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Chronic wound treatment vs. moist environment

(…) they affect up to half a million people in our country. If we add to this the number of family members caring for the people, that number will increase up to 1.5 million people directly related to the subject of chronic wound treatment (…)

The term “wounds” often evokes the notion of cut and stab wounds, which is a result of all sorts of crime fiction, novels and thrillers. These wounds of course require professional treatment and dressings but heal more quickly. It is much more difficult to treat so-called chronic wounds, which occur in up to half a million people in our country. If we add to this the number of family members caring for the people, that number will increase up to 1.5 million people directly related to the subject of chronic wound treatment, and thus – the principles of selection and dressing change.

Treatment of chronic wounds, or such as diabetic foot and pressure ulcers, and even burns, often lasts for months. It is very inconvenient for family members, as well as difficult for the person affected by this problem. This article is to encourage to become familiar with modern methods of chronic wound treatment in a moist environment, in accordance with principles developed by researchers. Let this article serve as an introduction to the topic and let it be some kind of hint, how in a modern way effectively and quickly treat chronic wounds.

Speaking of the modern chronic wound treatment, we do not recognise traditional dressings as bad. Traditional gauze dressings, bandages and plasters are good! No one questions their effectiveness, because they are perfect for the treatment of acute wounds (i.e. those resulting from mechanical reasons e.g. cuts, stab wounds, gunshot wounds and abrasions). In those cases sterile gauze dressings and plasters are most appropriate to be used.

EFFECTIVE CHRONIC WOUND TREATMENT

In case of chronic wounds (such as bedsores, burns, diabetic foot) as already as 40 years ago specialists discovered and clearly stated which conditions favour their rapid healing. This is the complete opposite to what traditional dressings provide. It turns out that a chronic wound will heal better if the following conditions are met:

moist wound healing environment – promotes natural wound cleansing processes, regeneration of damaged tissues and reduces pain. This allows the wound to heal on average 50% faster;
reduced pH value – lowering the pH value, the acidity of the wound environment increases, inhibiting bacterial growth;
tightly closed wound (occlusion) – protects the wound from being infected by bacteria present in the patient’s environment. The use of special dressings of polyurethane foams also protects the wound against mechanical damage;
stable temperature – stable temperature of about 37°C accelerates cell division, and thus regeneration of damaged tissues.

FEATURES OF A PERFECT DRESSING

Continuing research conducted by Georg Winter since 1962, William Tuner collected and summarised their results and presented them in 1979, defining the qualities of a perfect dressing. According to W. Turner a dressing, which, according to the modern (wet) wound healing model, will facilitate the healing process should:

maintain optimum moisture in the wound,
remove excess exudate and toxic components,
isolate the wound thermally,
allow gas exchange between the wound and the environment,
be impermeable to bacteria and other microorganisms,
be free from toxic particles and substances,
provide protection for the newly formed tissues,
be easily removed from the wound surface, without causing injury.

Dressings meeting the above criteria form a moist environment that favours important processes which take place in the wound, so that the healing process is about 50% faster with reduced sensation of pain and reduced risk of infection.

Why, despite the presence of a whole range of advanced dressings, the choice of the right one is so difficult?

Good identification of processes appearing during the wound healing process resulted in creating many specialised dressings with a number of very different characteristic features. Paradoxically, a large variety of dressings raises dilemmas about accurate selection in a specific situation. Remember that the decision to use a given dressing determines its effectiveness or lack thereof.

HOW TO CHOOSE THE DRESSING TO THE WOUND?

It seems that the choice of dressing must meet two basic criteria – we must remember that according to the modern wound healing approach there is no universal dressing that would meet requirements of every wound, and that choice must be aware, based on the correct diagnosis of the processes taking place in the wound and suitable for that characteristic features of the dressing.

To facilitate the correct dressing choice, you can use the wound classification based on the phenomena that take place in different phases of wound healing and based on that wound colour assessment.

leczenie_ran_przewl_w_srod_wilgot_15 — Photo 1. Application helping to adjust the dressing to a wound available on the website www.na-rany.pl

The scale consists of four colours respectively assigned to the specific stages of the wound healing process.

Selection of the dressing to the given wound while using the wound colour classification system becomes easier, because the wounds of the same type (colour) set similar challenges, and therefore require a similar procedure.

„BLACK” WOUND – NECROTIC TISSUE

OBJECTIVE OF THE TREATMENT:

removal of necrotic tissue

WOUND CHARACTERISTICS:

in form of dehydrated dead tissue
necrotic tissue covers the entire wound or is present locally in form of patches
exudate level – low (up to the point where necrosis turn into liquid discharge and separates from healthy tissue)
necrotic tissue inhibits the healing process – it is the source of infection for healthy tissues, constitutes a barrier to the building new tissue

PROCEDURE:

it is necessary to remove necrotic scab by a surgeon or in the autolysis process by the maintenance of a moist environment

RECOMMENDED DRESSINGS:

Medisorb G

„YELLOW” WOUND – NECROLYSIS

OBJECTIVE OF THE TREATMENT:

removal of necrotic tissue and preparing the wound bed for granulation

WOUND CHARACTERISTICS:

cream colour of the wound – yellow, fibrous
exudate level: high, medium, rarely low

PROCEDURE:

maintain a moist wound environment
control the level of exudate

RECOMMENDED DRESSINGS:

Medisorb SILVER and SILVER PAD – infected wounds with high level of exudate
Medisorb A – deep wounds with high or medium level of exudate
Medisorb P – shallower wounds with medium level of exudate
Medisorb P PLUS – shallower wounds with quite high level of exudate
Medisorb H – moderate and low exuding wounds
Medisorb G – infected wounds with low level of exudate (promotes wound cleansing by binding pre-hydrated dead tissue with microorganisms that colonise it)

„RED” WOUND – GRANULATING TISSUE

OBJECTIVE OF THE TREATMENT:

maintain a moist wound environment conducive to granulation
control the level of exudate

WOUND CHARACTERISTICS:

wound in a bright red colour, moist
uneven wound surface
the tissue is delicate, sensitive to pain, susceptible to infection

RECOMMENDED DRESSINGS:

Medisorb A, Medisorb P or Medisorb P PLUS – heavy and moderate exuding wounds
Medisorb H – moderate and low exuding wounds
Medisorb G – infected wounds with low level of exudate (promotes wound cleansing by binding pre-hydrated dead tissue with microorganisms that colonise it)
Medisorb A – in case of infected wounds with high level of exudate

„PINK” WOUND – EPITHELISING TISSUE

OBJECTIVE OF THE TREATMENT:

protection of new tissue
stimulation of skin formation

WOUND CHARACTERISTICS:

pink or white tissue appears on the wound surface
epithelial cells migrate from the wound edges to the centre

PROCEDURE:

encourage or support the process of skin formation
maintain a moist wound environment
protect against mechanical damage

RECOMMENDED DRESSINGS:

Medisorb H – moderate exuding wounds
Medisorb F – low exuding wounds

Professional wound dressing

Anna Rogalewska, Patrycja Judycka

Toruńskie Zakłady Materiałów Opatrunkowych SA

Evolving trends in wound dressing

From herbs and leaves, to gauze and bandage, to professional dressings, the practice of wound dressing has been evolving for tens of thousands of years. For over 60 years, Toruńskie Zakłady Materiałów Opatrunkowych (TZMO) has been delivering trend-setting products in wound dressing. Over the years, we have made changes to our range of dressings and the way we make them, but one thing has been constant: we continue to take care to deliver top-quality products that meet the most rigorous safety standards. TZMO’s Matopat-branded medical products have always been a symbol of high quality, innovation and biocompatibility.

Choosing the right dressing: What should patients take into account?

First of all, it’s the kind of wound, as different wounds heal differently. You will need a different dressing for a surgical wound, or incision (such wounds must be dressed precisely, in a sterile manner, by qualified medical personnel in a suitable place), a different one for a new post-injury wound and a yet different one for a difficult-to-heal wound with substantial tissue loss. Once you have identified the kind of wound you’re dealing with, you need a professional dressing that will not only reduce the risk of infection and offer optimal healing time and effectiveness, but also help the patient feel more comfortable. There has been a noticeable trend in the use of professional wound dressings: in the past, they were used only by medical professionals in hospitals, but now they are making their way to pharmacies. As a result, professional wound dressings can today be used by patients at home.

The properties of professional wound dressings

For a small cut or chafe, a clean and comfortable sticking plaster will do the job. Apply it to the affected area and leave it for a scab to form and the wound to heal. However, in the case of more serious wounds, such as surgical wounds, it is advisable to use professional dressings such as those used in hospitals. Professional surgical dressings are sterile, absorptive and flexible, and designed so that the adhesive can keep the dressing tight on the affected area, preventing dirt or other unwanted matter from penetrating the wound. At the same time, the absorption material should be sufficiently protected to prevent direct contact of the dressing with the surface of the wound or with the surgical sutures. Professional dressings are also air-permeable to allow the skin to “breathe”.

Examples of professional dressings for surgical wounds include Fixopore S and Fixopore F. The former is made of flexible, nonwoven fabric that easily fits in even hard-to-access areas of the patient’s body and will not limit the patient’s movement. A nonwoven fabric dressing is the basic type of dressing used by hospitals for surgical wounds. This dressing has a special, smooth layer of absorption material that will not get stuck on the wound or suture, thus allowing for safe and painless dressing changes without the risk of damage to the absorption material. The adhesive on the dressing is hypoallergenic. The other of the two products, Fixopore F, is made of ultra-thin polyurethane film that keeps moisture away from the wound. This helps patients to go about their regular daily activities without having to change their dressings frequently and without the risk of infecting the wound. The benefits of modern wound dressings can be enjoyed fully if the dressings are used in accordance with the user’s instructions.

Educating patients

A pharmacist’s role is not only to help patients choose the right dressing, but also to educate them about the need for taking proper care of their wounds. Wound cleaning and correct dressing changes are essential and, apart from the choice of dressing, will help the wound to heal quickly and without complications. A general rule in professional wound healing is that dressing changes should be as rare as possible, following the recommended dressing use time, and as frequent as possible, depending on the appearance of the wound and the condition of the dressing.

For more information about professional dressings for different wound types, please visit: en.matopat-global.com

Scar rehabilitation

Yearly about 1% of our population gets burned. The number of Poles affected by burn injuries reaches even 400,000 patients a year. Mostly 50-80% of the burned are children in the 2-4-year-old age group.

Burns can be divided by depth:

1^st degree – a superficial burn. Only the surface layers of the skin are affected. The symptoms include redness (erythema) and painfulness. The wound usually heals without any complications and scars.
2^nd A degree – extends into superficial (papillary) dermis. Those wounds are usually very red with clear blisters and are extremely painful. After 2^nd A injuries there might appear small discolorations or even scars.
2^nd B degree – extends into deep (reticular) dermis. In those type of burns superficial epidermal and dermal necrosis might appear. Those wounds are very painful, without blisters, pale or pinkish, grey, bricky or even black. Moreover, they may leave nasty hypertrophied scars.
3^rd degree – extends through entire dermis. These wounds are usually russet, brown, pale yellow or red.
4^th degree – extends through skin, subcutaneous tissue and into underlying muscles, tendons, bones, joints.

In the 3^rd and 4^th degree burns the skin reproductive layer is impaired or completely damaged.

Complications of burns

Quite a frequent complication of burns are hypertrophied scars and joint contractures. The hypertrophied scars appear, among other things, as a result of the increase in blood flow, fibroblast development and collagen deposition as well as of chronic oedema. In all those cases, when strong redness of the scar does not disappear up to two months, and the scar gets thicker and thicker, a keloid scar is very likely to develop. Keloids have a lumpy structure, which is a result of increased metabolism. Their growth is stimulated by microphages and fibroblasts, evoking an overgrowth of collagen fibres. Those complications are inconvenient because they delimit the functioning of the motor apparatus and at the same time they blemish the affected person.

Prophylactically appropriate positioning of the body and joint immobilisation by means of splints or orthopaedic devices is practised. It has also been proven that the application of constant pressure, increasing the capillary pressure of vessels i.e. about 25-30 mmHg, has a beneficial influence on scar formation, and prevents the overgrowth to a large extent. A long-lasting pressure causes an oxygen deficiency in tissues, a deceleration in metabolism and a fibroblast reduction. An increase in the activity of a collagen-decomposing enzyme (collagenase) results in a visible scar reduction.

The pressure method in supporting the post-burn scar treatment has been worldwide known for many years, and it is also commonly used in Poland. The pressotherapy is found to be the most effective method, though there are many alternative ones such as laser therapy, kriotherapy etc.

Apart from negative health effects, quite often the keloids are also harmful to patients’ mental state, resulting sometimes in social exclusion. In modern techniques, and medical procedures it is clearly stated that an effective post-burn rehabilitation needs to be designed in such a way to reduce the keloid formation. An important element of modern treatment support techniques is the application of compression combined with the activity of silicone dressings like e.g. Codosil^TM ADHESIVE.

Mechanism of post-burn scar formation

Every wound has the possibility of self-healing. Superficial wounds, in which the topmost layer of the skin (the epidermis) is scraped off, heal without leaving any scars. At the beginning of the healing process the wound is cleansed, so there appear a lot of macrophages and histiocytes. The neoformation of capillaries is evoked, facilitating the appearance of multipotent cells – lymphocytes, which have the ability to turn into fibroblasts. A fibroblast is a type of a cell that synthesises the macromolecules building connective tissue. This cell synthesises tropocollagen, which by polymerisation creates collagen fibres. As those fibres get created, the involution of capillaries takes place, the activity of fibroblasts is lost, and the reepithalisation process is initiated.

In burns, when the epidermis, the papillary layer and the reticular layer get damaged, a stronger hyperplasia of vessels is observed. The widening of vessels, and the appearance of anastomoses causes blood to stop in the healing place, and provides a good access to nutrients; a lot of highly active fibroblasts appear as a result of the production of a great number of collagen fibres.

The reconstruction along with the scar formation takes place at the newly created fibroblasts’ expense, where gradually myofibroblasts – responsible for contractility – get distinguished, while mastocytes take care of the progressive maturation of the scar. Biochemical tests of a scarring process show that there is an increased collagen synthesis in comparison with a normal healing process, and there are also qualitative disorders connected with the increase in the number of mucopolysaccharide matrices, and the decrease in the number of lipids (mainly linolic acid) in the scar. It seems that the reason for this lies in the reduced amount of collagenase (a collagen-decomposing enzyme), resulting from the increase of 1 – antitrypsin and 2 – mucoprotein globulins. Those effects occur probably along with a toxic mitochondrial activity in the damaged cells. This activity takes place in burns from the first moment up to the 10^th day of the healing process, when it is possible to notice that those symptoms stop, and a gradual comeback to a normal state, or also an objective steady growth takes place up to the 14^th and after the 21^st day, if any scarring complications appear.

Moreover, also the effect of the adrenal gland on scar fibroblasts, and their uncontested influence on scarring processes has been recognised. This is the base to examine possible mutual correlations between the prevalence of scarring complications and endocrinological changes in children. Obviously such a correlation takes place during a burn shock, and its further development is not known. Topical scar complications developing after a burn can be either of an aesthetic or of a functional type, or of both types simultaneously. From a histopathological point of view the cicatrical changes are of a hypertrophic, a contractile or a keloid type. Popularly it is said that this happens in 50% of burn cases; however, the factors indicating those changes has not been determined yet. Their impact on the early estimation of an actual scar development possibility is also not known. Especially when it goes about keloids – they are likely to develop even in 80% of places vulnerable to stretching or tension.

Pressotherapy – an effective therapeutic method for post-burn scars

An elastic pressotherapy as a preventive and therapeutic method started to evaluate in the 70s, and turned out to be very effective in supporting the treatment of post-burn complications. This method involves using hypercompression (or just compression) to give constant pressure on keloids. This pressure on the scar gives an ischemic effect, which makes afferent vessels smaller, which results in the reduction of vessel embryos. On one hand, the scar will be supplied with less blood if we reduce the number of blood vessels, but on the other hand, depending on the diameter of the vessel embryos, the blood flow will be increased, and there will be no stasis, which will further influence the reduction of produced collagen fibres, and prevent the wound area from shrinking.

A correctly applied pressotherapy involves the use of strong pressure on the wound after finished epithelisation by means of different types of bandages made of natural latex. Such products are produced of latex threads covered with synthetic fibres.

Their application on the scar and the stable pressure they give can change and improve the content and the quality of various tissue elements. This change in the tissue components results in the qualitative improvement, weakening and decreasing the size of the scar, and at the same time due to the accompanying ischemia, the characteristic red colour of the scar is fading.

General rules for the use of pressotherapy:

the pressure should be applied as soon as possible (from the moment of wound re-epithelisation, during the next 2-3 years – this is the estimated time for scar development), more or less 1 or 1,5 year;
constant uninterrupted and long-lasting application of pressure on cicatrical places through an individual adjustment of special compression garments with compression level from 20-25 up to 50 mm Hg/cm².

Flat seam in the Codopress^® garment provides higher comfort for the patient

To reach the best results it is necessary to observe and control the entire process of the compression rehabilitation, and to change the compression garment periodically since the knitted fabric loses its elasticity, or the patient’s size might change as well.

The time of the compression therapy is varied – optimally up to 2 years. If any topical complications appear such as skin irritation, intertrigo, skin breaks or patient’s psychical inconvenience – the pressotherapy should be temporarily interrupted and then repeated, trying to eliminate those symptoms. [1]

Compression levels in pressotherapy

Compression clothing is characterised by a precisely defined pressure level exerted on the patient’s body. The pressure is expressed in a unit – millimetre of mercury (mmHg). The efficiency depends on the size of the garment, which is to be individually adjusted to a given person after taking precise measures of the patient’s body. The effectiveness of the therapy is also affected by the choice of an appropriate compression level, which depends on the disorder type and its severity. It is highly important to choose the right compression level of a compression product, for too little pressure will bring no effect, and too big pressure can cause many undesirable side effects. The complications may start from very simple ones such as chafes, abrasions or maceration, up to more serious ones such as serous blisters or decubitus ulcers. Those and other side effects resulting from a wrongly chosen compression level, quite often make the patient break the therapy.

The most popularly used compression level classification is the one used in Germany, Switzerland and Italy. In all types of classifications class 1 means the lightest compression, and class 4 the strongest compression. The values express compression given by a product at the ankle joint high. It is important to maintain a compression gradation given on the limb at the entire length of the product. In this case usually there is a rule applied to use 100% compression of the given class (from 1 to 4) at the ankle high (distal part of the product), up to 40% of the compression in the closer (proximal) part.

Modele wyrobów uciskowych Codopress® — Models of compression garment Codopress^®

Producers use different classifications of compression; however, the one specified by the European Standardisation Commission distinguishes the following ones:

class 1 – light compression (18-21 mmHg),
class 2 – medium compression (23-32 mmHg),
class 3 – strong compression (34-46 mmHg),
class 4 – very strong compression (over 49 mmHg).

Efficient therapy with the application of compression garments Codopress^®

The success of the therapy highly depends on appropriately chosen compression clothing. Compression garments Codopress^® produced in Łódź (Poland) by Tricomed SA are used for supporting the treatment of post-burn scars and in prophylactic rehabilitation of burns. Up till now over 20 thousand products Codopress^® have been prepared, successively developing the product range, and improving the construction. The garment is produced of a highly elastic breathable knitted fabric of medical quality, composed of a polyurethane and polyamide yarn. This combination enables to obtain required parameters, and at the same time to provide high comfort for the user.

The manufacturing process makes it possible to produce the garment for every body part according to the compression class recommended by a doctor. The 1^st class compression (18-21 mmHg) is the one most frequently used. It is remarkable that all compression products Codopress^® are manufactured so that all seams are aside from all scars. Thanks to this the value of the therapeutic pressure is not changed in any way in this place.

The process of compression garment preparation:

Get a referral from a specialist.
Make an appointment with a person taking measures of the limb or other body parts.
Once the garment is sewn it needs to be tried on to make sure that it fits perfectly.
The patient is trained how to use and clean the product.

All compression garments should be worn permanently from 6 to 24 months after the wound healing process is finished, till visible rehabilitation effects appear (flattening, fading and softening). The entire therapy usually requires a few changes of the compression garments, along with the use up of the garment and the change of patient’s body size. It is important to remember to use the products only when the post-burn wound is fully healed – see pictures below:

Rana pooparzeniowa gotowa do terapii Codopressem® — Post-burn scar ready for the therapy with Codopress^®

Wyrób Codopress® założony na wyleczoną ranę pooparzeniową — Codopress^® garment applied on the scar

Individually prepared Codopress^® products:

give appropriate compression on the scar,
can be used with other types of therapy,
cause no allergic reactions or skin irritations,
release itching,
prevent from joint contractures.

Clinical trials

In specialised burn healing centres in Siemianowice (Poland) and Polanica Zdrój (Poland) – leading centres healing heavy burns – a wide range of patients were clinically examined. They tested the effectiveness of Codopress^® products in the rehabilitation of post-scar burns.

Clinics testing the Codopress^® clothing included the Burn Treatment Ward of the Municipal Hospital No. 2 in Siemianowice Śląskie ran by S. Sakiel, MD, and the Plastic Surgery Hospital in Polanica Zdrój under the supervision of K. Kobus, PhD, Dr h. c. What is more in the National Medicines Institute under the direction of W. Zalewski, PD tests were carried out as for the irritating effect on the skin of the knitted textile used in the production of Codopress^® products.

Materials and methods

Within 2 years compression products produced by Tricomed SA were tested in 40 patients at the age of 2 to 59 years old with the average burn area of 26%, and deep burns at the entire skin depth with the average area of 9%.

The patients were divided into two groups:

in the first group (20 patients) the compression products were applied right after the wound was healed,
in the second group (20 patients) the Codopress^® products were applied after about 3 months after the wound was healed.

The evaluation concerned the face, the neck, the chest, the upper and lower limbs. Overall in the first group 24 places and in the second group 30 places were observed.

The tested products were evaluated as for their usefulness in supporting the treatment of hypertrophied scars and keloids in 26 patients aged 3 to 58 years. Most of the hypertrophied scars and keloids were caused by hot fluids or fire. The entire healing period for a burn wound, starting from the application of the compression products, took a month up to 4 years. Before the application of pressotherapy, massages were applied. Body parts that were most often tested as for the usefulness of the compression products included: the knee and elbow joint, the buttocks, the hips, the shoulders, the chest, the upper and lower limbs.

Test results

The results of the carried out tests indicated that in hypertrophied scars and keloids treated with the compression products sweeping changes were noticed. The itch observed in 8 cases retreated after 3 weeks. The colour of fresh scars changed from bloody pale into flesh-like in 17 patients after 4 weeks. The height of the scar was reduced from average 4 mm at the beginning (measured from the healthy skin) up to 0-2 mm. The best results were observed in fresh scars, which were 4 weeks old. In the case of older scars those effects were visible after a longer period of time.

There were no allergic reactions noted. Washing by means of commonly available washing agents and an all-day-long utilisation did not affect the elasticity of the tested products. The best therapeutic results were observed on tights, lower legs and forearms. The patients had no objection to wearing the compression garments. All in all compression products Codopress^® undoubtedly contribute to faster rehabilitation of patients with after-burn deformations.

The summary of test results

While wearing Codopress^® products for a few months the following conclusions were made:

the scars were getting flatter,
the extremely red colour was gradually fading,
no allergic reactions to the material in Codopress^® products were observed,
in the same patients comparing not pressed scar places with the ones pressed by means of Codopress^® clothing there were visible differences in form of hypertrophies and hard scars in the not pressed places,
the application of the compression clothing just after the wound was healed brought better effects than in patients who used the products after hypertrophied scars appeared. [2]

Wyrób Codopress® założony na wyleczoną bliznę pooparzeniową — Codopress^® product applied on a healed scar

Conclusions

The tested products Codopress^®are very useful in the prophylaxis and rehabilitation of hypertrophied scars.
Compression garments need to be tailored according to the measured body dimensions of the wearer in order to provide high efficiency.
An early application (just after the wound is healed) of tailor-made compression products guarantees the best efficiency of the scar rehabilitation.
Constant wear of the clothing (13 hours a day) 1 to 2 years changed only if it is worn up or the patient’s size has changed:

prevents the development of hypertrophied scars,
causes the reduction and, in most cases, the regression of keloids,
improves the final aesthetic look.

Pressotherapy enables to continue physical rehabilitation and does not constrain the patient’s activity after the burn.
The knitted fabric used in Codopress^®products causes no irritating reactions.

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Associable therapy Codopress^® + Codosil^™ ADHESIVE

Silicone dressings adjunctive to scar treatment by means of pressotherapy have gained in popularity in the past 10 years. Their application decreases the growth of small blood vessels in a scar, and as a result the scar gets more elastic and flatter.

Many specialists recommend the associable therapy, combining a few methods individually adjusted to a given patient. One of them is compression therapy joined with dressings meant for scar rehabiitation. The dressing used for this type of combined therapy is Codosil^TM ADHESIVE.

Codosil^TM ADHESIVE is a soft multi-layer product designed for the rehabilitation of hypertrophied scars and keloids. Adhesive silicone layer is in the direct contact with the scar surface. The outer side of the dressing is secured with an anti-adhesive protection layer.

Codosil™ ADHESIVE:

releases the itching and pain,
does not present irritating and sensitising properties,
is susceptible to folding,
reveals sticky properties which makes it possible to stick to the skin’s surface repeatedly,
is meant for multiple use,
is easy to store and apply.

The silicone dressing can be applied as a preventive agent when the wound is fully closed (8-10^th day) or when first symptoms of a hypertrophied scar appear. Early application of the dressing increases the chance of proper scar rehabilitation.

The dressing is used only on skin that is not broken, remembering to make the dressing 1 cm bigger than the scar size. Prophylactically it should be worn 12 hours a day. In patients using the compression products Codopress^® along with the silicone dressing Codosil^TM ADHESIVE there were visible therapeutic effects observed: flattening, fading and softening of the scar. Moreover, the motor activity is improved and the risk of contractures is limited.

Codosil^TM ADHESIVE is recommended to be used:

in rehabilitation of hypertrophied scars and keloids,
as prophylaxis in people with hypertrophied scar and keloid tendencies,
in cosmetology for the rehabilitation of scars after aesthetic surgery.

Literature:

[1] Babiana Mossakowska, PhD, Professor, Presoterapia u dzieci (Pressotherapy in children).

[2] A. Nawrocki, doc., PhD, and others, Ocena kliniczna – Opracowanie technologii i ocena artykułów medycznych do zastosowania w chirurgii plastycznej (Clinical evaluation – The compilation of technologies and the evaluation of medical products to be applied in plastic surgery).

All Codopress^® products are individually prepared after taking measures. To make an appointment and get more information please contact us export@tzmo.com.pl.

Contemporary approach to chronic wounds

Elżbieta Szwałkiewicz

National Consultant in Nursing Chronically Ill and Disabled People

One of the indicators used to assess the quality of long-term care of an immobilised person is the skin condition in areas exposed to constant pressure. It would seem that nurses know everything on the prevention of pressure ulcers, and that is why I wonder what is the reason for such a high incidence of pressure ulcers in people who are under constant nursing supervision.

The scale of the problem entitles me to claim that in our country we have common and very serious failings in the care of the sick and disabled, both in stationary health-care and social assistance, as well as in home conditions. These neglects are the cause of immense suffering and generate substantial costs of treatment and care.

There have been many publications on the subject of pressure ulcers referring to numerous medical research and statistics. They repeat the same key information:

the major etiological factor is the pressure on tissue located over bone prominences, leading to the development of necrosis and then to ulceration,
skin damage occurs as a result of repeated pressure exceeds the average pressure in skin capillaries (32 mmHg), the impairment of sensation is a contributing factor,
the formation of pressure ulcers is accelerated by skin maceration, which is a consequence of increased humidity due to urine and faecal incontinence or perspiration,
the most common location is around the sacrum, ischiadic tubers, trochaners, ankles and heels,
each immobilised patient is at risk of pressure ulcer formation,
modern technologies ought to be used to reduce the pressure on the skin, such as specially designed mattresses, pillows, textiles and equipment for sliding movement, modern protective and therapeutic dressings, and aids absorbing urine,
the treatment cannot be focused on the topical management of decubitus ulcer.

Basic principles relating to prevention:

proper nutrition – adequate intake of protein, calories and fluids will prevent the occurrence of negative nitrogen balance, weakness and dehydration,
reduction or elimination of pressure and friction on the skin – this effect is achieved through the use of pressure relief mattresses and pillows, frequent change of body position, application of proper rules for lifting and moving patients,
strictly comply with the basic care principles of people with incontinence (also the faecal type), including:

daily washing and cleaning after every contamination with excretions,
systematic control of skin condition in areas exposed to moisture,
using absorbent products adequate to the level of micturition,
preventing skin inflammation through the use of special protective dressings,
protecting the skin against overdrying and irritants (urine and sweat) through the use of appropriate skin care products.

Modern approach to the treatment of pressure ulcers and other chronic wounds favours wound healing in a humid environment with the use of various specialist dressings, which are applied depending on the type and the location of the wound.

Scientific studies and practical experience have shown that increased moisture in the wound stimulates epidermisation, and this, in turn, stimulates the growth of connective tissue underlying the skin. Specialist dressings compared to conventional gauze dressings also affect the rate of healing. They prevent the damage to the young epidermis during each dressing change, and they contain substances that affect the treatment and healing of wounds. Not to be underestimated is the fact that effective protection of the interior of the wound against external factors, and to perform normal hygiene procedures without changing the dressing.

Therapeutic proceedings (including the selection of a dressing) and the cost depends on the type of wound and the stage of healing . Some wounds are treated for many months, sometimes over a year. There are often problems in the healing process, and the most dangerous of them cause infections. An unsecured wound may be infected with bacteria, viruses or fungi. They proliferate spontaneously and poison tissues with their secretions. The wound infection can spread quickly up to the form of sepsis, which threatens the patient’s life. The cost of treating infected chronic wounds significantly increases mainly due to the need to use more specialist dressings and the use of expensive antibiotics.

As a national consultant I observe with great concern that the number of people who suffer from pressure ulcers and other chronic wounds is not decreasing despite years of educational campaigns. The responsibility for this situation falls not only on the nurses but also on those responsible for creating the conditions for the care of sick and dependent people, and the National Health Fund as a payer financing the costs of treatment. It is difficult to understand the fact that the National Health Fund does not require health care centres to report on patients with bedsores and the course of treatment. Isolating procedures concerning the treatment of bedsores, and leaving the treatment costs within the institution in which they occur, would highly affect and activate the creation of suitable conditions for the prevention of pressure ulcers. It should of course take into account the fact that some chronic wounds are not the result of negligence but result from the patient’s physical condition; most often it relates to end-phase of long-term biologically devastating neoplastic disease.

As part of my own professional practice I was able to watch quite remarkable effectiveness of modern specialised dressings in the treating of pressure ulcers. Of course, the nurses should be aware of all the known methods of chronic wounds treatment, not only of pressure ulcers but also ulcers, malignant ulcers, diabetic foot ulcers and burns. The bottom line is to be aware that it is unacceptable not to obey the basic prevention principles and to expose the patient to the formation of pressure ulcers or other chronic wounds. Both health and financial consequences of economising on absorbent products and protective dressings are very serious, not only for the patient but also for the nurses and the unit they work for.

Successful treatment of chronic wounds

Elżbieta Szwałkiewicz

National Consultant in Nursing Chronically Ill and Disabled People

Even the most modern, well-matched to the wound type dressing will not facilitate the wound healing process if additional conditions conductive to further body regeneration will not be met.

These are:

proper body hygiene,
skin protect against irritating effects of urine,
suitable bed, mattress, bed linen and underwear,
elimination of pressure on the part of the body affected by a bedsore,
safe movement and positioning of the body,
adequate nutrition and hydration.

Modern technical solutions and technologies allow for the safe performance of hygienic activities, even in those patients with very sensitive skin and completely immobilised, without the risk and effort associated with their movement. On the market there is a wide range of skin care, hygiene facilitating devices available. When dealing with dry skin (frequently washed with soap), weakened, macerated, constantly subjected to the action of irritants, it is necessary to check the condition of the skin daily looking for signs of an allergic reaction. Appropriate preparations for cleansing and skin care of the sick are the ones that can be applied to sensitive and irritated skin, and have moisturising, greasing and elasticising properties. They should alleviate symptoms of inflammation, grease and protect the skin against irritants such as urine. For irritated and itchy skin soap should not be used only mild cleaning agents (lotions, foams). It is advisable to use cosmetics with as little allergic reactions as possible. The used cleaning and care products should be manufactured in sets by the same company as this will prevent the use of products of different chemical components coming into harmful interactions for the organism. Just wash the wound area, and always check the condition of the wound dressing and protection of the wound against pollution and getting wet during hygiene procedures.

Unpleasant for the patient and his/her environment urine odour can be eliminated by proper selection of absorbent materials and their appropriately frequent change – about four times a day. While changing be sure to cleanse the abdomen, genitalia, groin and buttocks.

A patient who cannot change the position from lying to sitting can be washed traditionally in bed, but can be also bathed in a special movable bathtub. The bathtub is taken into the patient’s room, one side wall is removed and is set along the bed. Then, using a cloth or a special sliding mat to move the patient (previously undressed and covered) into the tub. If the patient is on a drip, monitor, respirator, etc., the bath is carried out in the room next to the bed. This is possible when to the sink tap (located in the room) a shower hose of suitable length with a shower head is attached. Similarly, the drain hose must be of appropriate length to reach to a special outlet installed under the sink. If the patient is able to leave the room, he/she is taken on the bathtub to the bathroom with a shower post. The drain hose is introduced into the floor drain. Bathing in the supine position can also be done in a bathtub with an adjustable height. A person who cannot move, is moved (undressed and covered) by sliding onto a special man lift – a kind of trolley-stretcher. Following the transfer of the patient to the bathroom, the lift is placed on the bath, which rises (electric mechanism operated by means of a remote control) to the height appropriate for the carer, so that he/she does not to have to bend down. Then, the lift with the patient is lowered to the bottom of the tub. Most of the mentioned bathtubs has also an incorporated hydro massage device. The lift has the ability to raise the head rest so that the patient can be washed in a sitting or reclining position. In a set with the bathtub there are also available chair lifts that help people with paraplegia or the disabled to get to the bathtub and leave it. These people can also wash themselves in the shower using the lift or a sanitary chair. All institutions where there are patients with locomotor disabilities should have integrated systems for personal hygiene i.e. movable equipment integrated with cleaning equipment.

People unable to walk e.g. with paraplegia can use the toilet alone but there must be conditions created enabling the move from the wheelchair onto the toilet. The height of the toilet and the wheelchair should be similar. The side walls of the chair and security handles at the toilet should be tippable. Within easy reach of a person using the toilet there should be a shower head to wash and toilet paper to dry the skin. The ability to wash oneself with running water is highly important, because it is very difficult to clean the genital and anal area with toilet paper. In elderly people the skin is wrinkled and therefore its thorough cleaning off stool remnants is not possible by means of dry toilet paper, and repeatedly rubbing the sensitive and dry skin often leads to its damage. In the toilet there should be enough space for a disabled person to drive a wheelchair, park along the toilet, and after picking up the side part of the chair and the toilet handle, move onto the toilet. All people, regardless of their health and fitness, should be able to use the toilet. It should be kept in mind that when lifting and moving the patient strong point pressure on the body ought to be avoided and the sliding method to rotate the body ought to be applied. The need to clean and protect the skin is particularly important for people with disabilities who face the problem of urinary incontinence.

Please note that urine in contact with the skin is an external irritant, causing inflammation. The inflamed skin is red, irritated and painful. There appears also often swelling, itching and flaking of the skin. Patients trying to reduce the annoying itch scratch themselves, and ultimately break the continuity of the skin, leading to the formation of wounds. These scratches are the site of bacterial infection and the development of complex infected bedsores.

The desired effect can be achieved using hygienic disposable absorbent materials, sets for urine collection, specialist personal hygiene and cosmetic and protective preparations. Their offers is very rich in the market.

Diapers, anatomically shaped diapers or urine pads should be chosen according to their absorbent ability, the content of a urine binder, the type of protection against the leakage from the diaper, the ability to reduce unpleasant odours and the possibility to closely adjust to the body. It is also important that the absorbent body is covered with special nonwoven, which also separates the urine absorbed from the skin.

Urinary incontinence leads to constant moisture and maceration of the skin, which promotes its inflammation, damaging, resulting in the formation of bedsores. Therefore, it is necessary to systematically check the condition of the skin in areas exposed to moisture and the state of dressings, and maximally shorten the time of skin contact with urine.

Therefore, the selection of an absorbent product should be determined by the degree of urinary incontinence, the patient’s level of consciousness, time of the day and level of activity. People with pressure ulcers or very sensitive dry skin prone to irritation, should use the so-called breathable diapers. They differ from other diapers for instead of the protective film they have to a special air-permeable laminate.

While nurturing a bedridden person with urinary incontinence (UI) it necessary to use hygienic underpads to maintain the cleanliness of linen or to secure the chair. Do not use rubber underpads but pads made of cellulose with one side coated with special film protecting the chair or the bed against wetness. Here also breathable absorbent products should be applied. People with bedsores should avoid overheating in warm clothes and airless or overly heated rooms, and above all, they should avoid long-term pressure on the damaged skin and skin friction over the ground. This effect can be achieved by using a special sliding and equipment for sliding repositioning, pressure relief mattresses and pillows, frequent change of body position, the application of proper rules for lifting and moving the patient.

Significant reduction or elimination of pressure on the skin can be achieved by equipping the bed with an anti-bedsore mattress:

alternating pressure (so-called dynamic) anti-bedsore mattress where a motor pumps air into individual chambers of the mattress, filling them only some of them which allows to temporarily relieve another part of the body. Using the mattress does not cancel the obligation to adequately frequent change body position.
constant pressure anti-bedsore mattress, pumped using a hand pump, enabling to achieve appropriate pressure and reduce the pressure on the body surface. It is also important that it is made of a material with a unique antibacterial formula inhibiting the growth of bacteria and odour inhibitor. Using this mattress has a preventive effect and accelerates healing of existing wounds. This mattress is particularly useful in patients who dislike the sound of the pump motor in the dynamic mattress.

The time of healing a bedsore or any other chronic wound depends on the general state of health and on good nutrition with adequate supply of protein, calories and fluids.

Diabetic foot

Causes

The diabetic foot syndrome deals with changes appearing on the lower extremities in patients with diabetes.

The cause of the diabetic foot syndrome are changes in the blood vessels (ischemia), and damage to the nerves (neuropathy). Deterioration of vascularisation and innervation in diabetic patients usually progress simultaneously, but only one of these changes is dominant. The dominant factor determines the type of the diabetic foot syndrome, and so can be distinguished: ischemic diabetic foot syndrome or neuropathic diabetic foot syndrome.

Figure: diabetic foot syndrome – classification as for the dominant factor

Peripheral neuropathy i.e. peripheral neuritis – is one of the complications of prolonged hyperglycemia and affects both somatic and autonomic nerve cell projections in both legs. The patient has reduced sensation of pain, temperature and touch in the affected leg, and since feels no pain after an injury or compression, the skin is often damaged and ulcers are formed, which are often not noticed early enough and thus start to be treated too late. Late detection of the ulcers may be then too advanced to be successfully treated.

Motor neuropathy causes loss of muscle and foot tendons and, consequently, destruction of the joints. This in turn leads to the concentration of workload on a few small areas of the plantar surface, and further to the formation of callus. The final step of these changes is foot deformation.

Angiopathy i.e. damage to blood vessels – blood supply disorders are characterised by abnormal blood flow in the legs especially tibial and fibular artery. Uncontrolled diabetes favours the development of arterial diseases. The control of blood glucose content is one of the prevention ways, it is also a precondition for starting the process of wound healing.

Therefore, we can distinguish:

neuropathic foot ulcers, which constitute two thirds of all diabetic foot ulcers
angiopathic foot ulcers (~ 10%)
mixed foot ulcers (~ 25%)

Risk groups

People with diabetes mellitus.
People with undiagnosed diabetes!

This disease affects mostly people with type II diabetes i.e. the one not requiring insulin injections.

The complication in for of diabetic foot is present in approximately 20% of hospitalised patients because of diabetes, and is the cause of 50% of all limb amputations performed in surgical wards.

Symptoms

Neuropathic diabetic foot

The predominant symptoms:

loss of sensation to touch, pain and temperature

The patient does not feel the presence of a malicious stimulus such as a cut, burn, hurting by wearing tight shoes, the presence of a foreign body in the shoe. Insensitivity to pain is the basic element causing the formation of ulcers on the foot sole. The neuropathic diabetic foot is warm, with preserved flow in the arteries, but the foot joints and bones are deformed.

In some patients the changes appear in the joints and are formed by gradual destruction of small joints of the foot which results in considerable distortion of the feet. It is necessary then to wear special shoes made upon an individual order. Wearing normal ill-fitting shoes very often leads to the formation of ulcers.

Ischemic diabetic foot syndrome – angiopathic

The predominant symptoms:

increased sensitivity to pain

The main symptoms are: pain intensifying usually at night, often accompanying painful muscle cramps, tingling or numbness in the leg.

Depending on the level of stenosis and occlusion of arteries in the lower limb, necrosis appears on different areas of the foot.

The most severe form of the disease is the closure of large arteries in the lower limb above the knee. This results in tissue necrosis in the foot, and sometimes also in the lower leg. Necrosis affects mostly toes. Ischemic diabetic foot is characterised by preserved innervation while simultaneous impaired blood supply in the limb.

An untreated diabetic foot syndrome leads to the amputation of the limb.

Location

In patients with diabetic neuropathy ulcers are located primarily in areas of repeated injuries and affect usually the plantar surface of the foot around the metatarsal bone, heel and toes. Usually the neuropathic ulcers are painless.

In addition, as a result of neuroarthropathic disturbances, the foot is distorted in a characteristic way – grooved feet, mallet toes, changed way of walking, and in over-loaded points in the calluses (corns) are formed that can later cause non-healing wounds and ulcers.

In the case of ischemic diabetic foot chronic hypoxia causes that the foot begins to die – it swells, ulcers, necrosis and cracks appear, nails get deformed and soft tissues disappear and the whole foot becomes blue.

Treatment

A specialist in the field of diabetes, surgery (including vascular surgery) and orthopaedics is the competent person for ordering treatment. Nurses also actively participate in the therapy. The most important thing is to keep sugar level in blood in optimal physiological limits.

The treatment is both causal and local.

Wounds are surgically debrided, narrowed blood vessels are unblocked, various vascular grafts are used to allow bypass clogged arteries which improves blood flow in the foot. Along with the surgery blood sugar in the body is controlled and medicaments facilitating the treatment are dosed. In addition to insulin and antibiotics the patient receives medicines that improve blood circulation in the limbs, reduce blood viscosity, enabling to reach the ischemic structures, improve wound healing and scarring. Also appropriate diet is recommended.

Prevention

It most essential in the prevention of diabetic foot development is the proper treatment of diabetes, the control and maintenance of a normal blood sugar level.

After diagnosing diabetes the patient should:

quit smoking
gently and carefully take care of the feet
systematically control the circulation and innervation of the feet

If there are foot lesions, early physician intervention often prevents the need of amputation of the lower limb.

Everyday foot care in people with diabetes should consist of:

everyday observation – controlling blood flow and sensation, washing in warm (not hot) water, gentle and careful drying – especially the space between toes
care for nails – regular trimming (but not too short)
careful selection of shoes – should be sufficiently wide, the right size (patients with neuropathy, due to the worsening of sensation tend to buy too small shoes, smaller than the ones worn so far), the heel should be low and wide, shoes with laces are recommended
before putting on shoes the patient should check whether inside there are no sharp objects, outstanding seams or rolled inserts
wear non-binding and non-elasticated socks made of natural fibres (too tight socks can impede blood circulation)
protect the foot against excessive: soaking , exercises or heating (for example by means of an electric blanket or other energy sources)
do not use ointments on foot corns – unless your doctor tells otherwise

Any observed changes in the foot, such as swelling, colour change, loss of sensation should be consulted as soon as possible with a doctor.

Even minor cuts, skin cracks and wounds cannot be ignored and always need to be secured with sterile dressings and shown to the doctor during control visits. If there is no progress in the healing it is recommended to urgently consult the doctor.

Leg ulcers (crural ulceration)