Evidence Corner

  • Thu, 9/4/08 - 11:52am
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Author(s): 
Laura Bolton, PhD, FAPWCA

Dear Readers:

Venous ulcers (VU) can be slow to heal reducing patients’ economic well being and quality of life.1 The multitude of therapies and variations in application techniques can be baffling. For example, one may discover too late that required compression was insufficient, was applied incorrectly, or was not worn as prescribed.2 Wound care professionals learning how to optimize VU compression, primary dressings, surgical methods, and alternative modalities often turn to evidence summaries and systematic reviews to identify safe and effective protocols.3 This Evidence Corner discusses 2 systematic reviews with different conclusions about whether the primary dressing affects VU healing when used under effective compression. How does one resolve such an apparent discrepancy?

Laura Bolton, PhD, FAPWCA

Cochrane Systematic Review: Venous Ulcer Dressings

Reference: Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev. 2006(3):CD001103.
Rationale: The main treatment for VUs is compression. Primary dressings are usually applied to aid healing, improve patient comfort, or manage exudate.
Objective: This systematic review explored the effects of wound dressings on healing VUs.
Methods: The authors retrospectively reviewed prospective randomized controlled trials (RCTs) in all languages published before 2005 comparing dressing effects on time to healing, proportion healed, or rate of healing of patients with VU. RCTs evaluating topical agents and skin grafting were excluded as subjects of prior Cochrane systematic reviews. Searches included the Cochrane, MEDLINE, EMBASE, and CINAHL databases, derivative references, and queries to authors, wound professionals, and manufacturers. A different author checked data extraction. Study quality was assessed on group comparability at baseline, intent-to-treat analyses, follow-up completeness, allocation concealment and objective, and blinded outcome measures. Meta-analyses were performed on statistically homogeneous data of multiple studies addressing each question reviewed. Subgroup analyses tested for effects of study size, compression use, dressing type, and blinded assignment.
Results: Of 254 citations, 42 RCTs of 4- to 40-week duration involving 3,001 patients with a VU qualified for inclusion in the analyses. There were sufficient data for meta-analyses comparing hydrocolloid dressings with foams (4 trials, 311 patients), alginates (2 trials, 80 patients), other hydrocolloids (3 trials, 98 patients) or low-adhering dressings (9 trials, 928 patients); foam dressings with low-adherent (3 trials; 253 patients) or other foams (2 trials; 136 patients); and hydrogels with low-adherent dressings (2 trials; 134 patients). Many studies were underpowered. None of the meta-analyses revealed significant differences between healing effects of any 2 primary dressing categories. Effects of patient variables, such as ambulation and adherence to compression protocols, were not analyzed owing to insufficient data reporting.
Conclusion: Primary wound dressings applied beneath compression have not been shown to affect VU healing.

Journal of Vascular Surgery Review: Venous Ulcer Dressings

References: 

1. Phillips TJ. Successful methods of treating leg ulcers. The tried and true, plus the novel and new. Postgrad Med. 1999;105(5):159–174.
2. Ham S, Padmore J. Two-layer compression hosiery for patients with venous leg ulceration. Nurs Stand. 2006;20(45):68–76.
3. Bolton L, Corbett L, Bernato L, et al. Development of a content-validated venous ulcer guideline. Ostomy Wound Manage. 2006;52(11):32–48.
4. Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D. Systematic reviews of wound care management: (2). Dressings and topical agents used in healing of chronic wounds. Health Technol Assess. 1999;3(17 Pt 2):1–35.
5. US Food and Drug Administration. Chronic Cutaneous Ulcer and Burn Wounds—Developing Products for Treatment. Available at: http://www.fda.gov/cber/gdlns/ulcburn.htm. Accessed December 8, 2006.
6. van Rijswijk L, Beitz J. The traditions and terminology of wound dressings: food for thought. J Wound Ostomy Continence Nurs. 1998;25(3):116–122.
7. Bolton L, McNees P, van Rijswijk L, et al. Wound healing outcomes using standardized care. J Wound Ostomy Continence Nurs. 2004;31(2):65–71.

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