Moisture Management, Antiseptics, and Dressing Selection
Moisture Management and Antiseptics
Most antiseptics have a broad spectrum of action on cell walls, membranes, cytoplasmic organelles and DNA, making them bactericidal (McDonnell G, 1999). Antiseptic use should be reserved for nonhealable and maintenance wound healing classification. There is a general increasing momentum for antiseptic stewardship, similar to antibiotic stewardship, meaning that appropriateness of antiseptics should be justified and not overused without reason.
Moisture Management and Dressing Selection
At dressing change, the removed dressing should be examined along with the wound base. This includes assessing for:
- leaking dressing edges or striking through dressing backing to outer environment (problematic)
- sticking of dressing to wound bed (problematic) especially with visible bleeding points on removal
- saturation of the dressing (size or dressing type to be assessed): 75-100% heavy exudate, 25-75% moderate exudate and <25% small/scant exudate
- wound assessment including notation of the wound healing progression or a stalled wound
- patient input and feedback regarding past, current and future dressings
In a healable wound, there should be minimal or no adherence of the dressing to the wound bed, indicating that more moisture or moisture retentiveness is needed. On the other hand, if the wound is maintenance or nonhealable, one would expect the wound bed to be completely dry, following moisture reduction principles.
All dressings fall into the moisture continuum ranging from low to high exudate absorbing capabilities, as illustrated in this figure.
Figure 4. Dressing Selection and Moisture Continuum 2021©.
Dressing Selection & Moisture Continuum
Low Exudate —————————————————-High Exudate
| Hydrogels | Transparent Films | Hydrocolloids/ Acrylics | Alginates | Foams | Super-Absorbents (Diaper technology) |
|---|---|---|---|---|---|
| Donates moisture | Neither donates or absorbs moisture | Donates and absorbs a small to moderate amount of moisture | Absorbs moderate to large amount of moisture (Longer wear time) | Absorbs moderate to high amount of moisture (Foams vary and have a fluid exchange with wound surface) | Absorbs and “locks in” moderate to copious amount of moisture |
Reference – Adapted from: Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with Wound Bed Preparation 2015. Adv Skin Wound Care 2015;28(10):466-76
The size of the dressing selected can have a direct impact on moisture management. If the wound is moderately or heavily draining and a smaller than recommended dressing size is selected, this is going to result in excessive fluid on the wound bed and strike through will occur. In this case the wear time of the product will not be reached. Now there is also a risk of bacteria moving into the wound bed. On the other hand, if moisture needs to be reduced on the wound surface level, using a larger product than expected may help facilitate this goal. This is where patient and provider experience can positively influence the moisture management outcomes. If dressings overlap normal skin; consider protecting the wound margin (film forming liquid acrylate, zinc oxide, petrolatum).
Another dressing product selection factor that can influence moisture management is the readily accessible product formulary. Depending on location and resources, dressing choices to achieve moisture management goals may be very different. Some product formularies may be restrictive pertaining to limited product sizes available in an effort to reduce cost. This practice may adversely affect the wound healing trajectories. Also, in remote or under resourced locations, provider creativity may be required using less expensive products to achieve similar outcomes
Table 2. Summary of Modern Dressing Categories & Wound Healing Classifications
| SUMMARY OF MODERN DRESSING CATEGORIES & WOUND HEALING CLASSIFICATIONS | ||||
| Class | Description | Moisture Management Impact on healable Wound |
Moisture Management Impact on Nonhelable/Maintenance |
Indications / Contraindications |
|---|---|---|---|---|
| Adhesive Transparent Films/ Membranes |
Semipermeable adhesive sheets; impermeable to water molecules, micro-organisms | Appropriate: May create an occlusive barrier against bacteria |
Contraindicated: may cause excessive maceration, water surface fluid collection and wound deterioration, infection and sepsis |
Should not be used on draining or infected wounds Caution on fragile skin Should stay in place for several days |
| Nonadherent | Sheets of low adherence; prevents sticking to tissue; non-medicated tulles | Appropriate: Often used as a wound contact layer where moisture is wicked through nonadherent to secondary dressing |
May be appropriate: Allows any moisture to wick through to secondary level (may need slits in the contact layer) |
Prevents sticking to the tissue; May decrease pain at dressing change; May be left in place for several days |
| Hydrogels (Autolytic debridement) |
Polymers with high water content; available in gels, solid sheets or impregnated gauze | Appropriate: When used to promote autolytic debridement or if wound too dry |
Contraindicated: May cause excessive maceration, bacteria proliferation, wound deterioration, infection and sepsis |
Should not use on draining wounds; Avoid using solid sheets on infected wounds |
| Hydrocolloids (Autolytic debridement) |
May contain gelatin, sodium carboxymethylcellulose, polysaccharides and/or pectin; adhesive sheet dressings are occlusive with polyurethane film outer layer | Appropriate: When used to promote moisture balance for optimal healing May be coupled with alginate as the contact layer underneath Promotes autolytic debridement |
Contraindicated: May cause excessive maceration, bacteria proliferation, wound deterioration, infection and sepsis |
Should not be used on draining or infected wounds; Caution on fragile skin Should stay in place for several days; Odour may accompany dressing change and should not be confused with infection |
| Acrylics (Autolytic debridement) |
Two layers of adhesive transparent film that contain clear acrylic pad within | Appropriate: When used to promote moist wound environment for healing Promotes autolytic debridement |
Contraindicated: May cause excessive maceration, bacteria proliferation, wound deterioration, infection and sepsis |
Use on low-moderate exudate levels; Dressing stays in place for extended time; Wound may be visualized through clear dressing |
| Calcium Alginates (Autolytic debridement) |
Calcium sodium Alginate (seaweed derivative) in sheets or fibrous ropes | Appropriate: Helps manage optimal moisture levels for healing by converting to gel when moist Promotes autolytic debridement Bioresorbable and silver combination options |
May be appropriate: If varying levels of moisture within one wound, can help absorb to manage this challenge |
Inappropriate to use on dry wounds; Low tensile strength – not to be used to pack into narrow tunnels/sinuses; Some are bioresorbable |
| Composite dressings | Combination dressing layers to increase absorbency | Appropriate: Helps manage optimal moisture levels for healing by converting to gel when moist Promotes autolytic debridement Bioresorbable and silver combination options |
May be appropriate: If varying levels of moisture within one wound can help absorb to manage this challenge |
Inappropriate to use on dry wounds; Low tensile strength – not to be used to pack into narrow tunnels/sinuses; Some are bioresorbable |
| Super- Absorbents |
Highly absorbent dressing with fluid repellent backing | Appropriate: Helps manage, absorb and lock fluids Prevents leakage, strike-through Breathable, not occlusive |
May be appropriate: If varying levels of moisture within one wound can help absorb to manage this challenge |
Use on moderate to copious fluid levels Can stay in place for several days Versatile in form and function |
| Foams | Adhesive or non-adhesive polyurethane foam; some with occlusive back, sheet or cavity packing, some with fluid lock; Function as “fluid exchange” |
Appropriate: For low to moderate exudating wounds where dressing change is several days; Periwound protection needed and frequent monitoring initially to observe for maceration |
Contraindicated: May act as an occlusive layer, thereby increasing risk of excessive maceration and moisture, bacteria proliferation, wound deterioration, infection and sepsis |
Occlusive foams contraindicated for heavy exudating or infected wounds |
| Charcoal | Odour-absorbing charcoal within the product; This product does not reduce bacteria unless is a combination with an antimicrobial; Ideally the cause of odour should be corrected if possible |
Appropriate: If moisture levels low to moderate; Does not interfere with wound healing | May be appropriate; For dry, stable wounds with odour; For moderate to heavy exudating, inappropriate as charcoal may be inactivated by moisture Best approach is to target odour by managing bacteria or cause of odour |
Ensure edges are sealed or picture framed closed to enhance odour-absorbing feature |
| Hypertonic | Sheet, ribbon or gel impregnated with concentrated sodium; Requires frequent changing, easy to use | May be Appropriate: If excessive purulent exudate promote movement from in wound outwards |
Not appropriate: Not appropriate on dry wounds; May increase pain |
Stimulates wound cleansing by moving purulent exudate outward, thereby reducing bacterial burden |
Adapted from Canadian Association of Wound Care and Revised from Wound Bed Preparation 2012.
