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
increasing absorbency arrow.

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.