Topical agents play a critical role in alleviating wound-related pain. Slow-release ibuprofen foam dressings have demonstrated reduction in persistent wound pain between dressing changes and temporary pain on dressing removal . The topical use of morphine, tricyclic antidepressants (e.g., amitriptyline), NSAIDs, capsaicin, ketamine, and lidocaine/prilocaine has demonstrated effectiveness for pain relief [30▪,31]. However, the lack of pharmacokinetic data precludes the routine clinical use of these compounds at this time. There are many advantages to using local rather than systemic treatment. The active agent is delivered directly to the affected area, bypassing the systemic circulation, and the dose needed for pain reduction is lower, minimizing the risk of side effects.
Wound-related pain is often exacerbated with dressing changes that can persist for a long time (in some cases over 6 h) . Dressing materials adhere to the fragile wound surface due to the glue-like nature of dehydrated or crusted exudate requiring high peel force for removal. In addition, the granulation tissue and capillary loops may grow into the contact layer, especially with gauze dressings and with the use of negative pressure wound therapies, rendering mechanical trauma upon removal . According to a review of dressings and topical agents for post surgical wounds and healing by secondary intention, patients experienced more pain with gauze than any other advanced moisture balance dressings including foam, alginate, and hydrocolloid dressings [33▪]. Ironically, gauze continued to be one of the most commonly used dressing in clinical practice. Careful selection of dressings with an atraumatic and nonadherent wound contact layer, such as silicone, has been documented to limit skin damage/trauma with dressing removal and to minimize pain at dressing changes . Silicone coatings consist of chains of hydrophobic polymers with alternate molecules of silicone and oxygen. As compared with other adhesives, the silicone coatings produce a lower surface tension combined with a more extensive contact interface. Silicone-coated dressings adhere to intact dry skin but unlike traditional adhesives, they do not adhere to a moist wound bed. In a comparative study, Matsumara et al.[35▪] evaluated eight commonly used wound-care products with adhesives (soft silicon, hydrocolloid, polyurethane, and acrylic adhesives) and their potential effect on the epidermis in 10 normal volunteers. Dressings that incorporated soft silicone technology were less likely to cause skin stripping and removal of stratum corneum than other tested material.
Wound-related pain may extend beyond the wound margins to periwound skin. When drainage volume exceeds the fluid handling capacity of dressing material, enzyme rich and caustic exudate may spill over to wound margins causing maceration or tissue erosion and pain . Maceration of the periwound skin typically presents as white, wrinkled soggy tissue at the wound edge. In a crossover, randomized, controlled trial, patients with wound margin maceration and skin damage were prone to experience increased pain even before dressing changes . To contain and remove excess exudate from the wound, a plethora of absorbent dressings have been developed. Based on the absorbency, major categories of dressings include foams, alginates and hydrofibers. Selecting the right dressing and size to absorb the exudate from the wound and the appropriate frequency of dressing change is crucial to optimize persistent wound-related pain (see Fig. 2).
Some sealants, barriers, and protectants, such as wipes, sprays, gels, and liquid roll-ons, are designed to protect the periwound skin from causative wound exudate and trauma induced by adhesives (Table 3).
Increased painful symptoms have been linked to wound infection and warrant further assessment. In the presence of unexpected pain or tenderness, clinicians should be suspicious of wound infection. According to a systematic review, Reddy et al. validated that increased pain (likelihood ratio range, 11–20) is an indicator for chronic wound infection. Based on literature review and previous studies, the UPPER and LOWER wound infection checklist was developed incorporating a total of 10 signs and symptoms (Table 4) that are associated with critical colonization (upper compartment) and deep infection (lower compartment). The list of criteria to evaluate wound infection has been validated in previous studies [39,40]. There is no single individual sign or symptom that could accurately confirm the diagnosis of wound infection but a combination of two or three of these possible signs should be sought for the diagnosis in each level. By collating three clinical signs, the sensitivity and specificity for signs associated with critical colonization were reported as 73.3 and 80.5%, respectively . To reduce superficial and localized bacterial burden in chronic wounds, topical antimicrobial dressings (e.g., silver, iodine, honey, and polyhexamethylene biguanide) have been demonstrated to be effective .
Pain is an emotional experience that can be amplified by anticipation or negative expectation of discomfort; also known as nocebo hyperalgesia [8,43]. In fact, the perception of pain is amplified by individual's expectation of pain even when the stimuli are relatively innocuous. In a study of 96 patients with chronic wounds, Woo  reported that patients who experienced high levels of anxiety, also reported high levels of anticipatory pain, leading to high levels of pain at dressing change. The result is a vicious cycle of pain, stress/anxiety, and worsening of pain. In responding to a web-based survey, healthcare practitioners (n = 908) acknowledged that mental health concerns are common in people with chronic wounds . Over 60% of the respondents indicated that between 25 and 50% of people with chronic wounds suffer from mental disorders. Among all the symptoms, anxiety was rated the most common (81.5%). Anxiolytic agents and sedatives should be considered as part of the pain management toolkit to mitigate pain-related anxiety. In addition to pain, clinicians should pay attention to other sources of anxiety that may be associated with stalled wound healing, fear of amputation, body disfigurement, repulsive odour, social isolation, debility, and disruption of daily activities . Fear of addiction and adverse effects have prevented patients/residents from taking regular analgesics. In a pilot study, chronic wound patients described dressing change pain as being more manageable after receiving educational information [47▪]. Pain-related education is a necessary step in effecting change in pain management by debunking common misconceptions and myths that may obstruct effective pain management. Cognitive therapy that aims at altering anxiety by modifying attitudes, beliefs, and expectations by exploring the meaning and interpretation of pain concerns has been successful in the management of pain . This may involve distraction techniques, imagery, relaxation, or altering the significance of the pain to an individual. Patients can learn to envision pain as less threatening and unpleasant through positive imagery by imagining pain disappearing or by conjuring a mental picture of a place that evokes feelings and memories of comfort, safety, and relaxation . Emerging evidence suggests the importance of peer support can lead to improved outcomes in pain, healing, and quality of life .
Pain is a common concern and affects quality of life in people with chronic wounds. It is imperative to approach wound-related pain by first identifying the triggers related to wound pathologies or procedures, followed by evaluating the number of neurobiopsychosocial factors that may affect the pain experience. A variety of approaches drawing on expertise from interprofessional teams is crucial to optimize pain management.
Papers of particular interest, published within the annual period of review, have been highlighted as:
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 123–124).
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