Index: WOUNDS 2011;23(8):243–251

Abstract: The presence of a chronic ulcer presents a challenge to clinicians in long-term care while being both a physical and psychological burden to the residents and their families. Dressings play an important adjunctive role in concert with overall efforts to manage the underlying causes of chronic, non-healing wounds. With more than 2000 dressings and a variety of treatment protocols available, chronic wound management is as much an art as it is science. Each wound requires a unique combination of dressings that is matched to the needs of the patient and the clinical presentation of the wound. Treatment often depends on the skill level of the clinician and the ability to develop appropriate interventions and plan of care. This retrospective series of four case studies serves to demonstrate the improved potential for healing outcomes when collagen dressings are used appropriately.   During acute wound healing tissue growth is regulated by chemical mediators, such as cytokines and protease activity, resulting in extracellular formation, granulation tissue, remodeling, and wound closure.3 In chronic wounds, the very nature of the tissues may inhibit wound healing. An increased level of inflammatory cells and proteases, such as matrix metalloproteases (MMPs), will degrade the provisional extracellular matrix (ECM) and inhibit wound healing.4 Normally, MMPs assist in wound healing by controlling platelet aggregation, cell migration, tissue proliferation, angiogenesis, and collagen secretion. Tissue inhibiting metalloproteases (TIMPs) assist in regulating the MMP production. Failure to regulate the MMPs by the TIMPs results in overproduction of MMPs, which inhibits the wound from progressing through the normal sequence of wound healing.   The use of an alternative collagen source may accelerate wound repair and be of benefit on recalcitrant wounds (wounds not responding to treatment or appear to have stalled in the wound healing process). Research by DiCosmo5 indicates that the use collagen in a wound dressing may act as an alternative substrate attracting the excess MMPs away from the wound. The result is a binding of the MMPS to the non-native collagen allowing for stimulation of growth factors and an increase in the production of host collagen by fibroblasts.   Long-term care residents often have multiple comorbidities, polypharmacy, mobility, and age-related factors that may delay wound healing. Additionally, access to advanced wound products in the long-term care setting may be limited by purchasing and supply issues, lack of access to qualified personnel with chronic wound care management experience, and reimbursement. Access to advanced wound products and caregivers with the knowledge to utilize the appropriate dressing based on wound characteristics is vital to the wound healing cycle and is a challenge in the long-term care setting. Across care settings utilization of wet-to-dry gauze continues, often inappropriately, to the frustration of the residents experiencing pain and caregivers alike.6,7 The following series of case studies highlights the effective use of collagen as an appropriate dressing for use with chronic wounds during treatment in various long-term care settings.

Case Reports

  Case 1. Patient. A 68-year-old man with a history of severe cerebral vascular accident, coronary artery disease, and diabetes. This resident received nutrition via tube feeding and was primarily recumbent dependent. In May of 2008, he developed a necrotic left heel pressure ulcer that was determined to be a Stage III following visualization of the wound base. Treatment prior to this presentation consisted of daily debridement followed by xeroform gauze. Utilization of multipodus boots for heel positioning was implemented upon admission and continued throughout the course of this wound case and continued afterward.   The wound measured 7.3 cm long x 5.0 cm wide with an undetermined depth on 5/6/08 upon admission to a long-term care facility. The wound base was covered with approximately 50% eschar and 50% pink granular tissue. There was a large amount of detritus and residual blister noted at the periwound (Photo 1A). The wound had minimal creamy drainage without odor. Collagenase dressings were applied to the necrotic areas, a collagen wafer to the viable tissue, and a foam island secondary dressing. The dressing was changed daily to appropriately manage moisture levels at the wound tissue.   Approximately 1 month later, on 6/17/08, the left heel pressure ulcer had decreased in size to the dimensions of 4.2 cm long x 3.0 cm wide x 1.2 cm deep. The wound base was covered with approximately 75% stringy gray slough and 25% granulation tissue (Photo 1B).   The wound also had heavy amounts of opaque drainage and a foul odor. The wound team looked for clinical signs and symptoms of infection, did not observe any, and determined that the necrotic tissue and semiocclusive backing on the bordered foam contributed to the odor. Therefore, the dressing protocol was changed and collagenase was applied to the necrotic areas and calcium alginate for exudate management followed by a foam dressing, gauze wrap, and tape. Dressing changes were performed daily at this point.   Two months after initial assessment (7/16/08) the wound measured 2.8 cm long x 2.5 cm wide x 0.5 cm deep. The wound base was covered with approximately 50% stringy yellow slough and 50% granulation tissue (Photo 1C). The wound had moderate creamy drainage without odor. The dressings protocol continued with collagenase applied to the necrotic areas, collagen wafer to the viable tissue, and a foam island secondary dressing as a cover. The dressing continued to be changed daily due to the amount of slough and subsequent emulsification with enzymatic debridement necessitating daily monitoring of the wound tissue.   On 8/20/08, the wound dimensions were 0.8 cm long x 0.6 cm wide x Case 2. Patient. A 60-year-old man with a history of severe right cerebral vascular accident resulting in left hemiplegia. The resident had a history of previous left ischial ulcer “several” years ago. He was on a low-air-loss bed in a long-term care facility. Treatment 2 months prior to this presentation consisted of wet-to-dry dressings.   On 11/12/07 he presented with a Stage III left ischial pressure ulcer that measured 6.0 cm long x 4.5 cm wide x 3.0 cm deep. There was 4.0 cm of undermining present from 11–1 o’clock. There were scattered areas of yellow slough noted over the granulating wound base and the periwound area had scar tissue present (Photo 2A). The wound had moderate amounts of creamy drainage with no appreciable odor. The course of dressings used for treatment with this presentation was Panafil, collagen to the undermined area, and calcium alginate gently packed into the depth of the wound and covered with a foam pad that was secured with cloth tape and changed daily. (Note: Panafil was acceptable to use as an enzymatic debriding agent, as it was prior to the FDA notice regarding papain products).   Approximately 1 month later, on 12/18/07 the wound had decreased in size to the dimensions of 3.0 cm long x 2.5 cm wide x 2.0 cm deep with 3.0 cm of undermining at the 11–1 o’clock position. The wound base was covered with approximately 25% yellow slough and 75% granulation tissue. New epithelial tissue was visible at the wound edge (Photo 2B). The wound had minimal to moderate creamy drainage. The use of Panafil and calcium alginate was discontinued at this time. The dressing protocol consisted of collagen to the entire wound bed and undermined area, and covered with foam pad secured with cloth tape. The dressing was changed daily.   Approximately 2 months after initial presentation, on 1/22/08, the wound continued to decrease in size to the dimensions of 1.5 cm long x 1.5 cm wide x 0.3 cm deep with all undermined areas resolved. The wound base exhibited 100% beefy granulation tissue and there was minimal serosanguinous drainage (Photo 2C). The dressing protocol remained the same, utilizing collagen to the wound bed and daily dressing change.   The following month, on 2/28/08, the wound dimensions had changed to 2.5 cm long x 1.0 cm wide x 0.2 cm deep, representing an overall decrease in area despite an increased length. The wound base continued with 100% beefy granulation and minimal serosanguinous drainage (Photo 2D). The dressing protocol was not changed and additional staff education regarding the turning schedule and daily wound monitoring with dressing changes was provided along with a pressure reduction cushion to his wheelchair.   The wound was closed with evident scar tissue on 3/25/08 and the resident continued on a low- air-loss mattress (Photo 2E). To the best of the authors’ knowledge, the wound has remained closed.   Case 3. Patient. A 70-year-old Hispanic man with a history of multiple acute medical problems including, but not limited to, sepsis, nephrectomy, spinal abscess, and respiratory failure. He was admitted to a long-term care facility with seven full-thickness wounds (pressure and surgical), tracheostomy collar, and feeding tube. Treatment consisted of wet-to-dry dressings prior to this presentation. The resident participated in rehabilitation throughout the course of this scenario and was not placed on a low-air-loss surface to allow for optimal mobility outcomes.   On 8/24/07 he presented with a left flank surgical wound (dehiscence) from a nephrectomy. The wound dimensions were 3.0 cm long x 5.0 cm wide x 1.5 cm deep with 1.8 cm undermining from 6–2 o’clock. The wound base exhibited approximately 75% non-viable tissue and 25% granular tissue (Photo 3A1). The wound had moderate creamy exudate with no odor and there was edema and induration noted to extend 1.5 cm into the periwound area.   He had another surgical wound present on the midline of his back resulting from an irrigation and drainage procedure for a spinal abscess. This wound measured 5.5 cm long x 2.0 cm wide x 1.9 cm deep. This wound base exhibited approximately 50% granulation tissue and 50% non-viable tissue. There was moderate creamy drainage and slight induration with hyperpigmentation noted in the periwound area (Photo 3B1). The dressings utilized for both wounds were collagen wafers to the wound bed, followed by a foam pad, secured with tape, and changed daily.   Approximately 3 weeks later, on 9/14/07, the left flank wound dimensions had decreased to 2.0 cm long x 3.5 cm wide x 1.6 cm deep with 1.8 cm undermining present at 10–2 o’clock. The wound base was covered with approximately 50% yellow slough and 50% granulation tissue with nonviable tissue present in the undermined area. The periwound area had induration and resolving edema (Photo 3A2). The wound had moderate creamy drainage. At this time, the dressings utilized were changed to include Panafil in conjunction with the collagen, covered with a foam pad, secured with tape, and changed daily. (Note: Panafil was acceptable to use as an enzymatic debriding agent, as it was prior to the FDA notice regarding papain products).   Likewise, the midline back wound decreased in size to the dimensions of 4.5 cm long x 1.4 cm wide x 1.6 cm deep. The wound base exhibited approximately 75% granulation tissue and 25% yellow slough present mostly at the edges. There was resolving hyperpigmentation noted in the periwound area (Photo 3B2). The wound had minimal creamy exudate. The dressing protocol remained the same for this wound for the continued use of collagen foam pad secondary dressing secured with tape and changed daily.   Approximately 2 months after initial presentation (10/17/07), the left flank wound again exhibited smaller dimensions of 2.2 cm long x 1.2 cm wide x 0.7 cm deep and 1.5 cm of undermining present at 10–2 o’clock. The wound base and undermined area exhibited 100 % beefy granulation tissue (Photo 3A3). The wound had minimal serosanguinous drainage. The dressing protocol was changed to discontinue Panafil, but to continue with the collagen covered with a foam pad that was secured with tape and changed daily.   The midline back wound also decreased in size to 1.0 cm long x 0.4 cm wide x Case 4. Patient. An 89-year-old white woman with a history of dysphagia, anemia, congestive heart failure, dementia, and was receiving enteral nutrition with protein supplementation. In March 2009 she developed a sacral pressure ulcer that progressed to Stage IV in May 2009, resulting in hospitalization for debridement and treatment. The resident was re-admitted to the long-term care facility in July 2009 on negative pressure wound therapy (NPWT) and provided a low-air-loss mattress (Table 1).   On 9/8/09, NPWT was discontinued after use nearly 2 months of use. The wound measured 5.5 cm long x 5.5 cm wide x 2.5 cm deep with 2.0 cm of undermining present from 9–3 o’clock. The wound bed was 50% beefy granulation and 50% yellow fibrinous tissue with ~1 cm of sacrum exposed. The dressing protocol implemented at this time was collagen to the wound bed covered by a foam pad secured with tape, changed daily and as needed due to incontinence. One month later, on 10/9/09, the wound decreased in size to 3.5 cm long x 5.0 cm wide x 1.5 cm deep with 0.8 cm of undermining present from 9–3 o’clock. The wound bed was 100% beefy granulation tissue. The treatment protocol with collagen followed by foam dressings was continued. Photographs of these presentations are not available.   On 11/9/09, the wound continued to decrease in size with measurements of 2.5 cm long x 4.0 cm wide x 0.6 cm deep, all undermining was resolved. The wound edges demonstrated some epiboly that was treated with aggressive wiping of the wound edges with moistened gauze at each dressing change (Photo 4A). The same treatment protocol with collagen covered with foam dressing was continued (Table 2, Photos 4 B–D).   The wound continued to decrease in size monthly with this treatment protocol along with the utilization of a zinc skin protectant to the periwound until 2/7/10 when collagen was discontinued in light of the healing progression. At that time, the treatment was changed to gentamicin ointment followed by foam dressing with continued daily and as needed dressing changes due to incontinence.   However, approximately 1 month later, on 3/12/10, the wound measurements increased in size 5% (Photo 4E). The decision was then made to resume the collagen treatment protocol, which resulted in a return to a healing trajectory depicted in Table 2 and Figure 1. On 4/12/10, collagen was again discontinued due to the small size of the ulcer; the gentamicin ointment followed by a foam dressing protocol was implemented two times a day until the wound closed completely on 4/27/10. Unfortunately, this resident’s wound did reopen a few weeks later while experiencing a medical condition decline and it was present upon expiration in December 2010. During this course the wound status was managed with calcium alginate primary dressing.

Results

  This retrospective series of 5 wounds on 4 long-term care residents demonstrates a wound healing rate ranging from 0.22 cm2/day to 0.57 cm2/day and a minimum of a 42% reduction in area during approximately the first month of using collagen dressings (Table 2). Additionally, all wounds exhibited a positive healing rate of declining value throughout their course of treatment with collagen. All wounds demonstrated a healing curve when considering wound area over time (Figure 1).

Discussion

  The cases presented in this article, though dating back to 2007 and occasionally utilizing ointments that have since been removed from the market, demonstrate that healing can be obtained in long-term care residents with chronic wounds and multiple comorbidities when utilizing collagen appropriately.   The decisions regarding product usage over the episodes of care presented in this article were driven by wound characteristics, moist wound healing theory, and evidence based practice. In this series, collagen, sometimes in conjunction with enzymatic debriders, was used to achieve the desired balance in the wound bed to support wound repair. Studies have reported that collagen dressings may be an alternate substrate for excess MMPs5 and are compatible with collagenase.8.9 Likewise, other advanced wound products, such as calcium alginate and foam, were utilized when indicated to maintain an appropriately moist wound environment. Foam dressings when used for secondary wound coverage provide protection from outside trauma and assist in providing a moist, thermal wound microenvironment. Additionally, foam will vertically and horizontally remove unwanted levels of fluid, which may be counterproductive to wound healing. This helps minimize unwanted damage to newly forming, as well as periwound tissue.   It is not common knowledge to general nursing home staff or physicians to understand the use collagen dressings and their compatibility with topical treatments, nor to understand the nuances of chronic wound management. For example, use of iodine or silver products decreases the effectiveness of enzymatic debridement and may produce less than optimal outcomes.8,9 In the United States, physicians receive approximately 9 hours of wound education in 4 years of medical school.10 Independent work by one author (HH) estimates that nearly 21% of the US population (63,000,000 people) have common wounds, while there are only 17,700 accredited certified wound experts (combining the CWS, WOCN and WCC)—1 specialist per 3,559 people with a wound(s). This information further underscores the importance of chronic wound management and understanding the adjunctive role individualized dressing recommendations in conjunction with the overall effort to manage the underlying causes to progress healing.

Conclusion

  Wound experts and the international wound community agree that healthcare providers must be able to assess wounds properly and recognize characteristics that influence wound healing and wound dressing selection. Dressings play an important adjunctive role in concert with overall efforts to manage the underlying causes of chronic, non-healing wounds. No one product or category of dressing can meet the needs of every wound and numerous factors must be considered when selecting an appropriate dressing. Dressing selection should be based on characteristics, such as wound location; wound depth or stage; presence of any cavities, necrosis, incontinence, or drainage; condition of the wound edges and periwound; and any evidence of granulation, epithelialization, or infection. In addition to the wound, a number of other factors, such as the patient’s physical needs and care setting, must be considered. Individualized treatment, the knowledge of wound product indications, the patience to allow the product to physiologically interact with the body, and access to advanced wound products, are crucial in the long-term care setting to provide residents with the resources to achieve healing of chronic wounds.   With chronic or non-healing wounds, the addition of collagen via a dressing may restrain and reverse the negative effects of inhibiting factors such as MMPs. The result is a promotion of tissue granulation and epithelialization through the stimulation of growth factors and an increased production of host collagen in the extracellular matrix.   The authors realize that these are case studies and that a larger study with controls should be undertaken to assist in establishing the role of using additional collagen to assist in managing chronic or non-healing wounds.

References

1. Cuzell J. Choosing a wound dressing. Geriatr Nurs. 1997;16(6):260-265. 2. Hess CT, ed. Clinical Guide to Wound Care. 6th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2008. 3. Sussman C, Bates Jensen B. Wound Care A Collaborative Practice Manual for Health Professionals. 3rd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007. 4. Brett D. Review of collagen and collagen-based wound dressings. WOUNDS. 2008;20(12):347-353. 5. DiCosmo F. The role of collagen in wound healing. Adv Skin Wound Care. 2009;22(Suppl 1):13-16. 6. Cowan LJ, Stechmiller J. Prevalence of wet-to-dry dressings in wound care. Adv Skin Wound Care. 2009;22(12):567-573. 7. Ayello EA, Sibbald RG, Woo KY. Health care systems: what are the current problems? Ostomy Wound Manage. 2009;(4 Suppl):23. 8. Shi L, Ermis R, Kiedaisch B, Carson D. The effect of various wound dressings on the activity of debriding enzymes. Adv Skin Wound Care. 2010;23(10):456-462. 9. Shi L, Carson D. Collagenase Santyl ointment: a selective agent for wound debridement. J Wound Ostomy Continence Nurs. 2009;36(6S):S12-S16. 10. Patel NP, Granick MS, Kanakaris NK, Giannoudis PV, Werdin F, Rennekampff HO. Comparison of wound education in medical schools in the United States, United Kingdom and Germany. EPlasty. 2008;8:e8. The authors are from American Medical Technologies, Irvine, CA. Address correspondence to: Holly Korzendorfer American Medical Technologies 17595 Cartwright Rd. Irvine, CA 92614 Email: holly.korzendorfer@amtwoundcare.com