There has been a dramatic increase in the number and type of dressings available over the last 40–50 years. This was a result of the seminal paper by Winter (1962) that demonstrated wound healing was optimised in a moist environment in pigs, and subsequent research by Hinman and Maibach (1963) who had similar findings in experimental human skin wounds. The development of wound dressings and their accessibility increased in the 1970s and 1980s and innovation has continued, leading to a somewhat overwhelming choice of dressings becoming available.
Clinical staff assessing and dressing wounds can understandably struggle with deciding which dressing to select for which wound, with many products available and a range of evidence quality (Mangan and Shoreman, 2022). Patient knowledge of products available has also increased, sometimes leading to conflict over dressing selection (Ryan and Post, 2023).
Guest et al (2020) evaluated the burden of wounds to the NHS in 2017 to 2018 and found that 6% of costs were attributable to wound care products, with the cost of products for unhealed wounds being 93% higher than for healed wounds. They also found dressings and bandage types were frequently changed to alternative types at patients' dressing appointments (Guest et al, 2020), suggesting a lack of continuity of care. Atkin et al (2019) stressed that a standard of care should be implemented to promote wound healing. This included continuity of care and reassessment at timely intervals, allowing interventions to be effective while ensuring prompt action if wounds are not healing.
Wound assessment
Wound assessment is a prerequisite for selecting an appropriate dressing. Many frameworks are available to help with assessment including the triangle of wound assessment (Dowsett et al, 2015), which looks at the wound bed, wound edges and periwound (surrounding) skin (Figure 1) and TIMERS (Atkin et al, 2019) (Figure 2), which guides the clinician through:
Wound assessment should note the aetiology or cause of the wound, its duration and whether it is acute or chronic, the condition of the wound bed, pain levels and any comorbidities or medication that may affect or hinder healing. The Professional Records Standards Body (PRSB, 2023) specifies that documentation must include a baseline wound assessment at the patient's first appointment, with a description of the wound, wound measurement or mapping and documentation of how many wounds the patient has. This is supported by Wounds UK (2018) and Atkin et al (2019), who advise accurate recording of each aspect of holistic assessment. A digital image of the wound is also recommended (Wounds UK, 2018; Atkin et al, 2019; PRSB, 2023), which aids reassessment, especially when a different clinician is carrying out the review.
Wound assessment will identify priorities for care and guide dressing choice. The aim of care should be decided before a dressing is selected. For example, if the wound is sloughy, the aim of care will be to remove that slough and the dressing selected should support autolytic debridement of the wound. Autolytic debridement is a natural process where the body's own enzymes break down tissue that is not viable. This can be enhanced by optimising the wound environment by adding moisture or removing excess fluid (Atkin, 2014).
Structured reassessment and review of the wound care plan can occur at agreed intervals (PRSB, 2023). Generally, a full reassessment of the wound by a health professional is advisable every 2–4 weeks (Wounds UK, 2018). This allows time to observe whether a dressing is effective in achieving the wound care aim(s) as well as continuity of care.
Some aims of care will require interventions other than dressings or wound care products, such as suspected poor perfusion, which will necessitate referral to a specialist. Certain wound aetiologies will indicate the need to follow specific pathways – for example, a lower leg wound treated for 2 weeks or more with no red flags (as specified in the guidance), such as acute infection or limb ischaemia, should be considered for mild graduated compression therapy (National Wound Care Strategy Programme, 2023).
Ultimately, dressings and wound care products make up just part of the overall wound care package.
Ideal dressing
The ideal dressing should meet the aims of care, but other factors also influence choice. The concept of moist wound healing is central to optimising wound healing. Modern dressings are developed with this in mind, but the clinician must ensure the dressing can provide a moist environment without making the wound too wet and causing maceration (Wounds UK, 2018; Atkin, 2019). Choice may be influenced by a need to manage bacterial load or treat infection, or by unwanted non-viable tissue, such as slough (Atkin et al, 2019).
Practitioners may not be familiar with some dressing types, so can be reluctant to work with them as they will be less of an ideal choice, and there are formulary restrictions in most areas of the UK that must be considered (Gray et al, 2019).
Patient allergies, sensitivities and ethical or lifestyle preferences have to be considered (Wounds UK, 2018; Atkin et al, 2019). For example, a patient with a silicone allergy should not be given a silicone wound contact layer, and dressings that contain animal products may be unsuitable for some people.
The location and size of the wound need to be appraised. Most dressings come in a variety of sizes and shapes and, for patients, there may be cosmetic or comfort issues to consider. Ultimately, the patient should be amenable to the dressing applied and understand the reason for application. This will improve patient experience as well as concordance with care (Atkin et al, 2019; Squitieri et al, 2020; Ryan and Post, 2023).
Dressing types
The first modern wound dressing was created in the mid-1980s and was able to supply a moist environment and absorb fluids (Ghomi et al, 2019). There is now an extensive selection of dressings to choose from with new developments and new products becoming available.
Most dressings can be grouped into 10 generic types (Table 1). These types will be briefly explained, and some trade names given as examples, but not all those available will be listed. Understanding the type of dressing will help practitioners decide which category to select, and the brand chosen will depend on many factors including local formulary, cost and accessibility. Some products within the groups may differ slightly, but the way in which dressing types work and what they aim to do are usually similar regardless of brand.
Wound dressing categories and examples
Dressing type | Method of action | Examples include |
---|---|---|
Hydrocolloid | Provision of moisture |
Comfeel Plus |
Wound contact layers | Protect the wound bed and surrounding skin |
Adaptic Touch |
Hydrogel | Donate moisture to dry wounds |
Actiform Cool |
Gelling fibre | Absorbent |
Aquacel Extra |
Alginate | Absorbent |
ActivHeal |
Foam | Absorbent |
Allevyn |
Absorbent pads | Absorbent: level of absorbency depends on the type of pad | ConvaMax |
Film | Can visualise wound bed or periwound skin |
365 film dressings |
Odour absorbent | Charcoal absorbs odour | Actisorb |
Antimicrobial | Antimicrobial features are added to the dressing categories above in many cases | Dialkylcarbamoyl chlorid |
A primary dressing is one that is in contact with the wound bed. A secondary dressing covers the primary dressing and provides the absorbent cover and/or occlusive or protective layer. Many dressings can function as both primary and secondary dressings. Local dressing formularies will usually contain support with product selection and are a useful reference for clinicians (Gray et al, 2019).
Hydrocolloid
Hydrocolloids adhere to the skin and contain a layer that turns to a gel when combined with moisture from the wound. This allows provision of moisture to the wound bed and autolytic debridement. It requires relatively low levels of wound exudate to function and will likely not be suitable for more highly exuding wounds. Its occlusive nature means caution is required where infected wounds are concerned.
Hydrocolloids are usually waterproof so patients may shower with them on. The gel is generally made of gelatin, pectin or carboxymethylcellulose. It may be necessary to avoid dressings containing gelatin if the patient is vegan or vegetarian or for religious reasons.
Wound contact layers
Also known as low-adherence dressings, these are thin, mesh, non-adherent sheets that are designed to protect the wound bed and the surrounding skin while allowing cells in the wound to mobilise. They are available in silicone and non-silicone versions. The usually more expensive silicone-coated dressings are indicated for particularly vulnerable skin and for applying over skin tears.
These are primary dressings and usually require a secondary dressing unless already combined with a secondary dressing.
Hydrogel
Hydrogels are available in the form of sheets or in gel from a tube. Their composition is mostly water, so they donate moisture to dry wounds. This improves healing in drier wounds by providing a moist environment and can also assist with autolytic debridement. Those in sheet form can absorb low levels of exudate as well as donate moisture for debridement. Patients often report a cooling effect when hydrogels are applied. Some of these dressings will require a secondary dressing.
Gelling fibre
Gelling fibre dressings are made of synthetic fibres. They absorb exudate and turn into a gel when in contact with moisture. This means they are both absorbent and able to enhance autolytic debridement.
In areas of the wound where moisture levels are lower, the gel provides hydration. In wounds that are dry or have very low levels of moisture, gelling fibres may adhere, but can usually be soaked off if necessary. They are usually used as a primary dressing, but some gelling fibres have been combined with absorbent dressings to reduce the need for layering.
These dressings are available in flat sheets and in ribbons for filling cavity wounds.
Alginate
Alginate originates from algae or seaweed and is biodegradable. It comes in a flat sheet or ribbon and can absorb 15–20 times its own weight, making it beneficial for highly exuding or very wet wounds. It also has haemostatic properties. Caution should be taken on drier wounds in case the dressing adheres, although it can usually be soaked off.
This dressing type has been available for many years and is now used less frequently than some of the more modern products, such as gelling fibre dressings.
Foam
Foam dressings can be used as secondary dressings or as a combined primary and secondary dressing. They are available in adhesive and non-adhesive forms. Some have an added silicone wound contact layer, making them appropriate for patients with vulnerable skin or skin tears.
These dressings are absorbent and provide a moist environment. Some absorb greater amounts of fluid than others. Many patients report they feel protected with this dressing type because of the nature of the foam padding.
Some foam dressings can be cut to fit over the wound or around bony prominences and digits, and they are available in different shapes, such as sacral and heel.
Absorbent pads
Some thin absorbent pads are combined with adhesive to absorb very low levels of fluid, such as Cosmopor and Primapore. These are generally indicated for closed surgical incisions or superficial wounds (those that do not go beyond the depth of the epidermis).
Superabsorbent dressings contain polymers that can absorb large amounts of fluid making them appropriate for very wet wounds or wounds with exudate where you wish to leave the dressing on for a longer period of time. Their absorbency will be greater if the dressing is made with a larger number of polymers. It is important to consider the patient's mobility as the dressing can become heavy once filled with high levels of fluid from a wound.
These come in different sizes and shapes, some being large enough to encompass a lower limb. Some have a silicone wound contact layer attached.
Film
Semipermeable film dressings are available with or without an absorbent pad. The pad is usually suitable for wounds with low levels of fluid.
The film allows you to see the wound bed and/or periwound skin so assessment is possible without removing the dressing. These are a popular choice following surgery where the wound has been closed.
Film dressings are usually showerproof and allow vapour transfer to prevent the skin beneath from becoming overly moist or macerated.
They can be used as a secondary dressing or as a combined primary and secondary dressing. In some circumstances, they can also be used to help secure dressings instead of tape or a bandage.
Odour absorbent
Activated charcoal dressings absorb odour. Some can be used as a primary dressing, while others are applied as the top layer before the dressing is secured. While the reason for the odour should be addressed, these dressings prevent embarrassment caused by smells from the wound and can improve a patient's quality of life.
Antimicrobial
Antimicrobial features have been added to most of the dressing categories already outlined. Common types are iodine, honey, silver, dialkylcarbamoyl chloride (DACC) and polyhexamethylene biguanide (PHMB,) but this list is not exhaustive.
Iodine acts as an antiseptic and has been used to clean skin in theatres for many years. Both cadexomer iodine and povidone iodine release iodine when in contact with wound exudate (National Institute for Health and Care Excellence (NICE), 2023). Systemic absorption of iodine can occur with prolonged use (NICE, 2023). Examples include Iodoflex, Iodosorb and Inadine.
Honey has been used by generations of people throughout history. Medical-grade honey can be used to prevent or treat infection in wounds and has both antimicrobial and anti-inflammatory properties (NICE, 2023). It can also help reduce wound odour. When honey dressings are applied, some patients report a sensation as if something is drawing on the wound. This is thought to be an osmotic effect and will usually settle after a short period of time. Patients should be advised about the possibility of this feeling.
Dressings containing honey should be avoided in patients who are allergic to bee stings or who are sensitive to honey, and patients with diabetes should have their blood glucose monitored while honey dressings are used (NICE, 2023). Examples include Actilite, Algivon Plus, Medihoney and Revamil.
Silver ions work on bacteria in the presence of moisture from wound exudate (NICE, 2023). If the wound is too dry, some silver dressings may be ineffective. Flamazine and other products containing silver sulfadiazine (a type of medical silver) should not be used in patients with significant renal failure or hepatic impairment, during pregnancy or in neonates (NICE, 2023).
Silver dressings should be used only in wounds where there are clinical signs or symptoms of infection (NICE, 2023). Some examples are Flamazine, Acticoat, UrgoClean Ag, Aquacel Ag+ Extra, Mepilex Ag and Atrauman Ag.
DACC is a fatty acid derivative. Rather than killing bacteria, dressings coated with DACC bind to bacteria from the wound bed. This results in their removal when the dressing is taken off and a reduction in the bacterial load of the wound (Totty et al, 2017). Cutimed Sorbact is a dressing coated in DACC.
PHMB is a broad-spectrum antiseptic that penetrates bacterial cell membranes to kill bacteria (Rippon et al, 2023). Originally used in products such as swimming pool cleansing and contact lens solutions (Gray et al, 2010), it is now used in wound care in cleansing solutions and added to dressings (Rippon et al, 2023). Examples include ActivHeal PHMB Foam and Suprasorb X + PHMB.
An effective antimicrobial dressing should be used for a minimum of 2 weeks before reassessment to decide whether it has been effective (International Wound Infection Institute, 2022). If a decision is made to continue the antimicrobial dressing, reassessment should be carried out at least every 2 weeks and prolonged use should be avoided where possible.
Shared care
Shared care is the partnership formed between health professionals and patients or carers when they share a health goal. It relies on good communication and mutual responsibility for health (Ham et al, 2018). The author has observed from local practice as well as meetings and conferences that shared care has become more common in wound care since the COVID-19 pandemic. It inspires ownership and independence while maintaining some healthcare input, and supports the NHS Long Term Plan, which encourages supported self-management (NHS England, 2019).
In wound care, where patients and/or their carers can manage dressing changes, shared care can reduce attendance at appointments at healthcare facilities or home visits from a health professional. It may also allow patients to shower more frequently or manage dressing changes around other aspects of life.
When the patient and clinician agree to proceed with this model, the aim and plan of care must be agreed. The patient and/or carer will need advice and guidance on how to change the dressing, when it should be changed and what red flags to be mindful of. Review dates should be planned, and these will allow structured reassessment and review of the care plan and aim of care.
Other influencing factors
The competencies of the person changing the dressing will influence dressing choice. For example, if the clinician, patient, or carer changing the dressing does not have the comptency to apply a filler to a cavity wound, then selecting a dressing that does not have to be applied to the wound using a probe, such as a gel, may be preferable.
Patients, carers and clinicians who have experience of wound dressings will often favour certain dressing types or have greater knowledge of some over others. Considering patient personal preference and experience is necessary and will improve compliance and effectiveness of the dressing (Atkin et al, 2019). Patient preference in both dressing choice and outcome of care is important when planning any health intervention (Winn et al, 2015) and improving concordance will result in better outcomes for the patient (McKinnon 2013). As stated earlier, continuity of care is important for wound healing to progress without delay (Squitieri et al, 2020).
How often the dressing can or will be changed should influence choice. More highly absorbent dressings may be required if the dressing can be changed less often then would be preferred. Conversely, if a patient wishes to wash daily, then less absorbency may be needed, a cheaper dressing may be chosen or a waterproof option may be available. The reason a dressing is selected should be clearly stated in the patient's records and stockpiling should be avoided as a different dressing type or care plan might be indicated at reassessment.
Clinicians must be mindful of the local formulary, care pathways and local and national guidelines, which support dressing choice. Selecting an appropriate dressing decreases time to healing, provides cost-effective care and improves patient quality of life (Dabiri et al, 2016).
Conclusion
An extensive number of dressings are available in practice, which can be overwhelming. Establishing the aim of care through wound assessment will guide the clinician regarding the selection of an appropriate dressing. Continuity of care and regular reassessment will allow improvements to be seen and issues to be detected.
Dressings form a relatively small part of the overall wound care package and choice will be influenced by many factors including knowledge and experience, personal preference, wound type and condition of wound, and allergies or sensitivities. Clinicians should use the resources around them for support where appropriate and ensure pathways are followed where specific wound types are concerned.