Which Topical Dressing for Which Wound?

With more than 2,400 topical dressings, deciding which one is most appropriate for a particular wound can be daunting. The goal is to keep the wound bed moist and the periwound tissue dry, remove exudate without desiccating the wound, and provide a barrier against bacteria. The right dressing will increase healing rates and reduce pain and infection. The wrong dressing can, at the very least, delay healing or, worse, exacerbate the injury. 

A Decision Tree

Craig Broussard, PhD, RN, CNS, developed a dressing decision tree that incorporates five goals of topical care:

1. Optimize a moist wound environment.

2. Manipulate and stabilize the wound, reduce pressure, and manage edema.

3. Activate the wound environment. 

4. Control infection and bioburden.

5. Improve quality of life. 

To facilitate these goals, different dressings are applied. Although the decision tree removes some of the guesswork from dressing selection, the clinician must be mindful that wound healing is a factor of underlying etiology: The reason why the wound isn’t healing (eg, ischemic wounds need enhanced circulation/oxygenation or persons with diabetes-related wounds need to get their HbA1C levels in check) is of primary concern. The dressing’s role is to enhance the body’s ability to heal.

Moisture Balance 

Passive dressings—products that provide topical wound care but do not cause a specific action on the cellular level—address the amount of moisture in a wound. They can be categorized into four functions: protect the wound margins in macerated wounds, absorb drainage in heavily exudating wounds, maintain moisture in minimally exudating wounds, and hydrate dry wounds. 

Dressings that address maceration include films, hydrocolloids, and negative pressure wound therapy (NPWT)—applied alone or along with products that contain moisture barriers such as zinc oxide, dimethicone, and petrolatum. To absorb heavy drainage, the clinician can use dressings that incorporate alginates, hydrofibers, and foam (all of which usually require a secondary dressing). Note: While bulk gauze dressings are commonly used, they require frequent dressing changes and may increase risk for maceration. 

Maintaining moisture in a minimally exudating wound can be accomplished using film (no drainage, maintains a visual of the wound, and provides a barrier), hydrogel gauze (provides a cooling effect and addresses pain), saline gauze (keeps wound wet to moist), hydrocolloids (a gel is formed at the wound-dressing interface for moisture management and protection), and nonadherent dressings (although not all are absorptive). Dry, desiccated wounds require hydrogels, hydrogel gauze, and saline gauze to retain and/or add moisture.

Stabilizing the Wound

Mechanical dressings—products that alter the wound’s physical aspects—are used to address cavernous, undermined, or tunneled wounds, edema, and unrelieved pressure. The goals are to fill and obliterate the dead space, control swelling, and reduce or redistribute pressure. Gauze packing, packing strips, hydrogel gauze, sponge, material, and NPWT are options for undermining. 

When wounds exhibit heavy exudate in addition to undermining, dressings can be combined (eg, alginate or hydrofiber to fill, covered with a foam dressing). Using NPWT can help stabilize the wound by facilitating granulation tissue formation. Wounds with minimal exudate benefit from strips impregnated with hydrogel or saline. Care should always be taken not to overfill a wound. 

Edema, which is common in persons with venous ulcers, is managed using either static (paste) or dynamic/elastic (wrap) compression, intermittent pneumatic compression, or gradient compression stockings—not dressings (although the treatment is topical). Pressure redistribution and reduction involves ambulatory and nonambulatory offloading using devices beyond the dressing category. 

Dynamic Dressings

Dynamic dressings make something happen within the wound. For granulated but static wounds (those that need some biological support), platelet-derived growth factors, cadaveric skin, and allograft products (cellular and noncellular) are available. Each comes with specific indications by wound type; they are typically applied, left in place for an extended period, and covered with a secondary nonadherent dressing. 

Wounds that are failing to heal, and the underlying factors have been addressed, require a product that either stimulates or inhibits a process—eg, enzymatic debriding agents that contain copper chlorophyllin enhance tissue granulation, while other products help activate tissue growth stifled by overproduction of matrix metalloproteinases (MMPs). These products feature polyhydrogenated ionogen, oxidized regenerated cellulose, NPWT, hyaluronic acid, maltodextrin, and collagen. Dynamic dressings also may be used to manage necrotic wounds through autolytic, mechanical, or enzymatic debridement of nonvital tissue.

Anti-infective Dressings

The goal in infected wounds is to decrease bioburden and control infection. Dressings that maintain a moist wound environment (films, hydrocolloids, and hydrogels) facilitate autolytic debridement; enzymatic debriders include collagenase. These dressings require a secondary cover. Silver dressings are commonly prescribed to treat infection and/or provide an antibacterial barrier and are available in colloidal, ionic, and nanocrystalline form in hydrogels, films, alginates, hydrofibers, foams, and NPWT.

Another option—cadexomer iodine—contains elemental iodine in bead form to exchange exudate for iodine into the wound and is contraindicated in persons with iodine sensitivity. Antiseptics are considered controversial due to their potential cytotoxicity.

Quality of Life 

Pain and odor are two key concerns that affect the quality of life in patients with wounds. Dressings that address pain concerns include hydrogels, hydrocolloid film, impregnated gauze, compression bandages, and most of all, dressings that are nonadherent and/or do not inflict additional pain upon removal. Dressings that decrease or help eliminate wound odor include products with activated charcoal, silver, metronidazole, and dilute antiseptic solutions (see previous caution). 

In general, premedicating the patient before dressing change and increasing the frequency of dressing changes when possible also will help address these quality-of-life issues.

Once the underlying causes of the wound are stabilized and management issues have been prioritized, clinicians can make informed choices as to the most appropriate topical dressing/dressing combination to employ. As always, patient and caregiver ability to tolerate and afford the dressing selection and regimen must be of utmost importance. When the type of dressing is determined, clinicians can choose from the multitude of products listed in the respective dressing categories at www.wounds360bg.com. This site contains full product descriptions, user comments, and reimbursement coding guidance for all levels of practitioners. ■

This article was adapted from Broussard CL. Dressing decisions. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Malvern, PA: HMP Communications;2007;249-262.

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