Necrotic tissue is often black or yellow. It may be soft or it may form a scab (eschar). Necrotic tissue can contain bacteria – and if the bacteria grow, the wound will become infected.

Removal of necrotic tissue (debridement)

Necrotic tissue must be removed in order to support wound healing. Removal can be surgical, mechanical, enzymatic (such as maggot therapy), or it can be achieved by supplementing the body’s own ability to break down necrotic tissue (autolytic debridement). 

Choice of dressing

The autolytic debridement process is optimised when the wound is moist. Coloplast has a range of dressings that support moist wound healing. For optimal moisture balance in the wound, the hydrocolloid Comfeel dressing and the unique properties of the Biatain foam dressing both support the natural autolytic debridement process.

Purilon gel is ideal for gentle and effective autolytic debridement of tissue in both dry and moist necrotic wounds, when used in combination with a secondary dressing such as Comfeel or Biatain.

Maceration 

Exudate leaked from ulcers can cause maceration, a softening or sogginess and breakdown of the skin that results from on-going contact with excessive moisture. Maceration can lead to skin breakdown, causing the ulcer to grow or creating satellite ulcers. Macerated tissue is white in colour.

Erythema

Erythema is an abnormal redness of the skin caused by dilation of blood vessels. Redness of the peri-ulcer skin may be a sign of inflammation or wound infection. 

Fragile skin

As we grow older, the texture of our skin changes and our skin becomes thinner, weaker and less protective. If a wound is surrounded by fragile skin, dressings are more likely to cause skin irritation. You must examine the skin carefully before deciding to use either an adhesive or a non-adhesive dressing.

Choice of dressing

The Biatain dressing range offers dressings with superior absorption and exudate management properties for all types of skin conditions.

Normal, healthy skin has a smooth and resilient structure. With proper wound treatment and use of dressings with superior absorption and exudate management, the skin surrounding a wound may be perfectly healthy and suitable for adhesive dressings such as Biatain Adhesive or Biatain Super, Adhesive.

If the skin is very fragile, consider using a non-adhesive dressing such as Biatain Non-adhesive or Biatain Alginate.

In the inflammatory phase of wound healing, exudate levels are usually high. Non-healing, or chronic, wounds are often stuck in the inflammatory phase and may produce large amounts of exudate. Increased exudate levels can be a symptom of infection and increased oedema.

Wound exudate is a fluid composed of plasma, blood cells and platelets. Most of the wound exudate filters from the blood and/or lymph system into the wound area, but red blood cells and platelets leak from injured capillaries. Composition and viscosity varies, from thin and clear plasma fluid to thick yellow secretion containing high concentrations of white blood cells and bacteria.

Controlling exudate

If wound exudate is not properly controlled, it can leak from the dressing and result in the peri-ulcer skin being exposed to the exudate (1). This causes over-hydration maceration of the skin and can ultimately delay healing (2,3).

Maceration is a softening or sogginess and breakdown of the skin caused by on-going contact with excessive moisture. Macerated tissue looks white and maceration can cause an ulcer to grow or create satellite ulcers.

Macerated skin(2,3)

• Delays healing
• Increases risk of infection
• Increases friction risk
• Can result in wound enlargement

It is therefore very important that excess exudate is removed from the wound by an absorbent dressing. (4)

Control of exudate, removal of unhealthy tissue by debridement and management of bacterial load are all part of good wound bed preparation. The optimal wound dressing keeps the wound moist and absorbs exudate, locking it inside the dressing to prevent maceration.

Dressings for exuding wounds

We recommend the Biatain dressing range, which provides superior absorption - faster healing (5,6) of low to high exuding wounds. Biatain dressings effectively absorb and retain wound exudate, ensuring  a moisture balance that is optimal for healing of exuding wounds.(7,8)

Wounds that are not healing normally may have a bacterial imbalance resulting in local infection of the wound.

Likely signs of wound infection are one or more of the following:

• Delayed or stalled healing
• Odour
• Increased wound exudate
• Absent/abnormal/discoloured granulation tissue
• Increased pain at wound site

Other symptoms

Additional clinical symptoms may arise if the infection spreads to the healthy tissue surrounding the wound. Depending on the type of bacteria, the wound exudate may become more pus-like, and the peri-ulcer skin may be tender, red and painful. The patient may also have a fever.

Please remember that diabetic foot ulcers do not always present with the classical signs of local infection.

Dressings for infected wounds and wounds at risk of infection

If a wound is healing normally, a foam dressing with superior absorption such as Biatain is ideal. If the wound is infected or there is risk of wound infection, we recommend silver dressings such as Biatain Ag, or Biatain Alginate Ag. These provide superior absorption for faster healing of infected wounds (1-7). If the infection is spreading beyond the wound, the silver dressing must be combined with systemic antibiotic treatment at the discretion of a physician. 

Many patients say that the pain is the worst aspect of having a wound. Persistent or chronic wound pain not only affects patients’ quality of life, it can also be a major barrier to wound healing. Often, the consequences of painful wounds are underestimated and undertreated. 
The wound pain itself can be caused by tissue damage (nociceptive) or nerve damage (neuropathic).

Nociceptive pain: stimulus dependent and usually caused by tissue damage. The pain is described as gnawing, aching, throbbing and tender. 

Neuropathic pain: occurs spontaneously as a result of nerve tissue injury. The pain is most likely to be described as burning, stinging, shooting or stabbing. 

Management of wound pain 

First, treat the possible causes of pain, such as wound infection (e.g., by a silver dressing) and uncontrolled oedema.

Local pain management is an important first step for persistent wound pain and for painful procedures, such as dressing changes and debridement.

You should consider systemic treatment if the pain does not improve with local pain management.

Biatain Ibu – Superior absorption for painful wounds

Biatain Ibu is the first and only dressing to combine moist wound healing with local release of ibuprofen (1,2). Biatain Ibu is indicated for exuding wounds to provide moist wound healing. In addition, Biatain Ibu may reduce wound pain caused by tissue damage (nociceptive pain). The safety and performance of Biatain Ibu is supported by evidence from the largest randomised, comparative clinical trials ever performed on a wound dressing(1-3).

The patient

The patient – an 85-year-old woman – had been suffering from a venous leg ulcer on the lateral part of her lower left leg. The skin on her leg was fragile. The ulcer had persisted for five months at inclusion.

Previous treatment

Prior to inclusion, the ulcer had been treated with alginate dressings and compression therapy for ten weeks. Ulcer healing was delayed compared to the normally expected healing rate.

Biatain Non-Adhesive introduced

 When the patient began treatment with Biatain Non-Adhesive, the ulcer area was 4.9 cm². The ulcer contained 20% fibrinous tissue and 80% healthy granulation tissue. During the four-week treatment period, long-stretch compression bandages were applied.

This picture shows the ulcer at inclusion after cleansing:


Ulcer area was reduced by 73% after two weeks of treatment with Biatain Non-Adhesive:


The ulcer area was reduced by 95% after 4 weeks of treatment with Biatain Non-Adhesive:

Conclusion

During the four weeks treatment period:

• Biatain Non-Adhesive demonstrated remarkable reduction in ulcer size.
• Biatain Non-Adhesive caused no leakage or maceration, even under compression therapy.
• Biatain Non-Adhesive minimised pressure marks.
• Biatain Non-Adhesive was comfortable and easy to use.

Download full case description (PDF)

The patient

This patient suffered from heart failure, coronary heart disease, arterial hypertension and venous insufficiency in both lower limbs, as well as Alzheimer’s.

Deep foot ulcer

For four months, she had a very deep diabetic foot ulcer on the right foot with erythema, oedema, crepitation and heat in the surrounding tissues. She was referred to the A&E department and after examination by Vascular Surgery, her family was informed that the immediate treatment would involved supracondylar amputation since she was suffering from a grade 4–5 diabetic foot based on the Wagner scale.
 

Biatain Ag introduced

The family was opposed to this treatment, and the patient was returned to her home for monitoring by her family doctor and out-patient care and dressing by home nursing. Biatain Alginate Ag and Biatain Ag were used in combination with debridement and oral antibiotics.

This picture shows the ulcer at inclusion:


This picture shows the ulcer after five weeks of treatment with first Biatain Alginate Ag and then Biatain Ag Non-Adhesive:


Here we see the ulcer after four months’ treatment:


The ulcer was closed after 10 months’ treatment:

Conclusion

The objective set was to prevent amputation of the foot, ensure the well being and comfort of the patient and of the family. The method used began to bear fruit already seven days after the treatment started, with visible changes in the development of the wound.The wound closed ten months after the treatment was started.

Download full case description (PDF)

The patient

The patient was an 88-year-old woman with a highly exuding Stage III sacral pressure ulcer. The ulcer had persisted for two months and had previously been treated with standard moist wound healing products.
 

The ulcer

The ulcer had several signs of local infection, a significant odour, and was heavily exuding. A small undermining was present at the top of the ulcer and there was approximately 50% unhealthy necrotic tissue in the wound bed.

The first picture shows the infected, highly exuding pressure ulcer before Biatain Ag treatment:

Biatain Ag Adhesive introduced

Odour was eliminated after just one week of treatment:

This picture shows that the wound bed is clean and healing is progressing after four weeks of treatment:

Conclusion

During the one-month treatment period Biatain Ag effectively eliminated signs of local infection and supported healing of this heavily exuding sacral pressure ulcer. Elimination of odour and a significant increase in healthy granulation tissue was observed already after one week.

Download full case description (PDF)

Tips for prevention, assessment and treatment of pressure ulcers are available in:

Pressure ulcers – prevention and treatment: A Coloplast quick guide