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Occlusive dressings reduce or eliminate wound pain, increase the speed of reepithelialization in acute wounds and stimulate debridement and healing of chronic ulcers. During the first 10 to 14 days, a large amount of fluid may accumulate under the dressing, but this fluid is seldom the result of infection. Films, foams, hydrocolloids and hydrogels have different properties that commend them in different settings.
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One of our many roles as dermatologic surgeons is to provide wounds with a biologically favorable environment in which healing can proceed most efficiently. Over the past twenty years research in superficial wound healing has accelerated the introduction of new dressing materials. Various topical agents and occlusive inert dressings, which limit tissue death and maintain hydration, enhance epithelialization. Occlusive dressings will hasten regeneration up to twice that found in air-exposed sites. This characteristic is described in patients who have undergone dermabrasion.
BACKGROUND: Although occlusive dressings speed epithelialization, reduce inflammation and tenderness, reduce the chance of infection, stimulate healing of chronic wounds, and produce less scarring, they are still underutilized by physicians and nurses. The principal reasons for their underutilization are fear of infection, the time needed for instructing patients in their use, a lack of knowledge about occlusive dressings, and the general unavailability and high cost of the dressings. METHODS: This chapter describes the principles which help in selection of the proper dressing, discusses the mechanisms of action of occlusive dressings, lists some novel new occlusive dressings, and emphasizes some of the drawbacks of occlusive dressings for chronic wounds. CONCLUSION: While occlusive dressings have become an important treatment protocol, their role in opening the minds of clinicians to the possibility of controlling the repair process may be their greatest contribution to medical science.
BACKGROUND: Occlusive dressings have become increasingly popular in the management of wound care. Numerous types of occlusive dressings are presently available for the treatment of acute and chronic wounds. Occlusion enhances wound healing primarily by preventing wound dessication. As a result, epidermal necrosis and eschar formation do not occur, and wounds reepithelialize more quickly. OBJECTIVE: Choosing a dressing to meet the specific needs of the patient can often become confusing for the physician. We review the various types of occlusive dressings and their advantages and disadvantages in the practical management of acute and chronic wounds. METHODS: A literature review of the subject was performed. RESULTS: Occlusive dressings enhance reepithelialization by preventing wound dessication. Lower infection rates are generally achieved despite bacterial proliferation under some occlusive dressings. CONCLUSION: Occlusive dressings simplify wound care and are an excellent choice in the management of most acute and chronic wounds. This review should enable the clinician to choose the best dressing to meet the individual wound of the patient.
It is often supposed that occlusive dressings potentiate wound infection. However, even though heavy colonization by skin and wound flora is often seen under certain types of occlusion, clinical infection is not a frequent occurrence. Commensal wound flora consists of a variety of Gram-positive and Gram-negative organisms and fungi which do not appear to be detrimental to healing. Certain aspects of wound healing may in fact be promoted by bacterial colonization, although clinical infection can lead to wound breakdown and systemic infection. Wounds compromised by devitalized tissue, drains or sutures are more susceptible than clean wounds to clinical infection. Occlusive dressings may help prevent infection by presenting a barrier to potential pathogens, and hydrocolloid occlusive dressings have been shown to prevent dissemination of methicillin-resistant Staphylococcus aureus. The rate of clinical infection as deduced from published trials of dressings is lower under occlusion than when non-occlusive dressings are used, and this is likely to be a result of normal activity of the host defences under occlusive dressings.
This review discusses the microbiology of normal skin and wounds and examines the rates of infection reported under both conventional (nonocclusive) dressings and all occlusive dressings, together with cost factors. The overall infection rate under conventional dressings was 7.1% in 1085 wounds, whereas under occlusive dressings on 3047 wounds the rate was 2.6%. In studies in which the two dressing types were directly compared, the respective rates were 7.6% and 3.2%. The reasons for this difference may include both dressing-specific and host-specific factors, and these factors are discussed.
Because occlusive dressings and some creams have been found to speed epithelialization of blade-induced wounds, we studied the effect of two occlusive dressings and a polyglycerylmethacrylate cream containing low concentration of fibronectin on epithelialization in second-degree burn wounds. Cylindrical brass rods were heated in a boiling water bath, removed, wiped dry, and placed (6 sec) on the skin of domestic pigs. The burned epidermis was removed and each burn wound was assigned to one of the following treatment groups: (1) air-exposed, (2) DuoDERM (hydrocolloid dressing; Squibb Co., New Jersey), (3) Opsite (polyurethane dressing; Smith & Nephew, New Jersey), or (4) experimental cream. Several burn wounds were excised from each treatment group on Days 6 to 14 after wounding. The excised burn wounds were incubated in 0.5 M NaBr for 24 hr which allowed separation of the epidermis from the dermis. The epidermis was examined macroscopically for defects in the area of the burn. Specimens were considered healed when a defect was not present. Neither of the occlusive dressings changed the rate of epithelialization as compared to air exposure. Wounds which were treated with the experimental cream epithelialized faster than the air-exposed wounds (P less than 0.025).
BACKGROUND AND DESIGN: The use of occlusive dressings on partial-thickness wounds has been shown to promote early epithelization and connective tissue regeneration. Because Langerhans cells (LC) have been implicated in epidermal homeostasis we studied the rate of repopulation of LC in air-exposed vs occlusively dressed wounds. Partial-thickness wounds on the backs of pigs were treated with occlusive dressings (Tegaderm) for 3 days or left air exposed. On days 3, 5, 7, and 11 after keratome wounding, epidermal sheets from the regenerating wounds were isolated and stained for LC using indirect immunofluorescence. The LC populations were quantified in the interfollicular regions and expressed as average number of cells per square millimeter of epidermis. RESULTS: Normal skin control had 1024 +/- 93 LC/mm2 distributed uniformly. On day 3 after wounding occlusive-dressing-treated wounds had an LC repopulation of 46% of the original value. Langerhans cells in air-exposed skin could not be evaluated until epithelization occurred at day 5. Langerhans cells in both air-exposed and occlusive-dressing-treated wounds were 46% to 51%, 65% to 71%, and 91% of normal value, respectively, on days 5, 7, and 11. CONCLUSIONS: We conclude that at least in regenerating epidermis, the degree of repair of the new epidermis apparently plays a limited role in the migration of LC, as does the earlier growth of blood vessels.
This project compared the effects of hydrocolloid (HC) and hydrogel (HG) occlusive dressings and a polyethylene (PE) semi-occlusive dressing on the healing of acute full-thickness skin wounds on the forelimbs of 10 dogs. All treatments resulted in a similar degree of healing at postoperative days 4 and 7. No significant differences existed in the number of wounds that were more than 90% healed at postoperative day 28 between the group treated with the HG dressing and the group treated with the PE dressing. There were significantly fewer wounds more than 90% healed at postoperative day 28 in the group treated with the HC dressing. Wounds under the HG dressing had the largest mean percentage of contraction at postoperative days 21 and 28. Wounds under the HG dressing also had the largest contraction/re-epithelialization ratio (postoperative days 21 and 28) compared with wounds under the PE and HC dressings. Wounds under the PE dressing had a significantly higher mean percentage of re-epithelialization than wounds under both occlusive dressings on postoperative days 14, 21, and 28. Wounds under the two occlusive dressings had exuberant granulation tissue present more often than wounds under the PE dressing. The two occlusive dressings had significantly higher bacterial counts on wounds compared with wounds under the PE dressing; analysis of variance (ANOVA), P = .0008. Wounds under the HC dressing showed the poorest healing in all parameters.
We prospectively studied 174 patients on whom 226 unsutured parallel incisional (shave) and 3-mm punch skin biopsies were performed. Two wound-care programs, occlusive dressing therapy and conventional therapy, were compared. The biopsy sites were evaluated after 1 or 2 weeks for healing, pain, and infection. We found that healing was unrelated to the indication for biopsy or the patients' age, gender, or race. Occlusive dressing therapy-treated shave biopsy sites were 3.83 times more likely to be healed than those treated with conventional therapy. Regardless of the treatment method, a facial shave biopsy site was 3.6 times more likely to be healed than a biopsy site in other locations. No punch biopsy site had healed after 1 week. At 2 weeks, only 7% and 36% of conventional therapy- and occlusive dressing therapy-treated punch biopsy sites, respectively, had healed. Pain at the biopsy site was six times more common in both shave and punch biopsy sites treated with conventional therapy. The absence of pain with occlusive dressing therapy was significant for both types of biopsy. One punch biopsy site treated with conventional therapy became infected, and one treated with occlusive dressing therapy was suspected of being infected. Forty patients, who had biopsy sites treated with both therapies, preferred occlusive dressing therapy over conventional therapy by a ratio of 3:1 because of ease of wound care and lack of pain. We conclude that occlusive dressing therapy may be the wound management of choice for shave biopsy sites. Since punch biopsy sites do not heal readily, it may be more appropriate to suture them, at least until therapies are developed that more effectively speed their healing.
We evaluated a novel octylcyanoacrylate-based liquid occlusive dressing for partial-thickness wounds. One hundred and fifteen standardized wounds were created with an electric dermatome set at a depth of 600 micro on the flanks of three pigs and randomly treated with liquid occlusive dressing, a hydrocolloid dressing, or gauze. In one pig, wounds were swabbed with Staphylococcus aureus. Biopsies were taken after 4, 5, 6, and 21 days. Hemostasis was obtained in all wounds treated with the liquid occlusive. The percent reepithelialization of wounds treated with the liquid occlusive and hydrocolloid dressings were significantly greater at days 4 and 5 than control wounds (78% and 82% vs. 40%, p < 0.001 and 99% and 100% vs. 72%, p < 0.001, respectively). None of the liquid occlusive-treated wounds challenged with bacteria became infected. Foreign body reactions were least common in wounds treated with the liquid occlusive (p < 0.001). Scar depth was less for liquid occlusive- and hydrocolloid-treated wounds than controls (285 micro and 303 micro vs. 490 micro, p < 0.001). We conclude that excisional wounds treated with the liquid occlusive dressing reepithelialize as quickly as hydrocolloid-treated wounds. The liquid occlusive dressing is an effective microbial barrier and hemostatic agent resulting in fewer foreign body reactions than hydrocolloid-treated wounds or controls.
Two occlusive dressings--one zinc oxide medicated (Mezinc) and one hydrocolloid (Duoderm)--were compared in a prospective, randomized trial over a period of 8 weeks to determine their healing ability and effect on pain for venous and arterial leg ulcers. All patients were patch-tested before the study and colophony allergy was an exclusion criterion. Of the 43 outpatients included, 31 completed the trial and 6 patients randomized to each treatment group were withdrawn. The initial ulcer areas decreased after 8 weeks of treatment with Mezinc by 64% and by 48% after treatment with Duoderm. Ulcer pain was relieved in 50% of the patients--with a similar analgesic effect for the two dressings. Mezinc treatment was discontinued in 2 cases due to sensitization to colophony (one ingredient of Mezinc) which indicated a risk of contact allergy to colophony due to Mezinc treatment. 1103 consecutive eczema patients were patch-tested on the back with Mezinc and colophony 20% in petrolatum simultaneously. It was found that 42 (4%) of the patients showed allergic skin reactions to colophony and 19 (2%) to Mezinc. Both dressings were well tolerated by leg ulcer patients and there appeared to be no major differences in the efficacy of the two occlusive dressings.
Although the use of occlusive dressings in adults has been criticized in the literature, there has been little written on their use in the pediatric population. Management of dressing sites requires nursing judgement unique to this population. This study focused on the progression of microbial colonization and signs of inflammation occurring beneath repeated occlusive dressings applied to central venous catheter (CVC) insertion sites among 104 hospitalized children (neonate to 18 years). A noninvasive skin culture was obtained within 24 hours of CVC placement, 3 to 7 days later before the next routine dressing change, and at the time the CVC was discontinued or the child was discharged, whichever occurred first. Results showed a significant increase in microbial growth (p < or = .001) at the second dressing change, when serosanguinous drainage was heaviest, and continued significant growth (p < or = .001) when the dressing was discontinued. This microbial growth pattern was curious in the face of a 0.3% systemic sepsis rate. When neonates under 1,800 g were excluded from calculation, the pattern was not notable (p = .2119). Findings suggest the use of occlusive dressings during prolonged hospitalization for tunnelled CVCs does not lead to increased site infections in children over 1,800 g.
The efficacy of hydrocolloid occlusive dressing technique was compared with that of the conventional wet-to-dry gauze dressing technique in decubitus ulcer of stage I and II. Forty-four patients were randomly divided into two treatment groups and each received treatment according to the two different protocols. As a result, 80.8% of the hydrocolloid occlusive dressing group (group 1) and 77.8% of the conventional wet-to-dry gauze dressing group (group 2) healed completely with no statistically significant difference between the two groups. However, the time required for complete healing was shorter in group 1 with 18.9 days compared to 24.3 days in group 2. Ulcer healing speed was also slightly faster in group 1 with 9.1 mm2/day compared to 7.9 mm2/day for group 2. Average treatment time spent by a medical staff member was significantly shorter in group 1 with 20.4 minutes/day compared to 2017 minutes/day in group 2. The hospital cost of the ulcer treatment was higher in group 2 compared to group 1 even without taking into consideration the medical personnel's labor cost. These results indicate that the hydrocolloid occlusive dressing technique offers less time consuming and less expensive method of treatment compared to the conventional technique in stage I and II decubitus ulcers.
OBJECTIVE: To study the efficacy of electrolyzed oxidizing water (EOW) and hydrocolloid occlusive dressings in the acceleration of epithelialization in excised burn-wounds in rats. METHODS: Each of the anesthetized Sprague-Dawley rats (n=28) was subjected to a third-degree burn that covered approximately 10% of the total body surface area. Rats were assigned into four groups: Group I (no irrigation), Group II (irrigation with physiologic saline), Group III (irrigation with EOW) and Group IV (hydrocolloid occlusive dressing after EOW irrigation). Wounds were observed macroscopically until complete epithelialization was present, then the epithelialized wounds were examined microscopically. RESULTS: Healing of the burn wounds was the fastest in Group IV treated with hydrocolloid occlusive dressing together with EOW. Although extensive regenerative epidermis was seen in each Group, the proliferations of lymphocytes and macrophages associated with dense collagen deposition were more extensive in Group II, III and IV than in Group I. These findings were particularly evident in Group III and IV. CONCLUSIONS: Wound Healing may be accelerated by applying a hydrocolloid occlusive dressing on burn surfaces after they are cleaned with EOW.
Fifty patients with refractory psoriasis were treated with a combined method consisting in the application of occlusive dressings with Locacorten Tar ointment at night and of 'open' treatment (without occlusive dressings) with Locasalen ointment during the day. The aim of this trial was to obtain the benefit of the occlusive-dressing method without having to hospitalize the patients. The mean time required for the eradication of psoriatic scales was 3.46 days, while that needed for complete recovery was 14 days. The results clearly indicated that this combined approach has all the advantages of occlusives dressings but allows the patient greater freedom during the day. The very good effect of the treatment is also attributable to the triple action obtained with this combination: the anti-epidermoplastic effect of flumethasone pivalate, the squamolytic effect of salicylic acid, and the keratoplastic action of the tar compound.