First Line Advanced Wound Care Products

This category includes products such as wound cleansers, debridement pads and cloths, alginates, foams, hydrocolloids, hydrogels and films. Such treatments are generally available on wound care formularies and can often be used by health care professionals without involving a clinical specialist. However, protocols are in place for a reason and should be followed.

WOUND CLEANSERS

Wound cleansers are often solutions that are used to remove contaminants, foreign debris, and exudate from the wound surface. They are also utilised to irrigate a deep cavity wound. Wound cleansers are available in an assortment of products. From simple water and saline solutions to those with added ingredients that can include surfactants, wetting agents, moisturisers, and/or antimicrobials.

There are also a variety of methods for wound cleansers, such as a rinse or no rinse and wound soak. These products are designed to be used at every dressing change and can be used in conjunction with gauze, sponges or debridement pads and cloths. They may also be employed as a solution in a device that accomplishes irrigation and debridement. (Dermanet, 2022; Murphy et al., 2020)

In clinical practice, the decision on which cleansing agent to use is often largely based on local guidelines and personal preference.

An ideal wound-cleansing solution would:

Be non-cytotoxic
Not induce an immune response (be biocompatible)
Reduce the number of pathogenic bacteria
Not induce bacterial resistance
Be non-sensitising
Be easily accessible
Be cost-effective
Be stable with a long shelf life

(DermaNet, 2022)

Product	Advantage	Disadvantage
Water	Drinking water has an excellent safety profile. It is efficient, cost-effective, and easily accessible. Drinking water is an acceptable alternative when sterile water and normal saline are not available. The rate of wound infection when tap water is used is similar to that with normal saline.	Tap water is a possible infection risk and should be avoided in a deep wound, especially when there is an exposure of bone or tendon. The solution is not isotonic.
Sterile water	Sterile water is an option when normal saline is contraindicated or not available.	Sterile water has no antimicrobial properties. The unused contents of opened containers should be discarded. Prolonged soaking in water can result in increased wound exudate, requiring frequent dressing changes. Sterile water does not promote wound healing in the presence of a pathogenic biofilm. Irrigation with sterile water can be painful; analgesia may be required.
Normal saline	An isotonic solution that does not interfere with normal wound repair. It has low toxicity compared to other wound-cleansing solutions. It does not cause an allergic reaction or change the normal flora of the skin. Normal saline has a similar wound infection rate to drinkable tap water.	Does not cleanse dirty or necrotic wounds effectively. It has no antimicrobial properties. The unused contents of opened containers should be discarded.
Antimicrobial
Acetic acid	Acetic acid (vinegar) is inexpensive and readily available. It is effective against Staphylococcus aureus, MRSA, Pseudomonas aeruginosa, and other Gram-negative bacteria. It promotes wound healing.	It can sting on application.
Chlorhexidine	Chlorhexidine is a broad-spectrum antibacterial solution. It prevents the penetration and systematic spreading of bacteria, including MRSA (excluding any deep muscle invasion).	Chlorhexidine can cause skin irritation. It may be a sensitiser, causing allergic contact dermatitis – although rare. It does not affect mycobacteria, bacterial spores and certain viruses, including polioviruses and adenoviruses. Chlorhexidine is pH-dependent. Body fluids and tap water may inactivate with its antibacterial properties.
Povidone Iodine	Povidone iodine is useful for acute open wounds such as human or animal bites, stabs/punctures, and gunshot wounds. It is a broad-spectrum antimicrobial solution that provides limited coverage for many types of pathogens (e.g. S. aureus, yeasts, and viruses). Some studies have demonstrated a reduced infection rate in surgical wounds. It may be useful in treating excessive granulation tissue.	Povidone iodine is a cytotoxic agent that can delay wound healing. It can cause irritation, dryness, and discolouration. It is a sensitiser and has adverse effects on the thyroid gland. Povidone is not suitable for chronic wounds. Do not use it for more than 7 days.
Sodium hypochlorite	Diluted bleach has bactericidal properties including on biofilm. May be indicated in pressure ulcers with necrotic wounds to help reduce and control infection. It can be used to wash out deep wounds and cavities. It has been used over cancerous growths to control infection. It reduces odour.	May cause irritation if dilution not correct.
Hypochlorous acid	Rapid, broad-spectrum antimicrobial activity with low cytotoxicity. Can be used to loosen dressing as well as for cleansing.	Not always widely available.
Polyhexethylene biguanide (PHMB)	Some formulations may contain a surfactant. Also known as polyhexanide, is the antiseptic of choice for colonised and infected chronic wounds and burns. It is a broad-spectrum antimicrobial that is effective against a variety of pathogens, including MRSA, P. aeruginosa and other bacteria. Studies have shown that it accelerates wound healing and decreases the bacterial count. It does not cause antimicrobial resistance. PHMB has good clinical safety and is well tolerated with minimal toxicity. Contact allergy and anaphylaxis from PHMB have rarely been reported.	Not always widely available. Some formulations require 15 minutes soaking – (not always adhered to in practice).
Octenidine	Effective against P. aeruginosa and S. aureus biofilm It can be used for the decolonisation of multidrug-resistant organisms. It promotes wound healing and is non-sensitising.	For superficial skin wounds. Should be avoided in wounds near the sinus tracts.

Adapted from DermaNet, 2022; Murphy et al., 2020

DEBRIDEMENT PADS AND CLOTHS

As part of good wound hygiene, debridement of a wound is an important stage, and there are a variety of dressings that can be used. This section looks at those pertaining to mechanical debridement. The common forms seen today are debridement pads and cloths. These are often used in conjunction with wound cleansers.

Wounds, in general, can be sensitive and potentially painful. As such, the consideration of pain management should be part of a wound assessment prior to the practice of wound hygiene (cleansing and debridement).

Monofilament pads

These pads/mittens, with a soft, dense texture, usually consisting of 100% polyester fibres, are knitted to the reverse side and secured with polyacrylate. Debris and exudate are actively loosened from the wound by the fibres. Skin flakes and keratoses can also be detached from the surrounding skin. The loosened debris is removed and safely locked into the fibre material. (Nowak et al., 2022)

Microfibre Pads

These pads/mittens are usually made of polyester and polypropylene, with a front layer with microfibres and an absorbent backing layer.

Microfibres can be more effective at cleansing than traditional fibres due to their size and structure: one microfibre is approximately 1/100th the diameter of a human hair. This means that there are more of these fibres in comparison to a monofilament pad.

Microfibres work in a similar way to monofilament fibres, loosening and removing debris. However, microfibres can use microscopic ‘electrostatic forces’ to bind to particles, increasing their ability to lift and retain particles of slough and debris. (Ovens & Irving, 2018)

Foam Pads

Less common than the fibre counterparts, these debridement dressings consist of a two-sided polyester-polyurethane foam pad. Usually, the two sides are differing in colour to distinguish between the type of debridement activity. One side, which requires moistening prior to use, is designed to loosen and remove devitalised skin, slough etc. The other side is absorbent, intended for the management of exudate, and its design allows the foam to increase the surface area for the pad’s absorption and removal of non-viable tissue from the wound bed. (Barrett et al., 2022)

Debridement Cloths

The composition of the cloths is often made from looped fibres and pre-moistened to assist with debridement. The moistening agents can include surfactants that are known to disrupt biofilm. Some cloths may also have a ketolytic agent that assists with skin softening. (Gilles, 2019)

Debridement pads and cloths are designed for single use only.

Mechanical debridement and related products should be undertaken with caution in patients with bleeding disorders or those who are on anticoagulation therapy and/or who are in intolerable or unpreventable pain. (Nowak et al., 2022; Murphy et al., 2020)

It is worth noting that mechanical debridement does not replace the need to refer for specialist assessment if there are concerns or the wound is not progressing to healing in a timely manner. Mechanical debridement can be considered while the patient is waiting for a referral for sharp or surgical debridement if there are no contraindications. (Barrett et al., 2022)