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An online practice-based journal for clinicians worldwide | Vol 4 | Issue 4 | December 2013

2013 International Wound

Conference Round-up
Editorial and opinion
Making global wound care local
World Wound Week brings
international collaboration

Clinical innovations
Addressing the vertical and horizontal
aspects of the wound
Hyperbaric oxygen therapy as adjunctive
treatment for diabetic foot ulcers
Advances in wound dressing technology
Clinical update
Ten top questions and answers on the use of
dressings for pressure ulcer prevention

Case report
Use of honey to treat a necrotic wound after
laryngectomy and neck radiotherapy

Technology update
Using telehealth and photography for wound
assessment in Western Australia

Wound digest
 Contents DECEMBER 2013

Editorial and opinion

Kathy Day Page 3
Making global wound care local

Harikrishna K.R. Nair Page 4

EDITOR World Wound Week brings international collaboration
Suzie Calne
MANAGING EDITOR
Lindsey Mathews
Clinical innovations
SUB-EDITOR Addressing the vertical and horizontal aspects of the
Adam Bushby wound by using negative pressure wound therapy and
growth factors Page 6
PUBLISHER
Joon Pio Hong discusses how wound healing can be enhanced by increasing
Kathy Day granulation tissue and addressing epithelialisation
PUBLISHING DIRECTOR
Hyperbaric oxygen therapy as adjunctive treatment for
Rob Yates
diabetic foot ulcers Page 8
Luinio Tongson, Danielle L. Habawel, Rachelle Evangelista and John Lerry Tan report
EDITORIAL on their study findings, that adjunctive hyperbaric oxygen therapy improves healing
If you want to discuss an idea, contact the Editor
Advances in wound dressing technology Page 12
at scalne@woundsgroup.com or write to Suzie
Geoff Sussman outlines some innovative developments for advanced wound care
Calne, Wounds International,
1–2 Hatfields, London SE1 9PG, UK
Clinical update
Top ten questions and answers on the use of dressings for
JOURNAL DETAILS
pressure ulcer prevention Page 16
© Wounds International, a division of
C. Tod Brindle answers ten top questions on the evidence and use of prophylactic
Schofield Healthcare Media Ltd dressings for the prevention of pressure ulcers
1–2 Hatfields, London SE1 9PG, UK
Tel: +44 (0)20 7960 1510
Fax: +44 (0)20 7627 1570
Case report
No part of this journal may be reproduced The use of honey to treat a necrotic wound after laryngectomy
or transmitted in any form, by any and neck radiotherapy Page 22
means, electronic or mechanic, including Sonia Pereira, Pedro Ângelo and Ligia Ferreira present a case report showing the
photocopying, recording or any information effectiveness of a honey-based dressing at enhancing healing of a necrotic wound
retrieval system, without the publisher’s
permission.
Technology update
Page design by Optic Juice Using telehealth and photography for wound assessment in
Western Australia Page 26
Beth Sperring explains how videoconferencing and digital clinical images can be
ISSN 2044-0057 (Online)
used for effective wound assessment for patients and clinicians in rural locations

Wounds International is listed on CINAHL.

Visit http://www.ebscohost.com/cinahl
Research
Web: www.woundsinternational.com Wound digest Page 30
A summary of some important papers published on wound related issues

2 Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com

 Editorial and opinion
Making global wound care local
T
he International Wound Care
Conference in Kuala Lumpur on 18–20
October was attended by more than
800 delegates from Malaysia and the Asia
Pacific region. The theme of the conference
was ‘Global wound care made local‘, and
throughout there was an emphasis on
sharing experiences from different regions
around the world. This was echoed by the
deputy director general from the Malaysian
Ministry for Health, who opened the
conference with the launch of World Wound
Week, an initiative of the Malaysian Society
of Wound Care Professionals (MSWCP), World
Union of Wound Healing Societies, and the
Asian Academy of Wound Technology.
The conference has been an important
step in the development of wound care in
Malaysia. In the past year, all state hospitals
in the country have appointed wound care
teams as part of a government directive. This
has not only raised awareness of wounds,
but is also helping to standardise wound
care in Malaysia. However, these teams
require leadership through education and an
understanding of the size of the problem to
ensure judicious use of money.
Of course, it is not just about the cost of
managing the patient, but the cost to the
patient, which Geoff Sussman (Australia)
eloquently stated in his presentation on
‘Advances in dressing technologies and
innovations’. Saving limbs and reducing the
impact of living with a wound is important.
Next-generation dressings need to be smart
— to address the cause, the needs of the
patient and the wound.
It is an exciting time with new advances
in wound care, including stem cells, growth
factors and pharmacological interventions.
For Malaysia and some parts of the Asia
Pacific region, the process of registration is
fairly simple with early adoption of wound
care products. In Kuala Lumpur, this was
evident from the range and number of
companies exhibiting at the conference,
with over 30 stands in the exhibition and
hospitality areas.
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
The 2013 International
Wound Care Conference
The varied programme delivered by both
international and local speakers reflected
these advances in wound care practice, while
emphasising the importance of collecting
accurate data to ensure appropriate use
of products. Over the 3 days, Wounds
International, with the support of Professor
Keith Harding and Jacqui Fletcher (UK), The opening ceremony,
delivered three plenary sessions on the International Wound Care
science of pressure ulceration, elevated Conference, Kuala Lumpur.
protease activity in wounds (supported by
Systagenix) and wound infection, resistance
and the role of topical antimicrobials —
the latter delivered in association with the
International Wound Infection Institute. In
addition to the morning presentations, there
were a number of afternoon workshops
and free paper sessions. These were all well
attended and offered delegates a choice of Delegates attend a plenary session.
topics and a greater level of interaction.
Wounds International is delighted to
have had this opportunity to work with
Dr Harikrishna Ragavan Nair, President of
MSWCP, and his unstinting efforts to build
a collaborative wound care community for
both doctors and nurses working in the Asia
Pacific region. Thank you to the speakers for
providing such interesting sessions — it has
been a pleasure working with you. We would
also like to thank all those who attended (L–R) Kathy Day, Rob Yates, Harikrish-
and for sharing the excitement about what na K.R. Nair, Jacqui Fletcher.
the future holds for wound care in Malaysia
and the wider Asia Pacific region. Wounds
International looks forward to continuing
this important collaboration and supporting
clinicians in their day-to-day practice. n
Kathy Day
Publisher, Wounds International
If you would like further information about the
resources available on Wounds International Professor Keith Harding delivers a
and how these can be used to support ongoing presentation.
education and best practice, please contact Kathy
Day, the Publisher of Wounds International, at:
kathy.day@woundsgroup.com
3
 Editorial and opinion
In this guest editorial,
Harikrishna K.R. Nair
discusses the launch of the
World Wound Care Week
from 11–18 October and
the World Wound Care
Day on 18 October, and
the hope that this will
encourage international
collaboration.
References
1. Singh N, Armstrong DG, Lipsky
BA (2005) Preventing foot
ulcers in patients with diabetes.
JAMA 293: 217–28
2. Bakker K, Apelqvist J,
Schaper NC on behalf of
the International Working
Group on the Diabetic Foot
Editorial Board (2012) Practical
guidelines on the management
and prevention of the diabetic
foot 2011. Diabetes Metab Res
Rev 28(Suppl 1): 225–31
Harikrishna K.R. Nair is
Head, Wound Care Unit,
and Hospital Wound Care
Coordinator, Kuala Lumpur
Hospital, and President,
Malaysian Society of
Wound Care Professionals,
Kualar Lumpur, Malaysia.
4 Wounds International Vol 4 | Issue 34 | ©Wounds International 2013 | www.woundsinternational.com
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010
World Wound Week brings
international collaboration
I
nterest in wound care and the need for
expertise and specialist knowledge is
growing in epic proportions worldwide.
The interest in wound care in the Asia
Pacific region can be seen by the increase
in wound healing societies, such as for
burns and diabetic limb problems. There
is a huge variety of advanced dressings,
innovations, technologies and clinical
guidelines available, and there is continual
potential for growth. With the increasing
prevalence of diabetes there is an increase
in diabetic foot wounds, as a quarter of all
people with diabetes develop diabetic foot
complications[1]. Furthermore, the number
of amputations has also increased, and the
International Working Group on the Diabetic
Foot has noted that every 20 seconds a limb
is being amputated somewhere in the world
as a result of diabetes[2].
This is the reason the Malaysian Society of
Wound Care Professionals launched the World
Wound Care Week from 11–18 October 2013
in Kuala Lumpur Hospital, Kuala Lumpur,
Malaysia. It was a unique event, and there
was an exhibition, industry booths and a
special presentation of wound care kits
equipped with advanced dressings to wound
care teams from various hospitals and
health centres under the Ministry of Health,
Malaysia, in support of their contribution to
wound management. Furthermore, various
programmes were organised, which included
workshops, seminars, talks and surgical
sessions with consultants from various
disciplines and from numerous countries,
including Japan, France, South Korea, USA,
Australia and China.
This was a very significant event, with four
key themes emerging:
n First, the week was accepted
internationally and endorsed by the World
Union of Wound Healing Societies. The
aim was to celebrate wound care in the
region and share new initiatives. Various
programmes were organised to meet
this objective and bring people from a
number of locations together who have a
common goal.
n Second, it created a political platform
to provide a greater emphasis on
wound care, where governments,
non-governmental organisations,
the industry and the public are made
aware of the need for a standardised
and comprehensive care in managing
wounds.
n Third, we were able to share our
knowledge with subspecialties and learn
about new breakthroughs in wound
management, such as growth factors,
stem cells, new advanced dressings,
new diagnostics in wound care and scar
management.
n Fourth, initiatives and plans will be set
in motion to make new products and
innovations accessible, affordable and
available to all patients, and to meet the
objectives set out by the various wound
care organisations attending.
In addition, the International Wound
Conference 2013 was launched officially
on the 18 October, which was designated
as the World Wound Care Day. Participants
included delegates and distributors from
33 countries. The World Wound Care Week
and Day were endorsed by the World Union
of Wound Healing Societies, the Ministry of
Health of Malaysia, the Academy of Wound
Technology, the Asian Academy of Wound
Technology and Wounds International.
Incidentally, World Wound Care Day also
falls on St Jude’s Day; St Jude was a patron
saint of physicians. Finally, we have a day
in the year that is designated for wound
care, which can and will be celebrated
throughout the world by all wound care
professionals.
The aim is that the initiative and the
momentum put into place to support wound
care will continue, and will spur greater
collaboration and cooperation between
the various specialists and the nations in
achieving advanced and timely wound
care for all who need it. It is hoped that the
international community will embrace and
support the World Wound Care Week and the
World Wound Care Day. n
 Bring your wound care patients
out of hiding
Embarrassed by visible strikethrough,
worried by knocks and bumps,
frustrated by dressings that refuse to
stay in place; for people with chronic
wounds, hiding at home can feel like
their only option.
At Smith & Nephew our observational
research revealed all the reasons why
living with a chronic wound stops
people living the life they want to lead.
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T +44 (0) 1482 225181
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The results inspired us to create
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designed to help people with
chronic wounds regain their
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Find out how ALLEVYN Life can help
you bring your patients out of hiding
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Designed for life.
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36340
 News
Clinical Wounds
Clinical
Clinical
Clinical updateupdate
innovations
innovations
innovations

Wound management
Wounds International's clinical innovations section presents recent developments in
wound care. This issue, we focus on innovations in wound management discussed
in presentations given at the recent Wounds International conference held in Kuala
Lumpur on 11–18 October 2013.

Addressing the vertical NPWT facilitates the drainage of excessive fluid and debris

and horizontal aspects

from a wound, and thus results in decreased bacterial
counts and interstitial oedema, stimulation of granulation

of the wound by using

tissue formation and increased regional blood flow[3,4].
Animal experiments conducted by Argenta and

negative pressure
Morykwas[2,3] suggested that –125 mmHg is the optimal
negative pressure to increase blood flow, and has now

wound therapy and

been generally accepted as the clinical standard for NPWT
application.

growth factors
Various modes of NPWT have been introduced,
namely continuous and intermittent. A third option is
the cyclic mode, which operates its negative pressure

A
ny wound can be simplified in a style similar to a sine wave by oscillating between
into the vertical and horizontal the designated negative pressures (Curasys®, Curavac®;
aspects of defect[1]. The vertical Daewoong Pharmaceutical). Once it hits the upper target
wound depicts the defect from the skin pressure of –125 mmHg, the system shuts off and the
and down (dead space), whereas the pressure slowly drops until the lower target pressure is
horizontal wound depicts the actual reached, regardless of the time frame. As the change in the
skin loss. It is our goal to address these intralesional pressure is measured, the falling velocity of
two issues in order to achieve wound the pressure is closely associated with the defect volume
healing. in the cyclic mode. In other words, the larger the volume of
In cases with both a vertical and defect, the shorter the time taken for completing one cycle
Author: horizontal wound, it is preferable to of the system. Thus, the pressure movement is regulated
Joon Pio Hong reconstruct with a flap that provides by the preset pressures and the volume of defect, not
sufficient tissue to obliterate the dead by a specific time frame. It has the same efficacy as the
space, and at the same time a flap that has a skin paddle intermittent mode, but with reduced pain as the pressure
to cover the skin loss. A three-dimensional reconstruction is not dropped to 0 mmHg [Hong et al, in press].
can achieve positive results in complex wounds. However, Although there has been debate about the
in cases where microsurgery/flap surgery is not available, microvascular perfusion at the wound edge and wound
alternative options must be found. healing, it is generally believed that the improved
microvascular blood flow at the wound edge achievable
Negative pressure with NPWT has beneficial effects on wound healing[5].
wound therapy NPWT’s effect on increased tissue perfusion is thought to
Negative pressure wound therapy (NPWT) was introduced be beneficial, especially for treating ischaemic wounds.
in 1997 and its use has been extended to managing Therefore, when microsurgical reconstruction is not
many types of wounds, including diabetic foot ulcers, an option, NPWT is an efficient way to stimulate the
pressure ulcers, the open abdomen, chest wounds, skin production of granulation tissue to reduce wound depth.
grafts and traumatic lower extremity wounds[2,3,4]. It is now In patients presenting with loose skin margins, serial
considered to be one of the major advanced treatments sutures to pull the wound margins inward while applying
for difficult wounds. NPWT can be an effective method to reduce the wound
The mechanism of action of NPWT in wound healing width, as well as fill the vertical defect with granulation
is not fully understood, but numerous studies have tissue. NPWT is also useful in cases where amputation
attempted to show its effects in many scenarios. Broadly, stump sites are difficult to close or have dehisced after

6 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com

repair. Often, there is a small dead space where fluid
collects and eventually drains through the repaired site.
NPWT can stimulate granulation to fill the dead space.
During any application of NPWT, the end-point is when
granulation tissue has filled the vertical aspect of the
wound or covered all pre-exposed vital structures in
the wound. Once this has been achieved, the horizontal
aspect should be treated.
Once NPWT has been successfully administered, a flap
or skin graft can be applied. In small or moderately sized
wounds, secondary intention healing can be pursued.
In cases where secondary intention will take too long or
in cases when a skin graft is not available, or to expedite
healing for secondary intention or grafting, growth
factors can be considered to promote healing.
Epidermal growth factor
Epidermal growth factor (EGF) — which is produced by
platelets, macrophages and monocytes — interacts with
EGF receptors on epidermal cells and fibroblasts[6]. EGF
primarily acts to stimulate epithelial cell growth across
the wound, and also acts on fibroblasts and smooth
muscle cells. A number of studies have demonstrated
the effects of EGF on wounds through the shortening
of healing time, increasing the tensile strength of the
skin and reducing unfavourable tissue effects[7,8]. EGF is
also known to positively feedback to increase the EGF
receptors.
Debridement of necrotic tissue, infection control,
maintaining a moist wound environment and providing
abundant oxygenation to the tissue are all essential
elements of wound care. However, despite these efforts,
chronic wounds may still be resistant to treatment. One
reason for delayed healing in chronic wounds despite the
implementation of good wound care practices may be
found in lack of growth factors[9].
The author studied this hypothesis in a crossover
study[10] (a longitudinal study where subjects received
a sequence of different treatments), in which diabetic
foot ulcers of >6 months’ duration were debrided and
treated with hydrocolloids or composite dressings (i.e.
foams, Versiva [ConvaTec] or Aquacel® foam [ConvaTec]),
depending on the condition of the wound. If treatment
effect was minimal using advanced dressings for 3 weeks,
patients were switched to twice-daily treatment with
0.005% EGF and advanced dressings. Among the patients,
21 showed improvement using hydrocolloid or composite
dressing alone, and 68 were crossed over to treatment
with EGF and advanced dressing. Among the EGF-treated
patients, complete healing was noted in 52 patients
within an average of 46 days (range, 2–14 weeks).
The approach to wait for good standard of care to take
effect and use EGF only in cases where wound healing
is delayed over several weeks has become the standard
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical innovations Wound management
of practice. EGF is also used in cases where NPWT has
successfully achieved granulation but epithelialisation
(horizontal healing) becomes a priority.
Conclusions
Wounds need to be addressed in both the vertical and
horizontal aspects. The vertical aspect depicts the dead
space underneath the skin, where the wound can affect
muscles, tendon and bones. NPWT provides an efficient
way to enhance healing by increasing granulation,
thus improving the vertical aspect of the wound. Once
granulation is reached at the skin level, the horizontal
aspect (epithelialisation) must be adressed. EGF can
lead to rapid, effective skin closure by enhancing
keratinocyte activity. This combination can be used in
cases where the wound is of moderate size to avoid skin
grafts and to achieve efficient healing. n
AUTHOR details
Joon Pio Hong is Professor of Plastic Surgery,
Department of Plastic Surgery, Asan Medical Centre,
University of Ulsan, Seoul, Korea.
References
1. Pappalardo J, Plemmons B, Armstrong DG (2013) Wound healing
simplification: a vertical and horizontal philosophy illustrated. J
Wound Technol 19: 38–9
2. Argenta LC, Morykwas MJ (1997) Vacuum-assisted closure: a new
method for wound control and treatment: clinical experience. Ann
Plast Surg 38: 563–76; discussion 577
3. Morykwas MJ, Argenta LC, Shelton-Brown EI et al (1997) Vacuum-
assisted closure: a new method for wound control and treatment:
animal studies and basic foundation. Ann Plast Surg 38: 553–62
4. Morykwas MJ, Simpson J, Punger K et al (2006) Vacuum-assisted
closure: state of basic research and physiologic foundation. Plast
Reconstr Surg 117: 121S–6S
5. Borgquist O, Ingemansson R, Malmsjö M (2010) Wound edge
microvascular blood flow during negative-pressure wound therapy:
examining the effects of pressures from –10 to –175 mmHg. Plast
Reconstr Surg 125: 502–9
6. Nanney LB (1990) Epidermal and dermal effects of epidermal growth
factor during wound repair. J Invest Dermatol 94(5): 624–9
7. Brown GL, Curtsinger L 3rd, Brightwell JR et al (1986) Enhancement
of epidermal regeneration by biosynthetic epidermal growth factor. J
Exp Med 163(5): 1319–24
8. Epstein JB, Gorsky M, Guglietta A, Le N, Sonis ST (2000) The
correlation between epidermal growth factor levels in saliva and the
severity of oral mucositis during oropharyngeal radiation therapy.
Cancer 89(11): 2258–65
9. Gary Sibbald R, Woo KY (2008) The biology of chronic foot ulcers in
persons with diabetes. Diabetes Metab Res Rev (Suppl 1): S25–30
10. Hong JP, Jung HD, Kim YW (2006) Recombinant human epidermal
growth factor (rh-EGF) to enhance healing for diabetic foot ulcers.
Ann Plast Surg 56: 394–8
7
 News
Clinical Wounds
Clinical
Clinical
Clinical updateupdate
innovations
innovations
innovations
Hyperbaric oxygen
therapy as adjunctive
treatment for diabetic
foot ulcers
T
Authors: he gold standard for diabetic
Luinio Tongson, foot ulcer treatment includes
Danielle L. Habawel, debridement of devitalised wound
Rachelle Evangelista, tissue, management of any infection,
John Lerry Tan revascularisation procedures when
indicated and offloading of the ulcer.
Hyperbaric oxygen therapy (HBOT) has been promoted as an
effective adjunctive treatment for diabetic foot wounds[1]. The
effects of HBOT on improving wound tissue hypoxia make
it a useful adjunct in clinical practice for diabetic foot ulcers.
It may reduce the risk of lower-extremity amputation and
improve healing in people with diabetes with foot ulcers[1].
Diabetic foot ulcers are one of the most significant and
devastating complications of diabetes. The prevalence of
foot ulceration in the diabetic population is 4–10%[2]. It is
estimated that about 5% of all people with diabetes present
with a history of foot ulceration, and the lifetime risk of these
people developing this complication is 15%[2,3,4]. In the study
by Moxey et al, 70% of all non-traumatic amputations of the
lower limbs occurred in patients with diabetes[5].
The aim of the authors’ study was to evaluate the effects
of systemic HBOT on the healing course of diabetic foot
wounds and the amputation rate relating to foot ulcers in
people with diabetes.
METHODs
Between March 2012 and July 2013, 54 diabetic foot patients
with either Wagner grade 3 or 4 wounds who underwent
HBOT at the Dr James G. Dy Wound Healing and Diabetic
Foot Centre, Chinese General Hospital and Medical Centre,
Manila, Philippines, were included in the study. The protocol
for the diabetic foot wounds was HBOT at 2.5 absolute
atmospheres, administered once a day, 5 days a week, with
each session lasting 90 minutes. Alongside HBOT, standard
care included debridement, modern moist dressings and
negative pressure therapy if indicated, as well as metabolic
and nutritional management.
The study end point was ulcer healing and determining
the amputation rate of those patients who underwent HBOT.
A Wagner grade 3 ulcer was considered healed when it was
completely epithelialised and remained so until the next visit
in the study. Wagner grade 4 ulcers were considered healed
when the gangrene had separated and the ulcer below was
completely epithelialised. An improved grade 3 wound was
defined in this study as the presence of granulation tissue
8 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
after 4 weeks of HBOT. For grade 4 ulcers, improvement was
considered to be the separation of gangrene from the ulcer
below with the presence of granulation tissue. If extirpation
was above the ankle, it was categorised as major amputation.
RESULTS
The recommended minimum number of HBOT session for
people with diabetes and foot ulceration is 30[6]; the minimum
number of hyperbaric treatments included in this study was
five sessions, and the maximum number of treatments was 30
(giving an average of 13 treatments). Thirteen patients were
excluded from the study because they received less than
five sessions of HBOT. Of the remaining 41 individuals, 24
were male and 17 female, with an age range of 39–97 years
(average age, 65 years).
A total of 88% (36/41) of the participants showed an
improvement in their condition, while 12% underwent major
amputation. Of those 36 patients whose condition improved
with HBOT, 86% (31/36) had complete healing of their
diabetic foot ulcer and 14% had partial healing, where there
was granulation tissue in the wound bed but the wound had
not fully epithelialised by study end. Figures 1–2 show two
examples of diabetic foot ulcer healing after receiving HBOT.
Table 1 shows outcomes in relation to the number of HBOT
sessions. Of those patients who had 5–10 sessions of HBOT,
85% (12/14) with a Wagner grade 3 ulcer and 80% (8/10) with
a Wagner grade 4 ulcer showed wound improvement and did
not require a major amputation; thus, the amputation rate
was 15% (2/14) in those with a Wagner grade 3 ulcer and 20%
(2/10) in those with a Wagner grade 4 ulcer.
In those patients who received 10–20 sessions of HBOT,
there was an improvement in 85% (6/7) and 100% (4/4) in
patients with Wagner grade 3 and 4 ulcers, respectively. There
was a 15% (1/7) amputation rate among those with a Wagner
grade 3 ulcer. After 21–30 sessions of HBOT there was a 100%
improvement of both Wagner grade 3 (1/1) and 4 (5/5) ulcers.
DISCUSSION
The amputation rate for people with diabetes and
foot ulcers is 15–70 times higher than of the general
population[7]. Ischaemia, infection and retarded wound
healing are the most common causes of amputation.
Wound healing is oxygen dependent and is limited by its
availability at the cellular level. Elevated tension of oxygen
in plasma causes upregulation of growth factors, down-
regulation of inflammatory cytokines, increased fibroblast
activation, angiogenesis, antibacterial effects and enhanced
antibiotic action[7,8,9].
Treatment with HBOT involves the intermittent
administration of 100% oxygen at a pressure greater than
that at sea level. It is performed in a chamber with the
patient breathing 100% oxygen while the atmospheric
pressure is increased to 2–3 absolute atmospheres. This
results in an increase in the concentration of oxygen in
 Clinical innovations Wound management

Figure 1a. Diabetic foot ulcer (Wagner grade 3), which had Figure 1b. Surgical debridement was performed and the
been a non-healing wound for 2.5 months. There was a dressing changed daily; a broad-spectrum antibiotic was
black, hard covering on the wound site with foul, purulent given, and granulation was noted after five sessions of
discharge oozing from the wound. hyperbaric oxygen therapy (HBOT).

Figure 1c. Two weeks after 10 sessions of HBOT, with Figure 1d. Improved wound post-skin graft after
autolytic debridement and daily dressing changes, 2.5 months of treatment and adjunctive therapy.
granulation and epithelialisation were observed.

Figure 2a. A diabetic foot ulcer (Wagner grade 4), which had
not healed for 3 months; necrosis and slough were noted. Figure 2b. Transmetatarsal amputation was performed,
and granulation was observed after five sessions of HBOT.

Figure 2c. Three weeks after skin graft and 10 sessions

Figure 2d. The wound was completely healed after 3 months.
of HBOT.

Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com 9

 News
Clinical Wounds
Clinical
Clinical
Clinical updateupdate
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innovations

Table 1. Number of hyperbaric oxygen therapy sessions and their effect on the healing of
diabetic foot ulcers

Number of sessions of Wagner grade 3 Wagner grade 4

hyperbaric oxygen therapy diabetic foot ulcer diabetic foot ulcer
Improved Amputated Improved Amputated
5–10 12 (85%) 2 (15%) 8 (80%) 2 (20%)
10–20 6 (85%) 1 (15%) 4 (100%) 0
21–30 1 (100%) 0 5 (100%) 0

the blood and an increase in the diffusion capacity to
the tissues. The partial pressure of oxygen in the tissues
is increased, which stimulates neovascularisation and
fibroblast replication and increases phagocytosis and
leukocyte-mediated killing of pathogens in the wound.
There is strong evidence that fibroblasts, endothelial cells
and keratinocytes replicate at higher rates in an oxygen-rich
environment[10]. Based on these data, the concept is that
the administration of oxygen at high concentrations and
pressures might accelerate wound healing in diabetes.
The Undersea and Hyperbaric Medical Society’s
indications for the use of hyperbaric oxygen in wound
care includes the treatment of Clostridial myositis and
myonecrosis (gas gangrene), crush injury, compartment
syndrome and other acute traumatic ischaemias, arterial
insufficiencies, enhancement of healing in selected
problem wounds, soft tissue infections, refractory
osteomyelitis, delayed radiation injury, compromised
grafts, and flap and acute thermal burn injury[11]. Additional
indications recommended by the 2004 European Consensus
Conference on Hyperbaric Medicine[12] are surgery and
implant in irradiated tissue, post-vascular procedure
reperfusion syndrome and limb replantation. In the USA,
the new Medicare- and Medicaid-approved indication is
diabetic wounds of the lower extremity with the following
criteria: patients with type 1 or type 2 diabetes with a lower
extremity wound as a result of diabetes; wounds that are
Wagner grade 3 or higher; and patients that have failed a
30-day course of standard, conventional wound therapy[13].
Meanwhile, the Wound Healing Society has given HBOT a
level I evidence rating in their Guidelines For The Best Care Of
Chronic Wounds[14].
In the study by Faglia et al[15], HBOT was associated with
a reduction in amputation rates among patients who were
at risk of below-knee or above-knee amputation because
of severe ischaemia, underlying osteomyelitis, or both.
In the analysis of Heyneman and Lawless-Liday[16] on the
different clinical trials assessing the usefulness of HBOT
for the treatment of diabetic foot ulcers, amputation was
prevented in 82–95% of patients. HBOT resulted in a mean
limb salvage rate of 89%, compared with prevention of
amputation in 61% of patients who received conventional
therapy alone.
Chen et al[17] found that HBOT significantly improves
healing of diabetic foot ulcers in a dose-dependent manner.
They compared the efficacy of <10 HBOT sessions with
>10 HBOT sessions for the treatment of diabetic foot ulcers.
The investigators found that in the group that had <10
HBOT sessions, limbs were preserved from amputation
in 33.3% of the group; in those patients who had >10
HBOT sessions (mean, 22.8 sessions), 78.3% had their
feet preserved from amputation. In the present study,
the likelihood of wound healing and limb preservation
increased with the number of HBOT sessions received.
HBOT is recommended in Wagner 3 or higher diabetic
foot wounds and is initiated at the authors' institution
when 1 month of standard therapy fails to achieve results.
The authors found no data on the effect on healing and
amputation in patients with earlier treatment of HBOT.
HBOT may be unnecessary for the great majority of patients
who respond to appropriate standard wound care; however,
for those patients at risk of amputation, their wound needs
to be healed promptly with available adjunct therapies,
such as HBOT.
CONCLUSION
Treatment of diabetic foot wounds with an aggressive,
multidisciplinary therapeutic protocol in conjunction with
HBOT is effective in decreasing major amputations. It seems
that HBOT improves healing of diabetic foot ulcers in a dose-
dependent manner. The preliminary results are promising,
but large randomised controlled trials are necessary to
establish the efficacy of HBOT in the treatment of diabetic
foot ulcers. n
AUTHORs’ details
Luinio Tongson is Head, Dr James G. Dy Wound Healing and
Diabetic Foot Centre, General Surgeon and Wound Care
Specialist, Danielle L. Habawel, Rachelle Evangelista and
John Lerry Tan are HBOT and Wound Care Nurses, Dr James
G. Dy Wound Healing and Diabetic Foot Centre, Chinese
General Hospital and Medical Centre, Manila, Philippines.

10 Wounds
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Do you need to demonstrate
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A new international
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Understand what is meant
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management’
Appreciate the different
types of economic analysis
used in healthcare
Interpret information
on cost and cost-effective-
ness of wound care
modalities and protocols
Set up systems to collect
the data for analysis
Make an appropriate case
for cost-effective wound
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References
1. Lipsky BA, Berendt AR (2010) Hyperbaric oxygen therapy for diabetic
wounds: has hope hurdled hype? Diabetes Care 33(5): 1143–5
2. Abbott CA, Carrington AL, Ashe H, North-West Diabetes Foot Care
Study et al (2002) The North-West Diabetes Foot Care Study: incidence
of, and risk factors for, new diabetic foot ulceration in a community-
based patient cohort. Diabet Med 19: 377–84
3. Centers for Disease Control and Prevention (2005) Lower extremity
disease among persons aged ≥40 years with and without diabetes:
United States, 1999–2002. MMWR Morb Mortal Wkly Rep 54: 1158–60
4. Lauterbach S, Kostev K, Kohlmann T (2010) Prevalence of diabetic foot
syndrome and its risk factors in the UK. J Wound Care 19: 333–7
5. Moxey PW, Gogalniceanu P, Hinchliffe RJ et al (2011) Lower extremity
amputations—a review of global variability in incidence. Diabet Med
28: 1144–53
6. Latham E (2013) Hyperbaric oxygen therapy: enhancement of healing
in selected problem wounds. Medscape. Available at: http://bit.
ly/1f3TBdt (accessed 10.12.13)
7. Roeckl-Wiedmann I, Bennett M, Kranke P (2005) Systematic review of
hyperbaric oxygen in the management of chronic wounds. Br J Surg 92:
24–32
8. Chen SJ, Yu CT, Cheng YL, Yu SY, Lo HC (2007) Effects of hyperbaric
oxygen therapy on circulating interleukin-8, nitric oxide and insulin-like
growth factors in patients with type 2 diabetes mellitus. Clin Biochem
40: 30–6
9. Steed DL, Attinger C, Colaizzi T et al (2006) Guidelines for the treatment
of diabetic ulcers. Wound Repair Regen 14(6): 680–92
10. Katsilambros N, Dounis E, Makrilakis K, Tentolouris N, Tsapogas P (2010)
Atlas of the Diabetic Foot. 2nd edn. Wiley-Blackwell: 220. Available at:
http://bit.ly/1jIqz6A (accessed 10.12.13)
11. Gesell L (2008) Hyperbaric Oxygen Therapy Indications. 12th edn.
The Hypberbaric Oxygen Therapy Committee report. Undersea and
Hyperbaric Medical Society, Durham, NC
12. European Committee for Hyperbaric Medicine (2004) 7th European
Consensus Conference on Hyperbaric Medicine. ECHM, Lille. Available
at: http://bit.ly/ICQ7E8 (accessed 10.12.13)
13. CMS.gov (2003) Medicare national coverage determination for
hyperbaric oxygen therapy (20.29). Available at: http://go.cms.
gov/1jIu5Oq (accessed 10.12.13)
14. Robson MC, Barbul A on behalf of the Wound Healing Society (2006)
Guidelines for the best care of chronic wounds. Wound Regen Repair
14(6): 647–8
15. Faglia E, Favales F, Aldeghi A et al (1996) Adjunctive systemic
hyperbaric oxygen therapy in treatment of severe prevalently ischemic
diabetic foot ulcer. Diabetes Care 19(12): 1338–43
16. Heyneman CA, Lawless-Liday C (2002) Using hyperbaric oxygen to
treat diabetic foot ulcers: safety and effectiveness. Crit Care Nurse 22(6):
52–60
17. Chen C-E, Ko Y-H, Fong C-Y, Juhn R-J (2010) Treatment of diabetic foot
infection with hyperbaric oxygen therapy. Foot Ankle Surg 16: 91–5
12 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Advances in wound
dressing technology
O
ver the past 50 years
or so, the emphasis in
wound care research
has been on developing a
range of wound dressings
with properties of absorption,
hydration and more recently
antibacterial activity[1]. The
new developments have
Author: Professor Geoff Sussman lead to a shift from simple
dressings to more advanced
devices and products that incorporate pharmaceutically
active ingredients.
There is a need to improve the condition of wound bed
tissue and provide products that repair and regenerate
damaged tissue and optimise healing. This can be achieved
either by the addition of essential healing components or
by removing or neutralising elements that retard healing or
lead to ongoing tissue damage.
An urgent requirement is to develop effective point-of-
care diagnostic tests to identify and define the underlying
cause of wound breakdown. A point-of-care test that can
detect elevated protease levels is now available[2,3], but
much could be done if we had a better understanding
of the presence of inflammatory cytokines, wound pH,
autoimmune antibodies and other markers of infection.
There are cost implications with these newer treatments
and diagnostic tests, and it is important to not only look
at the unit cost of a product but also to explore the cost-
effectiveness of the intervention in relation to associated
and long-term costs, as well as cost savings[4,5]. If newer
methods of treatment prevent or reduce the length of
hospital stay and speed healing, then in the long term it is
possible to make an economic case for using them.
Keratin-based
wound management
An interesting example of a new wound treatment is the
development of keratin-based wound care products. The
ability of keratinocytes to migrate is critical for wound
re-epithelialisation[6,7]. Keratins are the major proteins in
keratinocytes and are essential for many cellular functions
(e.g. cell migration), and upregulation of keratin expression
has been observed in response to wounding[8,9].
Keratin-based products have been approved for use
in several regions of the world, including Australia, New
Zealand and the USA. A robust keratin matrix (Keramatrix®;
Keraplast Technologies LLC), designed for use on wounds
with moderate exudate levels or for use as an interface
with negative pressure wound therapy, has shown
positive results[6,8]. As the wound heals, the keratin matrix
 *

1-2

*Percentage of venous leg ulcers healed or improved^ within 12 weeks

Using PROMOGRAN®/PROMOGRAN PRISMA® on VLUs with less than 6 months duration1

87%
(n=20/23)

42%
(n=15/36)

Standard care on VLUs regardless of age of wound2

FIND OUT MORE

&

View references
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is absorbed into the wound and does not need to be
removed at dressing change[6,8].
The matrix is also available as a hydrogel (Keragel™;
Keraplast Technologies LLC), which is designed for
use in chronic dry wounds, acute wounds and for the
treatment of certain skin conditions, such as epidermolysis
bullosa[10–12]. Keragel provides moisture to a dry wound
as well as a keratin-rich environment to encourage cell
growth, leading to excellent healing outcomes[13]. The
author has used both forms of the keratin matrix with good
results at the Wound Clinic, Austin Hospital, Heidelberg,
Australia.
Pharmacological therapies
The adjunctive use of pharmacology also has benefits
in wound management, with some interesting agents
being used including angiotensin-converting enzyme
(ACE) inhibitors, monoclonal antibodies, topical
immunosuppressants and xanthine oxidase inhibitors.
An example was presented at the European Cardiology
conference held in Munich, August 2013, by Ahimastos
et al[14], whose randomised controlled trial demonstrated
that ACE inhibition improved walking ability and quality
of life in patients with peripheral arterial disease; an
improvement that impacts on wound healing and is
substantially beyond that reported with conventional
medical therapies.
Biologics, including monoclonal antibodies and in
particular tumour necrosis factor alpha-antagonists,
are now being extensively evaluated in the setting of
chronic wound healing. Preliminary studies and case
reports provide evidence of the clinical potential of these
compounds in treating Pyoderma gangrenosum[15,16].
The author’s facility has used calcineurin inhibitors such
as tacrolimus successfully for the induction or maintenance
of remission in immune and inflammatory disorders, such
as Pyoderma gangrenosum, necrobiotic xanthogranuloma
and vasculitic wounds[17–19]; it is applied topically as a 0.1%
ointment. Topical tacrolimus does not negatively impact
acute cutaneous wound healing[20].
Tacrolimus promotes melanocyte and melanoblast
growth and creates a favourable milieu for cell migration
via keratinocytes, which are possible mechanisms of how
tacrolimus ointment induces repigmentation in patients
with vitiligo[21].
Tacrolimus forms complexes with cytoplasmic
immunophilins, which block the action of calcineurin
in activated T-cells. This prevents the production of
interleukin-2 and other cytokines, which normally
stimulate T-cell proliferation and differentiation. Tacrolimus
is used for the prevention of solid organ transplant
rejection and the prevention and treatment of graft-versus-
host disease in stem cell transplants[22,23]. It is normally
administered intravenously or orally.
14
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
innovative developments
These are some examples of innovative developments for
advanced wound management. These interventions offer
promising additions and new possibilities, and suggest
that the future is bright for improved wound healing as we
uncover the mystery of tissue repair and develop new ways
of restoring tissue balance. n
AUTHOR details
Geoff Sussman is Associate Professor, Faculty of Medical
and Health Science, University of Auckland, Auckland,
New Zealand and Faculty of Medicine, Monash University,
Melbourne, Victoria, Australia.
References
1. Queen D et al (2004) Int Wound J 1(1): 59–77
2. Expert Working Group, Wounds International (2011) International
consensus. The role of proteases in wound diagnostics. Available at:
http://bit.ly/1bcAhdK (accessed 03.12.2013)
3. Dissemond J et al (2013) EPA made easy. Available at: http://bit.
ly/1d1VaqZ (accessed 05.12.2013)
4. Vu T et al (2007) Fam Practice 24(4): 372–9
5. Expert Working Group, Wounds International (2013) International
consensus. Making the case for cost-effective wound management.
Available at: http://bit.ly/1k6g7Dg (accessed 03.12.13)
6. Pechter PM et al (2012) Wound Rep Reg 20: 236–42
7. Davis S et al (2009) J Am Acad Dermatol 60(3, Suppl 1): AB201
8. Tang L et al (2012) Exp Dermatol 21(6): 458–60
9. Perez R et al (2009) Evaluation of the effects of two keratin
formulations on wound healing and keratin gene expression in a
porcine model. Presented at the Symposium on Advanced Wound
Care Conference, 26–29 April, Dallas, TX
10. Kirsner R (2009) J Am Acad Dermatol 60(3, Suppl 1): AB202
11. Arbuckle A (200) A case study series of the management of
Epidermolysis bullosa using Keragel T. Society of Paediatric
Dermatology, Portland, OR, USA
12. Balance K et al (2008) Improved healing of a diabetic foot ulcer using
new keratin dressing technology. Australian Wound Management
Association Conference Proceedings, 7–10 May, Darwin, NT
13. Hammond C et al (2010) Wound Pract Res 18(4): 189–95
14. Ahimastos AA et al (2013) JAMA 309(5): 453–60
15. Fonder MA et al (2006) J Burns Wounds Nov 20; 5:e8. Available at:
http://1.usa.gov/1aPcoVw
16. Juillerat P et al (2007) Dermatology 215: 245–51
17. Altieri M et al (2010) Ostomy Wound Management 56(9): 32–6
18. Tzellos TG, Kouvelas D (2008) Eur J Clin Pharmacol 64: 337–41
19. Khurrum Baig M et al (2004) Colorect Dis 6: 250–3
20. Namkoong S et al (2013) Exp Dermatol 22(5): 369–71
21. Lan CC et al (2005) Br J Dermatol 153(3): 498–505
22. Dayton JD et al (2011) J Heart Lung Transplant 30(4): 420–5
23. Watkins KD et al (2012) J Heart Lung Transplant 31(2): 127–31
Wounds
 International best practice
for DFU wound management

Implementing a
global wound care
plan for DFUs
� Effective debridement
and wound cleansing

� Recognition and treat-

ment of DFU infection

� Appropriate dressing
selection

� Importance of an
integrated approach

International expert working group

Development group:
Paul Chadwick, UK; Michael Edmonds, UK; Joanne McCardle, UK; David Armstrong, USA

Review group:
Jan Apelqvist, Sweden; Mariam Botros, Canada; Giacomo Clerici,Italy; Jill Cundell, Northern
Ireland; Solange Ehrler, France; Michael Hummel, Germany; Benjamin A Lipsky, USA;
José Luis Lázaro Martinez, Spain; Rosalyn Thomas, Wales; Susan Tulley, United Arab Emirates

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How to...
Ten top questions and answers
Author:
C. Tod Brindle
on the use of dressings for pressure
ulcer prevention

P
ressure ulcer (PU) prevention remains a
struggle for clinicians around the globe
and across all transitions of care. In most
situations, the use of evidence-based practice
and established PU prevention guidelines
provide the necessary interventions to protect
patients from these devastating injuries.
However, these same standards of practice
are not always enough for high-risk patients,
leaving clinicians to investigate adjunctive
therapies to add to their PU prevention
protocols. The recent rise in evidence
supporting the use of prophylactic dressings
for PU prevention has been supported by
two randomised controlled trials (RCTs)
demonstrating efficacy of a particular dressing
in preventing PUs[1,2]. This article serves as a
brief recap of the use of these dressings for PU
prevention by answering the top ten questions
regarding the evidence and their use.
a change in patient status will prevent PU
development. However, PUs continue to
plague patients and the clinicians that care for
them globally, and experts agree that not all
PUs are avoidable[4,5].
In high-risk patients, implementing
standards of practice may either not be
possible or not sufficient to adequately
protect the patient. For example, how
do the standard recommendations for
turning patients at least every 2 or 4 hours
depending upon the surface used[6] apply
to the patient who is undergoing a long
operating theatre procedure without the
possibility of repositioning, or to the severely
haemodynamically unstable patient who does
not tolerate turning despite techniques to
turn the sickest individuals[7]? Moreover, what
of the patient in severe respiratory distress
who requires head-of-bed elevation close
to 45 degrees, and therefore is unable to be

1 Why should dressings in PU prevention be considered?

C. Tod Brindle is Wound and
Ostomy Consultant, Virginia
Commonwealth University
Medical Centre, Richmond,
VA, USA.
The first thing that must be understood
when considering the use of dressings as part of
a comprehensive PU prevention strategy is that
dressings do not replace existing prevention
protocols. A foam dressing is not a specialty
bed; a foam dressing does not replace routine
turning and repositioning.
Guidelines for the prevention and
treatment of PUs have long been described
in the literature and are the focus of both
existing[3] and soon to be released updated
guidelines from the European Pressure Ulcer
Advisory Panel and National Pressure Ulcer
Advisory Panel. These guidelines discuss
well-known standards in prevention, such
as risk, skin and nutrition assessments and
interventions including turning, repositioning,
heel floating, pressure redistribution
surface selection, moisture management,
incontinence prevention strategies and
progressive mobility practices. For most
patients, attention to proper determination
of risk, implementation of these interventions
and escalation of interventions based upon
repositioned to appropriately reduce the
impact of friction, shear and pressure? Could
a dressing be used to decrease patients’ risk
when their mobility is severely compromised
or when excessive shear is involved?
Additionally, extremity immobility related
to rigid casts, splints or traction may prevent
the use of effective interventions such as
bilateral heel floating using pillows or the
application of heel offloading devices. In
this case, a recent RCT demonstrating the
efficacy of heel dressings for PU prevention[1]
suggests that certain dressings may provide
protection for the calcaneous from the inside
of the splint or cast until the device may be
removed. The inability to float the heel also
arises secondary to morbid obesity or even
related to agitation where compliance with
standards of practice is the primary deficit.
A dressing capable of reducing friction,
shear, microclimate and pressure may now
be seen as an additional option, after the use
of pillows or a heel offloading boot, when
standard interventions are not feasible or
effective.

16 Wounds
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2 Is there any evidence for the use of dressings
in PU prevention?
Initial studies looking at the prophylactic use
of dressings for PU prevention lacked statistical
significance[8,9,10,11]. Recently, Santamaria et al[1]
conducted a prospective, open–label, RCT of
440 trauma and critically ill patients who were
admitted to the emergency department (ED)
and ultimately into the intensive care unit (ICU)
of a university medical centre in Australia. The
control group (n=221) received standard PU
prevention practices; the intervention group
(n=219) differed only in the application of a
prophylactic sacral dressing (Mepilex® Border
Sacrum; Mölnlycke Health Care) and heel
dressings (Mepilex® Heel; Mölnlycke Health
Care). The patients were assessed and randomly
assigned in the ED; this occurred specifically
because of emerging evidence that suggests
the triage time carries a high prevalence and
incidence of PU development[12,13].
After 1 year, the researchers reported less
PUs in both the sacral and heel regions for the
intervention group when using dressings as
an adjunct to prevention (sacral — two PUs in
the dressing group versus eight in the standard
of care group, P=0.05; heel — five PUs in the
dressing group versus 19 in the standard of
care group, P=0.002). The use of dressings
resulted in a 10% reduction in incidence for the
intervention group with a hazard ratio of 0.19
(P=0.002), indicating that the application of a
dressing to high-risk patients in the ED/ICU was
superior to standard PU practices alone.
A second study by Kalowes[2] evaluated
whether the use of a sacral soft silicone foam
dressing (Meplex Border Sacrum, Mölnlycke
Health Care) would significantly lower PU
incidence. In this prospective, experimental
study, 367 medical-surgical/surgical trauma
and cardiac care ICU patients were randomised
into: a control group (n=184) receiving a
standard care intervention bundle, including
a pressure redistribution surface, turning
protocol, incontinence prevention and nutrition
management; and an intervention group (n=183)
receiving the same standard of care interventions,
but with the addition of the sacral dressing.
Over the 11-month study, seven PUs
(unstageable, deep tissue injury and stage II)
developed in the control group (4.21%) versus
one PU (deep tissue injury) in the intervention
group (0.6%); these results were found to be
statistically significant (P=0.001). The researchers
subsequently implemented the use of a
prophylactic sacral dressing to their standard of
care bundle for high-risk ICU patients.
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical Update Ten top questions and answers
The emerging clinical and in-vitro evidence
supporting the use of prophylactic dressings or “Clinicians may
PU prevention has led reviewers of the soon to struggle to fully grasp
be published 2014 International Pressure Ulcer how a wound care
Prevention and Treatment Guidelines (European
dressing has the
Pressure Ulcer Advisory Panel and National
capability of truly
Pressure Ulcer Advisory Panel) to consider the
need to address this topic.
protecting the tissue
from the forces of
pressure, shear, friction
3 How does dressing composition protect from
pressure, shear, friction and microclimate?
Clinicians may struggle to fully grasp how a
and microclimate.”
wound care dressing has the capability of truly
protecting the tissue from the forces of pressure,
shear, friction and microclimate. Researchers
showed in-vitro evidence that the physical
deformation of tissue secondary to the forces
applied during a loading event were likely
more damaging than the resulting ischaemia or
hypoxia that occurred[14]. Therefore, if repetitive
insults to the tissues could be potentially
avoided by diverting the forces applied to the
tissues away from the bony prominence or
through dissipation of the intensity, the skin
may be protected from injury.
Nakagami et al[15,16] looked at this possibility
when they compared the use of a transparent
film versus a hydrocolloid-ceramide wound
dressing to decrease PUs on the heel. The
authors concluded that while they showed
the dressings did in fact reduce shear and
friction, the dressings did not have an impact on
pressure, and therefore could not substitute for
heel floating. In this case it could be suggested
that the physical properties of the dressings
allowed for mitigation of two forces, but did not
encompass pressure or microclimate.
Further studies looking at the role of foam
dressing in decreasing pressure in patients with
diabetic foot ulcers during walking provide
more insight[17,18,19]. Four commercially available
dressings were tested and all showed minor
reductions in impact pressures. The studies
indicated that each dressing performed
differently and some dressings were less efficient
when wet. A dressing will never be capable of
reducing pressure to the level of redistribution
found in a specialist mattress; but in order for a
dressing to be an additional preventive measure,
the dressing construction must be capable
of mitigating and redistributing load as this
subsequently impacts shear.
As a result of the success of using the five-
layer silicone sacral dressing, as reported by
Santamaria et al[1] and Kalowes[2], in-vitro studies
were completed to assess how the dressing’s
construction provided benefit, and importantly
17
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how similar dressings compared based upon
“Intensive care their unique construction. Call et al[20] describe
patients have long an in-vitro comparison of nine competitor sacral
been identified dressings currently on the market. They assessed
how well the dressings reduced the coefficient of
for their increased
friction, reduced shear transmission through the
risk of pressure
dressing to the skin surface, and how much load
ulcer development could be deflected over the area of the dressing.
secondary to the In these studies, they determined that dressing
underlying comorbid materials and structure changed the impact of
conditions, decrease shear and loading forces, and that dependent on
in tissue tolerance structure and function the dressings may or may
and the therapeutic not be well suited for prevention.
interventions used by Further, the management or maintenance of
clinical staff.” an appropriate microclimate (relative heat and
humidity) is an important measure to assess.
Especially in critically ill patients and those
with obesity, cardiac conditions or on certain
medications, perspiration and insensible fluid
loss is a known contributor to altered skin
integrity via the impact of moisture-associated
skin damage[21]. Thus if a dressing is to be used
for prevention, it must be known how the
dressing manages moisture vapour transmission
and responds to heat retention.
Call et al[22] evaluated eight commercially
available sacral dressings and looked at the
amount of moisture held under the dressing, the
amount that was capable to be transmitted out
of the dressing and the amount of heat that was
trapped at the skin surface. Clinicians should
question the evidence of the chosen dressing’s
performance in these areas before using as an
additional intervention for PU prevention.
4 How should appropriate dressings be selected for the
protection of different anatomical areas?
Based on both the in-vitro and in-vivo evidence,
it is possible to determine that products such
as the soft silicone foam dressing used in
the aforementioned studies can be used for
protecting the sacrum and heel; other options
exist to protect from medical devices.
Black et al[23] recently provided a
review of literature and consensus panel
recommendations for the prevention of medical
device-related PUs. The authors described
several studies that highlighted the benefit
of various dressings (films, hydrocolloids and
thin foams) in the prevention of device-related
PUs. The differences in construction of these
one-, two- and three-layer dressings again
support the findings that the construction of
the dressing and the type of forces applied
to the area matters. While a film, hydrocolloid
or thin foam would have minimal impact on
the high levels of shear, pressure, friction and
18 Wounds
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microclimate on the sacrum, these forces are
dramatically less under medical devices such as
tracheostomies or noninvasive positive-pressure
ventilation (NIPPV) masks.
Medical device-related PU prevention is
primarily rooted in skin assessment under the
device, proper fitting and routine repositioning
of the device. Fletcher[24] outlines new
techniques to help reduce or prevent skin
damage beneath medical devices. Additionally,
device manufacturers are often unaware of
the potential harm caused by their products,
making clinician reporting of these events back
to the manufacturers vital.
5
ICU
Who is at risk and when should dressings be
considered as part of the prevention strategy?
Intensive care patients have long been
identified for their increased risk of PU
development secondary to the underlying
comorbid conditions, decrease in tissue
tolerance and the therapeutic interventions
used by clinical staff[25–27]. In the author’s facility,
after using sacral silicone foam dressings for
over 5 years and seeing the profound reduction
in PUs, the decision was made by the critical
care nursing council to begin applying the sacral
dressing to all admitted, non-ambulatory adult
ICU patients. This decision came in part because
of the high acuity of the patients in an academic
trauma centre, and because of the complexity
of PU aetiology, where tissue insult may far
precede cutaneous manifestation.
Operating room
The operating room (OR) has been linked to
PU formation in numerous studies[28,29,30]. The
use of a sacral foam silicone dressing has been
studied in the operating theatre. Brindle and
Wegelin[9] reported that in their cardiac surgery
evaluation of the dressing, one of the limitations
of the study were that both the intervention
and the control group had a sacral dressing
applied for their supine OR procedure, with the
control group having the dressing removed on
arrival to the ICU. This inherently affected the
statistical significance of the findings. However,
of interest was the fact that none of the PUs
that developed during the time of the study
in either group occurred until at least 6 days
after their operative procedure. This left the
authors considering that the dressing may have
had a protective effect in the OR, especially
considering the length of the overall procedures
in their study.
Castelino et al[31] evaluated the use of both

the sacral dressing and the same dressing in
different shapes on non-traditional sites during
operative procedures. In prone neurosurgical
patients they evaluated the preprocedural
application of sacral soft silicone foam dressings
to 104 patients and compared their outcomes
with 114 standard of care patients undergoing
the same surgery. They reported no PUs
developing in the preprocedural dressing group,
while 12/114 developed pressure injuries in the
standard of care group.
Emergency department (ED)
The ED is an often overlooked area of hospital
PU prevention measures, simply because of
the complexity of providing consistent care,
available equipment and merging prevention
with initial triage assessment and stabilisation.
Naccarrato and Kelechi[32] describe this dilemma
well, and provide insight via a literature
review and recommendations for developing
emergency nurse PU prevention guidelines.
The use of dressings may be beneficial for
prevention in high-risk patients who are waiting
to be admitted via the ED and have known
risk factors impacting tissue tolerance, such as
patients with spinal cord injury or those patients
who may be transported directly to the operating
theatre from the ED. Cubit and colleagues[33]
evaluated the application of Mepilex Border
Sacrum to men and women >65 years who had a
Waterlow Scale Risk Assessment score indicating
a high risk or very high risk for pressure injury
in an Australian ED. Subsequently, the authors
reported that patients who were not allocated
a dressing during their ED stay were 5.4 times
more likely to develop PUs than those who had
the dressing applied as part of their prevention
protocol. They concluded that the application of
a dressing in the ED seemed to be beneficial for
elderly and ‘at-risk’ patients.
In the author’s facility, patients entering the
trauma bay have a dressing applied to their
sacrum during primary assessment, as many
of these patients inevitably are sent to the
operating theatre or the ICU directly. The risk
of PU development in the ED and the benefit
of prophylactic dressing use was additionally
highlighted in the RCT by Santamaria et
al[1], as all patients were randomised and the
intervention dressings applied in the ED.
6 Does the dressing size make a difference?
When selecting an appropriate dressing for
PU prevention, it appears that size does matter.
Call et al determined in both of their in-vitro
evaluations[20,22] that the larger dressing sizes were
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical Update Ten top questions and answers
more adept at load deflection over their increased
surface area. The dressing needs to be larger than “The most difficult
the bony prominence it means to protect. aspect of using a soft
silicone foam dressing
7 Application and assessment: how do we implement?
The most difficult aspect of using a soft
silicone foam dressing to protect the sacrum
to protect the sacrum is
the proper application
is the proper application of the dressing to
of the dressing to
the body, as well as the technique used for the body …”
skin assessment. In the author’s setting the
Mepilex Border sacrum dressing is used, and
the following advice relates to this product. The
challenge for successful product application
stems from the anatomical variability of each
patient and the need to place the dressing so
that it is fully protecting the bony prominence.
For incontinent patients, proper application
is key to prevent undermining. The dressing
is occlusive and therefore, when applied
appropriately, urine and stool can be wiped
off of the top of the dressing without resulting
strike through. Clinicians should be careful not
to position the dressing too close to the anus
and ensure the distal pole of the dressing is well
sealed to the skin during application to further
prevent undermining.
The clinician should remember that the
primary area of protection is the sacrum, and this
should be the first focus of dressing application;
in some patients, a prominent coccyx or the
proximal portion of the gluteal cleft may also be
protected from intertriginous injury. The dressing
orientation should also be considered when
evaluating the width of the surrounding bordered
edge of the dressing. If during application it is
noted that the bordered edge alone is covering
a portion of the bony prominence, the dressing
may be flipped upside down, as the more narrow
edge of the proximal portion of the dressing may
allow for more coverage.
When applying the dressing, it is easiest
to remove the centre backing layer, fold the
dressing in half and focus on the application of
the distal pole of the dressing to the area around
the sacrococcyxgeal junction; this is the area
of dressing application that is of the greatest
importance to maintain a proper seal. The skin
should be clean and dry and free from skin
creams and barriers, as their use will interfere
with the dressing’s adhesive technology and
negate the preventive benefit. Thus clinicians
are encouraged to cleanse and dry the skin
with a pH-balanced cleanser, apply the dressing
to the dry skin and then use protective barrier
creams or moisturisers to the skin surrounding
the dressing after application.
When protecting the heel, the situation
19
 News
Clinical Wounds
Clinical
Clinical
Clinical updateupdate
innovations
innovations
innovations
“Not all patients
is generally more straightforward, as the
clinician should consider a specially shaped
heel version of the chosen dressing. The
require the use of a clinician must remember that the dressing
prophylactic dressing; must be large enough to not only protect the
in most cases, a posterior calcaneous but also the medial and
comprehensive lateral aspects of this bony prominence as
pressure ulcer well.
prevention strategy After dressing application, it is possible to
is sufficient to use a technique that allows for skin inspection
and reapplication without changing the
manage risk.”
dressing. This requires at least two people, so
that the clinician removing the dressing and
assessing the skin can use both hands on the
dressing without having to be concerned with
moving the patient. The key is to perform
the peel-and-peak technique slowly; if the
dressing is grabbed and removed too quickly,
the dressing edges will roll and decrease
the ease and effectiveness of reapplication.
The clinician should proceed, keeping the
dressing taut to prevent rolling, by starting at
the top left or right edge of the dressing and
pulling the dressing diagonally down, while
constantly pulling the dressing border out-
and-away so as to not let it fold downwards.
The distal seal of the dressing near the
sacrococcyxgeal junction should never be
removed, as this seal is the primary prevention
against undermining of the dressing from
incontinence. The dressing must be firmly
adhered to the skin throughout its entire
surface area to allow for proper loading
and deflection of the forces applied to the
dressing. Without this adherence, the dressing
is ineffective.
8 How often should a dressing placed on intact skin
be changed or the skin assessed?
The author recommends that clinicians
should determine the best method for
recommending skin assessments and dressing
changes according to their organisational
protocols. In the author’s practice, nurses have
been instructed to change the dressing every
72 hours and inspect the skin. However, one
should never restrict the skill or practice of
a registered nurse, and because of this the
nurses are encouraged to perform a peel-and-
peak technique if there is any concern over
skin integrity following a change in patient
condition or after a long OR procedure.
As reported by Brindle and Santamaria[34],
dressing removal and reapplication in
subsequent days did not result in significant
changes in adhesion quality.
20 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
9 When should a prophylactic sacral dressing not
be used?
Not all patients require the use of a
prophylactic dressing; in most cases, a
comprehensive PU prevention strategy is
sufficient to manage risk. However, there are
specific instances where dressings should
not be used or be discontinued from the
prevention protocol. While a properly applied
dressing is resistant to undermining from
incontinence, frequent faecal and urinary
episodes of incontinence may overwhelm the
dressing or create chemical denudation that
impedes adherence. Specifically, patients with
Clostridium difficile-induced diarrhoea are not
candidates for prophylactic sacral dressings
because of the frequency of soiling in these
cases. If the dressing needs to be changed
more than twice in a 24-hour period, it should
be discontinued in favour of alternative skin
protection, such as barrier creams in the case
of incontinence.
In general, ambulatory patients and
those capable of independent turning and
repositioning without sensory perception
deficits do not required preventive dressings.
Each organisation’s prevalence and incidence
data should be reviewed to identify populations
who are at risk, and the locations of the PUs that
are most common. For example, in the neonatal
ICU, sacral dressings are not used for prevention.
Morbid obesity may prevent the proper
application or benefit of a prophylactic
dressing. In the author’s facility, patients with
a body mass index >70 are common. For
these patients, changes in body shape, such
as deep skin folds and creases, prevent the
correct application of a sacral dressing for PU
prevention.
It is important to understand that
prophylactic dressings should never be
positioned under the grounding pad in the
OR; to be effective, the grounding pad must
be 100% in contact with the skin to prevent
arcing. For supine patients positioned in the
OR, the author’s facility uses the vastus lateralis
as the preferred location for grounding pad
application, which in no way interrupts the use
of a preoperatively applied sacral dressing.
10 Is there any evidence on the cost-effectiveness of
dressings for prevention?
A recent article by Santamaria and
colleagues[35] provided a cost–benefit analysis
of the previously published RCT by the same
researchers[1] Based on a 10% reduction in
PU incidence when a dressing was used, the

researchers determined their ICU could project
an annual cost savings between $172 880–
293 800 for the hospital.
Kalowes[2] similarly reported on the cost-
effectiveness of the use of sacral soft silicone
foam dressings; the author projected a
$40 000 annual cost of dressings for use in PU
prevention, with an overall savings of $325 000
for their hospital system via PUs prevented in
comparison with the control group.
In clinical practice, it is necessary for
facilities to determine how the product will
be used to reduce costs. While both sacral and
heel soft silicone foam dressings have been
proven to be efficacious in the prevention
of PUs, organisations need to ensure that
staff know which patients should have this
adjunctive therapy and, importantly, how to
properly apply the dressings and assess the
skin. Without proper in-service education and
instruction, product misuse may occur, related
to ineffective processes. n
References
1. Santamaria N, Gertz M, Sage S et al (2013) A
randomised controlled trial of the effectiveness of soft
silicone foam multi-layer dressings in the prevention of
sacral and heel PUs in trauma and critically ill patients.
Int Wound J doi: 10.1111/iwj.12101. Available at:
http://1.usa.gov/19bN2F6 (accessed 9.12.12)
2. Kalowes P (2013) Impact of 5-layered bordered
foam dressing on ICU patients’ sacral pressure ulcer
incidence. Am J Crit Care ( in press)
3. European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel (2009) Prevention and
Treatment of Pressure Ulcers. NUAP, Washington DC
4. Black JM, Edsberg LE, Baharestani MM et al; National
Pressure Ulcer Advisory Panel (2011) Pressure ulcers:
avoidable or unavoidable? Results of the National
Pressure Ulcer Advisory Panel Consensus Conference.
Ostomy Wound Manage 57(2): 24–37
5. Wound Ostomy Continence Nurses Society (2009)
Position statement on avoidable versus unavoidable
PUs. J Wound Ostomy Continence Nurs 36 (4): 378–81
6. Defloor T, Grypdonck M, De Bacquer D (2005) The
effect of various combinations of turning and pressure
reducing devices on the incidence of PUs. Int J Nurs
Stud 42(1): 37–46
7. Brindle CT, Malhotra R, O’Rourke S et al (2013)
Turning and repositioning the critically ill patient
with haemodynamic instability: a literature review
and consensus recommendations. J Wound Ostomy
Continence Nurs 40(3): 254–67
8. Brindle CT (2009) Outliers to the Braden Scale:
identifying high-risk ICU patients and the results of
prophylactic dressing use. WCET J 30(1): 11–18
9. Brindle CT, Wegelin J (2012) Prophylactic dressing
application to reduce pressure ulcer formation in
cardiac surgery patients. J Wound Ostomy Continence
Nurs 39(2): 133–42
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Clinical Update Ten top questions and answers
10. Chaiken N (2012) Reduction of sacral pressure ulcers
in the intensive care unit using a silicone border foam
dressing. J Wound Ostomy Continence Nurs 39(2): 143–5
26. Slowikowsk G, Funk M (2010)
11. Walsh NS, Blanck AW, Smith L, Cross M, Andersson L, Factors associated with PUs in
Polito C (2012) Use of a sacral silicone border foam patients in a surgical intensive care
dressing as one component of a pressure ulcer unit. J Wound Ostomy Continence
prevention program in an intensive care unit setting. J Nurs 37(6): 619–26
Wound Ostomy Continence Nurs 39(2): 146–9
27. Cox J (2011) Predictors of
12. Dugaret E, Videau M-N, Faure I, Gabinski C, Bourdel- pressure ulcers in adult critical
Marchasson I, Salles N (2012) Prevalence and incidence
rate of PU in an emergency department. Int Wound J
care patients. Am J Crit Care 20(5):
364–74
doi: 10.111/j/1742-481X.2012.01103.x
28. Aronovitch S (1999)
13. Nacarrato M (2013) Pressure Ulcer Prevention Wherever
One Travels. Presentation: 45th Annual Wound Ostomy
Intraoperatively acquired PU
Continence Nurse’s Society National Conference, prevalence: a national study. J
22–26 June, Seattle, WA Wound Ostomy Continence Nurs
26(3): 130–6
14. Gawlitta D, Li w, Oomens CW, Baaijens FP, Bader
DL, Bouten CV (2007) The relative contributions of 29. Tschannen D, Bates O, Talsma
compression and hypoxia to development of muscle A, Guo Y (2012) Patient specific
tissue damage: an in-vitro study. Ann Biomed Eng 35: and surgical characteristics in the
273–84 development of pressure ulcers.
Am J Crit Care 21(2): 116–27
15. Nakagami G, Sanada H, Konya C, Kitagawa A, Tadaka
E,Matsuyama Y (2007) Evaluation of a new PU 30. Schoonhoven L, Defloor T, van der
preventive dressing containing ceramide 2 with low Tweel I, Buskens E, Grypdonck M
frictional outer layer. J Adv Nurs 59(5): 520–9 (2002) Risk indicators for pressure
16. Nakagami G, Sanada H, Konya C, Kitagawa A, Tadaka ulcers during surgery. Appl Nurs
E, Tabata K (2006) Comparison of two PU preventive Res 15(3): 163–73
dressings for reducing shear force on the heel. J 31. Castelino ID, Mercer DM, Calland
Wound Ostomy Continence Nurs 33(3): 267–72
JF (2012) Reducing Perioperative
17. Chokalingam N, Ashford R (2004) A pilot study of the pressure ulcers in thoracic,
reaction forces at the heel during walking with the cardiovascular and spinal
application of four different wound dressings. J Tissue surgery patients: achieving ZERO
Viability 14(2): 63–6 incidence is possible! Available at
http://bit.ly/1ewRNtP (accessed
18. Ashford RL, Feear ND, Shippe JM (2001) An in-vitro
study of the pressure-relieving properties of four 26.11.13)
wound dressings for foot ulcers. J Wound Care 10(2): 32. Naccarato Mk, Kelechi T (2011)
34–8 Pressure ulcer prevention in the
19. Chokalingam N, Ashford RL, Dunning D (2001) The emergency department. Adv
influence of four wound dressings on the kinetics of Emerg Nurs J 33(2): 155–62
human walking. J Wound Care 10(9): 371–4
33. Cubit K, Mcnally B, Lopez V
20. Call E, Pedersen J, Bill B et al (2013) Enhancing pressure (2012) Taking the pressure off
ulcer prevention using wound dressing: what are the in the emergency department:
modes of action? Int Wound J doi: 10111/iwj.12123 evaluation of the prophylactic
application of a low shear, soft
21. Gray M, Black J, Baharestani M et al (2011)
silicon sacral dressing on high-risk
Moisture-associated skin damage: overview and
pathophysiology. J Wound Ostomy Continence Nurs medical patients. Int Wound J 10(5):
38(3): 233–41 579–84
22. Call E, Pedersen J, Bill B, Oberg C, Ferguson-Pell M 34. Brindle CT, Santamaria N (2013)
Dressings for pressure ulcer
(2013) Microclimate impact of prophylactic dressings
prevention: implementation into
using in-vitro body analog method. Wounds 25(4):
clinical practice. Ostomy Wound
94–103
Management (in press)
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dressings to enhance prevention of PUs caused by 35. Santamaria N, Liu W, Gerdtz M et
medical devices. Int Wound Journal doi:10.1111/ al (2013) The cost benefit of using
iwj.12111. Available at: http://1.usa.gov/IfAsdj soft silicone multilayered foam
(accessed 26.11.13) dressing to prevent sacral and
24. Fletcher J (2012) Device-related pressure ulcers made heel pressure ulcers in trauma and
easy. Wounds UK 8(2). Available at: www.wounds-uk. critically ill patients: a within-trial
com/pdf/content_10472.pdf analysis of the Border Trial. Int
Wound J doi:10.1111/iwj.12160.
25. Nijs N, Toppets A, Defloor T, Bernaerts K, Milisen K, van Available at: http://bit.ly/1cvWGTI
den Berghe G (2008) Incidence and risk factors for PUs
(accessed 9.12.12)
in the intensive care unit. J Clin Nurs 18: 1258–66
21
 Case report

Use of honey to treat a necrotic

wound after laryngectomy
and neck radiotherapy

Authors: Treatment of laryngeal cancer by laryngectomy requires effective

management to diminish wound infection and accelerate healing. This case
report outlines the use of a honey-based ointment to manage the supra-
tracheostomy necrosis that occurred post-laryngectomy. This resulted in
successful healing; honey-based products may accelerate healing as a result
of anti-inflammatory and antibacterial action and fibroblast stimulation.
Sonia Pereira

Pedro Ângelo
Ligia Ferreira
Sonia Pereira is Otolaryngology
resident of the CHLC —
Hospital de São José, Lisbon,
Portugal, and a Navy physician
working with hyperbaric
oxygen at Centro de Medicina
Subaquática e Hiperbárica,
Lisbon; Pedro Ângelo is
Otolaryngology resident at
the CHLN — Hospital Pulido
Valente, Lisbon; and Ligia
Ferreira is Otolaryngologist
at the Portuguese Oncology
Institute, Lisbon.
O
tolaryngologists from the Portuguese
Oncology Institute perform an
average of 100 laryngectomies per
year in the treatment of laryngeal cancer.
Common challenges faced include haematoma
formation, wound infection, wound dehiscence
and pharyngocutaneuous fistula. Persistent
non-healing wound dehiscence is relatively
frequent despite antibiotic coverage and
local wound care, because of the underlying
bad condition of the skin and the severe
comorbidities of the patients. The skin of the
neck is usually in a bad condition because
patients requiring a laryngectomy frequently
have a poor nutritional status and are
immunocompromised (because of the cancer).
Additionally, a significant number of them are
submitted to local radiotherapy before surgery.
The management of such situations is
difficult, expensive and both time- and resource-
consuming, often involving repairing surgical
flap coverage, which is not always successful.
More effective treatments are needed for these
patients, which accelerate healing and diminish
wound infection in a quicker manner than
current local and surgical treatments.
Case Report
A 64-year-old man presented with progressive,
long-term dysphonia. He was a heavy smoker
and a recovering alcoholic. He also suffered
from hypercholesterolemia and chronic
obstructive pulmonary disease. At physical
examination, a flexible laryngoscopy showed
lesions of both vocal cords with extension to
the anterior commissure and subglottis. The
neck exam was negative for adenopathies.
This patient was diagnosed with a laryngeal
tumour (T2N0M0). As he represented a serious
surgical risk, he was treated with radiotherapy
in November 2010. Failure of the primary
treatment led to laryngectomy and bilateral
selective neck dissection in June 2011.
Ten days later, extensive supra-tracheostomy
necrosis developed. This is common in
patients with head and neck cancer because
of the aforementioned ‘bad condition of the
skin’. The risk increases in patients submitted
to radiotherapy before surgery, since
radiotherapy itself can cause severe lesions to
the skin. Mechanical debridement and daily
silver dressings (Atrauman®, Hartmann) were
performed. One week after this, no significant
improvement had occurred.
Method
After receiving the patient’s consent, the
authors introduced a honey-based ointment
(L-Mesitran®; Triticum) on 11 July 2011. The
surgical wound was cleaned with saline, and
L-Mesitran was applied daily in a thin layer,
then covered with an absorbent hydrofiber
dressing (Aquacel®; Convatec). The surrounding
skin was treated with a hypoallergenic, semi-
permeable barrier cream (Cavilon®; 3M) to
avoid friction and the development of lesions
on the healthy skin. The primary dressing was
covered and fixed with a self-adherent dressing
made of apertured, non-woven polyester
fabric coated with a layer of an acrylic adhesive
(Mefix®; Mölnlycke Health Care). The patient
did not experience any pain during dressing
changes. There were no fetid odours and no
antibiotics were prescribed.

22 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
 A hive of
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MAR331
 Case report
“Three days after
the application of
L-Mesitran® (Triticum),
the wound started to
improve and closed in
approximately
2 months without
requiring surgical
procedures.”
24
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Results
Three days after the application of
L-Mesitran, the wound started to improve
and a skin graft was considered. Seven
days after, granulation tissue covered
more than 80% of the surgical wound.
The wound closed on 8 September 2011,
in approximately 2 months and without
requiring surgical procedures, such as skin
graft or flap coverage (see Figures 1–6).
Discussion
Laryngeal cancer is the second most
common type of head and neck cancer
and makes up 1–2% of all malignancies
Figure 1. 7 July 2011 — supra-tracheostomy necrosis
post-laryngectomy.
Figure 3. 11 July 2011 — the honey applied.
Figure 5. 24 August 2011.
Wounds
worldwide[1,2]. Approximately 12 500 new
cases of laryngeal carcinoma are diagnosed
each year in the USA, and the incidence is
higher in certain European countries (Spain,
France, Italy and Poland)[2].
Tobacco and alcohol are recognised as the
major risk factors for developing malignant
tumours of the larynx, but others are gaining
importance, such as infection with human
papilloma virus (in younger patients, with
higher social status)[3,4]. This is relevant as
the authors believe there will be a change in
the demographics of patients, who will not
be as old, or educationally and economically
disadvantaged as current patients.
Figure 2. 11 July 2011 — start of honey treatment.
Figure 4. 15 July 2011.
Figure 6. 19 September 2011 — wound fully healed.
 Case report The use of honey in cervical necrosis after laryngectomy and neck radiotherapy
The treatment of such a condition relies
on the stage of the tumour. Earlier stages
(I–II) can be treated with less invasive laser
surgery or radiotherapy, whereas more
advanced stages (III–IV) are treated with
chemo-radiotherapy or aggressive surgery,
such as total laryngectomy[5].
This patient was at stage II on referral, but
failed to respond to radiotherapy, which
led to a total laryngectomy salvage. Early
complications following this procedure are
haematoma formation, wound infection,
wound dehiscence and pharyngocutaneous
fistula[1,2,5].
Previously irradiated patients have a
higher risk of postoperative complications,
such as wound dehiscence and/or infection,
as a result of poor wound healing and soft
tissue fibrosis, frequently worsened by poor
nutritional status and other comorbidities.
The treatment of such wounds requires local
care with daily dressings and, sometimes,
surgical closure, along with a longer length
of stay in hospital[1,2,5].
In this case, the patient developed an
extensive wound dehiscence, which did
not respond to standard local wound care.
Silver dressings had been tried and were
not considered suitable in this case, because
of the need for prolonged use.[6,7,8] Honey-
based products may accelerate healing as
a result of their anti-inflammatory[9] and
debriding action[10], antibacterial activity[11,12]
and fibroblast stimulation effect[9,13]. In this
case, the regeneration of tissue was evident
and was completed within 2 months.
Conclusion
In this case, honey-based dressings showed
significantly better results over other
dressings that had been previously used,
achieving full healing of an extensive
necrotic wound in a few weeks, with no
adverse events and without the need
for extra surgery and grafting. Honey
dressings appear to be a cost-efficient,
non-invasive and safe therapy in irradiated,
laryngectomised patients who develop
postoperative wound dehiscence and/or
infection. n
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
References
1. Lydiatt WM, Lydiatt DD, Snyder MC (2012) Glottic
cancer. Available at: http://emedicine.medscape.
com/article/853055-overview (accessed 22
November 2013)
Case report
2. Hornig JD (2013) Supraglottic cancer. Available at:
http://emedicine.medscape.com/article/852908-
overview (accessed 22 November 2013)
3. Torrente MC, Rodrigo JP, Haigentz M Jr et al (2011)
Human papillomavirus infections in laryngeal
cancer. Head Neck 33(4): 581–6
4. Stephen JK, Chen KM, Shah V et al (2012) Human
Papillomavirus outcomes in an access-to-care
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Surg 146(5): 730–8
5. Johnson JT (2012) Malignant tumors of the larynx.
Available at: http://emedicine.medscape.com/
article/848592-overview (accessed 22 November
2013)
6. Jull AB, Rodgers A, Walker N (2008) Honey as a
topical treatment for wounds. Cochrane Database
Syst Rev Oct 8(4)CD005083. Available at: http://
www.ncbi.nlm.nih.gov/pubmed/18843679
(accessed 22 November 2013)
7. Thomas GW, Rael LT, Bar-Oh R et al (2009)
Mechanisms of delayed wound healing by
commonly used antiseptics. J Trauma 66(1): 82–90,
discussion 90–1
8. Bradshaw CE (2011) An in-vitro comparison of the
antimicrobial activity of honey, iodine and silver
wound dressings. Bioscience Horizons 4(1): 61–70
9. Molan PC (2006) The evidence supporting the use
of honey as a wound dressing. Int J Low Extrem
Wounds 5(1): 40–54
10. Subrahmanyam M (1991) Topical application of
honey in treatment of burns. Br J Surg 78(7): 497–8
11. Cooper R, Molan PC, Hardling KG (1999)
This case study was conducted with
Antibacterial activity of honey against strains of
the patient’s consent. It was part of
Staphylococcus aureus from infected wounds. J R
a preliminary study carried out to
Soc Med 92(6): 283–5 evaluate the effectiveness of honey
as a topical therapy in the treatment
12. Cooper R, Molan P (1999) The use of honey as an of complicated wounds. The purpose
antiseptic in managing Pseudomonas infection. J was to gather clinical data about
Wound Care 8(4): 161–4 this product’s benefits and risks, in
order to ascertain the utility of its
incorporation in standard hospital
13. DuToit DF, Page B (2009) An in-vitro evaluation of treatment protocol. The authors
the cell toxicity of honey and silver dressings. J declare no conflicting interests.
Wound Care 18(9): 383–9
25
 Technology and product reviews
Author:
Beth Sperring
Beth Sperring is Acting
Clinical Nurse Consultant,
Plastic Surgery Telehealth
Service, Royal Perth Hospital,
Perth, Western Australia,
Australia.
26
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
T echnology update :
Using telehealth and photography for
wound assessment in Western Australia
This article examines the use of telehealth in rural Western Australia.
The author provides case studies to explain how clinicians use
photography, secured communication and videoconferencing to
advise on treatment plans and monitor care pathways. Thus telehealth
supports staff working in remote sites and enables expert wound care
to be provided to patients no matter how rural their location.
T
elehealth has been described as
“the use of telecommunication
technologies to provide healthcare
services across distances”[1]. One-quarter
of the population of Western Australia live
in remote and rural sites and, according
to Moffatt and Eley[2], rural Australians
have benefited from telehealth because
it has increased access to health services
and improved the skills of healthcare
professionals, which in turn has decreased
disparities in rural and urban health.
The Plastic Surgery Telehealth Service was
established at the Royal Perth Hospital (RPH)
to provide equitable and timely expert review
for all Western Australians. Delivery of this
interdisciplinary telehealth service relies on
two basic forms:
n Videoconferencing.
n Store and forward.
Videoconferencing lets clinicians discuss
and observe in real time with remote patients
and staff. Despite the benefits offered by this
immediacy and interactivity, videoconference
images frequently lack the crisp, clear
perspective required for effective wound
assessment, necessitating the use of store
and forward.
Store and forward refers to technologies
and processes that allow clinical data, X-rays
and digital images be captured, stored locally
and transmitted securely to another site,
where the information is reviewed. Store
and forward is asynchronous — images are
Wounds
frequently taken and sent during separate
time frames from related videoconferences
— allowing flexibility in timing for capturing
and transmitting images.
Image quality
When associated with comprehensive
patient histories, good-quality wound and
trauma images can validate and enhance
wound assessment[3]. Images that provide
“an objective view of the wound” can be used
to track wound healing[4], and images that
incorporate environmental factors, such as
seating or mobility devices, can help clinicians
detect the factors that may inhibit healing.
Swann[5] discusses the importance
of achieving sharp, clear images and
standardising images to achieve uniform
size or quality, allowing for comparison of
the wound over time. Photographic skills of
nurses and patients vary, affecting the quality
of the images produced, but the requisite
skills can be acquired and improved through
practice[4].
High-resolution wound images may even
show more detailed views of wounds[6], which
can improve assessment and lead to more
effective management. In a teledermatology
study in which image colour and sharpness
were nearly always rated “good to excellent”,
Krupinski et al[7] reported 83% concordance
between in-person and digital diagnoses and
76% concordance between biopsy results and
digital diagnoses.

Sikka et al[8] studied images taken on
mobile phones and although image quality
was described as moderate (and not all
images were of usable quality), still found
a high rate of agreement in management.
These findings suggest images of lesser
quality may still prove to be useful.
EDUCATION AND TRAINING
Although the literature agrees about the
advantages of using digital images[9,10], there
is much discussion around the need for
appropriate training for all clinicians[11], the
skill level of clinicians required to reduce
variability[12] and the obstacles preventing the
use of telemedicine, such as lack of evidence
and the need to create a shift in culture[13].
In Western Australia, clinicians are trained
in the taking, transmitting and storing of
digital images. Guidelines for standardising
images are available to all staff on the
intranet and Internet. Quality control involves
the review of images received at the tertiary
centre, providing feedback to the nurse
photographer and reporting to management
when image quality is poor. In instances
of poor image quality, resource availability
is investigated and further education is
provided to up-skill the nurse photographer
as required.
Guidelines for standardising images have
been published by the Western Australian
Department of Health (WoundsWest)[14].
These cover:
n The optimum distance of the camera from
the wound.
n The correct camera settings to achieve
optimum image quality.
n The required perspectives (similar to the
lateral and oblique perspectives used to
take X-rays).
n The use of lighting and/or flash.
n The importance of reducing background
clutter.
n The best size and format to enable image
storing and forwarding.
CLINICAL APPLICATIONS
Digital photography is a relatively
cost-effective way of documenting the
progression of a wound, can be easily
incorporated into nursing practice[15]
and can aid in diagnosis[16]. As such,
digital photography is an important tool
in determining treatment options. The
following case studies illustrate the use of
videoconferencing and store and forward to
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Technology update Using telehealth and photography for wound assessment
manage plastic surgery trauma patients at
a distance. Informed consent was obtained
from both patients.
Technology and product reviews
Case study 1
Mr A is a 58-year-old man who lives 1500 km
north of Perth. He was referred for specialist
review after a metal sheet fell on his shin,
causing a laceration. The injury resulted
in a traumatic, distally based necrotic
skin flap. Initial surgical debridement was
undertaken at the regional site but, because
of complications with the skin flap’s viability,
he was transferred to Perth for secondary
debridement and returned home a few days
later.
Figure 1 was taken by the regional
nurse 1 week post-surgery, before the
videoconference. The image shows a swollen,
dusky skin flap with debris present within
the wound bed. The videoconference took
place with a nurse at both sites. The author,
[at the RPH site] used the photographs and
wound description provided by the rural
nurse to confirm the debris were dressing-
product residue. Options for removing
the debris included conservative fine
sharp wound debridement (CFSWD) or
autolytic debridement. The regional nurse
stated that she was neither confident nor
skilled in CFSWD, so options for achieving
autolytic debridement were discussed and a
hydrocolloid dressing decided on. The author
also stressed the importance of good wound
cleansing and skin hygiene.
Figure 1. Wound presented at a videoconference. It was established that the debris
around the skin flap was dressing-product residue, and a treatment plan was given via the
videoconference to the regional nurses and rural patient.
27
 Technology and product reviews

The wound image also showed swelling in

the foot and ankle. The interactive nature of
videoconferencing allowed the nurses and
Mr A to discuss treatment options to reduce
the swelling that would be compatible with
Mr A’s lifestyle. Consideration was given to:
n Local temperatures — these can reach

35°C, plus humidity, which affects wound

care choices as hydrogel dressings dry out
and emollients melt.
n Mr A’s ability to self-care — his ability to

effectively undertake dressing changes

himself were crucial, as he lives outside the
catchment area for domiciliary care services
and too far from the regional hospital to
Figure 2. Wound 2 weeks after surgery showing healing progression; the rural nurse attend for regular dressing changes.
confirmed that the maceration seen here went on to resolve. n Product availability — the range of

dressing products was reduced.

n Mr A’s home and work environment —

dust, dirt and air-conditioning had to be

accounted for.
Figure 2, taken 2 weeks post-surgery,
shows the progress towards healing. The
wound bed had healthy granulation tissue
and the wound margins were epithelialising.
In discussion with the rural nurse, it was
confirmed that the maceration seen in the
image had resolved. After suture removal, the
suture line was flat, pink and soft, suggestive
of a good scar outcome.

Case study 2
Mr B is a 62-year-old man who sustained a
crush injury to his left hand while working at
home, 400 km northeast of Perth. The Royal
Flying Doctor Service transferred him to RPH,
Figure 3. After sustaining a crush injury this patient was transferred to hospital for surgical
where surgical repair included a groin flap to
repair with a groin flap covering the deficit skin of his left hand.
cover the skin deficit to the dorsum of the left
hand (Figure 3).
Postoperative review was undertaken via
videoconference and the use of photography;
photos of the groin flap were taken weekly
and shared with the tertiary site using a secure
network. The images were used to assess the
colour and positioning of the flap. Further
assessment, including the warmth and texture
of the flap, was made in discussion with the
regional nurse and patient.
Clinical problem-solving, discussion of
the wound care options and the planning
of readmission for flap division were all
undertaken during videoconference sessions.
After division of the groin flap (Figure 5), the
patient's rehabilitation, including wound
review, scar management and range
Figure 4. Videoconferencing and digital photography were used to monitor wound healing
of movement, were supervised using
after flap division to allow the patient to be discharged to his rural home.
videoconferencing and digital photographs.

28 Wounds
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com

Consent and security
Managing wound images and patient
information involves issues of consent,
confidentiality, privacy and security. Addressing
these issues involves all health services and
professionals. Secured messaging systems must
be used to ensure compliance with policies,
regulations and acts that govern practice[17].
At RPH, digital images are catalogued using a
unique identification system that complies with
the Freedom of Information Act, the Western
Australian Health Data Management Policy and
the Federal Privacy Act. Images are accessible
and easily retrieved by those who have the right
to access them. Written permission for the use
of images is gained from each patient if being
used to support clinical review across health
services or being shared with a GP. Patients and
staff recognise that this process of collaboration
is important in improving outcomes.
Although there is increased awareness of
the medico–legal issues associated with the
sharing of information across organisations and
between service providers, new and advancing
technologies pose a grey area. Many such
technologies allow increased access and the
ability to share, without the appropriate level
of security, potentially leading to information
or images reaching unsecured sites. Bypassing
the constraints of a secure system may improve
information-sharing and timeliness of decision-
making, but clinicians should proceed with
caution, as issues of technical and clinical
standards to ensure patient privacy and
standardised practice are as yet unresolved[18].
DISCUSSION
Videoconferencing that incorporates digital
still images in the store and forward format
has improved the effectiveness and timeliness
of patient review by the RPH Plastic Surgery
Telehealth Service. A combination of digital
images, videoconferencing and phone
communication allows for quick and effective
reassessment when complications arise.
Secure electronic networking across health
services assists in care delivery. With patient
consent, a digital image and a discharge summary
can be shared with the extended team, including
the GP or community-based service provider.
Photographic images are used to comparatively
assess wounds and plan treatment options.
This encourages improved communication,
strengthening service provision.
Other benefits include reduced travel and
transport costs, as neither the specialist team
nor the patient needs to travel long distances for
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
Technology update Using telehealth and photography for wound assessment
wound reviews. Minimising patient travel also
leads to reduced time away from home, family and
community, which could increase quality of life.
Each videoconference session provides
an opportunity for continuing education,
while members of the specialist team gain an
understanding of varied work environments
throughout the state. Support and
encouragement in the use of videoconferencing
and photographic equipment from the Western
Australian Department of Health has built
confidence within the workforce, and nurses from
rural sites report that access to expert advice has
encouraged them to become more involved in
wound care.
CONCLUSION
Wound assessments using videoconferencing
and digital clinical images will be successful if the
images are sharp, well-composed and exhibit the
appropriate colour contrast. The images must be
reviewed in association with a comprehensive
medical and wound history and sent in a timely
manner to a clinician who has the technology
and skill to interpret the images. Wound
treatment plans generated by this collaborative
approach need to reflect the skill of the clinicians
providing the care and the resources available
while remaining focused on the patient and their
wound.
Telehealth can provide benefits for clinicians
and patients. It is an excellent example of how
technology can be used to build stronger
partnerships in wound care, support staff
working in remote and rural sites and provide
expert care to patients regardless of their
location. n
Acknowledgements
The author acknowledges: the Western Australian Country
Heath Service; the Medical Illustrations Department at
Royal Perth Hospital; Alan Hamilton, Manager of the State
Telehealth Service; and the patients who have agreed to
share their stories.
References
1. Mosby (2009) Mosby's Medical Dictionary. 8th edn.
Elsevier, Amsterdam
2. Moffatt JS, Eley DS (2010) The reported benefits of
telehealth for rural Australia. Austral Health Rev 43(3):
276–81
3. Bradshaw LM, Gergar ME, Ginger A (2011) Collaboration
in wound photography. J Adv Skin Wound Care 24(2):
85–92
4. Buckley KM, Adelson LK, Agazio JG (2009) Reducing the
risks of wound consultation. J Wound Ostomy Continence
Nurs 36(2): 163–70
5. Swann G (2010) Photography in wound care. Nurs Times
96(45): 9
6. Debray M, Couturier P, Greuillet F et
al (2001) A preliminary study of the
feasibility of wound telecare for the
elderly. J Telemed Telecare 7: 353–8
7. Krupinski E, LeSueur B, Ellsworth L
et al (1999) Diagnostic accuracy and
image quality using a digital camera
for teledermatology. Telemed J 5(3):
257–63
8. Sikka N, Pirri M, Carlin KN, Strauss R,
Rahmimi F, Pines J (2012) The use of
mobile phone cameras in guiding
treatment decisions for laceration
care. Telemed e-Health 18(7): 554–7
9. Samad A, Hayes S, French L,
Dodds S (2002) Digital imaging
versus conventional contact tracing
for the objective measurement of
venous leg ulcers. J Wound Care
11(4): 137–40
10. Santamaria N, Carville K, Ellis I,
Prentice J (2004) The effectiveness of
digital imaging and remote expert
wound consultation on healing
rates in chronic lower leg ulcers in
the Kimberley region of Western
Australia. Primary Intention 12(2):
62–70
11. Murphy RX, Bain MA, Wasser TE,
Wilson E, Okunski W (2006) The
reliability of digital imaging in the
remote assessment of wounds
defining a standard. Ann Plast Surg
56(4): 431–6
12. Houghton PE, Kincaid CB, Campbell
KE, Woodbury MG, Keast DH (2000)
Photographic assessment of the
appearance of chronic pressure and
leg ulcers. Ostomy Wound Manage
46(4): 20–30
13. Saffle JR, Edelman L, Theurer
L, Morris SE, Cochran A (2009)
Telemedicine evaluation of acute
burns is accurate and cost-effective.
J Trauma 67(2): 358–65
14. Prentice J, Baker R (2013) Digital
Photography in Wound Management.
Department of Health WoundsWest,
Perth, Western Australia
15. Phillips K (2006) Incorporating digital
photography into your wound-care
practice. Wound Care Can 4(2): 16-18
16. Hayes S (2003) Digital photography
in wound care. Nursing Times 99(42):
48–52
17. Ruotsalainen P (2010) Privacy and
security in teleradiology. Eur J Radiol
73(1): 31–5
18. Silverman RD (2003) Current legal
and ethical concerns in telemedicine
and e-medicine. J Telemed Telecare
9(S1): 67–9
29
 Wound digest
Wound digest
This digest summarises some important papers published on wound care.
SELECTED PAPERS OF INTEREST
1. An exploration of fourth-year undergraduate
nurses’ knowledge of and attitude towards
pressure ulcer prevention.
2. Avoidable antibiotic exposure for
uncomplicated skin and soft tissue infections
in the ambulatory care setting.
3. Negative pressure wound therapy for treating
foot wounds in people with diabetes mellitus
(Review)
4. Feelings of powerlessness in patients with
venous leg ulcers.
5. Current practice in the management of wound
odour: An international survey.
1 An exploration of fourth-year
undergraduate nurses’ knowledge of and
attitude towards pressure ulcer prevention
Readability a a
Relevance to daily practice a a
Novelty factor a a
n As student nurses will become future qualified healthcare
staff, it is imperative that during their 4 years of training
they receive education and develop skills pertaining to
the prevention and management of pressure. However,
there is insufficient time allocated to wound care in
university programmes and a lack of education on
pressure ulcer prevention.
n The authors undertook a quantitative, cross-sectional
survey (a total of 60 fourth-year undergraduates were
given questionnaires) to determine the extent of
undergraduate nurses’ knowledge of, and attitudes
towards, the prevention of pressure ulcers.
n It was found that the participants, while displaying a
positive attitude towards pressure ulcer prevention, had
a poor knowledge of pressure ulcer prevention.
n Ninety-seven percent of participants felt confident
in their ability to prevent a pressure ulcer and had a
moderate to high level of competency.
n The authors discovered that having a high level of
competency corresponded with having a positive
attitude towards pressure ulcer prevention, but did
not equate to possessing knowledge of pressure ulcer
prevention.
n In fact, attitude and knowledge had an inverse
relationship. The participant who obtained the highest
attitude score of 47 had one of the lowest knowledge
scores of 10. Conversely, the participant who had the
lowest attitude score of 31 obtained one of the higher
knowledge scores of 18.
30
Wounds International Vol 2 | Issue 2 | ©Wounds International 2010 International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
n The findings taken from this study can be used as
a baseline to inform future education and training
programmes in clinical and university settings. The
authors suggest that this will lead to improved patient
outcomes.
Cullen Gill E, Moore Z (2013) An exploration of fourth-year
undergraduate nurses’ knowledge of and attitude towards
pressure ulcer prevention. J Wound Care 22(11): 618–9, 620, 622
2 Avoidable antibiotic exposure for
uncomplicated skin and soft tissue
infections in the ambulatory care setting
Readability a a a
Relevance to daily practice a a a a
Novelty factor a a a a
n Soft tissue and uncomplicated skin infections are among
the most frequent indications for outpatient antibiotics.
The authors undertook a retrospective cohort study to
assess current prescribing practices and frequency of
avoidable antibiotic exposure.
n A total of 364 cases were analysed, comprising children
a a
and adults treated in the ambulatory care setting for
a
uncomplicated cellulitis, wound infection or cutaneous
a a
abscess between 1 March 2010 and 28 February 2011.
n The authors found that of 292 total cases where complete
prescribing data were available, 46% of these cases
encountered avoidable antibiotic exposure. Furthermore,
it was discovered that use of short-course, single-
antibiotic treatment strategies would have decreased
prescribed antibiotic days by 19% to 55%.
n It was concluded that approximately half of
uncomplicated skin infections are associated with
avoidable antibiotic exposure. Through the promotion of
single-antibiotic treatment approaches, total antibiotic
use could be substantially decreased.
Hurley HJ, Knepper BC, Price CS et al (2013) Avoidable
antibiotic exposure for uncomplicated skin and soft tissue
infections in the ambulatory care setting. Am J Med 126(12):
1099–106
3 Negative pressure wound therapy for
treating foot wounds in people with
diabetes mellitus (Cochrane Review)
Readability a a a
Relevance to daily practice a a a
Novelty factor a a a
n Negative pressure wound therapy (NPWT) can be used to
treat wounds in people with diabetic foot ulcers (DFUs).
This Cochrane systematic review aimed to provide clear
clinical guidance to facilitate decision making regarding
its use.
Wounds

n To assess the effects of NPWT, compared with standard
care or other adjuvant therapies, the review authors
looked at published or unpublished randomised
controlled trials (RCTs) that evaluated the effects of any
brand of NPWT in the treatment of DFUs, irrespective of
publication status or language of publication.
n The authors reviewed five studies with a total of 605
participants. Two studies (502 participants in total)
compared NPWT with standard moist wound healing.
The three remaining studies were small with limited data.
n The authors found that there is some evidence to
suggest that NPWT is more effective in healing DFUs
(in terms of reducing time-to-healing and reducing risk
of amputations) compared with standard moist wound
healing. This relates to postoperative amputation
wounds , as well as chronic, debrided DFUs.
n However, it was noted that these studies could be at risk
of bias. The limitations in current RCT evidence would
point to a need for further trials to be conducted. The
authors conclude that any potential change in practice
regarding the use of NPWT must be informed by clinical
experience and acknowledge the uncertainty around this
decision owing to data quality.
Dumville JC, Hinchliffe RJ, Cullum N et al (2013) Negative
pressure wound therapy for treating foot wounds in people
with diabetes mellitus (Review). Cochrane Database Syst Rev
17(10): CD010318
4 Feelings of powerlessness in patients with
venous leg ulcers
Readability a a a a
Relevance to daily practice a a a a
Novelty factor a a a a
n People with venous leg ulcers (VLUs) can experience
a variety of feelings, such as fear, feelings of loss,
grief and powerlessness, which may adversely affect
quality of life. Powerlessness can be described as a
feeling where the patient believes that nothing will
change the course of events, no matter what is done.
n The authors undertook an exploratory, descriptive,
analytic, cross-sectional study in Brazil, between
May 2010 and April 2012, to assess feelings of
powerlessness in 60 individuals with VLUs. Most
patients were women and aged ≥61 years. Fifty-three
percent of patients (n=32) had had a VLU for more
than 10 years. The majority were smokers (77%) and
non-alcoholics (87%).
n All participants responded to the Powerlessness
Assessment Tool (PAT) for adult patients. The PAT
consists of a 12-item measure of powerlessness rated
on a 5-point Likert-type scale (1 = never, 2 = rarely, 3 =
sometimes, 4 = often, 5 = always).
n Most patients reported a high PAT score indicative
of strong or very strong feelings of powerlessness or
loss of control. More than half (52%) of patients in this
Wounds International Vol 4 | Issue 4 | ©Wounds International 2013 | www.woundsinternational.com
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Wound digest
study reported total PAT scores ranging from 51–60,
while 32% had scores from 41–50.
n There were no significant differences in terms of
feelings of powerlessness between sexes, smokers
and non-smokers, alcoholics and non-alcoholics, and
different age groups. However, the authors found
that the presence of wound exudate and malodour
had a significant impact in the study population
(P=0.004).
n The authors conclude that assessment of feelings of
powerlessness may help to plan intervention that can
minimise the impact of living with a VLU.
Salomé GM, Openheimer DG, de Almeida SA et al (2013)
Feelings of powerlessness in patients with venous leg ulcers. J
Wound Care 22(11): 628, 630, 632–4
5 Current practice in the management of
wound odour: an international survey
Readability a a a a
Relevance to daily practice a a a a
Novelty factor a a a a
n Malodour has been regularly cited by patients and
carers as one of the most distressing and socially
isolating aspects of their wounds, which is detrimental
to their quality of life.
n There is no standardised approach to assessment and
management of wound odour. To collect baseline
data between May 2010 and April 2012 the authors
emailed an online questionnaire in English, Spanish,
Italian and German to wound care organisations
worldwide, palliative and oncology nursing
a
organisations, and wound management specialists.
a
n A total of 1444 individuals from 36 countries
responded. Sixty-five per cent (n = 926) saw patients
with wounds on a daily basis and 68% (n = 635) said
that they spent up to 25% of their working week
dedicated to wound management. Odour, pain and
wound exudate were the greatest challenges.
n Charcoal and silver-based dressings were the
two most prominent dressings used for odour
management; however, only 48.4% and 23%
respectively reported these to be effective.
Although the most effective treatment was cited
as antimicrobial agents, but were not the most
frequently used.
n Eighty-nine percent agreed that there was a need
to develop guidelines in this area as there is a ‘trial
and error’ approach to odour management. There is
low satisfaction with current approaches and further
research and education is needed on how to assess
and manage odour.
Gethin G, Grocott P, Probst S, Clarke E (2013) Current practice
in the management of wound odour: An international survey.
Int J Nurs Stand [Epub ahead of print]. Available at: http://bit.
ly/1corNxd (accessed 11.12.13)
31