Using a silicone-based dressing as a primary wound contact layer
Abstract
The use of silicone-based dressings as a primary contact layer for wound care can prevent epithelial stripping, pain and sensitivity and have been widely available for nearly 20 years. Cuticell Contact from BSN medical is the latest silicone-based dressing to add to the armoury of the wound care clinician. Using documented case studies the author explores the reasoning behind why clinicians should consider re-examining the use of silicone dressings. Key words: Moist wound healing ■ Primary contact layer ■ Silicone ■ Assessment ■ Transparent
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odays’ clinicians need to take a strategic approach when considering wound assessment and dressing selection. To achieve optimum outcomes, factors such as moist wound healing, wound-bed preparation, accurate wound assessment and appropriate pain control are all areas that require close attention before dressing selection should even be considered. Moist wound healing promotes an optimum healing environment for the process of autolytic debridement and formation of granulation tissue without letting a wound bed dry out (Winter, 1962). Clinicians adopting this approach to wound care have documented wounds healing up to 40% faster and the clear benefits this has to the patient (Jones, 2005; Bolton, 2007; Benbow, 2008). Wound bed preparation has been explored extensively since 2003 with useful tools such as the Applied Wound Management trio of assessment tools or continuums (wound healing, infection and exudate) (Grey et al, 2004) or the TIME assessment framework (Schultz et al, 2003; Falanga, 2004; Dowsett and Newton, 2005; Ligresti and Bo, 2007.) They instruct clinicians to assess wounds using criteria that can identify problems while using descriptors such as wound colour, exudate, and signs of infection, that can help to accurately document and assess ongoing cases. By rethinking an approach to wound care in this way problems with
Adam Derbyshire, Senior ANP, Albany House Medical Centre,Wellingborough, Northamptonshire Accepted for publication: October 2014
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wound colour, exudate and infection can be identified before dressing selection and application. In all cases clinicians need to accurately measure a wound so they can consider if a wound care treatment is being successful at future assessments, but emphasis is now focused on the steps the clinician should take before dressing. The following issues should be considered: ■■ Is the wound acute, chronic, or will it heal with primary or secondary intention? (Alves et al, 2009) ■■ Are there any pre-disposing factors such as diabetes, hypertension and anaemia? (Constantinides J et al, 2006) ■■ Are there visible signs of infection in the wound, debris or slough that needs to be removed, or excess exudate levels that are putting healthy skin in danger of being compromised? (Schultz et al, 2003. Thompson, 2005). Exudate levels should not be overlooked in any wound assessment. Increased exudate often indicates infection and the need for secondary intervention. Poor exudate management has also been shown to have both a physiological and psychological impact on patients (Selby, 2009; Upton and South, 2011; Wounds UK, 2013), and can cause excoriation and maceration to peri-wound skin, which can lead to increased wound size (Collier 2000; Cutting and White, 2002; Cameron 2004, Selby 2009). Heavy exudate levels, such as in traumatic or infected wounds, are the main reason why some dressings fall off (Jones, 2006) so the clinician needs to be experienced enough to judge the correct time to change the dressing and prevent accidental exposure or risk of introduced infection (Rippon et al, 2007). When choosing the ideal dressing the clinician should also consider if the product protects and insulates the wound, encourages a moist environment to aid with healing, absorbs excess exudate with a gaseous exchange mechanism, is nontoxic, cost effective, sterile, with added antimicrobial effect (if required) and is easy to remove (Constantinides et al, 2006; Dykes, 2007; Rippon et al, 2008). Clinicians should therefore carefully consider the dressings they elect to use on the patient. Previous dressing regimes should be discussed and any allergies identified. Patient compliance with previous dressing combinations should also be explored to ensure a positive outcome for the patient and prevent any avoidable concordance issues. Dressings can be classified as adherent, low adherent or non-adherent (Thomas, 1994), or the newer designation of atraumatic, where a dressing will not strip skin or cause trauma on newly granulating tissue or wound margins (Thomas, 2003a; Rippon et al 2008; White, 2014).
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Adam Derbyshire
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Adhesive dressings have been shown to cause skin trauma and epidermal cell stripping from repeat application and removal under laboratory conditions (Waring et al, 2011) with localised skin reactions, heightened sensitivity, pain and distress being identified in the test subjects (Dykes & Heggie, 2003. Zillmer et al, 2006. Lawton & Langoen, 2009). The use of barrier protection can reduce the stripping of these skin cells when dressings are removed (Krasner, 2001), however, clinicians should always adopt a regime that causes minimal trauma and pain to the patient as research has shown increased stress from pain can actually slow down wound healing rates (Upton et al, 2012a; Upton et al 2012b).
Wound pain Accidental trauma to the wound bed and margins during dressing change can alter a clinician/patient relationship from one of trust to one of poor concordance. The damage may increase pain for the patient and result in larger wound size and longer healing time (Hollinworth and White, 2006; Upton et al 2012a). In the late 1990s, it was suggested that nurses often dismissed the significance of wound pain (Hollinworth, 1999). To address this educational shortfall the European Wound management Association (EWMA) and the World Union of Wound Healing Societies (WUWHS) (EWMA, 2002; WUWHS, 2004) and a best practice statement on minimising trauma and pain in wound management (Gray, 2004) suggesting clinicians assume all wounds have the potential to be painful. The measurement of pain can be recorded with the visual use of pain scales (Reddy et al, 2003), Krasner, 2001) or more formal measurement tools such as Hollinworth’s (2005) template for the assessment of wound related pain or any of the useful templates available online at less-pain.com providing clinical frameworks for clinicians to help measure ongoing patient pain and pain at dressing change. However, pain scales and templates should not replace the initiative of the skilled clinician. If a patient is wincing before even being touched, or pulling their wound away, the chances are their pain is not controlled and analgesia may need to be considered, or they may have had a bad experience at a previous dressing change. In these cases pain has been shown to be more pronounced (Woo, 2010) and leads to additional stress and anxiety (EWMA, 2002; WUWHS, 2004; Solowiej et al, 2009; Solowiej et al, 2010; Upton and Solowiej, 2012). In these situations extra time, care and attention on the part of the clinician will be required to ensure that patient confidence can be restored. In some cases stopping the dressing procedure altogether and discussing a patient’s concerns before proceeding may seem ‘time expensive’ in a busy caseload schedule, but it may also form a sound framework for more efficient care and partnership later down the line. Individual pain management plans can be incorporated into the care package (Solowiej et al, 2010; Richardson, 2012) as a patient in no pain will have improved quality of life and lower anxiety at dressing change resulting in better adherence and time savings (Goode, 2004; Timmons
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et al, 2009). Trauma has also been shown to be reduced with soft silicone dressings as a primary contact layer (Kammerland and Eberlien, 2002).
Silicone as a primary layer Primary contact layers are not designed to be absorbent, but are instead engineered to allow exudate to pass through the dressing into an absorbent layer beyond (Meuleneire & Rucknagel, 2013). The benefits of using silicone as a primary layer in wound dressing include increased comfort, minimal adhesion, low trauma, low toxicity, flexibility, safety of use, longer wear time, cost effectiveness and pain reduction at dressing change (Dykes et al, 2001; Dykes and Heggie, 2003; So et al, 2003; Thomas, 2003a; Thomas, 2003b; Black et al, 2012). Silicone dressings have also been used on just about every wound variant imaginable in published text: Burns and Skin Grafts (Volemans and Kries, 1994; Platt et al, 1996; Bugmann et al, 1998; Durani and Ferguson, 2006; Edwards, 2009; Edwards, 2011), radiation burns (Adamietz et al, 1995; MacBride et al, 2008), accidental wounds in paediatric cases (Morris et al, 2009), ulcerated heels (Hampton, 2010), pressure ulcers (Meaume et al, 2003), leg ulcers (Gates, 2000), fungating wounds (Taylor, 1999;Young, 1999), Epidermolysis bullosa cases (Schober-Flores, 1999) and scar management (Mustoe et al, 2002). The first ‘silicone’ type primary dressing was tulle gras, incorporating a mesh design that reduced pooling and maceration caused by exudate levels. However, it often stuck and caused trauma on removal (Krasner, 1991). Safetac technology (Molnlycke) was created to counter this problem with the introduction of Mepitel (Meuleneire, 2002). Mepitel was shown to reduce pain and trauma at dressing change (Gotschall et al, 1998; Dahlstrom, 1995; Williams, 1995). Other silicone variants have followed including meshes such as Adaptic (Systagenix) (Bianchi and Gray, 2011; Romanelli et al, 2013) or silicone-coated foams for different levels of exudate such as Mepilex (Molnlycke) or Eclypse (Advancis Medical) (Rafter, 2011).
Wear time Meuleneire and Rucknagel (2013) suggest it is acceptable to leave a silicone primary dressing in place for a minimum of 5 days, with White (2014) recommending 7–10 days. Fourteen days without change is now a selling point from manufacturers of Mepitel and Mepitel One (Molnlycke) (Barrett, 2012) and Cuticell Contact (BSN medical, 2014). The transparent nature of the dressings mean that wounds can be observed without the need for change, and therefore the wound bed remains undisturbed and is allowed to heal of its own accord. The author recognises that frequent dressing changes incur costs and being able to see through silicone primary layers can prevent unnecessary removal and save money. As clinicians we should also understand that wear time relates to several contributing factors: exudate levels, infection, licensing information of a dressing product, the fragility of the skin and our own wound observations (Campbell et al, 2003; Hampton and Steven Haynes, 2005)
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Adhesive dressings
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PRODUCT FOCUS Cuticell Contact Cuticell Contact is the new silicone primary contact dressing from BSN medical that was introduced in Europe at the end of 2013 as a cost-effective alternative to similar silicone wound contact layers on the market. BSN medical state the silicone layer is suitable for superficial abrasions, skin damage caused by steroid atrophy or fragile skin, graft sites, post-operative care, second-degree burns and hypergranulating wounds. It offers the user a 14-day wear time dependant on wound type (BSN medical, 2014). There is limited further supporting literature available at the time of writing this review. On initial appearance the dressing looks remarkably similar to any other silicone wound contact layers on the market, however, it has larger porous holes on the surface. The manufacturer states this allows thicker exudate that could normally clog traditional silicone dressings to pass through, away from the wound bed and into the secondary dressing, thereby reducing maceration (Hallern, 2014). The second important aspect of the dressing only becomes apparent when you touch it. The dressing is only sticky on one side.This means unlike most competing silicone dressings it is extremely unlikely that an absorbent secondary dressing pad could adhere to the adhesive of the primary dressing and come away unintentionally when the secondary layer is being changed. This initiative also adds to ease of application as the dressing does not stick to the clinician’s gloves. The manufacturer suggests the adhesive is sensitive to the surface it is applied to, only sticking to the edges of wounds and not to the moist wound bed, while maintaining granulation by fostering a moist wound environment, with the resulting seal encouraging exudate to pass through the pores and not to creep across surrounding skin (Hallern, 2014) Directions for use specify that the surface of any wound is cleansed and the dressing is applied adhesive side down with an overlapping edge of not more that 2 cm. An adhesive dressing or retention bandage with a suitable absorbent layer should be used to secure the dressing in place (Hallern, 2014). It is made clear that in the case of a wound that is larger than the dressing, care should be taken by the clinician to ensure that there is no overlap of silicone dressing as this could inadvertently block the drainage pores and cause unwanted maceration caused by exudate build up. The dressing comes in the following sizes: 5 x 7.5 cm, 7.5 x 10 cm, 10 x 18 cm and 15 x 25 cm. The following three case studies were carried out in August/ September 2014 using the new dressing. The author agreed with BSN medical that the trial should be for a minimum of 2 weeks. However, patient response was such that some of these cases are still ongoing as the patients felt comfortable with the new regime.
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Case study 1 Mr B is a 35 year-old male with no pre-disposing factors or concerns regarding poor healing. He sustained a burn on his arm while cooking. Mr B was initially treated with a hydrocolloid dressing for 2 days before seeing the author. Unfortunately exudate levels from burn were such that the dressing came away and leaked, much to Mr B’s embarrassment. He reported that the wound was painful and felt hot.
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Figure 1. Case study 1
On assessment the wound was approximately 1.5 cm x 4.5 cm (Figure 1a) and was cleaned with normal saline before Cuticell Contact was applied as a primary contact layer (Figure 1b) with an adhesive padded dressing to secure it. The dressing was easy to apply and trim to size leaving an overlap as specified by manufacturer instructions. Mr B was advised to return for a dressing change and booked a consultation for 5 days later. Mr B discussed the wound the day after Cuticell Contact was applied with the author as he had to return to the surgery for another reason. He explained that he felt the dressing was much cooler with the new dressing regime on and that it had
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taken the heat out of the burn (this could also be because the inflammatory response was abating, as usually happens 3 days into the healing process). Mr B believed his pain levels were reduced and he felt happy with the dressing in place. This is a common occurrence when dressing a wound as research shows patient’s often report an analgesic effect when dressings are applied (Richardson, 2010). The wound was finally reviewed after 5 days (Figure 1c) and declared healed and the regime was stopped.
Case study 2 Ms K is a 37-year old female who was experiencing a bad case of weeping eczema of the ears. She attended surgery on 1 September 2014 with exudate dripping down the sides of her face and her long hair sticking to her ears. Every time she tried to move her hair from her ears the skin tore creating many small lacerations. Ms K was also allergic to both penicillin and erythromycin, with prescribed steroid and antibiotic lotions simply sliding off the soaked ears, making the situation even worse. Exudate was dribbling down Ms K’s face at the time of assessment and the ears were swollen and inflamed (Figure 2a). She was worried about client reactions to her appearance and the lacerations on her ears were very uncomfortable. She was also unable to sleep because of the skin sticking. There were multiple areas of trauma that were all very small but oozing. Ms K stated her ears felt more comfortable once the dressings were applied (Figure 2b).The silicone primary contact layer was able to cushion the fragile skin and protect it from anything sticking, and the holes in the dressing allowed exudate to pass straight through into the gauze envelope applied (Figure 2c). She was given instructions on how to change dressings as required. Ms K reported back that she had to change the gauze dressings frequently throughout the day but the primary dressing remained soothing. Hair was no longer sticking to her ears and creating fresh trauma. The swab result came back positive for streptococcus infection 2 days later and she was able to commence on a suitable antibiotic regime. Ms K returned on 11 days later. Her ears had dried up following antibiotic therapy and protection from further trauma.
Case study 3 Mr G is a 52-year-old male. He was found unconscious in the road following a possible hit and run in early August. He had sustained a large wound situated at the thoracic spinal level of his back (adjacent to T7-T9). Patient notes revealed
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he was put on antibiotics in the accident and emergency department, possibly because of the condition of the wound. Mr G refused to remain in hospital because of his lifestyle choices and elected to attend the surgery for treatment. Staff wanted to admit him back to hospital but he refused. The wound dressing regime from the hospital consisted of amorphous hydrogel and a hydropolymer adhesive dressing. Mr G attended surgery on an ad-hoc level and often failed to attend. The author was invited to assess the wound on 22 August 2014 (Figure 3a) to find the current treatment was not managing the wound in its present condition. The wound measured approximately 9 cm x 6 cm and was heavily filled with dead tissue. After discussion with Mr G it was decided that sharps debridement was an option to ascertain the true size of the wound and reduce the exudate levels (Figure 3b). Anyone considering sharp debriding should be suitably trained for removing such tissue before attempting to remove it (Benbow, 2008b). After the removal of the initial layer of dead tissue (Figure 3c) the wound was cleansed with saline, before applying Cuticell Contact (Figure 3d) and then securing the dressing with padded adhesive dressings to manage any exudate that came away (Figure 3e). Mr G returned on 4 days later and the wound was now ready for further surgical debriding (Figure 3f). Following debridement the wound was much cleaner (Figure 3g). Mr G was asked how he was finding the dressing regime. His response was that it felt cool and comfortable on his back. The dressing was easy to remove as it did not stick, and appeared to keep the wound moist but not soaking wet, as it was on initial presentation. The author also noted the ease at which more viscous exudate passed through the perforations of the dressing. The dressing even stayed in place over weekends (Figure 3h) and the author was able to observe the wound without removing the dressing so that a decision could be made regarding dressing change (Figure 3i). Owing to improvement over the 2-week product evaluation (Figure 3j), it was requested that Mr G continue on this dressing regime. It could be argued that the patient should have been sent to hospital despite his wishes, however, respecting patient choice and staying with the regime appears to be allowing his wound to heal without undue complication. More importantly, Mr G is attending regularly for dressing change. Whether this is due to the comfort of the dressing or the visible results is unclear. Care continues.
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Figure 2. Case study 2
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PRODUCT FOCUS Conclusion Silicone primary layer dressings have been in use for the last 20 years. Their use has been recommended as a first-line treatment (Mustoe et al, 2002) and has been shown to help reduce trauma and pain in patient care (Black et al, 2012), fulfilling nationally respected documents and guidelines on pain at dressing change (EWMA, 2002;WUWHS, 2004; Gray, 2004). As a primary dressing it is safe to remain in situ for up to 14 days (subject to secondary dressing change) (Barrett 2012; Hallern, 2014) and nothing toxic is absorbed from the primary dressing into the skin (White, 2014) Cuticell Contact is lower in cost per unit than other popular silicone wound contact layers on the drug tariff and continues this tradition as an alternative to current treatments with larger drainage holes, single-sided adhesive and transparency to enable the clinician to view the wound bed without disturbing the BJN primary dressing (Hallern, 2014).
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Conflict of interest: This article was supported by BSN medical Adamietz I, Mose S, Haberl A, Saran F, Thilmann C, Bottcher H (1995) Effect of self-adhesive, silicone-coated polyamide net dressing on irradiated human skin. Radiation Oncology Investigations 2(6): 277-82. doi: 10.1002/roi.2970020605 Alves J, Angeloni A, Arkadiusz J, Vanscheidt W, White R (2009) Guidelines for the treatment of acute minor skin wounds: A consensus by leading European experts. Mims Dermatology 5(2): I-VI Barrett S (2012) Mepitel One: a wound contact layer with safetac technology. Br J Nurs 21(21): 1271-7 Benbow M (2008a) Exploring the concept of moist wound healing and its application in practice. Br J Nurs 17(15): S4-S8 Benbow M (2008b) Selecting a Method for Wound Debridement. Mims Dermatology 4(2): 50-1 Bianchi J, Gray D (2011) ADAPTIC Touch non-adherent dressing. Wounds UK 7(1): 120-3 Black J, Clark M, Alves P et al (2012) Consensus statement. Global evidence based practice recommendations for the use of wound dressings to augment pressure ulcer prevention protocols. http://tinyurl.com/qyqfmck (accessed 23 October 2014) Bolton L (2007) Operational definition of moist wound healing. J Wound Ostomy Continence Nurs 34(1): 23-9 BSN Medical (2014) Data on file, (available on request) Bugmann P, Taylor S, Gyger D et al (1998) A Silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: a prospective randomized trial. Burns 24(7): 609-12 Cameron J (2004) Exudate and care of the peri-wound skin. Nurs Stand 19(7): 62-8 Campbell K, Keast D, Woodbury G, Houghton P (2003) Wear time in two hydrocolloid dressings using a novel in-vivo model. Wounds 15(92): 40-8 Collier M (2000) Management of patients with fungating wounds. Nurs Stand 15(11): 46-52 Constantinides J, Mahmood M, Georgeu G, Street L (2006) Hospital at Home a plastic surgery/burns model. Mims Dermatology 2(3): 2006 Cutting K, White R (2002) Maceration of the skin and wound bed: Its nature and causes. J Wound Care 11(7): 275-8 Dahlstrom K (1995) A new silicone rubber dressing used as a temporary dressing before delayed split grafting. A prospective randomised study. Scand J Plast Reconstr Surg Hand Surg 29(4): 325-7 Dowsett C, Newton H (2005) Wound bed preparation: TIME in practice. Wounds UK 1(3): 48-70. http://tinyurl.com/mnyksuu (accessed 23 October 2014) Durani P, Ferguson M (2006) Developments in burn scar therapy. Mims Dermatology 2(1): 12. http://tinyurl.com/lpty8cq (accessed 23 OCtober 2014) Dykes P (2007) The effect of adhesive dressing edges on cutaneous irritancy and skin barrier function. J Wound Care 16(3): 97-100 Dykes P, Heggie R, Hill S (2001) Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care 10(2): 7-10 Dykes P, Heggie R (2003) The link between the peel of forces of adhesive dressings and the subjective discomfort in volunteer subjects J Wound Care 2(7): 260-2 Edwards J (2009) The use of Silflex in burn wound management. Br J Community Nurs 14(9): S32-6 Edwards J (2011) Managing wound pain in patients with burns using soft silicone dressings Wounds UK 7(4):122-6. European Wound Management Association (2002) Position document: Pain at wound dressing changes. http://tinyurl.com/26unm9q (accessed 23 October 2014) Falanga V (2004) Position document: Wound bed preparation in Practice. http://tinyurl. com/k5luouo (accessed 23 October 2014) Gates A (2000) The use of a non-adherent silicone dressing in arterial leg ulceration. J Wound Care 9(2): 79-81 Goode M (2004) Psychological needs of patients when dressing a fungating wound: a literature review. J Wound Care 13(9): 380-2 Gotshall C, Morrison M, Eichelberger M (1998) Prospective, randomized study of the efficacy of Mepitel on children with partial thickness scalds. J Burn Care Rehabil 19(4): 279-83 Gray D (2004) Best Practice Statement: Minimising Trauma and Pain in Wound
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Figure 3. Case study 3
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KEY POINTS n The
use of silicone as a primary contact layer has been available for clinicians to use for the last 20 years
n Silicone
has been shown to be non-adherent to a moist wound bed and is less painful when removed
n Clinicians
should ensure a full assessment is undertaken of any wound, including the patient’s perception of pain and consider steps to address it
n All
wounds are painful
n Using
moist wound healing principles wounds have been shown to heal up to 40% faster
Management. Wounds UK, Aberdeen. Gray D, Jones V, White R et al (2004) Wounds UK Applied Wound Management Supplement. Wounds UK, London. http://tinyurl.com/lg9n3zx (accessed 24 October 2014) Hallern B (2014) Preventing hypergranulation, protecting epithelialisation cuticell contact silicone impregnated dressing for secondary healing, traumatic and chronic wounds BSN Medical (reference material) Hampton S, Steven-Haynes J (2005) ‘Skin maceration: assessment, prevention and treatment’. In: White R (ed.) Skin Care in Wound Management: Assessment, Prevention and treatment. Wounds UK, Aberdeen: 87-109 Hampton S (2010) An evaluation of a silicone adhesive shaped heel dressing Br J Nurs 19(6 Suppl): S30-3 Hollinworth H (1999) Conflict or diplomacy. Nursing Times 95(34): 63-8 Hollinworth H (2000) Pain and wound care .Wound Care Society Educational leaflet 7(2). Wound Care Society Hollinworth H (2004) An Overview of Trauma and pain Issues in the UK Best practice statement Minimising Trauma and Pain in Wound Management.Wounds UK, Aberdeen: 3-4 Hollinworth H (2005)Pain at wound dressing-related procedures: a template for assessment. World Wide Wounds. http://tinyurl.com/qpx9cs (accessed 24 October 2014) Hollinworth H,White R (2006) ‘The clinical significance of wound pain.’ In:White R, Harding K (eds) Trauma and Pain in Wound Care .Wounds UK, Aberdeen: 3-16. http://tinyurl.com/kozglrs (pdf - accessed 23 October 2014) Jones J (2005) Winter’s concept of moist wound healing: a review of evidence and impact on clinical practice. J Wound Care 14(6): 273-6 Jones V (2006). The use of gauze: will it ever change? Int Wound J 3(2):79-86 Kammerlander G, Eberlein T (2002) Nurses’ views about pain and trauma at dressing changes: a central European perspective. J Wound Care 11(2): 76-9 Krasner D (1991) An approach to treating skin tears ostomy wound management. Ostomy Wound Manage 32: 56-8 Krasner D (2001) Caring for the person experiencing chronic wound pain. Chronic Wound Care. HMP Publications, Wayne, Pa Lawton S, Langoen A (2009) Assessing and managing vulnerable periwound skin. Worldwide wounds. http://tinyurl.com/6sgnea5 (accessed 23 October 2014) Ligresti C, Bo F (2007) Wound bed preparation of difficult wounds: An evolution of the principles of TIME. Int Wound J 4(1): 21–9 MacBride S, Wells M, Hornsby C et al (2008) A case study to evaluate a new soft silicone dressing Mepilex Lite, for patients with radiation skin reactions. Cancer Nurs 31(1): E8-14. doi: 10.1097/01.NCC.0000305680.06143.39. Meaume S, Looverbosch D, Heyman H et al (2003) A study to compare a new selfadherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Manage 49(9): 44-51 Meuleneire F (2002) Using a soft silicone-coated net dressing to manage skin tears. J Wound Care 11(10): 365-9 Meuleneire F, Rucknagel H (2013) Soft silicones made easy. Wounds International May: 1-6 Morris C, Emsley P, Marland E et al (2009) Use of wound dressings with soft silicone adhesive technology. Paediatr Nurs 21(3): 38-43 Mustoe T, Cooter R, Gold M et al (2002) International clinical recommendations on scar management. Plast Reconstr Surg 110(2): 560-71 Platt A, Phipps A, Judkins K (1996) A comparative study of silicone net dressing and
paraffin gauze dressing in skin grafted sites. Burns 22(7): 543-45 Rafter L (2011) Management of acute cellulitis with the Eclypse Boot. Wounds UK 7(4): 62–8 Reddy M, Khor R, Queen D, Keast D, Sibbald R (2003) Practical treatment of wound pain and trauma: a patient-centered approach. An overview. Ostomy Wound Manage 49(4 Suppl): 2-15 Richardson C (2012) An introduction to the biopsychosocial complexities of managing wound pain. J Wound Care 21(6): 267-73 Richardson C, Upton D (2010) A discussion of the potential mechanisms for wound dressings’ apparent analgesic effects. J Wound Care 19(10): 424-30 Rippon M, White R, Davies P (2007) Skin adhesives and their role in wound dressings. Wounds UK 3(4):76-86 Rippon M, Davies P, White R, Bosanquet N (2008) Cost implications of using an atraumatic dressing in the treatment of acute wounds.J Wound Care 17(5): 224-7 Romanelli M et al (2013) Using ADAPTIC Touch Non-adhering silicone dressing: case studies booklet. Wounds international. http://tinyurl.com/nswpegg (accessed 23 October 2014) Schober-Flores C (1999) Epidermolysis bullosa: a nursing perspective. Dermatol Nurs 11(4): 243-256 Schultz G, Sibbald R, Falanga V et al (2003) Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 11(Suppl 1): S1-28 Selby T (2009) Managing exudate in malignant fungating wounds and solving problems for patients. Nurs Times 105(18): 14-17 So K, Umraw N, Scott J et al (2003) Effects of enhanced patient education on compliance with silicone gel sheeting and burn scar outcome. A randomised prospective study. J Burn Care Rehabil 24(6): 411-7 Solowiej K, Mason V, Upton D (2009) Review of the relationship between stress and wound healing: Part 1. J Wound Care 18(9): 357-66 Solowiej K, Mason V, Upton D (2010) Psychological stress and pain in wound care, Part 2: a review of pain and stress assessment tools. J Wound Care 19(3): 110-5 Solowiej K, Mason V, Upton D (2010) Psychological stress and pain in wound care, Part 3: management. J Wound Care 19(4): 153-5 Taylor R (1999) Use of silicone net dressing in severe mycosis fungoids J Wound Care 8(9): 429-30 Timmons J, Gray D, Russell F (2009) Silflex soft silicone wound contact dressing. Wounds UK 5(2): 56-61 Thomas S (1994) Low adherence dressings. J Wound Care 3(1): 27-30 Thomas S (2003a) Atraumatic dressings. World Wide Wounds. http://tinyurl. com/6s3pbu (accessed 23 October 2014) Thomas S (2003b) Silicone dressings: frequently asked questions. World wide wounds. http://tinyurl.com/l3kj7b9 (accessed 23 October 2014) Thompson D (2005) Wound bed preparation: a proactive treatment. Nursing In Practice 20: 70-2 Tokumura F, Ohyama K, Fujisawa H, Suzuki M, Nakatsuka H (1999) Timedependant changes in dermal peeling force of adhesive tapes. Skin Research and technology 5(1): 33-6. doi: 10.1111/j.1600-0846.1999.tb00201.x Upton D, Solowiej K (2012) The Impact of Atraumatic Vs Conventional Dressings on Pain and Stress. J Wound Care 21(5): 209-15 Upton D, Hender C, Solowiej K (2012a) Mood disorders in patients with acute and chronic wounds; a health professional perspective. J Wound Care 21(1): 42-8 Upton D, Solowiej K, Hender C, Woo, K (2012b) Stress and pain associated with dressing change in patient s with chronic wounds. J Wound Care 21(2): 53-61 Upton D, South F (2011) The psychological consequences of wounds: a vicious circle that should not be overlooked. Wounds UK 7(4): 136–8 Vloemans A, Kreis R (1994) Fixation of skin grafts with a new silicone rubber dressing (Mepitel). Scand J Plast Reconstr Surg Hand Surg 28(1): 75-6 Waring M, Bielfeldt S, Mätzold K, Wilhelm K, Butcher M (2011) An evaluation of the skin stripping of wound dressing adhesives. J Wound Care 20(9): 412-22 White R (2014) Evidence for atraumatic soft silicone wound dressing use. Wounds International 5(2): 104-9 Williams C (1995) Mepitel. Br J Nurs 4(1): 51-5 Winter G (1962) Formation of the scab and the rate of epithelisation of superficial wounds in the skin of the young domestic pig. Nature 193(4812): 293-4 Woo K (2010) Wound related pain: anxiety, stress and wound healing. Wounds UK 6(4): 92-8 World Union of Wound Healing Societies (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. MEP Ltd, London. http://tinyurl.com/ptthyk7 (accessed 23 Octover 2014) Wounds UK (2013) Best Practice statement: Effective exudate management. Wounds UK, London. Young T (1999) Fungating wounds: their diagnosis and management. Community Nurse 5(10): 53-4 Zilmer R, Agren M, Gottrup F, Karlsmark T (2006) Biophysical effects of repetitive removal of adhesive dressings on peri-ulcer skin.J Wound Care 15(5): 187-91
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Abstract
The use of silicone-based dressings as a primary contact layer for wound care can prevent epithelial stripping, pain and sensitivity and have been widely available for nearly 20 years. Cuticell Contact from BSN medical is the latest silicone-based dressing to add to the armoury of the wound care clinician. Using documented case studies the author explores the reasoning behind why clinicians should consider re-examining the use of silicone dressings. Key words: Moist wound healing ■ Primary contact layer ■ Silicone ■ Assessment ■ Transparent
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odays’ clinicians need to take a strategic approach when considering wound assessment and dressing selection. To achieve optimum outcomes, factors such as moist wound healing, wound-bed preparation, accurate wound assessment and appropriate pain control are all areas that require close attention before dressing selection should even be considered. Moist wound healing promotes an optimum healing environment for the process of autolytic debridement and formation of granulation tissue without letting a wound bed dry out (Winter, 1962). Clinicians adopting this approach to wound care have documented wounds healing up to 40% faster and the clear benefits this has to the patient (Jones, 2005; Bolton, 2007; Benbow, 2008). Wound bed preparation has been explored extensively since 2003 with useful tools such as the Applied Wound Management trio of assessment tools or continuums (wound healing, infection and exudate) (Grey et al, 2004) or the TIME assessment framework (Schultz et al, 2003; Falanga, 2004; Dowsett and Newton, 2005; Ligresti and Bo, 2007.) They instruct clinicians to assess wounds using criteria that can identify problems while using descriptors such as wound colour, exudate, and signs of infection, that can help to accurately document and assess ongoing cases. By rethinking an approach to wound care in this way problems with
Adam Derbyshire, Senior ANP, Albany House Medical Centre,Wellingborough, Northamptonshire Accepted for publication: October 2014
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wound colour, exudate and infection can be identified before dressing selection and application. In all cases clinicians need to accurately measure a wound so they can consider if a wound care treatment is being successful at future assessments, but emphasis is now focused on the steps the clinician should take before dressing. The following issues should be considered: ■■ Is the wound acute, chronic, or will it heal with primary or secondary intention? (Alves et al, 2009) ■■ Are there any pre-disposing factors such as diabetes, hypertension and anaemia? (Constantinides J et al, 2006) ■■ Are there visible signs of infection in the wound, debris or slough that needs to be removed, or excess exudate levels that are putting healthy skin in danger of being compromised? (Schultz et al, 2003. Thompson, 2005). Exudate levels should not be overlooked in any wound assessment. Increased exudate often indicates infection and the need for secondary intervention. Poor exudate management has also been shown to have both a physiological and psychological impact on patients (Selby, 2009; Upton and South, 2011; Wounds UK, 2013), and can cause excoriation and maceration to peri-wound skin, which can lead to increased wound size (Collier 2000; Cutting and White, 2002; Cameron 2004, Selby 2009). Heavy exudate levels, such as in traumatic or infected wounds, are the main reason why some dressings fall off (Jones, 2006) so the clinician needs to be experienced enough to judge the correct time to change the dressing and prevent accidental exposure or risk of introduced infection (Rippon et al, 2007). When choosing the ideal dressing the clinician should also consider if the product protects and insulates the wound, encourages a moist environment to aid with healing, absorbs excess exudate with a gaseous exchange mechanism, is nontoxic, cost effective, sterile, with added antimicrobial effect (if required) and is easy to remove (Constantinides et al, 2006; Dykes, 2007; Rippon et al, 2008). Clinicians should therefore carefully consider the dressings they elect to use on the patient. Previous dressing regimes should be discussed and any allergies identified. Patient compliance with previous dressing combinations should also be explored to ensure a positive outcome for the patient and prevent any avoidable concordance issues. Dressings can be classified as adherent, low adherent or non-adherent (Thomas, 1994), or the newer designation of atraumatic, where a dressing will not strip skin or cause trauma on newly granulating tissue or wound margins (Thomas, 2003a; Rippon et al 2008; White, 2014).
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Adam Derbyshire
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Adhesive dressings have been shown to cause skin trauma and epidermal cell stripping from repeat application and removal under laboratory conditions (Waring et al, 2011) with localised skin reactions, heightened sensitivity, pain and distress being identified in the test subjects (Dykes & Heggie, 2003. Zillmer et al, 2006. Lawton & Langoen, 2009). The use of barrier protection can reduce the stripping of these skin cells when dressings are removed (Krasner, 2001), however, clinicians should always adopt a regime that causes minimal trauma and pain to the patient as research has shown increased stress from pain can actually slow down wound healing rates (Upton et al, 2012a; Upton et al 2012b).
Wound pain Accidental trauma to the wound bed and margins during dressing change can alter a clinician/patient relationship from one of trust to one of poor concordance. The damage may increase pain for the patient and result in larger wound size and longer healing time (Hollinworth and White, 2006; Upton et al 2012a). In the late 1990s, it was suggested that nurses often dismissed the significance of wound pain (Hollinworth, 1999). To address this educational shortfall the European Wound management Association (EWMA) and the World Union of Wound Healing Societies (WUWHS) (EWMA, 2002; WUWHS, 2004) and a best practice statement on minimising trauma and pain in wound management (Gray, 2004) suggesting clinicians assume all wounds have the potential to be painful. The measurement of pain can be recorded with the visual use of pain scales (Reddy et al, 2003), Krasner, 2001) or more formal measurement tools such as Hollinworth’s (2005) template for the assessment of wound related pain or any of the useful templates available online at less-pain.com providing clinical frameworks for clinicians to help measure ongoing patient pain and pain at dressing change. However, pain scales and templates should not replace the initiative of the skilled clinician. If a patient is wincing before even being touched, or pulling their wound away, the chances are their pain is not controlled and analgesia may need to be considered, or they may have had a bad experience at a previous dressing change. In these cases pain has been shown to be more pronounced (Woo, 2010) and leads to additional stress and anxiety (EWMA, 2002; WUWHS, 2004; Solowiej et al, 2009; Solowiej et al, 2010; Upton and Solowiej, 2012). In these situations extra time, care and attention on the part of the clinician will be required to ensure that patient confidence can be restored. In some cases stopping the dressing procedure altogether and discussing a patient’s concerns before proceeding may seem ‘time expensive’ in a busy caseload schedule, but it may also form a sound framework for more efficient care and partnership later down the line. Individual pain management plans can be incorporated into the care package (Solowiej et al, 2010; Richardson, 2012) as a patient in no pain will have improved quality of life and lower anxiety at dressing change resulting in better adherence and time savings (Goode, 2004; Timmons
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et al, 2009). Trauma has also been shown to be reduced with soft silicone dressings as a primary contact layer (Kammerland and Eberlien, 2002).
Silicone as a primary layer Primary contact layers are not designed to be absorbent, but are instead engineered to allow exudate to pass through the dressing into an absorbent layer beyond (Meuleneire & Rucknagel, 2013). The benefits of using silicone as a primary layer in wound dressing include increased comfort, minimal adhesion, low trauma, low toxicity, flexibility, safety of use, longer wear time, cost effectiveness and pain reduction at dressing change (Dykes et al, 2001; Dykes and Heggie, 2003; So et al, 2003; Thomas, 2003a; Thomas, 2003b; Black et al, 2012). Silicone dressings have also been used on just about every wound variant imaginable in published text: Burns and Skin Grafts (Volemans and Kries, 1994; Platt et al, 1996; Bugmann et al, 1998; Durani and Ferguson, 2006; Edwards, 2009; Edwards, 2011), radiation burns (Adamietz et al, 1995; MacBride et al, 2008), accidental wounds in paediatric cases (Morris et al, 2009), ulcerated heels (Hampton, 2010), pressure ulcers (Meaume et al, 2003), leg ulcers (Gates, 2000), fungating wounds (Taylor, 1999;Young, 1999), Epidermolysis bullosa cases (Schober-Flores, 1999) and scar management (Mustoe et al, 2002). The first ‘silicone’ type primary dressing was tulle gras, incorporating a mesh design that reduced pooling and maceration caused by exudate levels. However, it often stuck and caused trauma on removal (Krasner, 1991). Safetac technology (Molnlycke) was created to counter this problem with the introduction of Mepitel (Meuleneire, 2002). Mepitel was shown to reduce pain and trauma at dressing change (Gotschall et al, 1998; Dahlstrom, 1995; Williams, 1995). Other silicone variants have followed including meshes such as Adaptic (Systagenix) (Bianchi and Gray, 2011; Romanelli et al, 2013) or silicone-coated foams for different levels of exudate such as Mepilex (Molnlycke) or Eclypse (Advancis Medical) (Rafter, 2011).
Wear time Meuleneire and Rucknagel (2013) suggest it is acceptable to leave a silicone primary dressing in place for a minimum of 5 days, with White (2014) recommending 7–10 days. Fourteen days without change is now a selling point from manufacturers of Mepitel and Mepitel One (Molnlycke) (Barrett, 2012) and Cuticell Contact (BSN medical, 2014). The transparent nature of the dressings mean that wounds can be observed without the need for change, and therefore the wound bed remains undisturbed and is allowed to heal of its own accord. The author recognises that frequent dressing changes incur costs and being able to see through silicone primary layers can prevent unnecessary removal and save money. As clinicians we should also understand that wear time relates to several contributing factors: exudate levels, infection, licensing information of a dressing product, the fragility of the skin and our own wound observations (Campbell et al, 2003; Hampton and Steven Haynes, 2005)
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Adhesive dressings
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PRODUCT FOCUS Cuticell Contact Cuticell Contact is the new silicone primary contact dressing from BSN medical that was introduced in Europe at the end of 2013 as a cost-effective alternative to similar silicone wound contact layers on the market. BSN medical state the silicone layer is suitable for superficial abrasions, skin damage caused by steroid atrophy or fragile skin, graft sites, post-operative care, second-degree burns and hypergranulating wounds. It offers the user a 14-day wear time dependant on wound type (BSN medical, 2014). There is limited further supporting literature available at the time of writing this review. On initial appearance the dressing looks remarkably similar to any other silicone wound contact layers on the market, however, it has larger porous holes on the surface. The manufacturer states this allows thicker exudate that could normally clog traditional silicone dressings to pass through, away from the wound bed and into the secondary dressing, thereby reducing maceration (Hallern, 2014). The second important aspect of the dressing only becomes apparent when you touch it. The dressing is only sticky on one side.This means unlike most competing silicone dressings it is extremely unlikely that an absorbent secondary dressing pad could adhere to the adhesive of the primary dressing and come away unintentionally when the secondary layer is being changed. This initiative also adds to ease of application as the dressing does not stick to the clinician’s gloves. The manufacturer suggests the adhesive is sensitive to the surface it is applied to, only sticking to the edges of wounds and not to the moist wound bed, while maintaining granulation by fostering a moist wound environment, with the resulting seal encouraging exudate to pass through the pores and not to creep across surrounding skin (Hallern, 2014) Directions for use specify that the surface of any wound is cleansed and the dressing is applied adhesive side down with an overlapping edge of not more that 2 cm. An adhesive dressing or retention bandage with a suitable absorbent layer should be used to secure the dressing in place (Hallern, 2014). It is made clear that in the case of a wound that is larger than the dressing, care should be taken by the clinician to ensure that there is no overlap of silicone dressing as this could inadvertently block the drainage pores and cause unwanted maceration caused by exudate build up. The dressing comes in the following sizes: 5 x 7.5 cm, 7.5 x 10 cm, 10 x 18 cm and 15 x 25 cm. The following three case studies were carried out in August/ September 2014 using the new dressing. The author agreed with BSN medical that the trial should be for a minimum of 2 weeks. However, patient response was such that some of these cases are still ongoing as the patients felt comfortable with the new regime.
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Case study 1 Mr B is a 35 year-old male with no pre-disposing factors or concerns regarding poor healing. He sustained a burn on his arm while cooking. Mr B was initially treated with a hydrocolloid dressing for 2 days before seeing the author. Unfortunately exudate levels from burn were such that the dressing came away and leaked, much to Mr B’s embarrassment. He reported that the wound was painful and felt hot.
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
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Figure 1. Case study 1
On assessment the wound was approximately 1.5 cm x 4.5 cm (Figure 1a) and was cleaned with normal saline before Cuticell Contact was applied as a primary contact layer (Figure 1b) with an adhesive padded dressing to secure it. The dressing was easy to apply and trim to size leaving an overlap as specified by manufacturer instructions. Mr B was advised to return for a dressing change and booked a consultation for 5 days later. Mr B discussed the wound the day after Cuticell Contact was applied with the author as he had to return to the surgery for another reason. He explained that he felt the dressing was much cooler with the new dressing regime on and that it had
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taken the heat out of the burn (this could also be because the inflammatory response was abating, as usually happens 3 days into the healing process). Mr B believed his pain levels were reduced and he felt happy with the dressing in place. This is a common occurrence when dressing a wound as research shows patient’s often report an analgesic effect when dressings are applied (Richardson, 2010). The wound was finally reviewed after 5 days (Figure 1c) and declared healed and the regime was stopped.
Case study 2 Ms K is a 37-year old female who was experiencing a bad case of weeping eczema of the ears. She attended surgery on 1 September 2014 with exudate dripping down the sides of her face and her long hair sticking to her ears. Every time she tried to move her hair from her ears the skin tore creating many small lacerations. Ms K was also allergic to both penicillin and erythromycin, with prescribed steroid and antibiotic lotions simply sliding off the soaked ears, making the situation even worse. Exudate was dribbling down Ms K’s face at the time of assessment and the ears were swollen and inflamed (Figure 2a). She was worried about client reactions to her appearance and the lacerations on her ears were very uncomfortable. She was also unable to sleep because of the skin sticking. There were multiple areas of trauma that were all very small but oozing. Ms K stated her ears felt more comfortable once the dressings were applied (Figure 2b).The silicone primary contact layer was able to cushion the fragile skin and protect it from anything sticking, and the holes in the dressing allowed exudate to pass straight through into the gauze envelope applied (Figure 2c). She was given instructions on how to change dressings as required. Ms K reported back that she had to change the gauze dressings frequently throughout the day but the primary dressing remained soothing. Hair was no longer sticking to her ears and creating fresh trauma. The swab result came back positive for streptococcus infection 2 days later and she was able to commence on a suitable antibiotic regime. Ms K returned on 11 days later. Her ears had dried up following antibiotic therapy and protection from further trauma.
Case study 3 Mr G is a 52-year-old male. He was found unconscious in the road following a possible hit and run in early August. He had sustained a large wound situated at the thoracic spinal level of his back (adjacent to T7-T9). Patient notes revealed
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he was put on antibiotics in the accident and emergency department, possibly because of the condition of the wound. Mr G refused to remain in hospital because of his lifestyle choices and elected to attend the surgery for treatment. Staff wanted to admit him back to hospital but he refused. The wound dressing regime from the hospital consisted of amorphous hydrogel and a hydropolymer adhesive dressing. Mr G attended surgery on an ad-hoc level and often failed to attend. The author was invited to assess the wound on 22 August 2014 (Figure 3a) to find the current treatment was not managing the wound in its present condition. The wound measured approximately 9 cm x 6 cm and was heavily filled with dead tissue. After discussion with Mr G it was decided that sharps debridement was an option to ascertain the true size of the wound and reduce the exudate levels (Figure 3b). Anyone considering sharp debriding should be suitably trained for removing such tissue before attempting to remove it (Benbow, 2008b). After the removal of the initial layer of dead tissue (Figure 3c) the wound was cleansed with saline, before applying Cuticell Contact (Figure 3d) and then securing the dressing with padded adhesive dressings to manage any exudate that came away (Figure 3e). Mr G returned on 4 days later and the wound was now ready for further surgical debriding (Figure 3f). Following debridement the wound was much cleaner (Figure 3g). Mr G was asked how he was finding the dressing regime. His response was that it felt cool and comfortable on his back. The dressing was easy to remove as it did not stick, and appeared to keep the wound moist but not soaking wet, as it was on initial presentation. The author also noted the ease at which more viscous exudate passed through the perforations of the dressing. The dressing even stayed in place over weekends (Figure 3h) and the author was able to observe the wound without removing the dressing so that a decision could be made regarding dressing change (Figure 3i). Owing to improvement over the 2-week product evaluation (Figure 3j), it was requested that Mr G continue on this dressing regime. It could be argued that the patient should have been sent to hospital despite his wishes, however, respecting patient choice and staying with the regime appears to be allowing his wound to heal without undue complication. More importantly, Mr G is attending regularly for dressing change. Whether this is due to the comfort of the dressing or the visible results is unclear. Care continues.
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Figure 2. Case study 2
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PRODUCT FOCUS Conclusion Silicone primary layer dressings have been in use for the last 20 years. Their use has been recommended as a first-line treatment (Mustoe et al, 2002) and has been shown to help reduce trauma and pain in patient care (Black et al, 2012), fulfilling nationally respected documents and guidelines on pain at dressing change (EWMA, 2002;WUWHS, 2004; Gray, 2004). As a primary dressing it is safe to remain in situ for up to 14 days (subject to secondary dressing change) (Barrett 2012; Hallern, 2014) and nothing toxic is absorbed from the primary dressing into the skin (White, 2014) Cuticell Contact is lower in cost per unit than other popular silicone wound contact layers on the drug tariff and continues this tradition as an alternative to current treatments with larger drainage holes, single-sided adhesive and transparency to enable the clinician to view the wound bed without disturbing the BJN primary dressing (Hallern, 2014).
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Conflict of interest: This article was supported by BSN medical Adamietz I, Mose S, Haberl A, Saran F, Thilmann C, Bottcher H (1995) Effect of self-adhesive, silicone-coated polyamide net dressing on irradiated human skin. Radiation Oncology Investigations 2(6): 277-82. doi: 10.1002/roi.2970020605 Alves J, Angeloni A, Arkadiusz J, Vanscheidt W, White R (2009) Guidelines for the treatment of acute minor skin wounds: A consensus by leading European experts. Mims Dermatology 5(2): I-VI Barrett S (2012) Mepitel One: a wound contact layer with safetac technology. Br J Nurs 21(21): 1271-7 Benbow M (2008a) Exploring the concept of moist wound healing and its application in practice. Br J Nurs 17(15): S4-S8 Benbow M (2008b) Selecting a Method for Wound Debridement. Mims Dermatology 4(2): 50-1 Bianchi J, Gray D (2011) ADAPTIC Touch non-adherent dressing. Wounds UK 7(1): 120-3 Black J, Clark M, Alves P et al (2012) Consensus statement. Global evidence based practice recommendations for the use of wound dressings to augment pressure ulcer prevention protocols. http://tinyurl.com/qyqfmck (accessed 23 October 2014) Bolton L (2007) Operational definition of moist wound healing. J Wound Ostomy Continence Nurs 34(1): 23-9 BSN Medical (2014) Data on file, (available on request) Bugmann P, Taylor S, Gyger D et al (1998) A Silicone-coated nylon dressing reduces healing time in burned paediatric patients in comparison with standard sulfadiazine treatment: a prospective randomized trial. Burns 24(7): 609-12 Cameron J (2004) Exudate and care of the peri-wound skin. Nurs Stand 19(7): 62-8 Campbell K, Keast D, Woodbury G, Houghton P (2003) Wear time in two hydrocolloid dressings using a novel in-vivo model. Wounds 15(92): 40-8 Collier M (2000) Management of patients with fungating wounds. Nurs Stand 15(11): 46-52 Constantinides J, Mahmood M, Georgeu G, Street L (2006) Hospital at Home a plastic surgery/burns model. Mims Dermatology 2(3): 2006 Cutting K, White R (2002) Maceration of the skin and wound bed: Its nature and causes. J Wound Care 11(7): 275-8 Dahlstrom K (1995) A new silicone rubber dressing used as a temporary dressing before delayed split grafting. A prospective randomised study. Scand J Plast Reconstr Surg Hand Surg 29(4): 325-7 Dowsett C, Newton H (2005) Wound bed preparation: TIME in practice. Wounds UK 1(3): 48-70. http://tinyurl.com/mnyksuu (accessed 23 October 2014) Durani P, Ferguson M (2006) Developments in burn scar therapy. Mims Dermatology 2(1): 12. http://tinyurl.com/lpty8cq (accessed 23 OCtober 2014) Dykes P (2007) The effect of adhesive dressing edges on cutaneous irritancy and skin barrier function. J Wound Care 16(3): 97-100 Dykes P, Heggie R, Hill S (2001) Effects of adhesive dressings on the stratum corneum of the skin. J Wound Care 10(2): 7-10 Dykes P, Heggie R (2003) The link between the peel of forces of adhesive dressings and the subjective discomfort in volunteer subjects J Wound Care 2(7): 260-2 Edwards J (2009) The use of Silflex in burn wound management. Br J Community Nurs 14(9): S32-6 Edwards J (2011) Managing wound pain in patients with burns using soft silicone dressings Wounds UK 7(4):122-6. European Wound Management Association (2002) Position document: Pain at wound dressing changes. http://tinyurl.com/26unm9q (accessed 23 October 2014) Falanga V (2004) Position document: Wound bed preparation in Practice. http://tinyurl. com/k5luouo (accessed 23 October 2014) Gates A (2000) The use of a non-adherent silicone dressing in arterial leg ulceration. J Wound Care 9(2): 79-81 Goode M (2004) Psychological needs of patients when dressing a fungating wound: a literature review. J Wound Care 13(9): 380-2 Gotshall C, Morrison M, Eichelberger M (1998) Prospective, randomized study of the efficacy of Mepitel on children with partial thickness scalds. J Burn Care Rehabil 19(4): 279-83 Gray D (2004) Best Practice Statement: Minimising Trauma and Pain in Wound
British Journal of Nursing, 2014 (Tissue Viability Supplement), Vol 23, No 20
Figure 3. Case study 3
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KEY POINTS n The
use of silicone as a primary contact layer has been available for clinicians to use for the last 20 years
n Silicone
has been shown to be non-adherent to a moist wound bed and is less painful when removed
n Clinicians
should ensure a full assessment is undertaken of any wound, including the patient’s perception of pain and consider steps to address it
n All
wounds are painful
n Using
moist wound healing principles wounds have been shown to heal up to 40% faster
Management. Wounds UK, Aberdeen. Gray D, Jones V, White R et al (2004) Wounds UK Applied Wound Management Supplement. Wounds UK, London. http://tinyurl.com/lg9n3zx (accessed 24 October 2014) Hallern B (2014) Preventing hypergranulation, protecting epithelialisation cuticell contact silicone impregnated dressing for secondary healing, traumatic and chronic wounds BSN Medical (reference material) Hampton S, Steven-Haynes J (2005) ‘Skin maceration: assessment, prevention and treatment’. In: White R (ed.) Skin Care in Wound Management: Assessment, Prevention and treatment. Wounds UK, Aberdeen: 87-109 Hampton S (2010) An evaluation of a silicone adhesive shaped heel dressing Br J Nurs 19(6 Suppl): S30-3 Hollinworth H (1999) Conflict or diplomacy. Nursing Times 95(34): 63-8 Hollinworth H (2000) Pain and wound care .Wound Care Society Educational leaflet 7(2). Wound Care Society Hollinworth H (2004) An Overview of Trauma and pain Issues in the UK Best practice statement Minimising Trauma and Pain in Wound Management.Wounds UK, Aberdeen: 3-4 Hollinworth H (2005)Pain at wound dressing-related procedures: a template for assessment. World Wide Wounds. http://tinyurl.com/qpx9cs (accessed 24 October 2014) Hollinworth H,White R (2006) ‘The clinical significance of wound pain.’ In:White R, Harding K (eds) Trauma and Pain in Wound Care .Wounds UK, Aberdeen: 3-16. http://tinyurl.com/kozglrs (pdf - accessed 23 October 2014) Jones J (2005) Winter’s concept of moist wound healing: a review of evidence and impact on clinical practice. J Wound Care 14(6): 273-6 Jones V (2006). The use of gauze: will it ever change? Int Wound J 3(2):79-86 Kammerlander G, Eberlein T (2002) Nurses’ views about pain and trauma at dressing changes: a central European perspective. J Wound Care 11(2): 76-9 Krasner D (1991) An approach to treating skin tears ostomy wound management. Ostomy Wound Manage 32: 56-8 Krasner D (2001) Caring for the person experiencing chronic wound pain. Chronic Wound Care. HMP Publications, Wayne, Pa Lawton S, Langoen A (2009) Assessing and managing vulnerable periwound skin. Worldwide wounds. http://tinyurl.com/6sgnea5 (accessed 23 October 2014) Ligresti C, Bo F (2007) Wound bed preparation of difficult wounds: An evolution of the principles of TIME. Int Wound J 4(1): 21–9 MacBride S, Wells M, Hornsby C et al (2008) A case study to evaluate a new soft silicone dressing Mepilex Lite, for patients with radiation skin reactions. Cancer Nurs 31(1): E8-14. doi: 10.1097/01.NCC.0000305680.06143.39. Meaume S, Looverbosch D, Heyman H et al (2003) A study to compare a new selfadherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Manage 49(9): 44-51 Meuleneire F (2002) Using a soft silicone-coated net dressing to manage skin tears. J Wound Care 11(10): 365-9 Meuleneire F, Rucknagel H (2013) Soft silicones made easy. Wounds International May: 1-6 Morris C, Emsley P, Marland E et al (2009) Use of wound dressings with soft silicone adhesive technology. Paediatr Nurs 21(3): 38-43 Mustoe T, Cooter R, Gold M et al (2002) International clinical recommendations on scar management. Plast Reconstr Surg 110(2): 560-71 Platt A, Phipps A, Judkins K (1996) A comparative study of silicone net dressing and
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