Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Monday, April 21, 2014
Wound infection and biofilm is one of the most exciting yet controversial topics in chronic wound management. Recent advances in the understanding of wound infection pathogenesis have generated tremendous interest in biofilm and how it is related to wound healing. Differentiation of critical colonization, deep wound infection, and biofilm is a challenging, but important, task. It is generally accepted that topical antimicrobial agents should be considered for localized wound infection and systemic agents are introduced for wound infection that involves soft tissue. Despite existing guidelines, only half of patients with diabetic foot ulcers received appropriate antibiotic therapy for the treatment of infection. Surgical site infection is a growing concern in the community. With the advent of a plethora of topical antimicrobial agents that have been developed in the last decades, clinicians are now challenged with decisions of when and what antimicrobial agents to use. According to results of the recent quick poll on this website, the majority of the readers agreed that general clinicians do not have adequate knowledge to manage wound infection. Researchers at Queen’s University School of Nursing in Kingston, Ontario, Canada recently surveyed 80 physicians and identified a significant knowledge gap in wound management, especially around wound infection and biofilm. There is a need to enhance the knowledge and build capacity for physicians to assess and treat wound infection and biofilms. It is very encouraging to observe that almost all respondents also acknowledged their roles in wound care and expressed a keen interest to further their knowledge.
Wednesday, January 22, 2014
Blisters are common across all ages. In general, blisters are formed in areas where friction is a problem, such as tight footwear rubbing against the feet. A Stage II pressure ulcer can present itself as a blister. Blistering is also a predominant clinical sign for certain autoimmune skin diseases, such as pemphigoid and pemphigus. There is no consensus for the management of blisters. We conducted a recent quick poll on our website asking you whether blisters should be deroofed or removed. The majority of respondents voted in favor of leaving the blisters intact.
I think the answer to whether to pop the blister or not will depend on a few factors:
1. Location: For areas such as the ankle, wrist, and elbow, where the blister may impair mobility or range of motion, it may be wise to drain the blister and use an atraumatic dressing to cover the area.
2. Stability of the blister: If the blister is large and protected by very fragile skin, it may be beneficial to manually drain the blister in a clean and controlled environment to minimize contamination of underlying tissue if the blister were deroofed accidentally.
3. Content of the blister: We usually recommend not to remove blisters that are clear and filled with serous fluid. However, pus and blood can be irritating to underlying tissue and may warrant prompt evacuation.
4. Pain: Blisters that are painful may also benefit from manual evacuation.
To evacuate a blister, you can use a sterile needle or lancet to puncture the epidermis without damaging the dermal layer. Manual expression may be required to drain the fluid. Keep the skin flap to cover the dermis and consider an atraumatic dressing for protection.
Monday, October 21, 2013
It has been demonstrated that when bacterial growth reaches a critical threshold of 105 bacteria per gram of tissue, bacterial toxins can cause tissue damage in the superficial wound compartment, delaying healing. This phenomenon is referred in the literature as critical colonization, increased bacterial burden, covert infection, or localized infection. It is estimated that half of chronic wounds exhibit signs that are consistent with local infection, which is often caused by biofilm that is defined as a community of microorganisms living in an extra cellular polysaccharide matrix and attached to a substrate or surface. The prevailing opinion supports the notion that biofilm may be one of the primary causes for wounds that do not progress to complete healing. There are ways to remove biofilms. Sharp debridement is effective in physically removing and disrupting the biofilm structure rendering bacteria more susceptible to antimicrobial treatment. It has been demonstrated that biofilm and bacterial count can be significantly reduced after wound debridement. The recent Quick Poll questioned on this website asked readers’ opinion whether biofilm would reform in 24 hours. Indeed, there is evidence that if the wound is left without any treatment of topical antimicrobial agents after debridement, the biofilm can be reformed within 24-48 hours. The questions are:
• Does early use of antimicrobial agents could prevent biofilm from forming?
• If biofilm is ubiquitous in wounds, how often should antimicrobial dressings be used to promote healing?
• What kind of antimicrobial dressings should be used to treat biofilm infection?
Further research is needed to provide answers to the questions. Feel free to share your thoughts and practice with your colleagues. We’d love to hear your feedback!
Wednesday, June 19, 2013
Wound cleansing has been part of routine wound care to remove surface debris, dried up exudate, and other proteinaceous materials that could trigger a pro-inflammatory response, promote bacteria growth, and impair normal wound healing. The need and technique for wound cleansing, however, has recently been challenged. Moore and Cowman1 reviewed randomized controlled trials that evaluated wound cleansing for pressure ulcers. Of all the randomized controlled trials reviewed, the authors did not find evidence to support the use of any particular wound cleansing solution or technique that promotes healing of pressure ulcers. Furthermore, there is evidence to dispute the notion that using nonsterile tap water could increase wound infection.2
Nonetheless, evidence should always be appraised critically and interpreted with caution considering the context in which evidence was developed. Before we adopt the use tap water for cleansing, we should question about the source of tap water, hygienic practice of the person with wounds, and other co-existing factors that put the person at risk for wound infection. Unless the underlying factors of pressure ulcers, including moisture, shear, friction, and nutrition, have been adequately addressed, routine cleansing of the wound is not likely to yield significant improvement in the healing. Based on results of the recent poll posted on this website, 90% of you believe that cleansing is needed, particularly for wounds that have deep sinus and undermining. However, irrigation of wounds with tunnels should be done with caution. It is important to ensure that the irrigation solution is retrieved by gently expressed the areas with undermining. Otherwise, excess residual fluid left in wound may spill over to the periwound skin causing maceration and potentially promote bacteria growth.
1. Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev 2013;3:CD004983.
2. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012 Feb 15;2:CD003861.
Monday, May 13, 2013
Share your skin and wound care questions or challenges with ASWC. Give us your comments and we’ll respond!