Common Nonsense: Rediscovering Moist Wound Healing

  Recently, a brave colleague earned her PhD surveying usual wound care practices in Ghana. Her literature review, published in Ostomy Wound Management,¹ described affordable moist wound healing options that speed wound healing while reducing infection, pain, and scarring.^2,3 Hippocrates and the ancient Egyptians knew the wisdom of such practice from careful observations of nature, but myths obliterated this knowledge for millennia. Nature, however, prevailed during the long dark ages of wound care, and we now we are rediscovering moist wound care is evidence-based.⁴ But the going isn’t easy. New technologies tempt uncritical minds with unsupported promises of outcomes, and the literature is replete with vague definitions of “moist wound healing” that obscure its basic truth.⁵   For example, a meticulous study by respected Cochrane reviewers⁶ failed to separate “occlusive” moisture-retentive dressings from less occlusive “modern” dressings in an initial study of open surgical wounds in hospitalized patients. When the same authors explored separate effects of truly moisture-retentive “occlusive” hydrocolloid or film dressings compared to alginates, hydrofibers, gauze or silicone dressings, they reported 7-day faster healing with hydrocolloid dressings (P P = 0.038), and 18% infections in donor sites dressed with gauze (retaining the least moisture) compared to 7.6% infections for all other dressings combined (P = 0.022). Clear evidence requires clear definitions.   Recently, a fresh glimpse of wound care’s dark ages ruled by myth sent me poring through the literature in search of evidence supporting a new term: moisture stasis. I found no clear operational definition and no prospective clinical trial verifying the alleged “harmful” effects — ie, that such practice supposedly fosters biofilm growth and potential infection on full-thickness wounds. Instead, the literature search reflected Nature’s truth: prospective, randomized, controlled trials supported faster healing with less pain and fewer infections of acute^3,7,8 or chronic wounds^9-13 when moisture stasis was maintained. In fact, resident organisms in occluded wounds decline as the wounds heal.^14,15   When you hear a new term, squelch the babble. Exercise your right to critically question the relevant concepts and require a clear definition and validating clinical studies, no matter how convincing the source. Clinicians and patients deserve scientific support to inform choices of care that work. –Laura Bolton, PhD

References

1. Benskin LL. A review of the literature informing affordable, available wound management choices for rural areas of tropical developing countries. Ostomy Wound Manage. 2013;59(10):20–41. 2. van Rijswijk L. Bridging the gap between research and practice. Am J Nurs. 2004;104(2):28–30. 3. Hein NT, Prawer SE, Katz HI. Facilitated wound healing using transparent film dressing following Mohs micrographic surgery. Arch Dermatol. 1988;124:903–906. 4. Bolton LL. Moist wound healing from past to present. In: Rovee D, Maibach H (ed). The Epidermis in Wound Healing. Boca Raton, FL: CRC Press;2004;89–101. 5. Bolton LL. Evidence-based report card: operational definition of moist wound healing. J Wound Ostomy Continence Nurs. 2007;34(1):23–29. 6. Ubbink DT, Vermeulen H, Goossens A, Kelner RB, Schreuder SM, Lubbers MJ. Occlusive versus gauze dressings for local wound care in surgical patients: a randomized clinical trial. Arch Surg. 2008;143(10):950–955. 7. 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. 8. Wyatt D, McGowan DN, Najarian MP. Comparison of a hydrocolloid dressing and silver sulfadiazine cream in the outpatient management of second-degree burns. J Trauma. 1990;30(7):857. 9. Boulton AJ Meneses P, Ennis WJ. Diabetic foot ulcers: a framework for prevention and care. Wound Rep Regen. 1999;7:7–16. 10. Bouza C, Saz Z, Muñoz A, Amate JM. Efficacy of advanced dressings in the treatment of pressure ulcers: a systematic review. J Wound Care. 2005;14(5):193–199. 11. de Laat EH, Scholte op Reimer WJ, van Achterberg T. Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature. J Clin Nurs. 2005;14(4):464–472. 12. Jones K, Fennie, K. Chronic wounds: factors influencing healing within 3 months and nonhealing after 5–6 months of care. J Am Med Dir Assoc. 2007;8(6):378–387. 13. O’Donnell TF Jr, Lau J. A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer. J Vasc Surg. 2006;44(5):1118–1125. 14. Friedman SJ, Su DS. Management of leg ulcers with hydrocolloid occlusive dressing. Arch Dermatol. 1984;120:1329–1336. 15. Gilchrest B, Reed C. The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressing. Br Dermatol. 1989;121:337–344.