Dressings and topical agents for treating pressure ulcers (Review)

172 Pages·2017·2.18 MB·English

CochraneDatabaseofSystematicReviews
Dressings and topical agents for treating pressure ulcers
(Review)
WestbyMJ,DumvilleJC,SoaresMO,StubbsN,NormanG
WestbyMJ,DumvilleJC,SoaresMO,StubbsN,NormanG.
Dressingsandtopicalagentsfortreatingpressureulcers.
CochraneDatabaseofSystematicReviews2017,Issue6.Art.No.:CD011947.
DOI:10.1002/14651858.CD011947.pub2.
www.cochranelibrary.com
Dressingsandtopicalagentsfortreatingpressureulcers(Review)
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARYOFFINDINGSFORTHEMAINCOMPARISON . . . . . . . . . . . . . . . . . . . 4
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Figure5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Figure6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Figure7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Figure8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Figure9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
ADDITIONALTABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 170
Dressingsandtopicalagentsfortreatingpressureulcers(Review) i
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Dressings and topical agents for treating pressure ulcers
MaggieJWestby1,JoCDumville1,MartaOSoares2,NikkiStubbs3,GillNorman1
1Division ofNursing,Midwifery&SocialWork,SchoolofHealthSciences,FacultyofBiology,Medicine &Health,Universityof
Manchester,ManchesterAcademicHealthScienceCentre,Manchester,UK.2CentreforHealthEconomics,UniversityofYork,York,
UK.3WoundPreventionandManagementService,LeedsCommunityHealthcareNHSTrust,StMary’sHospital,Leeds,UK
Contactaddress: Maggie JWestby,Division ofNursing, Midwifery &SocialWork,SchoolofHealthSciences,Faculty ofBiology,
Medicine&Health,UniversityofManchester,ManchesterAcademicHealthScienceCentre,JeanMcFarlaneBuilding,OxfordRoad,
Manchester,M139PL,[email protected].
Editorialgroup:CochraneWoundsGroup.
Publicationstatusanddate:New,publishedinIssue6,2017.
Citation: Westby MJ, Dumville JC, SoaresMO, Stubbs N, NormanG. Dressings and topical agents for treating pressure ulcers.
CochraneDatabaseofSystematicReviews2017,Issue6.Art.No.:CD011947.DOI:10.1002/14651858.CD011947.pub2.
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Pressureulcers,alsoknownasbedsores,decubitusulcersandpressureinjuries,arelocalisedareasofinjurytotheskinortheunderlying
tissue,orboth.Dressings arewidelyusedtotreatpressureulcersandpromotehealing,andtherearemanyoptionstochoosefrom
includingalginate,hydrocolloidandprotease-modulatingdressings.Topicalagentshavealsobeenusedasalternativestodressingsin
ordertopromotehealing.
Aclearandcurrentoverviewofalltheevidenceisrequiredtofacilitatedecision-makingregardingtheuseofdressingsortopicalagents
forthetreatmentofpressureulcers.Suchareviewwouldideallyhelppeoplewithpressureulcersandhealthprofessionalsassessthebest
treatmentoptions.Thisreviewisanetworkmeta-analysis(NMA)whichassessestheprobabilityofcompleteulcerhealingassociated
withalternativedressingsandtopicalagents.
Objectives
Toassesstheeffectsofdressingsandtopicalagentsforhealingpressureulcersinanycaresetting.Weaimedtoexaminethisevidence
baseasawhole,determiningprobabilitiesthateachtreatmentisthebest,withfullassessmentofuncertaintyandevidencequality.
Searchmethods
InJuly2016wesearchedtheCochraneWoundsSpecialisedRegister;theCochraneCentralRegisterofControlledTrials(CENTRAL);
OvidMEDLINE;OvidMEDLINE(In-Process&OtherNon-IndexedCitations);OvidEmbaseandEBSCOCINAHLPlus.Wealso
searchedclinicaltrialsregistriesforongoingandunpublishedstudies,andscannedreferencelistsofrelevantincludedstudiesaswellas
reviews,meta-analyses,guidelinesandhealthtechnologyreportstoidentifyadditionalstudies.Therewerenorestrictionswithrespect
tolanguage,dateofpublicationorstudysetting.
Selectioncriteria
Publishedorunpublishedrandomisedcontrolledtrials(RCTs)comparingtheeffectsofatleastoneofthefollowinginterventionswith
anyotherinterventioninthetreatmentofpressureulcers(Stage2orabove):anydressing,oranytopicalagentapplieddirectlytoan
openpressureulcerandleftinsitu.Weexcludedfromthisreviewdressingsattachedtoexternaldevicessuchasnegativepressurewound
therapies,skingrafts,growthfactortreatments,plateletgelsandlarvaltherapy.
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 1
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Datacollectionandanalysis
Tworeviewauthorsindependentlyperformedstudyselection,riskofbiasassessmentanddataextraction.Weconductednetworkmeta-
analysisusingfrequentistmega-regressionmethodsfortheefficacyoutcome,probabilityofcompletehealing.Wemodelledtherelative
effectivenessof any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed
thattreatmenteffectsweresimilar withindressings classes(e.g.hydrocolloid,foam).Wepresentestimatesofeffectwiththeir95%
confidenceintervalsforindividual treatmentscomparedwitheveryother,andwereportrankingprobabilitiesforeachintervention
(probabilityofbeingthebest,secondbest,etctreatment).Weassessedthecertainty(quality)ofthebodyofevidenceusingGRADE
foreachnetworkcomparisonandforthenetworkaswhole.
Mainresults
We included 51 studies (2947 participants) in thisreview and carried out NMA in a network of linkedinterventions for the sole
outcome ofprobability ofcompletehealing.Thenetworkincluded21differentinterventions (13dressings, 6topicalagentsand2
supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed
wounds.
Wejudgedthenetworktobesparse:overall,therewererelativelyfewparticipants,withfewevents,bothforthenumberofinterventions
and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high
imprecisionintheevidence,andthis,coupledwiththe(mainly)highriskofbiasinthestudiesinformingthenetwork,meansthatwe
judgedthevastmajorityoftheevidencetobeofloworverylowcertainty.Wehavenoconfidenceinthefindingsregardingtherank
orderofinterventionsinthisreview(verylow-certaintyevidence),butwereporthereasummaryofresultsforsomecomparisonsof
interventionscomparedwithsalinegauze.Wepresenthereonlythefindingsfromevidencewhichwedidnotconsidertobeverylow
certainty,butthesereportedresultsshouldstillbeinterpretedinthecontextoftheverylowcertaintyofthenetworkasawhole.
Itisnotclearwhetherregimensinvolvingprotease-modulatingdressingsincreasetheprobabilityofpressureulcerhealingcompared
with saline gauze (riskratio(RR) 1.65, 95% confidence interval (CI)0.92 to2.94) (moderate-certainty evidence:lowriskof bias,
downgradedforimprecision).Thisriskratioof1.65correspondstoanabsolutedifferenceof102morepeoplehealedwithprotease
modulatingdressingsper1000peopletreatedthanwithsalinegauzealone(95%CI13fewerto302more).Itisunclearwhetherthe
followinginterventionsincreasetheprobabilityofhealingcomparedwithsalinegauze(low-certaintyevidence):collagenaseointment
(RR2.12,95%CI1.06to4.22);foamdressings(RR1.52,95%CI1.03to2.26);basicwoundcontactdressings(RR1.30,95%CI0.65
to2.58)andpolyvinylpyrrolidonepluszincoxide(RR1.31,95%CI0.37to4.62);thelattertwointerventionsbothhadconfidence
intervalsconsistentwithbothaclinicallyimportantbenefitandaclinicallyimportantharm,andtheformertwointerventionseach
hadhighriskofbiasaswellasimprecision.
Authors’conclusions
Anetworkmeta-analysis(NMA)ofdatafrom39studies(evaluating21dressingsandtopicalagentsforpressureulcers)issparseand
theevidenceisofloworverylowcertainty(duemainlytoriskofbiasandimprecision).Consequentlyweareunabletodetermine
whichdressingsortopicalagentsarethemostlikelytohealpressureulcers,anditisgenerallyunclearwhetherthetreatmentsexamined
aremoreeffectivethansalinegauze.
More researchis neededtodetermine whetherparticular dressings or topical agents improve theprobability of healingof pressure
ulcers.TheNMAisuninformativeregardingwhichinterventionsmightbestbeincludedinalargetrial,anditmaybethatresearchis
directedtowardsprevention,leavingclinicianstodecidewhichtreatmenttouseonthebasisofwoundsymptoms,clinicalexperience,
patientpreferenceandcost.
PLAIN LANGUAGE SUMMARY
Whichdressingsortopicalagentsarethemosteffectiveforhealingpressureulcers?
Dressingsandtopicalagentsfortreatingpressureulcers
Reviewquestion
Wereviewedtheevidenceabouttheeffectsofdressingsandtopicalagents(suchasointments,creamsandgels)onpressureulcerhealing.
Therearemanydifferentdressingsandtopicalagentsavailable,andwewantedtofindoutwhichwerethemosteffective.
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 2
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Background
Pressureulcers,alsoknownasbedsores,decubitusulcersandpressureinjuries,arewoundsinvolvingtheskinandsometimesthetissue
thatliesunderneath.Pressureulcerscanbepainful,maybecomeinfectedandaffectpeople’squalityoflife.Peopleatriskofdeveloping
pressureulcersincludethosewithlimitedmobility-suchasolderpeopleandpeoplewithshort-termorlong-termmedicalconditions
-andpeoplewithspinalcordinjuries.In2004thetotalyearlycostoftreatingpressureulcersintheUKwasestimatedasbeingGBP
1.4to2.1billion,whichwasequivalentto4%ofthetotalNationalHealthServiceexpenditure.
Topicalagentssuchasointments,creamsorgelsareappliedtounhealedpressureulcersandleftinplacetotreatthewound;theymay
becoveredwithadressing.Someofthesetreatmentshavebeencomparedwitheachotherintrials,usuallycomparingtwotreatments
atatime.Weusedamethodcalled’networkmeta-analysis’tobringtogetherallthetrialresultsofdifferenttreatmentsinareliableway.
Wehopedthatthismethod,whichcomparesalltreatmentoptions,wouldhelpusfindoutwhichwasthebesttreatmentforhealing
pressureulcers.
Studycharacteristics
InJuly2016wesearchedforrandomisedcontrolledtrialslookingatdressingsandtopicalagentsfortreatingpressureulcersandthat
gaveresultsforcompletewoundhealing.Wefound51studiesinvolvingatotalof2947people.Thirty-nineofthesestudies,involving
2127people,gaveresultswecouldbringtogetherinanetworkmeta-analysiscomparing21differenttreatments.Mostparticipantsin
thetrialswereolderpeople;threeofthe39trialsinvolvedparticipantswithspinalcordinjuries.
Keyresults
Generally,thestudieswefounddidnothavemanyparticipantsandresultswereofteninconclusive.Thisproblemcarriedoverinto
thenetworkmeta-analysisandmadethefindingsunclear.Asaresult,itwasunclearwhetheronetopicalagentordressingwasbetter
thananother.Somefindingsforindividualcomparisonsmaybeslightlymorereliable.Protease-modulatingdressings,foamdressings
orcollagenaseointmentmaybebetterathealingthangauze;buteventhisevidenceisnotcertainenoughtobeanadequateguidefor
treatmentchoices.
Certaintyoftheevidence
Wejudgedthecertaintyoftheevidencetobeveryloworlow.Thenextstepmightbetodomoreresearchofbetterqualitytoseewhich
dressingsortopicalagentscouldbesthealpressureulcers.
ThisplainlanguagesummaryisuptodateasofJuly2016.
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 3
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SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation]
NMAevidenceforindividualnetwork:proportionwithcompletehealing- interventionsversussalinegauze
Patientorpopulation:peoplewithpressureulcers
Intervention:dressingortopicalagent
Comparator:salinegauze
Settings:hospital,communityorcarehome,orcombinations
Contrasts: Relativeeffect Anticipatedabsoluteeffects* (95%CI)- Certainty(quality)of
interventions versus (95%CI) from median of saline gauze control groupsin theevidence
salinegauze directevidence (GRADE)
MedianCGR Withinterventions
Alginatedressings RR1.09 157per1000 171 per 1000 (17 to ⊕(cid:13)(cid:13)(cid:13)
(0.11to10.57) 1000) Verylow1
14morepeoplehealedper1000
(140fewerto1000more)
Sequential hydrocol- RR0.50 157per1000 78per1000(1.9to 31. ⊕(cid:13)(cid:13)(cid:13)
loidalginatedressings (0.12to1.98) 2) Verylow1
79fewerpeoplehealedper1000
(138fewerto155more)
Basic wound contact RR1.30 157per1000 204 per 1000 (102 to ⊕⊕(cid:13)(cid:13)
dressings (0.65to2.58) 407) Low2
47morepeoplehealedper1000
(55fewerto250more)
Collagenaseointment RR2.12 157per1000 333 per 1000 (166 to ⊕⊕(cid:13)(cid:13)
(1.06to4.22) 663) Low3
176morepeoplehealedper1000
(9moreto506more)
Dextranomer RR4.76 157per1000 747 per 1000 (135 to ⊕(cid:13)(cid:13)(cid:13)
(0.86to26.39) 1000) Verylow4
590morepeoplehealedper1000
(22fewerto1000more)
Foamdressings RR1.52 157per1000 239 per 1,000 (162 to ⊕⊕(cid:13)(cid:13)
(1.03to2.26) 353) Low5
82morepeoplehealedper1,000
(5moreto196more)
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 4
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Hydrocolloiddressing RR1.22 157per1000 192 per 1,000 (9 to ⊕(cid:13)(cid:13)(cid:13)
with/withoutalginate (0.06to24.74) 1000) Verylow1
35morepeoplehealedper1,000
(148fewerto1000more)
Hydrocolloiddressings RR1.43 157per1000 225 per 1000 (157 to ⊕(cid:13)(cid:13)(cid:13)
(1.00to2.05) 322) Verylow6
68morepeoplehealedper1000
(from 0fewerto165more)
Hydrogel RR1.55 157per1000 243 per 1000 (160 to ⊕(cid:13)(cid:13)(cid:13)
(1.02to2.36) 371) Verylow6
86morepeoplehealedper1000
(from 3moreto214more)
Iodine-containing RR1.08 157per1000 170 per 1000 (91 to ⊕(cid:13)(cid:13)(cid:13)
dressings (0.58to2.03) 316) Verylow1
13morepeoplehealedper1000
(from 66fewerto159more)
Phenytoin RR1.27 157per1000 199 per 1000 (91 to ⊕(cid:13)(cid:13)(cid:13)
(0.58to2.80) 440) Verylow7
42morepeoplehealedper1000
(from 66fewerto283more)
Protease-modulating RR1.65 157per1000 259 per 1,000 (144 to ⊕⊕⊕(cid:13)
dressings (0.92to2.94) 462) Moderate8
102morepeoplehealedper1000
(from 13fewerto305more)
Polyvinylpyrrolidone + RR1.31 157per1000 206 per 1,000 (58 to ⊕⊕(cid:13)(cid:13)
zincoxide (0.37to4.62) 732) Low2
49morepeoplehealedper1000
(from 99fewerto575more)
Combination silicone RR1.93 157per1000 303 per 1,000 (60 to 1, ⊕(cid:13)(cid:13)(cid:13)
foamdressings (0.38to9.98) 000) Verylow1
146morepeoplehealedper1000
(from 97fewerto1,000more)
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 5
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Softpolymerdressings RR1.35 157per1000 212 per 1,000 (86 to ⊕(cid:13)(cid:13)(cid:13)
(0.55to3.27) 517) Verylow1
55morepeoplehealedper1000
(from 71fewerto360more)
Sugar+eggwhite RR0.70 157per1000 110 per 1000 (5 to 1, ⊕(cid:13)(cid:13)(cid:13)
(0.03to15.62) 000) Verylow1
47fewerpeoplehealedper1000
(from 152fewerto1000more)
Tripeptidecoppergel RR3.90 157per1000 612 per 1000 (163 to ⊕(cid:13)(cid:13)(cid:13)
(1.04to14.63) 1000) Verylow9
455morepeoplehealedper1000
(6moreto1000more)
Vapour-permeable RR1.45 157per1000 228per1000 ⊕(cid:13)(cid:13)(cid:13)
dressings (0.74to2.81) (118to440) Verylow1
71morepeoplehealedper1000
(from 39fewerto283more)
*Theriskintheinterventiongroup(andits95%CI)isbasedontheassumedriskinthecomparatorgroupandtherelative
effectof theintervention(andits95%CI).
CGR:controlgrouprisk;CI:confidenceinterval;RR:riskratio
GRADEWorkingGroupgradesofevidence
Highcertainty(quality):weareveryconfidentthatthetrueeffectliesclosetothatof theestimateof theeffect
Moderatecertainty(quality):wearemoderatelyconfidentintheeffectestimate:Thetrueeffectislikelytobeclosetothe
estimateof theeffect,butthereisapossibilitythatitissubstantiallydifferent
Lowcertainty(quality):ourconfidenceintheeffectestimateislimited:Thetrueeffectmaybesubstantiallydifferentfrom
theestimateof theeffect
Verylowcertainty(quality):wehaveverylittleconfidenceintheeffectestimate:Thetrueeffectislikelytobesubstantially
differentfrom theestimateof effect
1Majorityof evidenceathighriskof bias(downgradedonce);imprecision:verywideCI(crosses0.75and1.25)(downgraded
twice).
2Imprecision:verywideCI(crosses0.75and1.25)(downgradedtwice).
3Majorityof evidenceat highriskof bias (downgradedonce);imprecision:wideCIanddirect evidenceoncollagenasefrom
threestudies,11events(downgradedonce).
4Majority of evidence at high risk of bias (downgraded once): imprecision: wide CI (crosses 1.25) and direct evidence on
dextranomerfrom onestudy,sevenparticipantsandfourevents(downgradedtwice).
5Majorityof evidenceathighriskof bias(downgradedonce);imprecision:wideCI(downgradedonce).
6Majority of evidence at high risk of bias (downgraded once);inconsistency:heterogeneityin direct evidence(downgraded
once);imprecision:wideCI(downgradedonce).
7Majorityofevidenceathighriskofbias(downgradedonce);inconsistency:significantdifferencebetweendirectandindirect
estimates(downgradedonce);imprecision:verywideCI(crossed0.75and1.25).
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 6
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
8Imprecision: wide CI (crosses 1.25);(direct evidence for protease-modulating dressing: four studies,76 participants,31
events)(downgradedonce).
9Majority of evidence at high risk of bias (downgraded once): imprecision: wide CI (crosses 1.25) and direct evidence on
tripeptidecoppergelfrom onestudy,sixparticipantsandfiveevents(downgradedtwice).
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BACKGROUND One large European study estimated a hospital pressure ulcer
prevalence(Stage2andabove)of10.5%(Vanderwee2007)whilst
aUSstudyestimatedaprevalenceof9.0%(Stage2andabove)
Descriptionofthecondition acrossacute-care,long-termcareandrehabilitation settings(the
highest prevalence of 26% was in long-term acute-care settings
Pressure ulcers, also known as pressure injuries, bedsores, decu-
(VanGilder 2009)). In the UK, national pressure ulcer data are
bitusulcersorpressure sores,arelocalisedareasofinjury tothe
collectedacrosscommunityandacutesettings(althoughdatacol-
skin,theunderlyingtissueorboth.Theyoftenoccuroverbony
lectionisnotyetuniversal)aspartoftheNationalHealthService
prominences such as the sacrum (base of the spine) and heel
(NHS)SafetyThermometerinitiative(Power2012).About4.4%
(Vanderwee2007),andarecausedbyexternalforcessuchaspres-
of patients across these settings were estimated to have a pres-
sure,orshear,oracombinationofboth(EPUAP-NPUAP-PPPIA
sureulcer(Stage2toStage4)inNovember2014(NHSQuality
2014;NPUAP2016;Dumville2015a;Dumville2015b;Keogh
Observatory2015).
2013;Walker2014).
Wenotethatalltheprevalencefiguresquotedaboveareforat-risk
Riskfactorsforpressureulcerdevelopmenthavebeensummarised
populationscurrentlyreceivingmedicalcare.Thepointprevalence
intothreemaincategories:alackofmobility;poorperfusion(e.g.
ofpressure ulcerationinthetotal adultpopulation wasrecently
diabetesandvasculardisease)andlowskinstatus(Coleman2013);
estimatedas0.31per1000population(includingStage1)(Hall
thelattercategoryincludesthepresenceofstage1pressureulcers
2014).
orincontinenceorboth,whichalsoincreasestheriskofulceration
by producing a detrimental environment for theskin (Brandeis
1994). Treatmentsforpressureulcers
Pressureulcersvaryinseverity.Oneofthemostwidelyrecognised Therearetwomainstrategiesinthetreatmentofpressureulcers,
systemsforcategorisingpressureulcersisthatoftheNationalPres- namelyreliefofpressure-commonlyusingspecialistsupportsur-
sureUlcerAdvisoryPanel(NPUAP).Theirinternationalclassifi- faces(McInnes2011;NICE2014)-togetherwithmanagement
cationrecognisesfourcategoriesorstagesofpressureulcerandtwo of the wound environment using wound dressings. Other gen-
categoriesofunclassifiablepressureinjury.Stage1ulcersinvolve eralstrategiesincludepatienteducation,painmanagement,opti-
intactskin,butStages2to4describeprogressivelydeeperwounds misingcirculation/perfusion,optimisingnutritionandthetreat-
withlargerdegreesofskinandtissueloss:Stage2pressureulcers mentofclinicalinfection(EPUAP-NPUAP-PPPIA2014;NICE
havepartial-thicknessskinlossandexposeddermis;Stage3refers 2014).Pressureulcersarenormallyexpectedtoshowsignsofheal-
tofull-thicknessskinlossandexposedfattissue;andStage4ulcers ingwithin twoweeks,butthismay notoccur andtherecanbe
havefull-thicknessskinandtissueloss,withexposedfascia,muscle, deterioration(EPUAP-NPUAP-PPPIA2014).
tendon,ligament,cartilageorbone.Thetwocategoriesofunclas-
sifiablepressureinjuryarereservedforwoundsforwhichwound
depthorextent,orboth,cannotbeaccuratelydetermined;unclas- Impactofpressureulcersonpatientsandfinancial
sifiablepressureulcersaregenerallysevereandwouldbegrouped costs
clinicallywithStage3orStage4ulcers(EPUAP-NPUAP-PPPIA Pressureulcershavealargeimpactonthoseaffected;theulcerscan
2014)(seeAppendix1forfurtherdetailsofgrading). bepainful,andmaybecomeseriouslyinfectedormalodorous.It
hasbeenshownthatafteradjustmentforage,sexandco-morbidi-
tiespeoplewithpressureulcershavealowerhealth-relatedquality
Prevalence
oflifethanthosewithoutpressureulcers(Essex2009).
Pressure ulcers are one of the most common types of complex ThefinancialcostoftreatingpressureulcersintheUKhasbeen
wound.Prevalenceestimatesdifferaccordingtothetypeofpop- estimated torange fromGBP1214 for aStage 1ulcer toGBP
ulationassessed,thedatacollectionmethodsusedandperiodof 14,108foraStage4ulcer.Costsaremainlydominatedbyhealth
datacollectionandwhetherStage1ulcerswereincluded). professionaltime,andformoresevereulcers,bytheincidenceof
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 7
Copyright©2017TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
complicationsincludinghospitaladmission/lengthofstay(Dealey orrinsedawaywithsterilesaline.Bondingtoasecondaryviscose
2012).In2004, thetotalannual costoftreatingpressureulcers padincreasesabsorbency.Examplesinclude:Curasorb(Covidien),
in the UK was estimated as GBP 1.4 to 2.1 billion, which was SeaSorb(Coloplast)andSorbsan(Unomedical).
equivalentto4%ofthetotalNHSexpenditure(Bennett2004). Capillary-action dressings consist of an absorbent core of hy-
Pressureulcershavebeenshowntoincreaselengthofhospitalstay drophilicfibresheldbetweentwolow-adherentcontactlayers.Ex-
andassociatedhospitalcosts(Allman1999).FiguresfromtheUSA amplesinclude:Advadraw(Advancis)andVacutex(Protex).
suggest that for half a million hospital stays in 2006, ’pressure Films,i.e.permeablefilmandmembranedressingsareperme-
ulcer’wasnotedasadiagnosis;foradults,thetotalhospitalcost abletowatervapourandoxygen,butnottowaterormicro-or-
for these stays was USD 11 billion (Russo 2008). Costs to the ganisms.ExamplesincludeTegaderm(3M)andOpSite(Smith&
Australianhealthcaresystemfortreatingpressureulcerationhave Nephew).
beenestimatedatAUD285millionannually(Graves2005). Foamdressingscontainhydrophilicpolyurethanefoamandare
designedtoabsorbwoundexudateandmaintainamoistwound
surface.Thereareavarietyofversionsandsomeincludeadditional
absorbentmaterials,suchasviscoseandacrylatefibres,orparticles
Descriptionoftheintervention
ofsuperabsorbentpolyacrylate,whicharesilicone-coatedfornon-
ThisreviewincludesRCTsofanydressingsortopicalagentsap- traumaticremoval.Examplesinclude:Allevyn(Smith&Nephew),
plieddirectlyontoorintowoundsandleftinsitu,asopposedto Biatain(Coloplast)andTegaderm(3M).
productsusedtoirrigate,washorcleansewoundsandthosethat Honey-impregnateddressingscontainmedical-gradehoneythat
areonlyincontactwithwoundsforashortperiod. ispurportedtohaveantimicrobial andanti-inflammatory prop-
ertiesandcanbeusedforacuteorchronicwounds.Examplesin-
clude:Medihoney(Medihoney)andActivonTulle(Advancis).
Dressings
Hydrocolloid dressings are usually composed of an absorbent
Theclassificationofdressingsusuallydependsonthekeymaterial hydrocolloidmatrixonavapour-permeablefilmorfoambacking.
usedintheirconstruction,andwhetheradditionalsubstancesare Examplesinclude:Granuflex(ConvaTec)andNUDERM(Sys-
addedtothedressing.Severalattributesofanidealwounddressing tagenix).Fibrousalternativesthatresemblealginatesandarenot
have been described (BNF 2016; Bradley 1999), including the occlusivehavealsobeendeveloped:Aquacel(ConvaTec).
abilityofthedressingto: Iodine-impregnated dressings release free iodine, which is
• absorbandcontainexudatewithoutleakageorstrike- thoughttoactasawoundantisepticwhenexposedtowoundexu-
through,inordertomaintainawoundthatismoistbutnot date.ExamplesincludeIodoflex(Smith&Nephew)andIodozyme
macerated; (Insense).
• achievefreedomfromparticulatecontaminantsortoxic Low-adherencedressingsandwoundcontactmaterialsusually
chemicalsleftinthewound; consistofcottonpadsthatareplaceddirectlyincontactwiththe
• providethermalinsulation,inordertomaintainthe wound. They can be non-medicated (e.g. paraffin gauze dress-
optimumtemperatureforhealing; ing,salinegauzedressing)ormedicated(e.g.containingpovidone
• allowpermeabilitytowater,butnotbacteria; iodineorchlorhexidine).Examplesincludeparaffingauzedress-
• optimisethepHofthewound; ing, BP1993 andXeroform(Covidien)dressing-anon-adher-
• minimisewoundinfectionandavoidexcessiveslough; entpetrolatumblendwith3%bismuthtribromophenateonfine
• avoidwoundtraumaondressingremoval; meshgauze.
• accommodatetheneedforfrequentdressingchanges; Odour-absorbentdressingscontaincharcoalandareusedtoab-
• providepainrelief;and sorbwoundodour.Oftenthistypeofwounddressingisusedin
• becomfortable. conjunctionwithasecondarydressingtoimproveabsorbency.An
exampleisCarboFLEX(ConvaTec).
There are numerous and diverse dressings available for treating
Otherantimicrobialdressingsarecomposedofagauzeorlow-
pressureulcersandtheirpropertiesaredescribedbelow.
adherentdressingimpregnatedwithanointmentthoughttohave
Absorbentdressingsareapplieddirectlytothewoundandmay
antimicrobial properties.Examplesinclude:chlorhexidinegauze
be used as secondary absorbent layers in the management of
dressing(Smith&Nephew)andCutimedSorbact(BSNMedical).
heavilyexudingwounds.ExamplesincludePrimapore(Smith&
Protease-modulatingmatrixdressingsaltertheactivityofprote-
Nephew),Mepore(Mölnlycke)andabsorbentcottongauze(BP
olyticenzymesinchronicwounds.Examplesinclude:Promogran
1988).
(Systagenix).
Alginatedressingsarehighlyabsorbentfabrics/yarnsthatcomein
Silver-impregnateddressingsareusedtotreatinfectedwounds,
theformofcalciumalginateorcalciumsodiumalginateandcanbe
as silver ions are thought to have antimicrobial properties. Sil-
combinedwithcollagen.Thealginateformsagelwhenincontact
verversionsofmostdressingtypesareavailable,includingsilver
withthewoundsurface;thiscanbeliftedoffatdressingremoval,
Dressingsandtopicalagentsfortreatingpressureulcers(Review) 8
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