SAFETY AND EFFICACY REPORT
Silver Dressings
Eric K. Mooney, M.D.,
Ph.D.
Craig Lippitt, M.S., P.A.-C.
Jeff Friedman, M.D.
and the Plastic Surgery
Educational Foundation
DATA Committee
Cooperstown, N.Y.
S
ilver-containing dressings have become
the latest and greatest “innovation” in
wound care products. Silver-containing
solutions and compounds, however, have en-
joyed over a century of use as topical wound
treatments.1– 4 It is not the efficacy, safety, or
antibacterial quality of silver itself that is novel
to these products, for these are well known.
The “innovation” involved in these new wound
care products is the simple fact that silver itself
is incorporated within the dressing rather than
being applied as a separate salt, compound, or
solution. Since the efficacy of silver itself is not
at stake, the basic issues in choosing a silver-
containing dressing can be broadly conceptu-
alized in terms of (1) the characteristics of the
“carrier” dressing and (2) the delivery of silver
by the dressing to the wound. Keeping these
basic issues in mind can help make sense of
some of the media marketing blitz accompa-
nying these products.
WHAT’S AVAILABLE
The antimicrobial efficacy of silver wound
dressings is influenced by silver content and the
dressing formulation. A short list of available
silver dressings follows. It is not intended to be
exhaustive, as the list is growing rapidly. Rather,
the list should be seen as illustrating various
carrier dressing materials used in conjunction
with various silver delivery “reservoirs.”
Acticoat-7 (Smith & Nephew, Hull, United King-
dom) dressing consists of three layers of poly-
ethylene mesh coated with nanocrystalline
(⬍20 nm diameter) silver and two layers of
rayon polyester. The nanocrystalline silver pro-
Received for publication May 27, 2005.
Copyright ©2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000200786.14017.3a
666 www.plasreconsurg.org
vides an initial large bolus of silver to the
wound followed by a sustained release.
Actisorb Silver 220 (Johnson & Johnson, New
Brunswick, N.J.) is an activated charcoal dress-
ing to which silver is bound. Actisorb works by
adsorbing bacteria onto the charcoal compo-
nent, where they are killed by silver. The “odor-
eating” nature of the charcoal is used as a
marketing focus.
Aquacel-Ag hydrofiber (Convatec, Skillman, N.J.;
70:30 sodium: silver carboxymethylcellulose hy-
drofiber) is an absorptive dressing. Cations in
the wound fluid displace the silver bound to
the hydrofiber, providing a sustained, slow re-
lease of silver cations.
Arglaes (Medline, Mundelein, Ill.) is silver-
impregnated polymer film. The silver reservoir
is Ag/CaPo4, formed as glasses co-extruded in a
polymer matrix.
Contreet-H (Coloplast, Marietta, Ga.) is a dense
hydrocolloid dressing that has silver bound to
the hydrocolloid.
SilvaSorb (Medline) is a polyacrylate matrix with a
silver halide reservoir.
Silverlon (Argentum LLC, Willowbrook, Ill.) is a
polymeric fabric coated with metallic silver by
autocatalytic electroless chemical plating. A
marketing focus is the three-dimensional fabric,
which has a large surface area and is flexible.
SILVER DELIVERY SYSTEMS AND
ANTIMICROBIAL CONCEPTS
Silver ion is a highly reactive species, readily
binding to negatively charged proteins, RNA,
DNA, chloride ions, and so on. This property lies
at the heart of its antibacterial mechanism but also
complicates delivery to the wound bed, because it
is readily bound to proteins within the complex
wound fluid. In “complex wound broth” models,
effective antibacterial levels of silver may rise over
80 to 2000 times that required in simple aqueous
solutions.5–7 This requires a certain minimum sil-
Volume 117, Number 2 • Silver Dressings
ver reservoir capable of reaching a sustained re-
lease of silver in the face of negatively charged
wound exudate components. For instance, mini-
mum bactericidal concentrations range between 5
and 50 ppm for most clinically relevant bacteria8,9
and up to 60.5 ppm for methicillin-resistant Staph-
ylococcus epidermidis based on in vitro studies.10 This
has become a major focus of marketing strategy
and controversy. Acticoat and Arglaes lie at the
high end of silver delivery (70 ppm and 30 ppm,
respectively),11 whereas Actisorb and SilvaSorb lie
at the low end (⬍1 ppm).12 Aquacel-Ag is said to
deliver 1 ppm.12 It must be remembered, however,
that these results are based on in vitro or analytic
assays, such as aqueous washout studies. The rele-
vance of such raw numbers to efficacy in actual wounds
is unknown. Thus, Acticoat and Aquacel-Ag have
both been shown to be effective in several in vitro
studies, even though silver delivery varies between
the two. Perhaps the efficacy is explained by the
differing mechanisms utilized by the respective
dressings. Acticoat uses silver nanocrystals as a de-
livery system. Nanocrystals are unique in that they
release silver ion and metallic silver (which is as-
sumed to later supply silver ions). They supply a
large amount of silver to the wound initially and
then sustain release for up to 7 days. Both the large
surface area of the crystals and the unique release
of metallic silver (Ag0) are said to be responsible
for sustained release. In Aquacel-Ag, however, sil-
ver is displaced from the carboxymethylcellulose
carrier as it is hydrated, thereby achieving a grad-
ual, sustained release. Obtaining sustained silver
release is thought to be a key mechanism to the
product’s effectiveness. Perhaps bacteria are also
sequestered by the carboxymethylcellulose. This
example alone illustrates not only that the raw
amount of silver supplied to the wound is impor-
tant but also that the rate and duration may be just
as important. The interaction of the carrier ma-
terial may control these latter processes. Another
unique delivery system is activated charcoal/silver.
As noted above, charcoal may adsorb and seques-
ter the bacteria, ultimately to be destroyed by the
silver. Clearly, this proposed mechanism does not
even rely on supplying silver to the wound inter-
face itself. Along these same lines, Muller et al.13
reported significant in vitro Pseudomonas endotox-
in-binding capacity by Actisorb Silver 220. Other
silver reservoirs include halides, Ag/CaPo4, and
metallic silver.
IN VITRO STUDIES
Lansdown2 points out that many of the studies
on the efficacy of new silver products are spon-
sored by the manufacturer and tend to promote
the benefits of the product under investigation.
Most of these studies are in vitro studies in culture
media on zonal inhibition plates. For instance,
Acticoat-7 has been found to be effective against
150 pathogenic organisms, including methicillin-
resistant Staphylococcus epidermidis and vancomycin-
resistant enterococcus. Most of the other manu-
facturers make similar claims about the broad
spectrum of antimicrobial activity.
ANTIMICROBIAL CONCEPTS AND
COMPARATIVE STUDIES
When silver dressing are compared, it is often
in the language of bacteriology. Thus, differences
will be quoted in zones of inhibition, minimum
inhibitory concentrations, minimum bactericidal
concentrations, and log reductions to stress some
difference between products. In short, zones of
inhibition are broadly seen as least reliable and
certainly least applicable to the actual clinical
wound situation. For instance, Acrymed has re-
leased zonal inhibition studies showing SilvaSorb
and Acticoat to have greater antimicrobial activity
than Arglaes.14 Thomas and McCubbin15,16 used
zones of inhibition to compare 10 different silver
dressings. In general, Acticoat, Contreet-H, Aqua-
cel Ag, SilvaSorb, and Silverlon performed well.
When choosing a silver dressing, however, do not
rely on solely on zone of inhibition studies. Smith
and Nephew emphasize minimum bactericidal
concentrations over minimum inhibitory concen-
trations. They go one step further and argue that
a log reduction of 3 is equivalent to bactericidal
nature and therefore necessary.17 They further
emphasize 30-minute log reductions greater than
3. An emphasis on 30-minute kill rates favors sys-
tems that deliver large silver boluses to the
wound.6 It is intimated that this may also prevent
emergence of resistant organisms.18 This, of
course, would make Acticoat the most effective
agent, particularly for methicillin-resistant Staph-
ylococcus epidermidis, Pseudomonas aeruginosa, and
vancomycin-resistant enterococcus, based on these
time kinetic criteria alone. Remember, however, that
these are in vitro studies, and the correlation with
clinical wounds is not defined and certainly
speculative.19
IN VIVO STUDIES
Very few randomized prospective studies on
the use of silver have been published. Despite this
fact, press releases such as the following appear:
“University Hospital will soon be treating patients
with an anti-microbial dressing called [ ] that is
667
 Plastic and Reconstructive Surgery • February 2006
used to reduce the risk of infections and fight
antibiotic resistant bacteria . . . use of [ ] will allow
[cardiac surgery] patients to take fewer antibiotics
and recover more quickly and completely than
before.”20 No large study has been published inves-
tigating the prospective use of silver dressings in
preventing postoperative wound infections. In fact,
one small “quasi-experimental, prospective, con-
trolled, randomized study” in cardiac patients found
no significant difference in terms of infection be-
tween the treatment group and the control group.21
Tredget et al.22 published a randomized pro-
spective study in which Acticoat was compared
with silver nitrate in 30 burn patients. The fre-
quency of burn wound sepsis and secondary bac-
teremias was found to be less in those treated with
Acticoat. Statistical significance was not discussed.
The authors recommended a larger study.
The outcomes of 75 chronic skin lesions with
signs of infection that were treated with Actisorb
were compared by Cassino et al. 23 with 75 wounds
in which conventional dressings and systemic an-
tibiotics were used. No statistical difference in ef-
fectiveness was noted, although 30-day infection
recurrence rates were much higher in the antibi-
otic-treated group.
Other studies involving donor-site dressings
and so on have been published (with mixed
results),24 but the bulk of the literature involving
human wounds has involved case studies or clin-
ical observations series. Although the broaden-
ing clinical experience supports the safety and,
perhaps, efficaciousness of silver dressings, this
simply has not been proven in human, random-
ized, prospective studies. Certainly, the current
trend seems to indicate that this will be the case.
WOUND-HEALING EFFECTS
Besides its antimicrobial activity, silver may
have other beneficial effects on the wound bed.
Wright et al.25 noted reduced levels of matrix
metalloproteinases and a higher frequency of
apoptosis in a porcine model of contaminated
wounds treated with nanocrystalline silver. They
suggested that silver alters the inflammatory
events in the wound. Paddock et al. 26 have found
an inhibitory effect on certain proinflammatory
cytokines (tumor necrosis factor-alpha) as well.
In one study, zinc metabolism was upregulated,
implying increased epithelialization.27,28
CONCLUSIONS
Silver-containing dressings have been shown to
have broad-spectrum antimicrobial action against
yeasts, molds, and bacteria in vitro. Silver has low
668
mammalian cell toxicity and does not induce resis-
tance if used at adequate levels. Broadening clinical
experience has confirmed the safety of these dress-
ings, and it is reasonable to anticipate that efficacy in
vivo will be proven based on the mounting in vitro
evidence. However, silver dressings are relatively ex-
pensive, although costs are mitigated by sustained-
release products that may be effective for up to 7
days. Nevertheless, large, prospective, randomized
trials of these products do not exist, so evidence-
based medicine cannot as yet help the clinician de-
cide when to use them. Patients with small, partial-
thickness burns would seem to be good candidates
for such therapy. Nursing home patients anticipat-
ing subacute or chronic grafting may be another
group, based on decreasing wound care acuity (once
weekly dressings) and institutional exposure to me-
thicillin-resistant Staphylococcus epidermidis and resis-
tant organisms. The list goes on. Since the number
of potential applications of these products is virtually
limitless, the clinician must balance the cost of ongoing
wound care, as well as the risk and effect of incurring
infection, with the cost of the silver dressing itself.
SELECTED BIBLIOGRAPHY
Burell, R. E. A scientific perspective on the use of
topical silver preparations. Ostomy Wound Manage.
49 (Suppl.): 19, 2003.
Demling, R. H., and Desanti, R. N. Effects of silver on
wound management. Wounds 13 (Suppl. A): 5, 2001.
Lansdown, A. B. G. Silver 1: Its antibacterial properties
and mechanism of action. J. Wound Care 11: 125,
2002.
Lansdown, A. B. G. Silver 2: Its antibacterial properties
and mechanism of action. J. Wound Care 11: 173,
2002.
WEB SITES
http://www.contreet.com
http://www.jnjgateway.com
http://www.convatec.com
http://www.silverlon.com
Eric K. Mooney, M.D., Ph.D.
Bassett Healthcare
One Atwell Road
Cooperstown, N.Y. 13326
eric.mooney@bassett.org
REFERENCES
1. Burell, R. E. A scientific perspective on the use of topical
silver preparations. Ostomy Wound Manage. 49 (Suppl.): 19,
2003.
2. Lansdown, A. B. G. Silver 1: Its antibacterial properties and
mechanism of action. J. Wound Care 11: 125, 2002.
Volume 117, Number 2 • Silver Dressings
3. Klasen, H. J. A historical review of the use of silver in the
treatment of burns: II. Renewed interest for silver. Burns 26:
131, 2000.
4. Demling, R. H., and Desanti, R. N. Effects of silver on wound
management. Wounds 13 (Suppl.): 5, 2001.
5. Ricketts, C. R., Lowbury, E. J., Lawrence, J. C., et al. Mech-
anism of prophylaxis by silver compounds against infection
of burns. Br. Med. J. 1: 444, 1970.
6. Burell, R. E. A scientific perspective on the use of topical
silver preparations. Ostomy Wound Manage. 49: 11, 2003.
7. Spacciapoli, P., Buxton, D., Tothstein, D., and Friden, P.
Antimicrobial activity of silver nitrate against periodontal
pathogens. J. Periodont. Res. 36: 108, 2001.
8. Yin, H. Q., Langford, R., and Burrell, R. E. Comparative
evaluation of the antimicrobial activity of Acticoat antimi-
crobial barrier dressing. J. Burn Care Rehabil. 20: 195, 1999.
9. Hall, R. E., Bender, G., and Marquis, R. E. Inhibitory and
cidal antimicrobial actions of electrically generated silver
ions. J. Oral Maxillofac. Surg. 45: 779, 1987.
10. Maple, P. A., Hamilton-Miller, J. M., and Brumfitt, W. Com-
parison of the in-vitro activities of the topical antimicrobials
azelaic acid, nitrofurazone, silver sulphadiazine and mupi-
rocin against methicillin-resistant Staphylococcus aureus. J. An-
timicrob. Chemother. 29: 661, 1992.
11. Wright, J. B., Hansen, C. E. T., and Burrell, R. E. The com-
parative efficacy of two antimicrobial barrier dressings: In-
vitro examination of two controlled release of silver dress-
ings. Wounds 10: 179, 1998.
12. Yin, H. G. Antimicrobial effects of Acticoat nanocrystalline
silver-coated dressing. Presented at the John A. Boswick Burn
and Wound Care Symposium, Maui, Hawaii, February 2003.
13. Muller, G., Winkler, Y., and Kramer, A. Antibacterial activity
and endotoxin-binding capacity of Actisorb silver 220. J.
Hosp. Infect. 53: 211, 2003.
14. Gibbins, B. L., and Hopman, L. An in-vitro comparison of
SilvaSorb, a new antimicrobial polyacrylate absorbent wound
dressing containing silver with the silver-containing antimi-
crobial film dressings. 1999. Available at http://www.
acrymed.com/Aug2002/SilvaSorbTargetedActivity.html.
Accessed May 27, 2005.
15. Thomas, S., and McCubbin, P. A comparison of the antimi-
crobial effects of four silver-containing dressings on three
organisms. J. Wound Care 12: 101, 2003.
16. Thomas, S., and McCubbin, P. An in-vitro analysis of the
antimicrobial properties of 10 silver-containing dressings. J.
Wound Care 12: 305, 2003.
17. Stratton, C. W., and Cooksey, R. C. Susceptibility tests: Spe-
cial tests. In A. Balows (Ed.), Manual of Clinical Microbiology.
5th Ed. Washington, D.C.: American Society of Microbiology,
1991. Pp. 1153-1165.
18. Wright, J. B., Lam, K., and Burrell, R. E. Wound management
in an era of increasing bacterial antibiotic resistance: A role
for topical silver treatment. Am. J. Infect. Control 26: 572, 1998.
19. Parsons, D. Polishing the information on silver. Ostomy
Wound Manage. 49: 10, Aug 2003.
20. 6/24 GW introduces new anti-microbial dressing Arglaes.
Available at http://www.gwhospital.com/p7726.html.
21. Redmile, B. G., Shinn, K. M., and Bell, G. F. Comparing the
effectiveness of Arglaes film, antimicrobial barrier dressing,
to Covaderm, current standard dressing, on surgical inci-
sions of patients undergoing cardiac surgery using the car-
diopulmonary bypass pump. November 2002. Available at
http://www.udmercy.edu/crna/research/shinn.htm.
22. Tredget, E. E., Shankowsky, H. A., Groeneveld, A., and Bur-
rell, R. A. Matched-pair randomized study evaluating the
efficacy and safety of Acticoat silver-coated dressing treat-
ment of burn wounds. J. Burn Care Rehabil. 19: 531, 1998.
23. Cassino, R., Ricci, E., and Aione, P. Treatment of 150 infected
chronic skin lesions with Actisorb: A review. Presented at
Centro Vulnologico Italiano, Turin, Italy, 2002.
24. Innes, M. E., Umraw, N., Fish, J. S., et al. The use of silver
coated dressings on donor site wounds: A prospective, con-
trolled matched pair study. Burns 27: 621, 2001.
25. Wright, J. B., Lam, K., Buret, A. G., Olson, M. E., and Burrell,
R. E. Early healing events in a porcine model of contami-
nated wounds: Effects of nanocrystalline silver on matrix
metalloproteinases, cell apoptosis, and healing. Wound Re-
pair Regen. 10: 141, 2002.
26. Paddock, H. N., Schultz, G. S., Perrin, K. J., et al. Clinical
assessment of silver-coated antimicrobial dressing on MMPs
and cytokine levels in non-healing wounds. Presented at the
Annual Meeting of the Wound Healing Society, Baltimore,
Md., 2002.
27. Demling, R. H., and DeSanti, L. The rate of re-epithelializa-
tion across meshed skin grafts is increased with exposure to
silver. Burns 28: 264, 2002.
28. Lansdown, A. B. G. Silver 2: Its antibacterial properties and
mechanism of action. J. Wound Care 11: 173, 2002.
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