Treating and managing difficult wounds require the latest wound care techniques and strategies.

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r. H.M. is 49 years old and recently underwent surgery to create a colostomy secondary to Crohn’s disease.

Figure 1

He seems to be progressing well until the home care nurse arrives 4 weeks post-operation to evaluate his ability to perform ostomy care. As the patient removes his shirt, which is visibly blood-stained, he states, “My belly incision isn’t doing too well.” The home care nurse notes that Mr. H.M.’s abdominal incision has dehisced. The wound bed is clean and beefy red, but dressing this wound (see Figure 1) is going to be a real challenge, especially given the fact that Mr. H.M.’s colostomy is in close proximity to the wound. She calls Mr. H.M.’s physician and begins to plan the dressing regime after receiving the doctor’s orders to, “keep it clean and moist…you can use whatever you think is best.”
       How many times have you seen a similar patient and had a related conversation with the physician? You have no clue where to begin, how to manage the wound’s needs, and how to secure the dressing. Difficult-to-dress wounds are nothing new. In fact, since the body is not linear, wounds often drain exudate in large amounts, and adhesives can irritate sensitive skin, thus many wounds are considered “difficult to dress.” This article will attack the issue of difficult-to-dress wounds offering support and solutions to your most perplexing dressing dilemmas.

Unique Solutions to Pesky Locations

       The contours and constant movement of the human body make attaching any wound dressing challenging.

Table 1

Many wounds occur in predictable areas, such as lower leg venous or arterial wounds, sacral/coccygeal pressure ulcers, or plantar surface diabetic neuropathic wounds. Some wounds are particularly difficult to dress, given the location. They include:
• Facial and neck wounds
• Finger and toe wounds
• Scalp wounds
• Sacral wounds
• Scrotal and vulva wounds
• Fistulas
• Oral mucosa wounds
• Tunneling and undermining wounds
• Heel wounds.
       Facial wounds can be taxing. L. Mike Nayak, MD, Director, Facial Plastic and Cosmetic Surgery at St. Louis University (St. Louis, Mo), says that the form of the face and neck can represent a dressing nightmare. Dr. Nayak states, “The face presents a myriad of convexity and concavity—a real dressing trial. Dressing the face, head, and neck can be problematic, since 4 sense organs live and function in this complex region. So, talking, eating, vision, and other activities of daily living (ADLs) can be affected. The face also has many sebaceous glands, which make attaching dressings tricky due to the oily texture that is produced.” Dr. Nayak goes on to explain the importance of moist wound healing, nonadherent dressings to increase healing outcomes and diminish scarring, and antimicrobial control to prevent infection. He recommends referring to a plastic surgeon early, since any wound on the face that heals by secondary intension and contraction can produce dysfunction and deformity (eg, an eyelid that will not completely close, a nostril that is deformed, making breathing difficult, or a mouth that cannot close and open properly). He also recommends that the plastic surgeon and wound specialist work together, stating that the wound specialist, “knows a lot more about dressing the wounds after I have done my part.” Dr. Nayak uses a lot of stretch-net type dressings in his practice. “It is basically a tubular stretchy netting that is placed over the entire face and cut in the area that needs to be open,” he says. He also uses mastoid or Barton’s dressings if the ear is involved.
       Burns, dermatologic manifestations, and acute and chronic wounds on the face and neck can be managed with a variety of tools and techniques. Since the face is important to our body image, prevention of scarring can be crucial. Depending on the exudate level (from dry to heavy), dressing choices like thin-sheet hydrogels (wet wounds or skin conditions), amorphous hydrogels (dry wounds), silicone dressings (pain relieving), and thin foams (moderately moist to wet) work well.
       Contact layers like silicone-coated mesh, such as Mepitel^® Soft Silicone Wound Contact Layer (Mölnlycke Health Care, Newtown, Pa), allow dressing changes and cleansing to take place while the wound stays protected by the mesh. SPAND-GEL^™ dressing sheets (Medi-Tech International, Inc., Miami, Fla) offer full-face mask, half-face mask, breast wrap, and neck wrap primary wound dressings that provide a cooling, moist healing environment and conform to these awkward areas. Holding these dressings in place is the tricky part (this article will cover those issues in the “securement” section).
       Finger and toe wounds present small areas that are highly contoured and difficult to handle, dressing-wise. Consider extremely flexible dressings, such as rope-shaped alginates (wet, highly absorbent), cellulose (both absorbent and moisturizing, depending on the wound’s needs), amorphous hydrogels (dry wounds), hydrogel impregnated gauze (dry wounds), or flexible composite dressings (both a primary and secondary “band-aid” type application). Cutting-edge dressings like ionic silver powder alginates offer both absorption as well as broad-spectrum antimicrobial control. Dressings like Arglaes Powder^® (Medline Industries, Inc., Mundelein, Ill) allow the clinician to “salt and pepper” the wounds, even in the tiniest, most contoured areas. Another option specifically for these regions is Toe-Aid^™ toe and nail dressings (Southwest Technologies, Inc., North Kansas City, Mo) consisting of soft glycerin gel pads with T-shape securement tape.
       Scalp wounds are often troublesome due to the shape of the head and the fact that hair does not present a friendly area to secure a dressing. Shaving a small area surrounding the wound is not the most cosmetically effective measure but may be the only practical solution. If the patient’s hair is long enough, a small pony tail can be gathered in a rubber band to help secure the dressings without tape. Other options include use of a stocking-type cap or a mesh “helmet” to fasten the dressings without tape. Remember that cleansing scalp wounds is very important. Reclining the patient and utilizing a small emesis basin to collect the wound cleanser is 1 option to keep the patient as dry and comfortable as possible.
       Scrotal or vulva wounds are perhaps the most confounding dressing quandaries. Due to the frequently moist and greatly curved and dynamic area of intertriginous skin, it is difficult to get dressings to stick and to stay in place. If the tissue loss is partial thickness, a high-quality second- or third-generation barrier cream or ointment may be the answer. Look for products with dimethicone and zinc oxide or 1 of the new advanced products with combinations of silicones, antioxidants, and nutritional properties from amino acids and their vitamin cofactors.
       If you can thoroughly dry the skin and obtain a sufficient seal, some of the moisture-proof island or composite dressings can be helpful. If unable to dry the skin adequately prior to dressing application, a crusting technique, using skin preparation and stoma powder, may be effective. Another option is to apply 1 of the new, thin, hydrocolloid dressings that offer superior wet-tack (ie, the ability to stick to moist skin). As you apply the dressing, carefully smooth out any wrinkles and avoid stretching the hydrocolloid. If the dressing requires “heat” sealing, apply the palm of your gloved hand to gently warm the dressing to the skin’s surface for better adhesion. Be careful, however, with hydrocolloids on sensitive, fragile skin. They can be too aggressive for these areas, causing more harm, such as skin tears and epidermal stripping, when removed or hardening and wrinkling in the skin folds.
       Fistulas (connection between 2 organs or between an organ and the skin) present another dressing predicament. Fistulas can be managed in a variety of ways. One of the more practical is pouching with a specially designed, large ostomy appliance or collection device. Other options include cannulization with a drainage device and application of negative or suction wound therapy. The patient should also be referred for a surgical consultation, since abnormal communication between organs or between an organ and skin can have detrimental effects long-term, such as fluid and electrolyte imbalances.

Tunneling and Undermining Wounds

       Tunneling (extensions of the wound bed into adjacent tissue) and undermining (areas of the wound bed that extend under the skin, creating a pocket around the ulcer’s edge) can produce dressing troubles. They are typically seen in chronic wounds, especially pressure ulcers. These areas must be filled, allowing the wound to granulate effectively. Again, the question of whether the wound is wet or dry is important in product selection based on fluid handling. If the wound and its tunnels and/or undermining edge is dry, application of an amorphous hydrogel or a hydrogel-impregnated gauze is a good option. The term amorphous literally means “without form,” so these dressings conform to any shape given to them. Novel applications of amorphous hydrogels, such as Carrasyn^® Spray Gel with acemannan hydrogel (Carrington Laboratories, Inc., Irving, Tex) and DermaSyn^™ Spray (DermaRite Industries, LLC, Paterson, NJ), allow the gel to actually be sprayed into difficult to reach spots. If the wound has suspected bioburden, consider a silver hydrogel to eradicate bacteria and fungus. An added benefit with ionic silver is that it is an anti-inflammatory and can also help alleviate pain. Another option for the dry wound with tunneling or undermining is the use of wet wound therapy with a polyacrylate gel pad activated with Ringer’s solution.
       The wet wound with tunneling and/or undermining can be managed with a variety of products, such as alginates, alginates with carboxymethylcellulose (CMC), hydrofibers, powder alginates, cavity-type hydrogel sheets, alginates with collagen, collagen pads or particles, cavity-type foams, soft silicones, and other absorptive wound fillers. Keep in mind that what goes in must come out, so choose dressings that are easy to remove or flush from these troublesome areas.

Heel Ulcers

       Prevalence rates of pressure ulcers in nursing homes range from 2.3% to 28%.¹ Many of these ulcers affect the heels. Heels, due to their shape, bony prominence, and frequent pressure in the supine position, often fall victim to pressure. Again, look at the wound’s needs. Is it wet or dry? Is it flat, or does it have depth? Then consider the many specialty heel or “star burst” shaped dressings now available. Dressings shaped specifically for the heel are widely available. Offloading devices can perform double duty by also acting as dressing securement devices.

Oral Mucosa Wounds

       Wounds of the mouth and xerostomia (dry mouth) present particular difficulty because of the structure and constant moist environment.
       Common causes of oral dysfunction and stomatitis include cancer therapies like radiation and chemotherapy, bone marrow transplant, leukemia, surgery, some medical conditions (eg, renal failure and consequent dialysis), intubation, diabetes, nutritional compromise, over 400 medications, and the aging process. Tomes and Gallucci² showed that the effects of hydrogen peroxide (H₂O₂) rinses on the normal oral mucosa are detrimental in the following ways:
• The antibacterial properties may promote fungal overgrowth in the oral cavity
• H₂O₂ inhibits mucosal tissue granulation in persons with oral lesions
• Due to its rapid decomposition in vivo (within the body), the germicidal action of H₂O₂ is thought to be short-lived, limiting its use as a topical antiseptic
• Healthy human volunteers experienced hypertrophy of the papillae of the tongue and mouth discomfort when rinsing 2–3 times daily with varying dilutions of H₂O₂.
       The study clearly suggested that nurses reconsider the use of H₂O₂ as an agent for oral care.
       Until recently, peroxide rinses and harsh chemical rinses were the only oral care products available. The key in preventing and treating mouth ulcers is to maintain the balance of moisture, enzymes, and proteins. One product line, Bioténe^® (Laclede Co., Rancho Dominguez, Calif), contains specific ingredients to do just that:
• Lactoferrin is an iron-binding protein secreted by salivary glands and gingival fluids. It inhibits pathogenic bacteria by depriving them of iron, which bacteria require for growth.
• Lysozyme is an enzyme that splits the cell wall of pathogenic bacteria, killing them without disturbing healthy oral flora, which helps stabilize the mouth’s environment and is known to have a positive effect on oral yeast.
• Glucose oxidase and lactoperoxidase are enzymes that create a constant flow of OSCN ions (hypothiocyanite), a strong, safe antibacterial agent.
       The Bioténe products are available in a mouthwash with calcium, a mouth moisturizer, and a toothpaste.

Large Surface Wounds

       Wounds that make up a large portion of the body can not only cause pain and discomfort for the patient but are a labor- and cost-intensive barrier to healing. For instance, consider burns, multiple pressure ulcers, and large or multiple surgical incisions or wounds. Look for dressings that meet the needs of the wounds and can remain in situ (ie, in place) for longer periods of time. A patient with multiple draining pressure ulcers on a large percentage of his or her body (see Figure 2) may do well with sizeable absorbent foams dressings to address his or her draining wounds, for instance.

Figure 2

       Comfort is paramount when a great body surface area is dominated by dressings. Preserve the patient’s overall ability to move and conduct normal activities of daily living as much as possible. As the wounds progress, heal, and get smaller, be sure to re-evaluate the dressing regimen, evolving to keep pace with the wound’s changing needs.

Creative Securement

       Think outside of the obvious, tape “box” when securing a dressing. Epidermal stripping and skin tears often occur as a result of tape and/or tape removal. Tape-free alternatives include:
• Mesh garments and underwear
• Stockinettes
• Gentle paper tapes
• Gentle tack technology
• Montgomery straps
• Transparent secondary dressings
• Stretchy woven gauze wraps
• Cohesive bandage: tape that sticks to itself, not to the skin
• Thin foam that can be used as a wrap
• Tubular light-compression dressings offered in sizes from infant arms to large thighs.

Beyond Skin Care: Ointments, Protectants, and Barriers

       With partial-thickness tissue loss and stage 1 and stage 2 pressure ulcers, “dressings” can take the form of barriers and protectants like second- and third-generation products containing zinc oxide, dimethicone, and some of the newer, high-tech silicone combinations. When the adhesive of a dressing could cause more harm and securement is not possible, these ointments and creams can be an easy alternative. Make sure that the products you choose can be used on both closed and open skin and that if the tissue loss presents a wet environment, the barrier chosen will “stick” to the wet area.

Shape, Thickness, and Conformability

       When choosing a dressing regimen for difficult-to-dress wounds, bear in mind shape, thickness, and conformability. Where is the dressing placed? Will it potentially bunch up or create pressure, shear, friction, or discomfort? Does it conform to the shape of the body part? Is it flexible? Is there a form of the dressing that is specially shaped for the particular body part that you need? For example, Exu-Dry^® (Smith & Nephew, Inc., Largo, Fla) provides a multitude of shapes and sizes, including arm, arm/shoulder, scalp/face, elbow/knee, boot/foot, hand, neck buttocks, leg, and burn jacket/vest as well as pediatric versions of some of these shapes. Ask your manufacturers and distributors for help and solutions. A new option that performs double duty (ie, moisturizes dry wounds while handling exudate) is Medline’s XCell*^™, a bioengineered cellulose that is thin, cool, extremely flexible, and conformable and comes in several sizes, including a rope to twist into a variety of shapes.
       One of the most conformable and flexible dressings is the transparent dressing. The only issue is that transparent dressings do not absorb exudate. A new dressing that offers some absorption of light drainage is 3M^™ Tegaderm^™ Absorbent Clear Acrylic (3M Health Care, St. Paul, Minn). A few of the latest, thin hydrocolloids offer answers to the flexibility and conformability issues while addressing light to moderate exudate. An example is Comfeel^® Plus Clear (Coloplast Corp., Marietta, Ga).

Absorbent Capacity and Wear Times

       In addition to challenging wound locations, the amount of drainage can prove problematic as well. Frequent dressing changes can cause pain, trauma, decreased healing outcomes, and increased cost due to product use and caregiver time. New high-tech absorbent products provide longer wear times and the answer to copious exudate issues. Consider alginates, alginate and CMC combinations, foams, hydrofibers, polyacrylates, and highly absorptive polymer dressings to address wounds with high exudate levels. Remember to attend to the wound’s edges. If a wound is wet and has abundant drainage, chances are the wound margin could be in jeopardy. A barrier, whether the polymer type or a cream or ointment variety with zinc oxide or dimethicone, should be applied with each dressing change.

Best Dressed

       Do not be afraid to try new techniques, dressings, and ideas on your difficult-to-dress wounds. If you need assistance, be sure to confer with a wound care expert, such as an enterostomal therapy (ET) nurse, wound, ostomy, and continence nurse (WOCN), or certified wound specialist (CWS). These practitioners are experts in dressing choice and application. Other great resources are your wound care product specialists and industry clinicians working for the advanced wound care companies. Do not be afraid to call them and get them involved. Also, the more difficult-to-dress wounds that you tackle, the better and more confident you will become.