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Joel W. Beam, EdD, LAT, ATC, contributed to conception and design; acquisition and analysis and interpretation of the data; and drafting, critical revision, and final approval of the article.
Reference/Citation: Wiechula R. The use of moist wound-healing dressings in the management of split-thickness skin graft donor sites: a systematic review. Int J Nurs Pract. 2003; 9:S9–S17.
Clinical Question: Do rates of healing, infection, and pain differ depending on whether nonmoist or moist dressings are used to manage superficial to partial-thickness wounds?
Data Sources: Investigations were identified by CINAHL, MEDLINE, Pre-MEDLINE, Cochrane Library, Current Contents, Health STAR, EMBASE, Expanded Academic Index, and Dissertation Abstracts International searches. The search terms included skin, graft, and donor. Additional searches were performed with reference lists and bibliographies of retrieved studies.
Study Selection: To be included in the review, each study had to fulfill the following criteria: it had to be an intraindividual or prospective randomized controlled trial of human subjects; it had to include patients with postharvest split-thickness skin graft donor sites; it had to evaluate the effectiveness of primary and secondary wound dressings; and it had to have outcome measures that included healing (objective), infection (subjective), and pain (objective).
Data Extraction: Data extraction and study quality assessment procedures were developed specifically for this review based on Cochrane Collaboration, Centre for Reviews and Dissemination, and Joanna Briggs Institute protocols and were performed independently by the author. Details of the procedures were not fully explained. The principal outcome measures were healing (proportion of sites healed within the study period or time to complete healing), rate of infection, and pain scores. The studies were grouped according to broad dressing type (nonmoist and moist) and specific types of moist dressings (hydrocolloids and polyurethane semipermeable transparent films). When comparable, study results were pooled and analyzed with a fixed-effects model. Data within broader dressing categories (nonmoist and moist) were analyzed with a random-effects model. χ 2 analysis was used to determine heterogeneity among the studies. RevMan software (version 4.04; Cochrane Centre, Oxford, UK) was used for statistical analysis.
Main Results: The searches identified 111 studies and 1 integrative review, of which 58 studies met the inclusion and exclusion criteria. Inconsistency and variation in outcome measures and incomplete reporting of results prevented analysis of many studies. Wound healing was measured by days to complete healing (when dressings could be removed without trauma and pain) and wounds healed by day X (removal of dressings at regular intervals). Wound infection was subjectively measured based on clinical signs of infection (edema, heat, pain, or smell). Visual analog scales were used to measure pain levels.
Among the broad categories of nonmoist (sterile gauze, fine mesh gauze, Xerofoam [Tyco Healthcare Group LP, Mansfield, MA]) and moist (DuoDERM hydrocolloid [ConvaTec, Princeton, NJ], Tegaderm transparent film [3M Health Care, St Paul, MN], Opsite transparent film [Smith & Nephew, London, UK]) dressings, the outcomes of healing, infection, and pain were analyzed. In 6 studies, the findings significantly favored moist dressings, compared with nonmoist dressings, for days to complete healing (weighted mean difference [WMD] = −3.97, 95% confidence interval [CI] = −5.91, −2.02). In 9 studies, wounds healed by day X (day 7, 8, 9, 10, or 12) were analyzed. The results were varied and inconclusive because of a small number of trials and subjects. Among 10 studies, no significant difference was noted in infection rates between nonmoist and moist dressings (odds ratio [OR] = 0.41, 95% CI = 0.14, 1.18). Three studies using visual analog scales for the outcome of pain were converted into a uniform scale of 1 to 10 (10 representing most painful). The findings significantly favored moist dressings over nonmoist dressings (WMD = −1.75, 95% CI = −2.94, −0.56).
Among nonmoist and specific types of moist dressings, a subset analysis was performed to examine the outcomes of healing, infection, and pain. For days to complete healing, 2 investigations significantly favored hydrocolloid dressings over nonmoist dressings (WMD = −2.19, 95% CI = −2.89, −1.49). Additionally, in 2 studies, hydrocolloid dressings were significantly favored over other moist dressings (semiocclusive hydrocolloid and transparent film) for days to complete healing (WMD = −1.45, 95% CI = −2.17, −0.74). In 3 studies, the data significantly favored polyurethane semipermeable transparent film dressings over nonmoist dressings for days to complete healing (WMD = −2.82, 95% CI = −3.58, −2.07). For infection rates, 4 studies significantly favored hydrocolloid dressings over nonmoist dressings (OR = 0.21, 95% CI = 0.07, 0.65). In 4 other studies, polyurethane semipermeable transparent film dressings were significantly favored over nonmoist dressings with regard to infection rates (OR = 0.28, 95% CI = 0.09, 0.91). For the outcome of pain, varied outcome measures and insufficient data prevented analysis among specific types of moist dressings.
Conclusions: Moist dressings decreased the days to complete healing and pain scores when compared with nonmoist dressings. Among the broad categories of nonmoist and moist dressings, no differences were found in infection rates. The data on specific types of moist dressings revealed that days to complete healing were decreased with hydrocolloid dressings compared with nonmoist and other moist dressings. Hydrocolloid dressings also decreased infection rates compared with nonmoist dressings. Polyurethane semipermeable transparent film dressings also decreased days to complete healing and infection rates compared with nonmoist dressings. Overall, the data indicated that hydrocolloid dressings are more effective than nonmoist dressings in terms of rates of healing, infection, and pain in the management of superficial to partial-thickness wounds. The variations in outcome measures among the included studies should be considered in interpreting these findings.
During participation in athletic and work activities, healthy individuals often sustain acute skin trauma. Among the various wounds suffered, superficial to partial-thickness abrasions (eg, turf burn) are perhaps the most common. Debate surrounds the appropriate dressing techniques for the management of abrasions. Compounded by the lack of evidence-based standards in the literature to guide treatment practices and the myriad of available wound dressings, athletic trainers many times rely on ritualistic techniques (ie, use of sterile gauze, adhesive strips, or patches as dressings) or proceed with unanswered questions. Although wound management techniques have changed drastically over the last 30 years, the development of evidence-based standards for athletic trainers is lacking. The evidence-based literature examining dressings has traditionally focused on the chronic wound environment, an environment with underlying pathologic conditions and a subsequent delay in the normal healing process. Furthermore, few investigators have examined the acute wound environment and dressing application guidelines for the healthy population.
Wiechula examined the postharvest management of the split-thickness skin graft (STSG). The STSG harvesting process produces a superficial to partial-thickness wound at the donor site. This surgical wound is the equivalent of a superficial to partial-thickness abrasion sustained by healthy individuals as the result of acute mechanisms. 1 These wounds involve removal of the epidermis or superficial dermis (or both). Superficial to partial-thickness experimental wound models have been used to examine the effects of dressings on rates of healing. 1 Although the mechanism of injury is different, the healing sequence of the STSG and abrasion occurs through the process of re-epithelialization, as epithelial cells migrate across the wound surface from the edges to cover the wound. 2 Epithelial cover typically is completed within 7 to 14 days. 3 Based on the similar wound depth and healing sequence of these wounds, this review can be used to develop evidence-based standards for the management of superficial to partial-thickness abrasions.
The findings in this review indicated the use of moist dressings for the management of superficial to partial-thickness wounds to increase healing rates and lower pain scores without increasing infection rates. Since the 1960s, the use of occlusion and a moist wound environment have increased rates of healing, decreased rates of infection and pain, and prevented reinjury of the wound. However, many athletic trainers have been reluctant to adopt moist or occlusive dressings. In a survey of 280 athletic trainers in various employment settings, Goldenberg 4 found that only 20% of the respondents used occlusive dressings. Also in this sample, 15 of the 63 athletic training faculty members responding did not use occlusive dressings. Beam 5 examined wound dressing techniques being taught by athletic training faculty in didactic and clinical settings in undergraduate athletic training education programs. Among the 41 faculty members who responded to the survey, 52% (n = 21) instructed their students to cover abrasions with nonocclusive dressings, while 47% (n = 19) taught their students to use occlusive dressings on abrasions. These findings and the absence of evidence-based management standards for acute wounds support the need for additional work to develop guidelines for athletic trainers.
This review by Wiechula has several limitations. The definition of healing used in the included studies (complete epithelial cover of the donor site) and the 2 outcome measures of healing can be problematic. The author cautioned that removal of some adherent dressings from a healed site may actually damage the fragile epithelium. As a result, the outcome measure of days to complete healing judged the donor site to be healed when dressings could be removed without trauma and pain. The frequency of dressing removal was not reported in the review. This measure is more clinically relevant, but Wiechula suggested that the skill and experience of the health care professional in removing the dressing could introduce operator error and bias. The outcome measure of wounds healed by day X used removal of dressings at random intervals (day 7, 8, 9, 10, or 12) to judge healing. Wiechula stated that although this method provides a more objective measure of healing, removal of the dressings can interrupt the healing process and is clinically less relevant. Additionally, the lack of consistent criteria to measure the outcomes of infection and pain and incomplete results prevented comparisons among all studies in the review.
Variations in the performance of nonmoist and moist dressings with regard to impermeability to bacteria, removal of excess exudate, and insulation and protection of the wound may explain the lack of homogeneity, which makes it more difficult to compare results. Although moist dressings were favored over nonmoist dressings, the strength of the evidence is reduced based on these variations. Also, determination of the one best dressing for the management of superficial to partial-thickness wounds was not possible from the studies in the review.
In summary, the findings of this review support the use of moist dressings to cover superficial to partial-thickness wounds. When compared with nonmoist dressings, moist dressings increased the rate of healing, decreased the rate of pain, and had no effect on the rate of infection. Athletic trainers should base decisions on the use of moist dressings on the type of wound, the purpose of the dressing, the availability and cost of other dressings, and the needs and activity level of the healthy individual. Additional research is needed, with intraindividual and randomized controlled trials on standardized superficial to partial-thickness wounds, to compare various types of moist dressings and to identify their effects on healing, pain, and infection. Others should examine the effectiveness, practicality, and cost-effectiveness of moist dressings in cases involving acute skin trauma, such as abrasions, avulsions, blisters, incisions, lacerations, and punctures among healthy individuals in various athletic and work settings.