Wound Cleansing and Moisture Management
Wound cleansing and skin care are an integral part of managing patients with VLU’s. An expert Advisory Board came to a consensus that the term ‘wound cleansing’ should be replaced with ‘wound hygiene’ as the term to resonates with health professionals to support optimal care (Murphy et al., 2019). The purpose of wound hygiene is to remove surface contaminants, bacteria, dead tissue and excess wound fluid from the wound bed and surrounding skin (McLain et al., 2021).
Wound and skin hygiene should be performed at every dressing change. This is particularly important in venous leg ulcer patients as dressings and compression therapy often have longer wear time (sometimes up to 1 week). Dressing changes present the only opportunity for a thorough skin and wound assessment, evaluation of current compression therapy, wound cleansing, and skin moisturizing. Moisturizing the skin is recommended to maintain healthy skin integrity. For patients who are capable of showering, this is recommended. The removal of dressings to shower can enhance both physical and psychological well-being. Each of these interactions provide an opportune time for patient education and long-term planning.
Various products can be used for cleansing including, saline, potable water, and proprietary products with surfactants. Surfactants are widely used to help remove foreign matter, biological debris, and biofilm. The surfactant lowers the surface or interface tension between a liquid and a solid (such as debris and biofilm), helping to disperse surface components. The dispersed solids can then be removed more easily with a cleansing pad or cloth (Murphy et al., 2019). It is important to avoid products with a high pH (destroys the antibacterial skin’s acid mantle). Perfume or masking scents in products can be irritating to the skin and cause contact allergic dermatitis that can lead to further skin breakdown.
Venous leg ulcers represent a unique challenge for both patients and clinicians. Their common location on the gaiter area is problematic with gravity moving fluid and exudate downwards. In addition, they are usually large in size and may present with copious exudate and resulting maceration. This exudate can be the result of inflammation, infection or edema making moisture management an important consideration.
A balanced moist wound environment facilitates cellular growth and collagen proliferation within a healthy noncellular matrix. Okan et al., 2007 assert “a balanced moist surface facilitates the action of growth factors, cytokines, and chemokines, thus promoting cellular growth and the establishment of a provisional wound matrix.” Moist wound healing is recommended for healable venous leg ulcer wounds where the cause can be corrected. Re-epithelialization is ideal on a flat surface. Excess moisture in the wound bed can impair the healing process and damage the surrounding skin, leading to periwound maceration. If the excess moisture is left unchecked, healing can be impeded. There may also be subsequent breakdown and further deterioration of the wound bed.
In contrast, inadequate moisture in the wound environment, related primarily to exposure of the wound environment to air, promotes wound desiccation, necrosis, eschar formation resulting in poorer wound healing rates. The formation of eschar, therefore, slows the ability of regenerative cells (keratinocytes) to migrate from the wound periphery into the wound center (Okan et al., 2007). For nonhealable/maintenance wounds, the goals of care are focused on decreasing moisture and bacteria levels while prioritizing patient comfort. Optimal migration and re-epithelialization are hindered by eschar formation.