33 %), followed by aminoglycoside antibiotic s and balsam of Peru [22]. There are also increasing numbers of reports
of contact sensit ization to product s which are used directly for wound treatment
(Table 2) [23].
It is important when selecting t est subst ances for patch test ing to also include
wou nd dressing products.

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Table 2 Examples of allergens found i n woun d therapies which have been alr eady
r eported in conjunc tion with contact sensitizati on in patients with chronic wounds.
Hydrocolloids
Colophonium (up to 14 % of all patient s)
Polyisobutyl derivatives (rarely)
Carboxymethyl cellulose (rarely)
Hydrogels
Propylene glycol (up to 18 % of all patients)
Fatty gauze
Wool wax alcohols (up to 35 % of all pati ents)
Arlacel 83 (rarely)
Antimicrobial therapies
PVP iodine (up to 20 % of all patients)
Neomycin (up to 20 % of all patients)
Cet yl stear yl alcohol (up to 17 % of all pat ients)
Gentamicin (up to 10 % of all patient s)
Benzoyl peroxide (up to 4 % of all patients)
Cocamidopr opyl betaine (up to 3 % of all patient s)

Negative pressure wound therapy

Negative pressure treatment, or vacuum therapy, refers to various systems wh ich
use an electronic cont rol unit to apply a specific suction level to the tissue. A primary use for ne gat ive pressure wound therapy in t he treatment of patient s with
ch ronic wounds in dermatology is wou nd bed preparation, with the aim of
promoting granulation.
wound healing, e.g., reduction of edema, wou nd cleansing, or me chan ical elimin ation of bacteria and wound secretions. The option of usin g the system with
instillation allows for cleansing (also with antiseptic s) without removing the
d ressing; hence, ne gative pressure therapy may also be u sed in clinic ally infe cted
wound s. Disadvantages of negative pressu re therapy in clude the odor, irritation
of the area arou nd the wound, and the sometimes considerable pain associated with treatment. T he most important requirement for its use is that negative
pressu re may be applied with an airtight seal. Cu rrent negative pressure therapy systems consist of a sterile, replaceable sponge or coated gauze, and a noncollapsible tube system with a suction pump un it which generates negative pressure acc ording to ind ividual patient needs. Ch ronic wounds are usually treated
w ith suc tion levels of 75125 mmHg. The surrounding skin should be prote cted
against maceration. Protective polyacrylate or silico ne fi lms may be placed over
the skin as a protec tive measure. For ch ronic wounds, negative pre ssure th erapy
de vices may be le ft in place for 25 days. If pain occ urs whe n the dressing is
ch anged, one may apply fatty gauze under the sponge or reduce the suction level
or time [24, 2 5].

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Other physical t reatment methods which may be u sed in patients with chronic
wou nds include electrostimulation therapy, ex tracorporeal shock wave therapy,
hyperthermia, laser therapy, plasma therapy, u ltrasound, or wat er-filtered infrared-A radiation [26 ].

Bacteria and infections

A prerequisite for efficient wound healing is the elimination, or avoidance, of clinically relevant wound infec tions. One should take into account that nearly every
chronic wound is contaminated or colonized with microorganisms, and t hat this
is generally clinically unproblematic. The diagnosis of a clinically relevant wound
infe ction should t hus be based on the corresponding clin ical findings with the cardin al symptoms of tu mor, c alor, dolor, rubor, and fu nctio laesa. I n patients with
suspected systemic infection, a blood count should be obt ained. In many patients
with chronic wounds, both CRP and ESR are elevated, even when they do not
have an infection. Other diagnostic c riteria include a fever and chills. Wit h a few
exceptions, systemic antibiotic therapy shou ld only be given if there is a systemic
infe ction.
Specific hygien ic measures should be used in patients with problem bacteria,
such as M RSA. I n patients with chronic wounds who have colonizat ion, but who
do not have a systemic infection, topical t reat ment with modern antiseptics is considered adequate [2729].
In chronic wounds, a bacterial smear should be taken, whenever possible,
from the wound surface for example using the Essener Rotary technique).
The Essener Rotary technique involves applying gentle pressure to take the
bacteriological smear from the wound surface, moving from the outer edge
inward in a circular fashion to obtain a representative sample of bacteria for
identification [30]. For deep wounds, extensive soft tissue infections, or in the
framework of surgical intervention, biopsies should be taken from clinically
suspicious areas.

Antiseptics
Polyhexanide (polyhexamethylene biguanide, PHMB) belongs to the biguanide
substance class. Along with wound cleansing solutions containing preservatives,
polyhexanide is also now increasingly found in hyd rogels and wound dressings as a
first-line substance for use in antimicrobial wou nd therapy. Thus, in clin ical use, it
is also more feasible to ensure the cont act time of ten minutes. Polyhex anide should
not be used on ex posed cartilage, in the inner ear, or the CNS
In Germany, octenid ine is found in medications as octenidine dihydrochloride. A clear solution, octenidine w ith 2 % phenox yethanol is the fi rst-line choice for
antimicrobial treatment of chronic wounds. The contact time for octenidine is at
least two minutes. There is also a hyd rogel preparation which may be left in place
for 24 hours. The octenidine solution should not be injected w ith pressure into the
tissue, as this c an lead to necrosis. In addition, octenidine should not be used at the
same time as povidone iodine, because iodine rad icals may be released wh ich can
irritat e the tissue and cause discoloration.
Preparations containing povidone iodine (polyvinylpyrrolidone [PVP] iodine) have long been central to treatment in Germany of pat ients with acute, posttraumatic wounds, as well as for preoperative preparat ion. Problems include the
high rate of contact sensitization, discoloration of wounds, which makes evaluation
of the wound difficult , and potential inactivation due to blood, pus, and wou nd

550 2 01 4 De ut sc he D er m a t ol ogis che Ge se ll sch af t ( D DG) . P ubl ishe d by J ohn Wil e y & S ons L td . | JD DG | 1 610- 03 7 9/2 014 /12 07

CME Article

Table 3 Modified mor phine hydr ogel for wound treatment developed in Essen.
Compared to the NRF formulation, propylene glycol was replaced by polyhexanide
(LavaseptT M ).

Morphine hydrochloride trihydrate

0.1 g

Ethylenediamine tetra-acetic acid sod ium salt 0.1 g

Hydroxyethyl cellulose 400

4.5 g

Lavasept concentrate 20 %

0.2 ml

Purified water EuAB

ad 100.0 g

exudate. In hard-to-heal wounds, wit h Gram-negative bacterial such as Pseudomon as aeruginosa, it may be advisable to briefly use PVP iodine [2 , 5, 2729]. Studie s
have also shown that PVP iodine preparations can effectively neutraliz e proteases
and thus possibly have a positive influence on the wound healing process [31].

Pain
Pain is a complex subjective, perceptual phenomenon, which is influenced by numerous physiological, psychological, emotional, and social factors. Pain leads to
a diminished qualit y of life, has a negat ive effect on patient compliance, and is
an independent risk factor in delayed wound healing. Most patients with chron ic
wounds report having at least temporary pain due to their wou nd. Pain intensit y
may be evaluated using various sc ales. In Germany, the visual analogue scale (VAS)
is the most widely used.
It is important when measuring pain to determine ac tual pain as well as pain
be tween dressing changes. For values =4, improved pain therapy and avoidance of
pain should be the goal. For patients with painful wounds, one mu st seriously consider whether continuous systemic pain therapy, in accordance with the analgesic
ladder of the World Health Organization ( WHO), may be advisable [32].
Using other measures is also often helpful, if changing the dressing is pain ful.
Firmly adherent dressings can be removed almost painlessly if they are soaked for
at le ast 30 minutes prior to removal in Ringer solution. Crusts may be softened
using compresses soaked in olive oil or ointment and removed atraumatically using
a wooden spatula. Local anesthetics in the form of lidocaine and prilocaine cream
are suitable as supportive therapy. The cream should be applied to the wound for
at le ast 60 minutes before cleansing is performed [33]. The effectiveness may be
incre ased by using occlusion wit h semi-permeable films. There are also wound
d ressings available which release low- dose ibuprofen [21]. Morphine hydrogels are
of ten highly ef fective; these may b e applied d irectly to the wound and lef t in place
for 24 hours (Table 3) [34].

Conclusions
It is clearly evident that moist wound therapy, which is adapted to t he wound
healing phases, and make s use of modern wound care products, can help ensu re
an optimal wound milieu, avoid complications, improve the patients quality of
life, and fac ilitate t he healing of chronic wounds. Still, c ausal treatment of the
u nderlying disease(s), on the basis of a thorough and usually interdisciplinary
d iagnosis, is the main requirement for long-term healing of chronic wounds.

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551

CME Article

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Correspondence to
Prof. Dr. med. Joachim Dissemond
Klinik und Poliklinik fr Dermatologie
Venerologie und Allergologie
Universittsklinikum Essen
Hufelandstrae 55
45122 Essen, Germany
E-mail: joachim.dissemond
@uk-essen.de

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1. Wie lange muss eine Wunde mindestens bestehen, wenn sie entsprechend
der aktuellen Leitlinienempfehlungen als
chronisch bezeichnet werden kann?
a) 4 Wochen
b) 6 Wochen
c) 8 Wochen
d) 12 Wochen
e) 24 Wochen

2002 and a meta-analysis of 19752003 data. Br J Dermatol 2004; 150: 92935.

a) Wasserstoffperoxid-Lsung
Wann sollte
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24 Peinemann
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Ethacridinlactat-Lsung
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eine
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c)
Polihexanid-Lsung
25 Ubbink DT, Westerbos SJ, Evans D et al. Topical ne gative pressure for treating chronic
Cochrane Database Syst Rev 2008; 16: CD001898.
a)
Wenn mit
auchAntibiotika
systemische
Infektionsd)wounds.
Farbstoff-Lsungen
Therapie
erfolgen?
26 Dissemond
J. Physikalische Therapien des chronischen Ulcus
cruris.
Hautarzt 2010;
zeichen
vorliegen.
e) Mer bromin-Lsung
61: 38796.
b) Wenn groe Mengen von Bakte27 Dissemond J, Assadian O, Gerber V et al. Classification of
Wounds
at Risk (W.A.R.
rien
in Abstrichen
nachgewiesen
6.Score)
Welche
werdentreatment
im Rah-with pol ihexanide A practice-oriented exandLebewesen
their antimicrobial

men
sogenannten Skin
Biochirurgie
pertder
recommendation.
Pharm Physiol 2011; 24:
c) 24555.
Wenn
MRSA in Abstrichen
wurden.
28 Dissemond
J, Gerber
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therapeutisch
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und lokal
infizier ter Wundend)mitWenn
Polihexanid.
Wundmanagement
a)kritisch-kolonisierter
Behandlung mit steril
gezchteten
sich Rtungen
um die
nachgewiesen wurden.

2. Welche Aussage zu Wundverbnden

ist falsch?
a) Hydrogele sind fr ein autolytisches
Dbridement geeignet.
b) Wenn Hyaluronsureprodukte in
Kontakt mit Wundsekret kommen
bildet sich ein hydrophiles Gel.
c) Kollagene sollen durch die Freisetzung von Proteasen wirken.
d) Hydrofasern knnen Flssigkeit bis
zu etwa dem 40fachen ihres Eigengewichts aufnehmen.
e) Alginate wirken auch hmostyptisch.

3. Welcher Inhaltsstoff wird derzeit

bereits kommerziell in sogenannten
Wundstartern fr die Wundtherapie
verwendet?
a) Plasmin
b) Fibrin
c) Fibrinogen
d) Elastase
e) Hmoglobin

4. Welcher der folgenden Verbandsysteme eignet sich auch besonders gut

fr den Einsatz bei ftiden, neoplastischen Wunden?
a) imprgnierte Fettgaze
b) offenpor iger Schaumstoff
c) Vakuumtherapie
d) Aktivkohleverband
e) okkludierende Folien

5. Welches Antiseptikum wird auch

fr den Einsatz bei Patienten mit

2009;
3: 628.
Blutegeln
29 OMeara
S, Al-Kurdi
Ol ogun
Y, Ovington LG. Antibiotics and antiseptics for venous
b) Behandlung
mit D,
steril
gezchteten
e) Wenn
ein grzeigen.
ner Belag auf der
Wunden
l eg ulcers. Cochrane Database Syst Rev 2010; 1: CD003557.
Fliegenmaden
30 Al Ghazal P, Krber A, Klode J et al. Evaluation of the Essen Rotar y as a new technique
c) Behandlung mit steril gezchteten
Wunde besteht.
for bacterial swabs: re sults of a prospective controlled clinical investigation in 50 pa-

Kangal-Fischen
with chronic le g ulcers. Int Wound J 2014; 11: 449.
d)tients
Behandlung
mit steril gezchteten
10. Welche Aussage zu Honig in der
31 Eming SA, Smola -Hess S, Kurschat P et al. A novel property of povidon-iodine: InhibiSeeigeln
Wundbehandlung ist falsch?
tion of excessive protease levels in chronic non-healing wounds. J Invest Dermatol
e) Behandlung mit steril gezchteten
a) Fr die Wundbehandlung sind
2006; 126: 27313.
Seidenr
aupen
32 Heinl in J, Schreml S, Babilas P et al. Cutaneous wound healing. Therapeutic inter venHoni gpr parationen aus Tuben und
tions. Hautarzt 2010; 61: 61126.
impr
gni erte
Wundauflagen erhlt33 Briggs M, Nelson EA. Topical agents or dressings for pain
in venous
leg ulcers.
7. Es sind aktuell Wundau flagen fr die
b) Honi
lich.gpr parationen sind auch antiBehandlung
von Patienten
mikrobiell
34 Huptas
L, Rompoti
N,Syst
Herbig
S2010;
et chronial. 4:
Schmerzreduktion
bei
Patientenwirksam.
mit chroCochrane
Database
Revmit
CD001177.
schen
Wunden
erhltlich,
c) Honi gprErste
parationen
nischem
Ulcus cruris
durchdie
ein zudem
neu entwickeltes Morphin-Gel:
Re sultateknnen
einer fr ein
ein
Analgetikum
enthalten.
Welches
klinischen
Untersuchung.
Hautarzt
2011; 62(4): 2806. osmotisches Dbridement eingeAnalgetikum wurde hier zugesetzt?
setzt werden.
d) Durch die Anwendung von Honiga) ASS
prparationen kann es zu starken
b) Paracetamol
Schmerzen kommen.
c) Ibuprofen
e) Honigpr parationen werden meist
d) Diclofenac
bei sehr exsudativen Wunden
e) Cox-2-Hemmer
eingesetzt.
8. Welche Aussage zu Spllsungen fr
chronische Wunden ist richtig?
a) Glukoselsungen sind eine Spllsung der ersten Wahl.
b) Der Einsat z von Leitungswasser
kann als hygienisch unbedenklich
empfohlen werden.
c) Physiologische Kochsalzlsungen
knnen nach Anbruch mindestens
fr eine Woche verwendet werden,
wenn sie gekhlt gelager t wurden.
d) Wundspllsungen sollten bei Applikation mglichst krperwarm
sein.
e) Wundspllsungen sollten mglichst als Teilkrperbad angewendet
werden.

Liebe Leserinnen und Leser,

der Einsendeschluss an die DDA fr diese Ausgabe ist d er (15. August 2014). Die
richtige L sung zum Thema Die n ichtsyndromalen Ichthyosen aktueller
Stand in Heft n o. 2 (Februar y 2014) ist:
(1b, 2c, 3b, 4e, 5d, 6c, 7b, 8c, 9b, 10b).
Bitte verwenden Sie fr Ihre Einsendung
das aktuelle Formblatt auf der folgenden
Seite oder aber geben Sie Ihre Lsung
online unter http://jddg.akademie-dda.de
ein.

chronischen Wunden als ein Prparat

der ersten Wahl empfohlen?

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