Professional Documents
Culture Documents
easy
Pressure ulcers
and hydrocolloids
Volume 2 | Issue 4 | November 2011 www.woundsinternational.com
NPUAP/EPUAP classification:
Category/Stage 1: Non- Category/Stage II: Partial thickness skin Category/Stage III: Full thickness skin loss (fat Category/Stage IV: Full thickness tissue loss
blanchable redness of intact skin loss or blister* visible) (muscle/bone visible)
*Photograph used with the kind permission of Dale Copson, MSc, BSc(Hons) RN, Tissue Viability Nurse Specialist, formerly of Southern Derbyshire Acute Hospitals NHS Trust.
Other photographs courtesy of ConvaTec.
This is a general educational article on Hydrocolloids and pressure ulcers. Not all claims made herein are attributable to ConvaTec’s hydrocolloid products.
1
made
easy
Pressure ulcers
and hydrocolloids
properties that are useful in the management of pressure Box 2 Tips for pressure ulcer assessment
ulcers including: n Systematic assessment and monitoring of progress can be
n production of a moist wound environment facilitated through the use of a validated wound assessment
n management of exudate instrument6
n facilitation of autolytic debridement
n Use of photography (with appropriate consent) is helpful to
provide a baseline, and a serial library, upon which improvement or
n provision of a barrier to micro-organisms deterioration may be determined19
n helping with pain management10. n A standardised method for categorising/grading pressure ulcers
should be employed
n Wound size should be monitored every one to two weeks; other
Creating an optimal environment for healing wound characteristics should be monitored at each dressing
Hydrocolloid dressings create a moist wound environment change6
that is known to be beneficial to wound healing11.
n During each assessment, care should be taken to identify and
address specific patient concerns regarding treatments and wound
Specifically, hydrocolloids are believed to promote status6
angiogenesis, increase the number of dermal fibroblasts, n Wounds that have been identified as healable, but that are not
progressing within the first two weeks of treatment should have
stimulate the production of granulation tissue, and increase
the plan of care re-evaluated and changes in patient specific
the amount of collagen synthesised10. characteristics assessed6
2
Table 1 Study summaries
Study reference Therapy Design Selection criteria Clinical outcomes
Hollisaz M, et al. BMC Hydrocolloid dressing (n=31) Randomised clinical Category/Stage I and More ulcers, regardless of location and Category/Stage,
Dermatology 2004; vs phenytoin cream with gauze trial II pressure ulcers in were completely healed in the hydrocolloid group than
4: 1825 (n=30) vs simple dressing (wet paraplegic males in the other groups
gauze) (n=30) (n=83 with 91 ulcers)
Chang KW, et al. Med Hydrocolloid (Duoderm CGF Randomised controlled Category/Stage II Adherence to wound bed, exudate handling, overall
J Malaysia 1998; 53(4): (ConvaTec)) vs saline gauze trial or III pressure ulcers comfort and pain during dressing removal all
428-3126 (n=34) significantly favoured hydrocolloid
Mean reduction in surface area measurement was
34% for hydrocolloid. Patients treated with gauze
experienced a mean 9% increase in surface area
Graumlich J, et al. J Hydrocolloid vs collagen Randomised, parallel Category/Stage II Healing rates and overall healing time were similar in
Am Ger Soc 2003; 51: group, single blind, (80%) or III (20%) both groups
147-5427 controlled trial pressure ulcers; Costs were estimated as $222 for hydrocolloid and
median age 83.1 years $627 for collagen per patient for 8 weeks
Meaume S, et al. J Dressings used on venous leg Development of cost- The models were For pressure ulcers, a hydrocolloid (DuoDERM
Wound Care 2002; ulcers and pressure ulcers effectiveness models used to calculate cost (ConvaTec)) was most cost-effective in France
11(6): 219-2428 based on a literature per ulcer healed over
review a 12 week period
Kerstein M, et al. Dis Pressure ulcer and venous leg Modelling study using The cost of 12 Costs per patient healed were lowest for pressure
Manage & Health ulcer protocols outcomes from a weeks of wound ulcers treated with hydrocolloids and highest for
Outcomes 2001; literature review care was modelled those treated with saline gauze due to differences in
9(11): 651-329 for modalities with person-time required
a pooled evidence
base of at least 100
wounds
Heyneman A, et al. J Hydrocolloid dressings Systematic review Randomised Hydrocolloids had greater absorptive capacity, shorter
Clin Nurs 2008; 17(9); of hydrocolloids in controlled trials of time for dressing change and less pain during dressing
1164-7330 pressure ulcers hydrocolloids in the changes than did gauze dressings
treatment of pressure Hydrocolloids seemed to be less expensive than
ulcers (28 studies in collagen, saline and povidone soaked gauze, but more
total) expensive than hydrogel, polyurethane foam and
collagenase
Hydrocolloids are more effective than gauze dressings
for reducing wound dimensions, but less effective than
alginates, polyurethane dressings, topical enzymes and
biosynthetic dressings
3
maceration. Good absorbency has n absorbing wound exudate, so Indeed, a systematic review noted that
been identified as an ideal characteristic keeping excessive moisture and hydrocolloids were more effective than
of a dressing used for pressure ulcer potentially damaging proteolytic gauze dressings for enhancing wound
prevention34. In addition, thin hydrocolloids enzymes away from healthy skin35. healing, and were associated with lower
are much easier to handle than are film levels of pain and reduced time for
dressings because they are less likely to fold Autolytic debridement dressing changes30.
on themselves. In the presence of devitalised tissue,
hydrocolloid dressings facilitate
Irrespective of the stage of healing, autolytic debridement by creating a Practicalities
hydrocolloids are also useful as a secondary moist wound–dressing interface10. Selecting a hydrocolloid dressing
dressing because of their waterproof However, the decision to use a Thicker hydrocolloid dressings are most
backing and ability to reduce shear and hydrocolloid dressing will be depend appropriate for moderate levels of
friction. The interaction between the on the level of exudate in the wound. If exudate. Conversely, if exudate levels
hydrocolloid and the primary cavity filler the wound has low to moderate exudate are low or the dressing is being applied
must always be considered. For example, a hydrocolloid may be an appropriate to skin at risk of further breakdown, a
a hydrocolloid, Hydrofiber® or alginate treatment choice, but if the wound has a thin dressing may be most appropriate.
cavity filler may be usefully covered with a high level of exudate, a more absorbent Similarly, as the pressure ulcer heals and
hydrocolloid dressing, but amorphous gels primary dressing may be needed9. exudate levels drop, it may be necessary
tend to produce too wet an environment to use a thinner dressing.
for a hydrocolloid dressing to manage. Moist wound healing
The gel formed when exudate is Hydrocolloid dressings are not designed
Protection of periwound skin absorbed by a hydrocolloid maintains a to be used with a secondary dressing. If
Hydrocolloid dressings generally overlap moist wound–dressing interface while exudate levels are high, an alternative
the wound edge and extend onto healthy preventing fluid accumulation on the dressing may be needed.
skin and protect periwound skin by: wound surface. Hydrocolloids are therefore
n providing a protective covering to also of value in the management of clean Where the skin is at risk of breakdown, ie in
the healthy periwound skin shallow granulating pressure ulcers. Category/Stage I pressure ulcers, choosing
4
a thin hydrocolloid dressing (eg DuoDERM® be required if exudate production is delivery of high quality care37. Hydrocolloid
SignalTM or DuoDERM® Extra Thin) will high, eg at the start of treatment, or if dressings can be used on pressure ulcers to
reduce the chances of it wrinkling and infection is suspected. the point of wound closure.
rucking and causing further problems7.
Removing hydrocolloid Cost-effectiveness
Applying hydrocolloid dressings Hydrocolloids have been shown to
dressings Unless early removal is required for be more cost effective than gauze in
The hydrocolloid dressing selected should clinical reasons, hydrocolloid dressings the treatment of pressure ulcers28, 29
be an appropriate size and shape for the should stay in place until the gel bubble (Table 1). This appeared to be mainly
wound, and overlap onto normal skin for that forms comes close to the edge of due to the lower clinical contact time
about 3cm (1.25 inches) around the wound. the dressing36. The gel will allow easy required during treatment with a
and atraumatic removal of the dressing. hydrocolloid dressing.
Hydrocolloid dressings should be warmed If removal is required before the gel
between the hands before application. bubble has formed, careful removal by
Warming enhances the adhesiveness and lifting the edge and peeling away the Author details
pliability of the dressing, allowing it to better hydrocolloid while moistening the skin
Fletcher J1, Moore Z2, Anderson I3,
conform to the wound contours. Generally, is recommended36. Some dressings Matsuzaki K4.
it is advised that the patient does not put incorporate a system to indicate 1. Senior Lecturer, Section of Wound
weight over the dressing for 20-30 minutes when dressing change is required (eg Healing, Department of Dermatology
and Wound Healing, School of Medicine,
after application to give the dressing time to DuoDERM® SignalTM). Cardiff University, Cardiff, UK, and Fellow,
stick properly36. National Institute for Health and Clinical
Excellence, UK
For how long should a 2. Immediate Past President of EWMA and
If leakage is or may be a problem from hydrocolloid be used? Lecturer in Wound Healing & Tissue
Repair and Research Methodologies,
one side of the dressing, eg due to The use of a hydrocolloid in the treatment Royal College of Surgeons, Ireland
gravity, consider applying the dressing plan may be continued as long as the 3. Programme Tutor, Tissue Viability,
so that there is greater overlap onto dressing meets the clinical objectives. At and Reader in Learning and Teaching
in Healthcare Practice, University of
the skin on that side36. Dressings with each dressing change the wound and other Hertfordshire, Hatfield, UK
tapered edges are less likely to wrinkle, clinical parameters should be assessed to 4. Associate Professor, Department of Plastic
and Reconstructive Surgery, St Marianna
ruck or roll up. Hydrocolloid dressings determine what adjustments are required University School of Medicine, and
are waterproof: patients can continue to to the current plan of care6. The use of Department of Plastic and Reconstructive
Surgery, Kawasaki Municipal Tama
shower or bath with the dressing in situ. a systematic approach to assessment is Hospital, Miyamae, Kawasaki, Japan.
particularly useful, ideally with use of a
Frequency of dressing change reliable and valid assessment tool6. Supported by an educational grant from
In general, hydrocolloid dressings ConvaTec. The views expressed in this
‘Made Easy’ section do not necessarily
are changed every three to five At all times, careful documentation of the reflect those of ConvaTec. Reprinted with
days, although some may be able to patient and wound is essential to enhance permission of Wounds International.
stay in place for up to seven days. communication, provide a rationale for (®/™ unless otherwise stated indicates the
However, more frequent changes may decision making and to demonstrate the trademark of ConvaTec Inc.)
Summary
Pressure ulcers are a widespread problem and are highly costly in terms of resource usage and
detrimental effect on quality of life. Hydrocolloid dressings promote moist wound healing, manage
exudate, aid autolytic debridement and assist with pain management. They may also be used as a
primary dressing for Category/Stage I or II pressure ulcers, shallow Category/Stage III or IV pressure
ulcers, and for newly formed skin.The shiny outer surface and tapered edges of some newer
hydrocolloid dressings help to protect tissues from further pressure-related damage by reducing the
effects of pressure, shear and friction, and reducing the likelihood of rucking, wrinkling or edge rolling.
To cite this publication
Fletcher J, Moore Z, Anderson I, Matsuzaki K. Hydrocolloids and pressure ulcers Made Easy. Wounds International 2011; 2(4): Available
from: http://www.woundsinternational.com
© Wounds International 2011
AP-011780-MM
5
References aureus and hydrocolloid dressings.
Pharm J 1988; 243; 787-88.
dressings for the treatment of pressure
ulcers. BMC Dermatology 2004;
13. Lawrence JC. Reducing the spread of 4(18):unpaginated.
1. Vanderwee K, Clark M, Dealey C, et al.
Pressure ulcer prevalence in Europe: a bacteria. J Wound Care 1993; 2: 48-52. 26. C hang KW, Alsagoff S, Ong K, Sim PH.
pilot study. J Eval Clin Pract 2007; 13: 14. Bowler PG, Delargy H, Prince D, Fondberg Pressure ulcers – randomised controlled
227-35. L. The viral barrier properties of some trial comparing hydrocolloid and saline
occlusive dressings and their role in gauze dressings. Med J Malaysia 1998;
2. Bennett G, Dealey C, Posnett J. The cost
infection control. Wounds 1993; 5(1): 1-8. 53: 428-31.
of pressure ulcers in the UK. Age Ageing
2004; 33(3): 230-35. 15. Knowles EA, Westwood B, Young MJ, 27. G raumlich JF, Blough LS, McLaughlin
Boulton AJM. A retrospective study of RG, et al. Healing pressure ulcers with
3. Hospitals ‘name and shamed’ on
the use of Granuflex and other dressings collagen or hydrocolloid: a randomized,
bedsores record which costs NHS £4bn a
in the treatment of diabetic foot controlled trial. J Am Geriatr Soc 2003;
year. The Telegraph, 4 Jul 2011. Available
ulcers. Proceedings of the 3rd European 51(2): 147-54.
at: http://www.telegraph.co.uk/health/
healthnews/8613764/Hospitals-named- Conference on Advances in Wound 28. M eaume S, Gemmen E. Cost-
and-shamed-on-bedsores-record-which- Management; 19-22 October 1993. effectiveness and wound management
costs-NHS-4bn-a-year.html (accessed 10 London: Macmillan, 1993; 117-20. in France: pressure ulcers and venous
October 2011). 16. Boulton AJ, Meneses P, Ennis WJ. Diabetic leg ulcers. J Wound Care 2002; 11(6):
foot ulcers: a framework for prevention 219-24.
4. Bales I, Padwojski A. Reaching for the
moon: achieving zero pressure ulcer and care. Wound Repair Regen 1999; 7(1): 29. K erstein M, Gemmen E, van Rijswijk L, et
prevalence. J Wound Care 2009; 18(4): 7-16. al. Cost and cost effectiveness of venous
137-44. 17. Nakagami G, Sanada H, Konya C, et and pressure ulcer protocols of care. Dis
al. Comparison of two pressure ulcer Manage Health Outcomes 2001; 9(11):
5. Lohi J, Sipponen A, Jokinen JJ. Local
preventive dressings for reducing shear 651-63.
dressings for pressure ulcers: what is
the best tool to apply in primary and force on the heel. J Wound Ostomy 30. H eyneman A, Beele H, Vanderwee K,
second care? J Wound Care 2010; 19(3): Continence Nurs 2006; 33(3): 267-72. Defloor T. A systematic review of the
123-27. 18. Ohura T, Takahashi M, Ohura N Jr. use of hydrocolloids in the treatment
Influence of external forces (pressure of pressure ulcers. J Clin Nurs 2008; 17:
6. European Pressure Ulcer Advisory Panel
and shear force) on superficial layer and 1164-73.
and National Pressure Ulcer Advisory
Panel. Treatment of pressure ulcers: subcutis of porcine skin and effects of 31. M oore Z, Cowman S. The role of
Quick Reference Guide. Washington DC: dressing materials: are dressing materials nutrition in the prevention and
National Pressure Ulcer Advisory Panel; beneficial for reducing pressure and management of pressure ulcers.
2009. Available at: http://www.epuap. shear force in tissues? Wound Repair Geriatrics and Aging 2008; 11: 295-98.
org/guidelines/Final_Quick_Treatment. Regen 2008; 16(1): 102-7. 32. B ouza C, Saz Z, Muñoz A, Amate J.
pdf (accessed 23 September 2011). 19. Localio RA, Margolis D, Kagan SH, et al. Efficacy of advanced dressings in
7. Wicks G. A guide to the treatment of Use of photographs for the identification the treatment of pressure ulcers: a
pressure ulcers from grade 1–grade 4. of pressure ulcers in elderly hospitalized systematic review. J Wound Care 2005;
Wound Essentials 2007; 2: 106-13. patients: validity and reliability. Wound 14(5): 193-99.
Repair Regen 2006; 14: 506-13. 33. G ray M, Weir D. Prevention and
8. Heenan A. Frequenly asked questions:
hydrocolloid dressings. World Wide 20. Wyatt D, McGowan DN, Najarian MP. treatment of moisture-associated skin
Wounds, 1998. Available at: http:// Comparison of a hydrocolloid dressing damage (maceration) in the periwound
www.worldwidewounds.com/1998/ and silver sulfadiazine cream in the skin. J Wound Ost Continence Nurs 2007;
april/Hydrocolloid-FAQ/hydrocolloid- outpatient management of second- 34(2): 153-57.
questions.html (accessed 27 September degree burns. J Trauma 1990; 30(7): 34. B utcher M, Thompson G. Pressure
2011). 857-65. ulcer prevention: can dressings
9. Thomas S, Loveless P. A comparative 21. Nemeth AJ, Eaglstein WH, Taylor JR, et protect from pressure ulcer damage?
study of the properties of twelve al. Faster healing and less pain in skin An advertorial. Wounds International
hydrocolloid dressings. World Wide biopsy sites treated with an occlusive 2009; 1(1). Available at: http://www.
Wounds 1997. Available at: http:// dressing. Arch Dermatol 1991; 127(11): woundsinternational.com/article.php?c
www.worldwidewounds.com/1997/ 1679-83. ontentid=122&articleid=8793&page=3
july/Thomas-Hydronet/hydronet.html 22. Fletcher J. Wound assessment and the (accessed 21 September 2011).
(accessed 27 September 2011). TIME framework. BJN 2007; 16(8): 462-66. 35. Thomas S. The role of dressings in
10. Q ueen D. Technology update: 23. Gorecki C, Brown JM, Nelson EA, et al. the treatment of moisture-related
Understanding hydrocolloids. Wounds Impact of pressure ulcers on quality of skin damage. World Wide Wounds
International 2009; 1(1). Available at: life in older patients: a systematic review. 2008. Available at: http://www.
http://www.woundsinternational.com/ J Am Geriatr Soc 2009; 57: 1175-83. worldwidewounds.org/2008/march/
article.php?issueid=1&contentid=129& Thomas/Maceration-and-the-role-of-
24. Gray D, White R, Cooper P, Kingsley dressings.html (accessed 27 September
articleid=229 (accessed 23 September A. Applied wound management and
2011). 2011).
using the wound healing continuum
11. Finnie A. Hydrocolloids in wound in practice. Wound Essentials 2010; 5: 36. Fletcher J. The benefits of using
management: pros and cons. Br J 131-39. hydrocolloids. Nursing Times 2003;
Community Nurs 2002; 7(7): 338-42. 99(21): 57.
25. Hollisaz MT, Khedmat H, Yari F. A
12. Wilson P, Burroughs D, Dunn J. randomized clinical trial comparing 37. Dimond B. Pressure ulcers and litigation.
Methicillin-resistant Staphylococcus hydrocolloid, phenytoin and simple Nursing Times 2003; 99 (5): 61-63.