Pilonidal sinus is a painful inflammatory disease of the skin characterized by the appearance of a cyst in the skin with pus discharge. The cause of this disease is said to be the deep penetration of hair in the skin, infecting the area. Although this disease mostly occurs in the sacrum, it can also appear in other parts of the body such as the umbilicus, the axilla, or the pubic area.1 Annually, 70,000 people in the US are afflicted with pilonidal disease, and the incidence has been reported to be 26 per 100,000 people. The condition mostly affects younger adults, and men are twice as likely as women to develop it.2
Depending on the disease’s progression, various treatments are available; these can be divided into invasive and noninvasive procedures. Among the noninvasive or nonsurgical procedures are shaving the inflamed and infected area, injecting phenol into the sinus, and antibiotic therapy.3 In cases where the treatment of the disease is not possible through noninvasive or pharmaceutical methods, various surgical procedures are used, from creating a simple incision to drain the wound to more complex procedures such as using skin and muscle flaps to fill the space caused by the excision.4 Because one of the risk factors for recurrence is a closed surgical technique, open surgery is recommended.5 In an open surgical procedure, the surgical area is not sutured or covered with a flap, and wound healing can occur gradually with proper wound dressings. Therefore, wound care and using the right dressing are among the most important postoperative measures.6
Considering the importance of wound dressing in open surgeries, an appropriate type of dressing is required. An ideal dressing should match the shape and size of the wound, be able to absorb excessive wound discharge while maintaining the wound’s temperature and humidity, prevent bacteria from entering the wound, create proper pressure to maintain homeostasis, reduce pain during the healing process and while changing the dressing, alleviate pain, promote autolytic debridement, accelerate wound epithelialization, and not require frequent replacement/be cost effective.7
Today, modern wound dressings with many of these features have replaced conventional dressings that lacked them. Alginate, hydrocolloid, foam, and hydrogel dressings and transparent films are among the most practical options that have been used widely for dressing various types of ulcers in recent decades.8–10
At present, a wide variety of hydrocolloid dressings are available that are produced by different companies. These dressings are mainly used to treat superficial wounds with low or intermediate exudate to accelerate the formation of granulation tissue on the wound surface.11 Alginate dressings derived from marine algae compounds have been used to shorten the wound healing process for a wide range of chronic and acute ulcers for years.12 Hydrogel dressings have achieved popularity over the last three decades as effective products to maintain a moist wound bed, promote autolytic debridement, and reduce pain.5
With these modern dressings, depending on the specific product, stage of the wound healing process, and type of wound, the frequency of dressing changes may be significantly reduced,13 which reduces the patient’s time traveling between home and treatment centers considerably. As a result, patients will also feel less pain during dressing changes, and the wound healing process will be accelerated.14 The mean duration of wound healing after open surgery is about 40 to 50 days, depending on the physical condition and nutrition status of the patient.15 However, studies show that applying modern dressings can reduce this period by 5 to 7 days.16
Another criterion for choosing the right type of dressing is cost. Typically, after open pilonidal sinus excision, daily dressing of the surgical site involves cleaning the wound with a normal saline solution and filling it with moist sterile gauze.17 In many developed countries, this traditional or conventional wound dressing is an acceptable choice because of easy access to nursing care centers, the presence of experienced nurses at the patient’s bedside, and the possibility of receiving wound care at home with effective insurance coverage.12 In Iran, conventional dressings are cheaper than modern dressings, but the frequent daily trips between home and healthcare facilities to change the dressing and repeated fees increase long-term expenses. As a result, patients tend to continue their wound care at home, although this increases the risk of wound infections and disease relapse.
On the other hand, some modern dressings, despite being effective in the wound healing process, are not favored by patients and physicians because of the costs per dressing change. Therefore, it seems that the development of methods that do not impose additional costs on patients while maintaining the effectiveness of the modern types of dressings should be a priority for the medical community.
For example, hydrocolloid dressings usually serve as secondary dressings to maintain wound moisture, but their use can increase the cost of treatment considerably. One traditional dressing is a product called Vaseline gauze (Kaveh BGC Co, Saveh, Iran), which is mainly used for burn wounds or skin grafts. This product is a continuous nonfraying nonadherent occlusive dressing impregnated with Vaseline. This absorbent gauze has a fine mesh fabric that does not stick to the wound and is easily applied to all body parts. Its mesh fabric lets the wound breathe appropriately while maintaining a moist wound healing environment.18 Therefore, it is possible that by using Vaseline gauze instead of hydrocolloid dressings as a secondary wound dressing, treatment costs could be reduced for patients and families while providing optimum conditions.
To ascertain this, the present study was designed and conducted to assess the effect of three methods of dressing wounds (conventional, modern, and modified) on the healing process of pilonidal sinus wounds. Outcome measures included wound size reduction, the amount of pain experienced by patients during dressing changes, treatment costs, and the length of patients’ leave from work.
This clinical trial (registration no. IRCT2014072118553N1, reviewed and registered by the Iranian Registry of Clinical Trials) was conducted on 60 patients who were candidates for pilonidal sinusectomy. A convenience sample of patients was included in the research based on the following criteria:
- no skin disease or immunocompromise
- no history of immunosuppressive drugs
- planned operations by surgeons with similar experience using a similar procedure
- no diabetes
- no signs of organ paralysis or immobilization
- a body mass index between 19 and 35 kg/m2
- a surgical wound depth and length of 4 to 7 cm
Written informed consent was obtained from all participants, and they were provided with complete study information, including the right to withdraw at any stage of the study and data confidentiality.
After the surgery but before the wound cavity was filled with moist sterile gauze, the depth and length of the surgical wound was measured and recorded using a standard millimeter ruler. Then the patients were randomly assigned one of three 20-member groups.
In the first (modern standard) group, the wounds were dressed through the standard method recommended for alginate, hydrocolloid, and hydrogel compounds. In the first week and after the surgeon’s first visit to the ward, the wound cavity was filled with hydrogel (Comfeel; Coloplast, Humlebaek, Denmark), and a hydrocolloid dressing (Comfeel Plus; Coloplast) was used as a secondary dressing to cover the wound. This procedure was repeated three times in the first week. In the second week, the hydrogel was replaced by alginate (Biatain Alginate; Coloplast), and the dressings were changed every 2 days. The same method was used every 3 days during the third week. Finally, in the fourth week, only the hydrocolloid dressing was replaced every 4 days.
In the second group, a modified dressing was used. In this method, Vaseline gauze was applied instead of the transparent hydrocolloid dressing.
In the third (traditional) group, the dressing change was performed through daily cleaning and filling the cavity with sterile gauze.
Based on the arrangements made with patients, the depth and the length of the wounds were measured once a week for 1 month. In addition, patients’ pain levels were measured and recorded when changing the dressing, using the 11-point numeric rating scale. In this scale, zero represents no pain; 1 to 3, mild pain; 4 to 6, moderate pain; and scores higher than 7 represent severe pain.
During the 1-month evaluation, the number of dressing changes, the wound healing process, the amount of pain experienced by patients, the total costs associated with each method, and the length of leave from work were entered into the SPSS 19 software program (IBM, Armonk, New York). Then the data were analyzed using descriptive and inferential statistical methods (χ2 test, 1-way analysis of variance, Student t test, and Wilks Λ test).
Based on the results of this study, there were no significant differences among groups based on demographic information (age, gender, and body mass index). The results associated with the wound healing process based on the wound size reduction (length and depth) are shown in Table 1; the modified method led to the highest reductions in wound size (P < .001). The findings on pain experienced and reported by patients within 4 weeks of surgery are shown in Table 2; the standard method had the lowest self-reported pain scores (P < .001).
The comparison of the average total dressing costs among the three groups is shown in Figure 1. Although the total dressing cost of the modified method is comparable with that of the traditional method and 50% less than the standard method (Figure 1), it reduced the average number of days for sick leave (taken in the first 4 weeks after treatment) in comparison with both traditional and standard methods (Figure 2).
For this study, researchers examined the consequences of using three dressings (traditional, standard, and modified methods) on the healing process of wounds caused by pilonidal sinus surgery including the wound healing process and period, the pain experienced by the patients during dressing changes, the treatment costs, and the duration of patient leave from work.
Based on the results of this study, after 2 weeks, there was a significant difference in mean wound length among the three groups (P < .05), indicating shorter wound healing time in the modified and standard groups over the traditional group. This is consistent with the findings of Xakellis and Chrischilles.19
The results concerning the wound healing process in the first and second weeks indicate the similar effectiveness of all three dressing methods, which is consistent with the findings of Dumville et al,20 O’Meara et al,21 and Viciano et al.22
Another outcome measure was the amount of pain experienced by the patients during dressing changes, the means of which were measured and compared in the three groups every week. During the first dressing changes, patients reported pain scores ranging from 4.5 to 5.4, which is consistent with the findings of the study conducted by Stewart et al23 (average pain scores, 5 out of 10). There was a significant decrease in pain levels experienced by the patients during dressing changes over all 4 weeks. However, the pain scores in the standard and modified groups were lower than those in the conventional group, which was consistent with the results of the study of Viciano et al.22 Dinah and Adhikari13 also confirmed that pain experienced during alginate and foam dressing changes is less than the pain caused by packing sterile gauze (consistent with the results of the current study).
In addition, in another study comparing permanganate, Betadine gauze, and alginate dressing in hemorrhoidectomy patients, it became clear that patients in the alginate group experienced less pain during dressing changes, and their wound healing took less time;24 again, this is in agreement with the results of the present study.
The treatment cost over the 4-week study period was also assessed; a significant difference was observed among the three groups. The modified dressing method cost the least of all studied methods. Although the traditional method and using ordinary gauze in each dressing change cost less per dressing change, that does not include the cost of the nurse performing the dressing change. Therefore, it seems that, because of the decrease in the number of dressing changes, the total cost of applying modified dressings is not significantly different from that of traditional methods.
In accordance with this finding, Payne et al25 showed that because of the lower number of dressing changes, using foam dressings to treat stage 2 pressure ulcers is cheaper than using moist gauze alone. In a comparative study on the cost of wound healing with a hydrocolloid dressing and moist gauze, Xakellis and Chrischilles19 found that the cost of hydrocolloid wound dressings is 3.3 times higher per dressing change; however, in treating stage 2 pressure ulcers, a moist gauze dressing took eight times longer than hydrocolloid dressings. Their findings also indicated that with a gauze dressing wound healing is slower, the infection rate is higher, and the long-term cost of treatment is 3.45 times higher than the hydrocolloid method, which is consistent with the results of the present study.19
The amount of participant leave from work was the last outcome measure evaluated in this study; this is one of the most important patient concerns in postoperative care after open surgical procedures. In a study on the parameters for the management of pilonidal disease, Steele et al4 stated that the surgical treatment of chronic pilonidal disease through excision of diseased tissue with primary closure is usually associated with a more rapid return to work. A significant difference was observed in the amount of leave taken from work when comparing the three groups (P < .001). Participants in the traditional dressing group took the most leave (reported to be more than 10 days), whereas in the standard and modified dressing groups this number averaged 6 to 7 days.
Because of financial constraints (the high cost of purchasing needed dressings and visiting the patients at home for wound changes), it was not possible to continue this study for longer than 4 weeks. Therefore, the wound healing process is reported up to the end of the fourth week. Because the wounds were not healed entirely in some patients, there is a possibility that extending the study period would have altered the results. Moreover, the small sample size examined in this study, along with a narrow distribution of the samples from the demographic point of view, limits the generalization of the results outside the Iranian population.
Considering the positive results seen with the use of modern wound dressings that contain alginate and hydrocolloid compounds, the use of these products in wound dressings is recommended. Because nursing care centers are becoming more common in Iran, future studies might involve performing a more accurate financial analysis in comparing the effectiveness of these dressing methods across facilities. In addition, the authors suggest that the surgeons and nurses responsible for performing dressing changes be trained in using modified methods that are more cost effective than standard procedures.
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