CME-Article

Submitted: 27.12.2013 DOI: 10.1111/ddg.12351

Accepted: 13.3.2014
Conflict of interest
Joachim Dissemond has served as consul-
tant and/or paid speaker for and/or
­participated in clinical trials sponsored by Modern wound care – practical aspects
companies including 3M, B. Braun, BSN,
Coloplast, Convatec, Draco, Hartmann AG, of non-interventional topical treatment
KCI, Lohmann & Rauscher, Medoderm,
Sastomed, Systagenix, UCB and Urgo. of patients with chronic wounds
Matthias Augustin has served as consultant
and/or paid speaker for and/or participated
in clinical trials sponsored by companies
that manufacture drugs used for the treat-
ment of psoriasis including Abbott, Almirall,
Amgen, Biogen Idec, Celgene, Centocor,
Janssen-Cilag, Leo, Medac, MSD (formerly
Essex, Schering-Plough), Novartis, Pfizer
(formerly Wyeth). Sabine Eming has been
advisor to Paul Hartmann AG. Tobias Ge-
orge has received honoraria for lectures
from Urgo and Lohmann & Rauscher. Hauke
Schumann has been advisor to Birken AG.
Thomas Horn, Sigrid Karrer, Markus Stücker
declare no conflict of interest.

Joachim Dissemond1, Matthias Summary

Augustin2, Sabine A. Eming3, The treatment of patients with chronic wounds is becoming increasingly complex. It
Tobias Goerge4, Thomas Horn5, was therefore the aim of the members of the working group for wound healing (AGW)
Sigrid Karrer6, Hauke Schu- of the German Society of Dermatology (DDG) to report on the currently relevant as-
mann7, Markus Stücker8, for pects of non-interventional, topical wound treatment for daily practice. ­Beside neces-
the working group for wound sary procedures, such as wound cleansing and débridement, we describe commonly
healing (AGW) of the German used wound dressings, their indications and practical use. Modern antiseptics, which
Society of Dermatology (DDG) are currently used in wound therapy, usually contain polyhexanide or octenidine.
(1) Clinic for Dermatology, University Physical methods, such as negative-pressure treatment, are also interesting options.
Hospital Essen, Germany It is always important to objectify and adequately treat pain symptoms which often
(2) Institute for Health Services affect these patients. Modern moist wound therapy may promote healing, reduce
Research in Dermatology and
complications, and improve the quality of life in patients with chronic wounds. To-
Healthcare (IVDP), University Medical
gether with the improvement of the underlying causes, modern wound therapy is an
Center, Hamburg- Eppendorf
(3) Department of Dermatology, important aspect in the overall treatment regime for patients with chronic wounds.
­University of Cologne, Cologne,
­Germany
(4) Klinik für Hautkrankheiten, ­Allgemeine Introduction
Dermatologie und Venerologie, University
Hospital Münster, Germany
(5) Clinic and policlinic for Dermatology, Physiological wound healing is a complex process. The primary goal of this tempo-
Venereology and Allergology, ­Helios rally and regionally controlled series of events is to restore tissue integrity and fun-
Klinikum Krefeld, Germany ction. In regard to the skin, the wound healing process encompasses a time period
(6) Department of Dermatology, which depends on many factors and which may be divided into several consecutive
­University Hospital Regensburg, phases [1]. There is still no standardized, accepted consensus on the definition of
­Germany
chronic wounds. Along with duration, there are problems owing to the highly va-
(7) Department of Dermatology,
­Freiburg University Hospital, G
­ ermany riable factors related to the pathophysiology. Most current classifications are based
(8) Department of Dermatology, only on time. In the following, “chronic” refers to wounds which have persisted for
Ruhr-University Bochum, Germany. more than eight weeks [2].
Even if there is scant scientific evidence on the effectiveness of wound care
Section Editor products in accelerating the healing of chronic wounds, there is consensus
Prof. Dr. Jan C. Simon, Leipzig among experts in the field concerning the use of modern wound care products,
especially in regard to improving quality of life [2]. New discoveries in topical

© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207 541
 CME Article
Chronic wounds are presently defined
as those which have persisted for more
than eight weeks.
Today it is generally accepted that
­proper wound care should aim to
­create a moist wound milieu.
At the beginning of wound therapy, it
is often necessary to perform débride-
ment, or at least to cleanse the wound.
For wound care, Ringer solution or
­physiological saline solution are the
­cleansers of choice.
The use of tap water is only permissible
in Germany if filters with a maximum
pore size of 0.2 μm are used.
Mechanical débridement using sterile
compresses is often sufficient for the
removal of loosely adherent coatings,
such as fibrin.
542 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
wound care have made the treatment of patients with chronic wounds more
complex. Thus it was the aim of the working group for wound healing (AGW)
of the German Society of Dermatology (DDG) to present a review article on the
current, relevant aspects of topical, non-interventional wound care for use in
daily practice.
Modern wound care
Before treatment of any patient with a chronic wound begins, the relevant under-
lying factors should be diagnosed and, whenever possible, treated. Wound healing
may be promoted by topical wound care. The concept of moist wound care was
pioneered by George D. Winter. In preclinical studies done in 1962, he showed that
a moist wound milieu promoted wound healing [3].
Wound cleansing
At the beginning of wound therapy, it is often necessary to perform débride-
ment, or at least to cleanse the wound. In addition to necrotic areas, fibrin,
crusts, or dressing remnants must also be removed [4]. For wounds that are
to be cleansed when changing the wound dressing, Ringer solution or phy-
siological saline solution are the cleansers of choice. Sterility is no longer
ensured once the container has been opened. Solutions which do not contain
preservatives must be used immediately. For practical purposes, it is often
more feasible to use cleansing solutions which contain preservatives, such as
polyhexanide, or which are completely used up in a single dressing change.
Care should be taken to ensure that the solution has been warmed to body
temperature [5].
The use of tap water is strongly debated among experts [6]. The German law
on the prevention of infection, and the recommendations of the Commission for
Hospital Hygiene and Infection Prevention (KRINKO) of the Robert Koch Institu-
te (RKI), have unequivocally stated that only sterile cleansing liquids may be used
for wound care. The use of tap water is only permissible in Germany if filters with
a maximum pore size of 0.2 μm are used [7].
Patients rarely purchase such filters, given their expense. Yet, for doctor’s
­offices and wound clinics, they represent a viable alternative if one wishes to con-
tinue using tap water.
Débridement
Débridement should be as radical as necessary, but as gentle as possible. Treatment
of chronic wounds often begins with mechanical débridement. Mechanical débri-
dement using sterile compresses is often sufficient for removal of loosely adherent
coatings, such as fibrin.
For painful wounds, in particular, one therapy option is to use a monofilament
fiber product, which involves minimal pain. Firmly adherent coatings and necrotic
areas usually have to be removed surgically. Other alternatives include biosurgical
débridement with medicinal larvae or physical débridement with ultrasound, plas-
ma, or laser. These methods are usually only offered by specialized wound care
centers. In outpatient care, especially, autolytic techniques, such as hydrogels and
proteolytic enzymes are used. For effective débridement, it is imperative to plan the
necessary pain therapy in advance and to discuss it with the patient [4, 8].
CME Article
Activated carbon wound care dressings
are used, for example, for foul-smelling
wounds and ulcerated tumors.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
Table 1  Requirements for modern wound dressings.
  Reasonable cost
  Conforms to body contours
  Atraumatic dressing changes
  A bsorption of wound exudate (also with compression therapy)
  Permeable to oxygen, water vapor, and carbon dioxide
  Simple and complete removal
  E asy to apply
  Mechanical protection
  May be cut to size, or available in a variety of shapes and sizes
  Protection against microorganisms
  Sterile packaging
  Prevention of dehydration
  Contains hypoallergenic materials
  Contains non-toxic materials
  Thermal insulation
Materials for modern wound care
In everyday practice, dressings are recommended as part of modern moist wound care
for most chronic wound patients. No single dressing is optimal for all wound types
(Table 1). In Germany, there are currently more than 1,000 different medical products
for use in chronic wounds, and many manufacturers have their own declarations. This
makes the steadily growing market for such products increasingly difficult to navigate
(Figure 1). The following discussion focuses on only a few, widely used types of wound
care products and briefly discusses their presumed modes of action [9–13].
Activated carbon
Activated carbon wound care dressings are made up of fibers consisting of c­ arbonized
cellulose products. The compresses reduce odors and absorb ­endotoxins, and they
also have bactericidal properties. They are thus especially suitable for foul-smelling
wounds and ulcerated tumors.
The dressings are placed in the wound and fixed in place with compresses.
Some of the products available cannot be cut to size, as this would leave activated
carbon in the wound. For wounds with only a limited amount of exudate, the dres-
sing should be moistened regularly. For wounds with a large amount of exudate,
an absorbent secondary dressing should be used and the surrounding area should
be protected against maceration, as currently activated carbon dressings can only
­absorb a small amount of moisture. The dressing should be changed every 1–3 days.
Alginate
Alginate products consist of a loose dressing structure made up of fibers which are
composed of red or brown algae. After contact with sodium salts present in the
blood or in wound secretions, the alginate fibers absorb the secretions to form a
543
 CME Article
Figure 1  Phase- and exudate-dependent use of wound products for the treatment of patients with chronic wounds.
Given that alginates also have hemost-
atic effects, they are also suitable for
achieving hemostasis, for instance, fol-
lowing surgical débridement.
Fly larvae may be used for selective
­biosurgical débridement.
544 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
moist hydrophilic gel; bacteria and detritus are enclosed in the gel structure. The
speed and amount of gel formation depend on the amount of exudate absorbed and
the fiber weave. Alginates are capable of absorbing up to 20 times their own weight.
Depending on the product, calcium, zinc, or manganese is supplied to the wound
milieu. Alginates are used for deep, jagged, or heavily exuding wounds, e­ ither for
wound cleansing or to promote granulation. Given that alginates also have hemost-
atic effects, they are also suitable for achieving hemostasis, for ­instance, following
surgical débridement.
Depending on the type of wound and the amount of exudate, either dry or
moist alginate is applied. Compresses may be placed in deep wounds and pocket
wounds; tamponade may also be used. For heavily exudative wounds, it is advisable
to use an absorbent secondary dressing for example a superabsorber. For clinically
infected wounds, the dressing should be changed daily. For all other wounds, a new
dressing should be placed every 2–5 days, depending on the amount of exudate.
Biosurgery
Biosurgery refers here to the treatment of wounds with medical grade maggots.
Species that are suitable for use in biosurgery include larvae belonging to the Lucilia
sericata (gold fly), as they are capable of performing highly selective débridement.
Biosurgical débridement does not cause bleeding, and is associated with mini-
mal or no pain. Fly larvae have the potential for lysis of bacteria, including methi-
cillin-resistant Staphylococcus aureus (MRSA). The larvae are placed directly on
CME Article
Chitosan products may be used for
hemostasis, for example, after surgical
débridement.
Honey preparations used in osmotic
débridement can cause severe pain.
Products containing hyaluronic acid
are often used for wounds with a large
amount of exudate to promote granula-
tion and for wound cleansing.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
the wound. If free-roaming larvae are used, a cage must be built around the wound
using the net that comes with the larvae and gel strips or stoma paste. Nowadays,
fly larvae are more common; these come contained in a BioBag. Depending on the
wound shape, the bag should be moved every day, as it is only effective on the area
over which it is directly placed. Highly absorbent compresses should be used as a
secondary dressing. The dressing should be changed after 3–5 days.
Chitosan
Chitosan is a biopolymer that is derived from chitin. It is available in wound dres-
sings or as a spray. It is believed to promote various aspects of wound healing,
given its positively charged surface. Chitosan products may be used in all phases of
wound treatment, after adequate débridement has been performed. They may also
be used for achieving hemostasis after surgical débridement.
The wound dressing should be cut to size before being placed on the wound.
When using the spray, it must be allowed to dry for at least 90 seconds before
applying the secondary dressing. Depending on the type of product, the dressing
should be changed every 1–3 days.
Honey
Honey wound care preparations come in tubes or as impregnated dressings.
The osmotic effect, leading to wound dehydration, and low pH values, as well
as the release of small amounts of hydrogen peroxide and methylglyoxal, exp-
lain its antimicrobial properties as well as the often severe pain reported during
treatment.
Given that honey is a natural product, its effectiveness varies depending on
the source of the product and the processing methods used. Honey-based pro-
ducts are used for wounds with a small amount of exudate for osmotic débri-
dement and elimination of bacteria. These products should be applied to the
wound only, taking care to avoid the surrounding area. How often to change the
dressing depends on how quickly the honey is diluted by the exudate. Honey is
water-soluble and can be washed off during dressing changes, which are done
every 1–3 days.
Hyaluronic acid
Hyaluronic acid wound dressings are available as gel, fiber compresses, micro-
granules, and sprays; hyaluronic acid products may also be used for tampona-
de. Hyaluronic acid forms a hydrophilic gel upon contact with wound exudate.
­Products containing hyaluronic acid are often used for wounds with a large amount
of exudate to promote granulation and for wound cleansing.
Depending on the type of wound and amount of exudate, hyaluronic acid
may be applied in its dry form, or combined with Ringer solution; gel formati-
on is absolutely essential for the release of hyaluronic acid. The wound should
be covered with a secondary dressing. The dressing should be changed after
1–3 days.
Hydrofiber dressings
Hydrofibers or aqua fibers are composed of sodium carboxyl cellulose. Fluid ab-
sorption occurs vertically only; no fluid should be released horizontally. This is
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 CME Article
Hydrofiber dressings can rapidly absorb
up to 40 times their weight in exudate.
They are used especially for dry wounds
to facilitate autolytic débridement.
Hydrocolloids are used mainly for su-
perficial wounds, with little exudate, to
promote granulation or epithelization.
For chronic wounds, impregnated gau-
ze is generally unsuitable for use as the
sole wound dressing.
Collagens are believed to bind excess
levels of proteases in chronic wounds.
546 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
intended to avoid maceration about the wound margins. Hydrofiber dressings can
rapidly absorb up to 40 times their weight in exudate.
After absorbing the wound exudate, the fibers rapidly transform into a firm,
transparent gel. Hydrofiber products may be used for wounds with a large amount of
exudate to promote granulation and for wound cleansing. The hydrofiber dressing is
placed on the wound and may extend over the wound margin. The wound should be
covered with a secondary dressing. The dressing should be changed after 1–3 days.
Hydrogel dressings
Hydrogels are preparations that contain up to 95 % water, along with organic ad-
ditives such as pectin and starch, or gelling agents. Generally, a tube or syringe is
used to place the gel in the wound. Hydrogel sheets, which are placed on semi-per-
meable films, are available for wound therapy. Hydrogels can provide moisture to
the wound as well as absorb excess wound exudate. They are especially suitable for
dry wounds to facilitate autolytic débridement.
Hydrogels may also be combined with various other dressing materials, in order
to keep these – or other structures (such as exposed tendons) – moist. The hydrogel
sheets are applied in 3–5 mm thick layers, and are then covered with impregnated
gauze or semi-permeable film dressings. The dressing is changed every day for débri-
dement; during the granulation phase, the dressing should be changed every 2–3 days.
Hydrocolloid dressings
Hydrocolloid dressings are made of a polyurethane film or foam, on which there
is a self-adhesive mass made of elastomers and adhesives, with particles that are
capable of swelling to absorb large amounts of exudate (such as gelatin, car-
boxymethyl cellulose, or pectin). As it absorbs the wound exudate, the hydrocol-
loid mass liquefies to form a viscous gel. Hydrocolloids are used mainly for su-
perficial wounds, with little exudate, to promote granulation or epithelization.
Self-adhesive hydrocolloid dressings may also be applied without a secondary
dressing; these conform to body contours. The dressing should extend 2–3 cm
beyond the wound margin to ensure that it adheres sufficiently without leading
to maceration of intact skin. Depending on the amount of exudate, hydrocolloid
dressings may be left on the wound for 3–5 days.
Impregnated gauze
Impregnated gauze dressings are fiber nets which are coated with ointments, hy-
drocolloid, silver, or silicone. The impregnation prevents the dressing from sticking
to the wound base. This type of dressing is primarily used for acute wounds, tem-
porary coverage of chronic wounds, and to prevent the adhesion of other dressing
materials. For chronic wounds, impregnated gauze is generally unsuitable for use
as the sole wound dressing.
Depending on the wound and the product, the dressing should be changed
after 1–7 days.
Collagen
Collagen wound care products are currently available in fleece, powder, or sponge
form. Different mechanisms of action have been described, especially concerning
modification of the pro-inflammatory wound milieu through protease binding.
CME Article
Foam wound dressings should be in
­direct contact with the wound bed.
Wound products containing silver are
used for antimicrobial treatment.
They can absorb up to 100 times their
own weight and store the exudate in
their polymer structure.
Currently available products for pro-
teolytic débridement include colla-
genase as well as streptodornase and
streptokinase.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
Collagen may be used for the promotion of granulation and epithelization,
especially in previously stagnant wound healing. Due to their hemostatic proper-
ties, they are also used after surgical débridement. They are applied as a dry or
moist dressing to the wound surface, extending to the wound margin. A secondary
dressing should be placed over the collagen dressing. Depending on the product
used, the dressing should be changed after 1–5 days. Most of the collagen will have
been absorbed by the time of the dressing change; it is usually only necessary to
rinse off any remaining residue.
Foam
Foam dressings are made of non-irritating polyurethane foam. The surfaces
may be coated for example, with silicone or heat-treated. Foams may be used
for moderately or strongly exuding wounds to promote granulation and epit-
helization. If the dressing does not come with adhesive border or an additional
superabsorber, it may be cut to size; the wound dressing should extend at least
2 cm over the wound margin. The dressing should be in direct contact with the
wound bed.
Depending on the amount of exudate, the wound dressing should be changed
after 1–7 days.
Silver
Wound products may contain silver in the form of silver ions, elementary sil-
ver, nanocrystalline silver, or anorganic silver complexes. Silver ions are either
firmly attached to the dressing materials or they are released after contact with
wound exudate. Silver ions form complexes with bacterial proteins, which lead
to damage of the cell membrane, enzymes, or DNA, and irreversibly damage the
bacteria.
Wound dressings containing silver are often used in patients with infected
wounds. Depending on which materials the silver is attached to, the size of the
dressing may be modified to fit the individual wound. In wounds with little exu-
date, the dressing should be moistened regularly. Depending on the product, the
dressing should be changed after 1–7 days.
Polyacrylate super-absorbers
Polyacrylate super-absorbers consist of neutralized, cross-linked polyacrylic acid
molecules. They can absorb up to 100 times their own weight and store the exudate
in their polymer structure.
Polyacrylate super-absorbers inhibit excessive protease activity and normalize
the wound micromilieu. They thus support wound cleansing and the formation of
granulation tissue. Depending on the amount of exudate, the dressing should be
changed after 1–3 days.
Proteolytic enzymes
Proteolytic enzymes enable selective débridement, which may be accomplished
­without pain or bleeding. They are safe, quick and easy to apply. Yet treatment
can take a very long time. If the wound margin is not protected, maceration of the
surrounding area may occur. At present, an ointment with collagenase, and a gel
with streptodornase/streptokinase are available.
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 CME Article
Advanced wound care products are a
new, highly diverse group of therapies
which aim to actively influence the
wound milieu.
There are also increasing numbers
of reports of contact sensitization to
products which are used directly for
wound treatment.
548 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
The preparations are applied, after mechanical wound cleansing, in 2–5 mm
layers. They should be covered with non-adhesive dressings. Depending on the
chosen preparation, the wound dressing should be changed after 12–24 hours.
Other products
There are many other products which do not clearly belong to one of the afore-
mentioned groups. Of particular interest are advanced wound care products which
are also declared as wound (kick)starters. These are a new, highly diverse group
of therapies for use in wound treatment. Their primary aim is to actively influence
the wound milieu.
By interacting with the wound, they are intended to alter the wound milieu or
wound surface. Advanced wound care products are used in chronic wounds which,
despite optimal, causal therapy, remain hard-to-heal.
The aim of products containing collagen and cellulose (PromogranTM ;
­Systagenix), nano-oligosaccharide factor (NOSF, UrgoStartTM ; Urgo), or polyhy-
drated ionogens (PHI-5, TegadermTM Matrix; 3M), is to directly reduce matrix
metalloproteinases (MMPs) [14, 15]. A test procedure is also currently offered
(WoundchekTM ; Systagenix) for detecting increased levels of various proteases
(increased protease activity [EPA]). Currently used growth factors include pla-
telet-derived growth factor (PDGF), which is available as a gel (RegranexTM ;
Janssen-Cilag) for the treatment of diabetic foot syndrome, as well as epidermal
growth factor (EGF), which comes in a wound dressing (NeodermTM ; Trime-
dicales) [16]. Another new, innovative product uses porcine hemoglobin in the
form of a spray (GranuloxTM ; Sastomed), which may be applied directly to the
wound surface, along with conventional wound products. The spray is suppo-
sed to transport oxygen from the air into the wound, and is thus suitable for
all types of hypoxic wounds [17]. There is also a paste, containing modified
starch (poloxamer) that is intended to reduce wound pH levels (CadexomerTM ;
Smith&Nephew) [18]. Other products contain, e.g., the extracellular mat-
rix protein (ECM) amelogenin (XelmaTM ; Mölnlycke) [19], coagulation factor
XIII (FibrogramminTM ; CSL Behring) [20], the analgesic ibuprofen (Biatain
IbuTM ; ­C oloplast) [21], tensides (PolymemTM ; Mediset), or negatively charged
microspheres (PolyHealTM ; Mediwound).
Many of the underlying ideas, and the therapeutic approaches, related to these
wound care products are very interesting. One may expect that, in the future, more
solid recommendations for their targeted use may become available. At present,
there is still lacking scientific data and high quality and controlled clinical trials
are required to proof their clinical effectiveness[11–13].
Contact allergens in wound therapies
The current literature contains several reports of an increased incidence of contact
sensitization in patients with chronic wounds, compared to the normal popula-
tion. In patients with chronic venous leg ulcers, contact sensitization rates of up
to 80 % have been cited. The most commonly identified contact allergens among
these patients are wool wax alcohols (18–33 %), followed by aminoglycoside an-
tibiotics and balsam of Peru [22]. There are also increasing numbers of reports
of contact sensitization to products which are used directly for wound treatment
(Table 2) [23].
It is important when selecting test substances for patch testing to also include
wound dressing products.
CME Article

Table 2  Examples of allergens found in wound therapies which have been already
reported in conjunction with contact sensitization in patients with chronic wounds.

Hydrocolloids
  Colophonium (up to 14 % of all patients)

  Polyisobutyl derivatives (rarely)

  Carboxymethyl cellulose (rarely)

  Hydrogels

  Propylene glycol (up to 18 % of all patients)

  Fatty gauze

  Wool wax alcohols (up to 35 % of all patients)

  Arlacel 83 (rarely)

  Antimicrobial therapies

  P VP iodine (up to 20 % of all patients)

  Neomycin (up to 20 % of all patients)

  Cetyl stearyl alcohol (up to 17 % of all patients)

  Gentamicin (up to 10 % of all patients)

  Benzoyl peroxide (up to 4 % of all patients)

  Cocamidopropyl betaine (up to 3 % of all patients)

Negative pressure therapy may be Negative pressure wound therapy

a first-line option for promoting Negative pressure treatment, or vacuum therapy, refers to various systems which
­granulation. use an electronic control unit to apply a specific suction level to the tissue. A pri-
mary use for negative pressure wound therapy in the treatment of patients with
chronic wounds in dermatology is wound bed preparation, with the aim of
­promoting granulation.
In addition, negative pressure therapy can also promote various aspects of
wound healing, e.g., reduction of edema, wound cleansing, or mechanical elimi-
nation of bacteria and wound secretions. The option of using the system with
instillation allows for cleansing (also with antiseptics) without removing the
dressing; hence, negative pressure therapy may also be used in clinically infected
wounds. Disadvantages of negative pressure therapy include the odor, irritation
of the area around the wound, and the sometimes considerable pain associa-
ted with treatment. The most important requirement for its use is that negative
pressure may be applied with an airtight seal. Current negative pressure thera-
py systems consist of a sterile, replaceable sponge or coated gauze, and a non-­
collapsible tube system with a suction pump unit which generates negative pres-
sure according to individual patient needs. Chronic wounds are usually treated
with suction levels of 75–125 mmHg. The surrounding skin should be protected
against maceration. Protective polyacrylate or silicone films may be placed over
the skin as a protective measure. For chronic wounds, negative pressure therapy
devices may be left in place for 2–5 days. If pain occurs when the dressing is
changed, one may apply fatty gauze under the sponge or reduce the suction level
or time [24, 25].

© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207 549
 CME Article
Systemic antibiotics should only be
administered if there is a systemic
­infection.
Polyhexanide and octenidine are cur-
rently the first-line antiseptics for pati-
ents with chronic wounds.
550 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
Other physical treatment methods which may be used in patients with chronic
wounds include electrostimulation therapy, extracorporeal shock wave therapy,
hyperthermia, laser therapy, plasma therapy, ultrasound, or water-filtered infra-
red-A radiation [26].
Bacteria and infections
A prerequisite for efficient wound healing is the elimination, or avoidance, of cli-
nically relevant wound infections. One should take into account that nearly every
chronic wound is contaminated or colonized with microorganisms, and that this
is generally clinically unproblematic. The diagnosis of a clinically relevant wound
infection should thus be based on the corresponding clinical findings with the car-
dinal symptoms of tumor, calor, dolor, rubor, and functio laesa. In patients with
suspected systemic infection, a blood count should be obtained. In many patients
with chronic wounds, both CRP and ESR are elevated, even when they do not
have an infection. Other diagnostic criteria include a fever and chills. With a few
exceptions, systemic antibiotic therapy should only be given if there is a systemic
infection.
Specific hygienic measures should be used in patients with problem bacteria,
such as MRSA. In patients with chronic wounds who have colonization, but who
do not have a systemic infection, topical treatment with modern antiseptics is con-
sidered adequate [27–29].
In chronic wounds, a bacterial smear should be taken, whenever possible,
from the wound surface for example using the “Essener Rotary” technique).
The “Essener Rotary” technique involves applying gentle pressure to take the
bacteriological smear from the wound surface, moving from the outer edge
inward in a circular fashion to obtain a representative sample of bacteria for
identification [30]. For deep wounds, extensive soft tissue infections, or in the
framework of surgical intervention, biopsies should be taken from clinically
suspicious areas.
Antiseptics
Polyhexanide (polyhexamethylene biguanide, PHMB) belongs to the biguanide
substance class. Along with wound cleansing solutions containing preservatives,
polyhexanide is also now increasingly found in hydrogels and wound dressings as a
first-line substance for use in antimicrobial wound therapy. Thus, in clinical use, it
is also more feasible to ensure the contact time of ten minutes. Polyhexanide should
not be used on exposed cartilage, in the inner ear, or the CNS
In Germany, octenidine is found in medications as octenidine dihydrochlori-
de. A clear solution, octenidine with 2 % phenoxyethanol is the first-line choice for
antimicrobial treatment of chronic wounds. The contact time for octenidine is at
least two minutes. There is also a hydrogel preparation which may be left in place
for 24 hours. The octenidine solution should not be injected with pressure into the
tissue, as this can lead to necrosis. In addition, octenidine should not be used at the
same time as povidone iodine, because iodine radicals may be released which can
irritate the tissue and cause discoloration.
Preparations containing povidone iodine (polyvinylpyrrolidone [PVP] iodi-
ne) have long been central to treatment in Germany of patients with acute, post-­
traumatic wounds, as well as for preoperative preparation. Problems include the
high rate of contact sensitization, discoloration of wounds, which makes evaluation
of the wound difficult, and potential inactivation due to blood, pus, and wound
CME Article
All patients should assess their pain
­level using instruments such as the
­visual analogue scale.
© 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207
Table 3  Modified morphine hydrogel for wound treatment developed in Essen.
Compared to the NRF formulation, propylene glycol was replaced by polyhexanide
(LavaseptTM).
  Morphine hydrochloride trihydrate 0.1 g
  Ethylenediamine tetra-acetic acid sodium salt 0.1 g
  Hydroxyethyl cellulose 400 4.5 g
  L avasept concentrate 20 % 0.2 ml
  Purified water EuAB ad 100.0 g
exudate. In hard-to-heal wounds, with Gram-negative bacterial such as Pseudomo-
nas aeruginosa, it may be advisable to briefly use PVP iodine [2, 5, 27–29]. Studies
have also shown that PVP iodine preparations can effectively neutralize proteases
and thus possibly have a positive influence on the wound healing process [31].
Pain
Pain is a complex subjective, perceptual phenomenon, which is influenced by nu-
merous physiological, psychological, emotional, and social factors. Pain leads to
a diminished quality of life, has a negative effect on patient compliance, and is
an independent risk factor in delayed wound healing. Most patients with chronic
wounds report having at least temporary pain due to their wound. Pain intensity
may be evaluated using various scales. In Germany, the visual analogue scale (VAS)
is the most widely used.
It is important when measuring pain to determine actual pain as well as pain
between dressing changes. For values ≥4, improved pain therapy and avoidance of
pain should be the goal. For patients with painful wounds, one must seriously con-
sider whether continuous systemic pain therapy, in accordance with the analgesic
ladder of the World Health Organization (WHO), may be advisable [32].
Using other measures is also often helpful, if changing the dressing is painful.
Firmly adherent dressings can be removed almost painlessly if they are soaked for
at least 30 minutes prior to removal in Ringer solution. Crusts may be softened
using compresses soaked in olive oil or ointment and removed atraumatically using
a wooden spatula. Local anesthetics in the form of lidocaine and prilocaine cream
are suitable as supportive therapy. The cream should be applied to the wound for
at least 60 minutes before cleansing is performed [33]. The effectiveness may be
increased by using occlusion with semi-permeable films. There are also wound
dressings available which release low-dose ibuprofen [21]. Morphine hydrogels are
often highly effective; these may be applied directly to the wound and left in place
for 24 hours (Table 3) [34].
Conclusions
It is clearly evident that moist wound therapy, which is adapted to the wound
healing phases, and makes use of modern wound care products, can help ensure
an ­optimal wound milieu, avoid complications, improve the patient’s quality of
life, and facilitate the healing of chronic wounds. Still, causal treatment of the
underlying disease(s), on the basis of a thorough – and usually interdisciplinary –
­diagnosis, is the main requirement for long-term healing of chronic wounds.
551
 CME Article

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 CME Article

Fragen zur Zertifizierung durch die DDA

1. Wie lange muss eine Wunde mindes- a) Wasserstoffperoxid-Lösung
tens bestehen, wenn sie entsprechend b) Ethacridinlactat-Lösung
der aktuellen Leitlinienempfehlungen als c) Polihexanid-Lösung
„chronisch“ bezeichnet werden kann? d) Farbstoff-Lösungen
a) 4 Wochen e) Merbromin-Lösung
b) 6 Wochen
c) 8 Wochen
d) 12 Wochen 6. Welche Lebewesen werden im Rah-
e) 24 Wochen men der sogenannten „Biochirurgie“
therapeutisch eingesetzt?
a) Behandlung mit steril gezüchteten
2. Welche Aussage zu Wundverbänden Blutegeln
ist falsch? b) Behandlung mit steril gezüchteten
a) Hydrogele sind für ein autolytisches Fliegenmaden
Débridement geeignet. c) Behandlung mit steril gezüchteten
b) Wenn Hyaluronsäureprodukte in Kangal-Fischen
Kontakt mit Wundsekret kommen d) Behandlung mit steril gezüchteten
bildet sich ein hydrophiles Gel. Seeigeln
c) Kollagene sollen durch die Freiset- e) Behandlung mit steril gezüchteten
zung von Proteasen wirken. Seidenraupen
d) Hydrofasern können Flüssigkeit bis
zu etwa dem 40fachen ihres Eigen-
gewichts aufnehmen. 7. Es sind aktuell Wundauflagen für die
e) Alginate wirken auch hämostyptisch. Behandlung von Patienten mit chroni-
schen Wunden erhältlich, die zudem
ein Analgetikum enthalten. Welches
3. Welcher Inhaltsstoff wird derzeit Analgetikum wurde hier zugesetzt?
bereits kommerziell in sogenannten a) ASS
Wundstartern für die Wundtherapie b) Paracetamol
verwendet? c) Ibuprofen
a) Plasmin d) Diclofenac
b) Fibrin e) Cox-2-Hemmer
c) Fibrinogen
d) Elastase
e) Hämoglobin 8. Welche Aussage zu Spüllösungen für
chronische Wunden ist richtig?
a) Glukoselösungen sind eine Spüllö-
4. Welcher der folgenden Verbandsys- sung der ersten Wahl.
teme eignet sich auch besonders gut b) Der Einsatz von Leitungswasser
für den Einsatz bei fötiden, neoplasti- kann als hygienisch unbedenklich
empfohlen werden.
schen Wunden?
c) Physiologische Kochsalzlösungen
a) imprägnierte Fettgaze
können nach Anbruch mindestens
b) offenporiger Schaumstoff
c) Vakuumtherapie für eine Woche verwendet werden,
d) Aktivkohleverband wenn sie gekühlt gelagert wurden.
e) okkludierende Folien d) Wundspüllösungen sollten bei Ap-
plikation möglichst körperwarm
sein.
5. Welches Antiseptikum wird auch e) Wundspüllösungen sollten mög-
lichst als Teilkörperbad angewendet
für den Einsatz bei Patienten mit
werden.
­chronischen Wunden als ein Präparat
der ersten Wahl empfohlen?
9. Wann sollte bei Patienten mit chro-
nischen Wunden eine systemische
­ herapie mit Antibiotika erfolgen?
T
a) Wenn auch systemische Infektions-
zeichen vorliegen.
b) Wenn große Mengen von Bakte-
rien in Abstrichen nachgewiesen
­wurden.
c) Wenn MRSA in Abstrichen
­nachgewiesen wurden.
d) Wenn sich Rötungen um die
­Wunden zeigen.
e) Wenn ein grüner Belag auf der
­Wunde besteht.
10. Welche Aussage zu Honig in der
Wundbehandlung ist falsch?
a) Für die Wundbehandlung sind
­Honigpräparationen aus Tuben und
imprägnierte Wundauflagen erhält-
lich.
b) Honigpräparationen sind auch anti-
mikrobiell wirksam.
c) Honigpräparationen können für ein
osmotisches Débridement einge-
setzt werden.
d) Durch die Anwendung von Honig-
präparationen kann es zu starken
Schmerzen kommen.
e) Honigpräparationen werden meist
bei sehr exsudativen Wunden
­eingesetzt.
Liebe Leserinnen und Leser,
der Einsendeschluss an die DDA für die-
se Ausgabe ist der (15. August 2014). Die
richtige Lösung zum Thema „Die nicht-
syndromalen Ichthyosen – aktueller
Stand“ in Heft no. 2 (February 2014) ist:
(1b, 2c, 3b, 4e, 5d, 6c, 7b, 8c, 9b, 10b).
Bitte verwenden Sie für Ihre Einsendung
das aktuelle Formblatt auf der folgenden
Seite oder aber geben Sie Ihre Lösung
online unter http://jddg.akademie-dda.de
ein.

554 © 2014 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2014/1207