Dressings for specific ulcer or wound characteristics

Introduction

This section provides advice for:

  • cavity wounds
  • infected wounds
  • malodorous wounds
  • wounds with hypergranulation tissue
  • painful wounds.

For advice about dressings for fragile skin, extensive wounds, dry wounds, moist wounds and wet wounds, see Overview of appropriate wound dressings based on wound characteristics.

Cavity wounds

Assess the dimensions and characteristics of a cavity wound to determine management.

Wounds with dead space (ie cavity wounds) usually require packing. Packing a cavity wound aims to encourage healing from the base. If the wound heals across the surface, pockets can form that can become an abscess.

Wound packing should loosely fill dead space. Considerations include:

  • whether the wound base is entirely visible
  • cavity depth
  • exudate quantity and consistency
  • location
  • aetiology.

Packing a wound can lead to adverse outcomes including putting pressure on tissues (which prevents healing and may cause tissue damage), impeding exudate drainage, and retention of packing material. Generally fistulae are not packed. Other wounds in which packing may be inappropriate include narrow sinus tracts (where packing prevents drainage of fluid), or wounds with undermining (where tissue surfaces are close together and packing may produce excessive pressure).

If packing is appropriate, use a dressing that does not lose its integrity when saturated, and can be removed in one piece without causing tissue trauma. Always leave a ‘tail’ of dressing outside the wound.

For cavity wounds with low exudate, consider an impregnated hydrogel dressing.

For cavity wounds with moderate to heavy exudate, consider a gelling fibre, hydrocapillary action dressing (see c_lwg2-c17-s4.html#lwg2-c17-s4__tlwg2-c17-tbl13), or a non-film backed foam covered with an absorbent pad dressing.

Specialised cavity dressings also exist.

At each dressing change, document anything removed from or put into the wound.

Infected wounds

All chronic wounds contain bacteria. This can represent normal flora, colonisation or infection (see Common causes of a red leg).

For clinically infected wounds, collect a wound swab using the Levine technique. For management of infected wounds, see Ulcer and wound infection.

Antimicrobial dressings are listed in c_lwg2-c17-s4.html#lwg2-c17-s4__tlwg2-c17-tbl13. Assess the efficacy of antimicrobial dressings after 2 weeks. If clinical signs of infection have not improved, or there are no signs of healing, consider an alternative antimicrobial dressing, the need for systemic antibiotic therapy, and other factors affecting ulcer and wound healing. Specialist advice or review may be required. Antimicrobial dressings are usually not continued for prolonged periods.

Malodorous wounds

Malodour can be caused by a number of factors, such as infection, exudate or necrotic tissue. Always address the cause of odour, if possible. For management of infection, see Ulcer and wound infection.

Local management strategies include topical metronidazole gel (use 0.75% gel applied to wound once or twice daily at dressing change) and a foam dressing (including charcoal-containing foam), gauze soaked in an antimicrobial solution, or an antimicrobial dressing. More frequent dressing changes and wound cleansing also reduce odour.

Mechanical or sharp debridement to remove necrotic tissue may be indicated.

If the cause of the odour is unable to be managed (eg a malignant wound), consider a dressing containing activated charcoal to adsorb odour. See c_lwg2-c17-s4.html#lwg2-c17-s4__tlwg2-c17-tbl13 for examples.

Wounds with hypergranulation tissue

Hypergranulation is abnormal tissue that interferes with epithelialisation. It bleeds easily, is soft and spongy, and exceeds the wound margins. Hypergranulation often occurs in an excessively moist wound, and can be associated with covert infection or chronic inflammation.

Treatment options include hypertonic saline gauze, or foam dressings with silver (eg Biatain Ag; see c_lwg2-c17-s4.html#lwg2-c17-s4__tlwg2-c17-tbl13). Silver nitrate can be effective for small areas of hypergranulation tissue; however, silver nitrate is caustic, so should only be used short term. Alternatively, consider removal of hypergranulation tissue by mechanical or sharp debridement.

Hypergranulation tissue can be a sign of a malignant wound, so wound and patient history, and clinical presentation are important. Undertake a biopsy (for histopathology) of hypergranulation tissue that does not respond to standard treatment or for wounds with an atypical appearance.

Painful wounds

Careful dressing selection can reduce pain and anxiety at dressing changes, and reduce the risk of tissue trauma. Dressings with silicone are often comfortable and can be removed with minimal trauma. This includes foams with a silicone contact surface or a silicone wound contact layer. Silicone wound contact layers can be left in situ for up to 14 days, with more frequent changes of the secondary dressing. For dry wounds, a sheet hydrogel can provide moisture and comfort to the wound.

If a dressing is adhered to the wound, soaking the dressing with a solution containing a surfactant or softening agent (eg Prontosan, Octenilin) for at least 10 minutes can assist with removal.

See also Ulcer and wound pain.