Acute Wounds
Cleansing of pin-site wounds associated with orthopaedic fixators using saline, alcohol, hydrogen peroxide or antibacterial soap to prevent infections was not effective compared with no cleansing. For the local care of burn wounds, the effectiveness on wound healing of topical negative pressure compared with silver sulfadiazine remains unclear, owing to insufficient evidence. For burn wounds silver sulfadiazine should be discouraged, as several trials showed a trend towards wound healing delay and increased pain and infection rates (81).
Conversely, topical honey was strongly proven to reduce wound healing time compared with film or gauze-based dressings for burn wounds. If acute wounds need cleansing, drinkable tap water is strongly effective in reducing wound infections compared with saline solutions. For closing traumatic lacerations, tissue adhesives compared with standard wound care were strongly effective. Despite a slightly increased rate of wound dehiscence and higher cost, tissue adhesives can be considered a reasonable alternative. This seems particularly relevant as the improved cosmetic outcome is gaining in importance (81).
Venous Ulcers
No trials were found comparing compression therapy with no compression to prevent recurrence of healed venous leg ulcers. The following systemic treatment options are available when first-choice options fail, and should be considered alongside patient preferences, costs and wound type. For instance, pentoxifylline was strongly effective in promoting wound healing compared with placebo, in combination with compression therapy. This was true for people of all ages with a venous ulcer and in any care setting, with a duration varying from 4 to 26 months (81).
Despite controversy about its clinical indications, pentoxifylline is an inexpensive drug with few side-effects and a number needed to treat (NNT) of four patients to improve wound healing significantly. One small trial, in which 18 venous ulcers were included with treatment failure for over 1 year, did not provide sufficient evidence on the effectiveness of hyperbaric oxygen therapy (HBOT) versus placebo therapy. Oral zinc was strongly ineffective for ulcer healing compared with placebo. None of the trials comparing the routine use of antibiotics and antiseptics with standard care, other antibiotics or placebo provided strong or consistent fairly strong evidence on quicker wound healing. Therefore, no antimicrobial drug should be used without evidence of colonization or infection (81).
For local treatment, skin grafting compared with standard care was not effective for venous ulcer healing, except for bilayer artificial skin treatment of ‘hard to heal’ ulcers. The high cost of this treatment is an important factor to consider. Strong evidence of effect was shown for high compression versus low compression, whereas elastic bandages were more effective than inelastic bandages. Limited evidence of effect was shown when comparing multicomponent and single-component systems. Some small trials showed significantly positive effects in terms of quicker ulcer healing when comparing compression therapy, as bandages or pneumatic devices, with no compression therapy. A simple, comfortable local dressing, such as low-adherent knitted viscose, can be used beneath compression bandages, as there was strong evidence that no dressing type had an additional beneficial effect over any other (81).
For sharp debridement, there was strong evidence that a eutectic mixture of local anaesthetic (lidocaine–prilocaine), as opposed to placebo, provided effective pain relief (although the impact of debridement on healing was unclear and lidocaine–prilocaine is not licensed for use in open wounds in all settings). In contrast, there was strong evidence of no effect on pain relief for ibuprofen slow-release foam dressing compared with other foam dressings. Limited evidence of effect is available for the following local antimicrobial therapies in addition to compression therapy to increase healing rates: slow-release iodine, Cadexomer, compared with standard care or hydrocolloid, and ethacridine lotion 0·1 per cent versus placebo. Systemic side-effects from the potential absorption of iodine should be considered when using iodine for the treatment of wounds. Ethacridine lotion is seldom used in practice as a wound disinfectant; this could be due to poor accessibility (81).
Diabetic Ulcers
For the prevention of diabetic ulcers, patient education, as opposed to usual care or brief education, had limited effectiveness in developing foot care knowledge and behaviour that might decrease the incidence of subsequent ulceration or amputation. Pressure-relieving interventions, such as orthotic devices or therapeutic shoes, tend to reduce the incidence of ulceration and callus formation compared with standard therapy, although there was insufficient evidence to draw a strong conclusion (81).
Systemic additional treatment with HBOT, as opposed to placebo or control treatment, is strongly effective in decreasing major amputations, with a NNT of four patients. There is insufficient evidence that systemic treatment with granulocyte-colony-stimulating factor (GCSF) can help cure infections or heal ulcers. On the other hand, G-CSF, compared with standard care, had limited effectiveness in decreasing the need for surgical intervention, especially amputation. However, the small therapeutic bandwidth and high costs mean that this therapy should not be used as a first treatment option, but only when other treatment options fail. There is strong evidence of benefit for the local application of hydrogels after debridement compared with standard treatment after debridement, gauze-based dressings or standard care to promote wound healing. There is a lack of relevant trials comparing silver-based wound dressings in diabetic foot ulcers. Evidence on the effectiveness of total costs as pressure-relieving treatment is very limited (81).
Pressure Ulcers
Strong evidence for the effectiveness of high-specification foam mattresses (contoured-foam support surfaces comprising foam of different densities) and limited evidence for low air-loss mattresses was found over standard hospital foam mattresses and standard beds for prevention of pressure ulcers. In one large trial, limited evidence was found for a mixed nutritional supplement diet to reduce the development of pressure ulcers more than a standard hospital diet. No conclusions from available Cochrane evidence can be made regarding the effectiveness of systemic treatments. Regarding local treatments, there is strong evidence that therapeutic ultrasound is ineffective compared with placebo ultrasound, with ulcer healing as the main outcome (81).
The possible positive effect on ulcer healing of electromagnetic therapy remains unproven, as only two small trials have been performed, with no convincing evidence for effectiveness. Furthermore, no particular wound cleansing solution or technique has shown any substantial effect on ulcer healing. Miscellaneous chronic wounds: Insufficient evidence is available for the use of topical silver for the treatment of infected or contaminated wounds. A trend towards a positive effect on healing time was seen in a small trial of honey at the cost of more adverse events in comparison with Edinburgh University Solution of Lime (EUSOL). No evidence-based conclusions for systemic treatments can be drawn. Topical negative-pressure therapy was not shown to be effective for healing chronic wounds in seven small trials. Despite the absence of evidence from CSRs, topical negative-pressure therapy is frequently used in practice (81).
