Hello, and thank you for joining me for Navigating Topical Wound Management. My name is Dot Weir. I'm a nurse clinician and educator from Holland, Michigan, and I appreciate the American Academy of Dermatology allowing me to spend some time with you on this important topic. My background is primarily, for the last 21, 22 years, has been outpatient wound care. And so we pretty much see the walking wounded, as I know many of you do. But we talk about, many times, we talk about patient wounds in terms of being a chronic wound, and I'm not a big fan of that term, because a chronic wound can make you think of something that someone's going to have for life. I like to think of these wounds as complex, because they are wounds on very complex patients, as well as hard to heal wounds, wounds that have a barrier, that if we can just find the barrier and identify what is holding the wound back from healing, we can usually get it to go on and close. So one of the first things we're going to do as we approach a patient with a hard to heal wound is to make sure we have the correct etiology so that we can provide the correct kind of supportive care. If it's a venous leg ulcer, as long as we know that their perfusion status is adequate, we're going to use some sort of compression. If they have diabetes or have a diabetic foot ulcer, a plantar ulcer, we're going to need to offload them, hopefully with a gold standard of total contact casting, but in the absence of being able to do that, some sort of offloading. If it's a pressure injury, we want to look at those things that have put them at risk for this, making sure they have adequate nutrition, that we're aware of their level of continence or incontinence, and certainly provide any kind of some sort of a pressure redistribution device on their chair or on their bed or both so that we can make sure we're redistributing the pressure to allow that to heal. If there's an arterial issue, then hopefully we can get some sort of vascular intervention for the patient so that they can reperfuse that foot. And of course, in the absence of that, then we would just need to protect them from injury. And then last but not least, certainly something that's well known to folks in dermatology is the importance of recognizing that wound that is not healing based on using the right kind of supportive care. So if it looks like it's atypical, then it probably is atypical. So we want to have a low threshold for biopsy because we may need to have some sort of medical intervention versus just topical intervention. One of the things that's very important to me and that I find myself lecturing on quite frequently is wound cleansing. All wounds, regardless of the type, and the peri-wound should be cleansed at each dressing change. Through the use of fluorescence imaging, which I'm going to show you in just a moment, we have found that the peri-wound is often more contaminated than the actual wound bed. The other thing that we have learned is that wet callus and wet skin, macerated skin, holds onto bacteria like a sponge. Before I get into how we clean, one of the things we have to keep in mind is that cleaning a wound can be painful for the patient. So one of the first things I ask a patient when I walk into the room is, does it hurt when we clean your wound? Because if it does, we're not going to be able to do it adequately because no one wants to inflict that kind of pain on somebody. And interestingly, I can tell you that something as little as 2% lidocaine jelly can go a long way towards helping the procedure of cleansing become more tolerable for the patient. But the other thing to consider is that if we want the patient's family to clean the wound or a home care nurse to clean the wound, then we should consider ordering some type of topical anesthetic for the patient at home. Now you have to work with the pharmacy sometimes because we have to sometimes find one that their insurance will pay for, but it's usually possible. What we clean with is critically important, and I'll talk a little bit about that in just a moment. But we want to avoid toxicity because it does matter. In our decision to whether we're going to allow a patient to shower is just on a case-by-case basis. Depending on the patient's general hygiene, the location of the wound, possibly knowing what the water source is, their host immunity, are they on any kind of medications or therapies that could reduce their immune system, then we might want to consider not having them shower. So let's go back to the peri-wound skin. So what you're looking at in that middle picture, that bottom picture, is a wound that clearly is closing. But if you notice around the periphery of the wound, there is some significant maceration, some debris up here that might be residue from a previous dressing change, similarly down here. Now these fluorescent imaging devices, they emit a safe violet light, and those bacteria that produce porphyrins reflect back in this light, sort of like a wood's lamp. So most gram-negative, gram-positives that do fluoresce will fluoresce sort of a scarlet red color, and it has been found that pseudomonas specifically reflects back in a cyan, sort of hot white color. Now look at this same wound under fluorescence imaging. You can see all of that macerated skin is just filled with bacteria, here's a little pseudomonas up here. And again, it's not necessarily impacting the wound closure, maceration will, but I use this just to illustrate how much bacteria is actually in that peri-wound area. So as we choose a wound cleanser, we want our choice to be non-toxic, we want to strive for a high therapeutic index, meaning we want something that's going to be effective in reducing the bacterial load, in reducing the bacteria, effective in neutralizing or killing the bacteria, but with a low toxicity to the patient's host cells. So that information is available, you can do a search for it because there's been some newer papers that have been published related to this. Additionally, we want to use something that's going to help neutralize the pH, something that's going to lower the pH, because most chronic wounds have been found to have a relatively high pH, and sometimes I'm talking in the 7, 8, 9 range. We know that in a high pH range, that cells and bacteria love a high pH, so they're going to be more prolific. The negative proteases, the matrix metalloproteases, are at a higher level, are much more hostile to the wind environment in a high pH, and there's even a difference in the oxygen diffusion to the tissues in a lower pH. So lots of reasons to really know what the pH of the cleansers are that we're using on it. If we're going to deliver those solutions with a high enough PSI to make a difference, dribbling a little bit of normal saline onto a wound bed and blotting it with a gauze is not going to scare anything off of that wound. We need to ideally scrub that wound to the, like I mentioned, with the pain issue to the extent that the patient can tolerate it. But if we're going to irrigate it, historically in the literature you've seen this 35cc syringe with a 19-gauge angiocath. Well those are difficult to find. So as this chart shows, you can find a 20cc syringe with an 18-gauge angiocath. And under normal irrigation it would deliver about a 12 PSI, hopefully enough to dislodge any debris from the surface of the wound. Not likely to do anything to attached bacteria. That would be better done through debris and through scrubbing, but at least it will help to dislodge some of the debris and detritus that's still sitting on the surface of the wound. So closing out on cleansing, stay tuned. The International Wound Infection Institute, who I will bring up again, we are, I'm the secretary of this group and we're working on a document on the evidence of wound cleansing. We've got some new definitions that are in here that we arrived at through a Delphi process. And it is in the works right now, depending on when you're listening to this. So we're looking at a March 2025 release of this document. So this is our website, the woundinfection-institute.com. You can join the IWII and be on our mailing list for our newsletters and hear about our different presentations that are done, as well as be notified when the cleansing document is released. So now as we look to talk about dressings, one of the things that has driven our dressing decision over many years, starting back in the late 70s, although this lab data, this work done by George Winter was done back in the 60s. But we have been adopting and embracing a moist wound healing environment for many years now. Actually, I was just starting in my wound care career when we were making this transition from a lot of wet to dry dressings over to more moisture enhanced wound healing. And so this is just the work that was originally done by Dr. Winter looking at, he created wounds on the backs of domestic pigs. Some he covered with a saran type of material to occlude it. And again, these were partial thickness wounds. And then the rest he left open to scab. What he found was that the wounds that were kept moist, the new cells migrated off the wound edge and migrated across the wound bed with low protease activity needed and much more readily and much more rapidly. And the dry environment with that scab, the cells would need to stop. They would need to produce a protease to lift that scab out of the way, migrate a little bit, lift the scab out of the way. Anyway, it just simply took longer and required greater uses of proteases. And so again, this is well into 40 years that we've been practicing the concept of moist wound healing. So when we look at our dressing choices, the ideal dressing will help us to manage the exudate appropriately, I'll readdress that. Not drying it out or not overly macerating, and we saw what maceration can do. So it'll provide a nice environment for healing. We want something that's non-occlusive or has the best gas exchange or moisture vapor permeability as possible. Ideally, thermally insulating. The less often we change dressings and the less often we change the temperature of the wound bed, the less recovery that the cells have to make. We want it to be impermeable to bacteria, provide a barrier to contamination. We don't want to leave any particles or anything behind that could be either toxic to the wound bed or conducive to bacterial growth, but also to act as a foreign body. And as I've mentioned, we want it to not hurt. It needs to be non-traumatic or minimally painful on removal. If we're going to use it with some sort of a support device, if you're going to have to have a multi-layer wrap or a total contact cast on and we want it to stay on for a week, then we need a dressing that can stay in place that long also. And of course, it needs to be user-friendly. We don't want anything that's too confusing that's just going to add to the cost if we use a lot of dressings together. And many times, again, we're asking the family members to be able to do this. So we try to keep it simple and make it easy for whoever's going to be doing that follow-up care. Let's take a moment to look at the challenges with Exudate because in my next slide, I'm going to tell you that drainage does drive our dressing decisions. The challenges with Exudate are well known. First of all, the skin issues that we've already talked about, the maceration, erosion of the peri-wound area, certainly pain, and the potential for secondary infections and at the minimum, local colonization of bacteria in the peri-wound area. There's huge quality of life issues in terms of the odor to the Exudate, the appearance of it, the soiling of their clothing, of their bed linens, sometimes the ability to visualize this drainage through their dressings or on their dressings, I should say, like you see up in that top right corner. And then the frequency of the dressing changes. If we have a lot of Exudate, they're going to have to be changed more often. That's going to increase the cost and they may have a challenge with access to care. Perhaps they don't qualify for home care and the family members are going to be having to do these dressing changes frequently. So as I've already alluded to, dressing selection is many times going to be driven by the amount of drainage. We say drainage drives dressing decisions. And so that makes our wound assessment the most critical piece of this, because we need to know how much Exudate do they have? What is the history of other dressings that they've used? And to remember that wounds are dynamic. They're going to change, so our treatments along the way are also going to change. We want our choice of dressings to be evidence-based. You're not going to find a lot of randomized control trials in the dressing world, but they need to have a good FDA approval to be marketing for what they say that they will do. So we want to have as much evidence as possible, but if we make our decisions based on goals that we've set from our assessment, then they're usually going to be the right ones. And so each time we do our assessment of these wounds, we want to begin that with the end in mind. What's our current goal? It may start out being we need to get it debrided of necrotic tissue. And then once that's clean, then we want to manage the Exudate. We want to create a moist environment. And again, that could change along the way. So as I mentioned, our assessment is going to drive our treatment decision or our decision to change our treatment. As we change dressings, if we find a lot of pooling, as you see in this top left in this middle one, I know that middle wound looks terribly infected, but she was a patient with lymphedema, horrible lymphedema actually. And what you're looking at is just pooled Exudate and erosion of the skin surrounding her wound because it just wasn't being adequately absorbed. We're going to look at the color of the Exudate. That will maybe drive us to use an antimicrobial dressing if there's any kind of odor that we recognize in the wound bed. When we go to take the dressing off, as you see in this top right picture, it looks like it's absorbing Exudate pretty well. But when you take that off, if you still see maceration, it's not doing a good enough job. And then this is just another example of fluorescence imaging, which I wish everyone had this in their hand because it tells us so much about how good a job the dressing is doing, how well we are doing with cleansing. So that's before the fluorescence imaging. And this is again, you can see all of the contamination in this peri-wound area, meaning that the wound needs to be cleaned much better. So now let's take a look at the basic dressing categories. There are a lot of caveats to this, but we're going to look at some of the basic dressing categories and what it can do for the wounds that we take care of. Clearly gauze is one of the most rudimentary and fundamental dressings out there. And I believe that gauze is really better for cleansing than any dressing. We have gotten away from using any kind of wet to dry dressings because of the traumatic injury that it can do to the healthy wound bed, if it's a healthy wound bed. But it is sometimes used temporarily as a packing and a filling material if we're going to be needing to deliver some sort of a solution to the wound bed. Our first entry into Moist Wound Healing was with the film dressings. These are moisture vapor permeable dressings that, if anybody's had an IV in the last 20 years and they've had a film dressing on their body, and they don't do a lot for chronic draining wounds. They don't do anything for draining wounds because they don't absorb anything. So they are moisture vapor permeable. They are good for covering and protecting a vulnerable area or a recently closed area as the wound matures. We sometimes use them also to waterproof a dressing in if the patient does want to shower. So again, not something that's used as a primary dressing very often in open draining wounds. The hydrocolloids are sort of a sleeper dressing. We don't use them too much anymore. The hydrocolloid dressings are a wafer type of dressing. They've come a long way in the 40 years they've been on the market. The edges are now beveled. They're anatomically shaped. But these are fairly occlusive dressings. And what happens when you put them down onto the wound bed, the body side or the wound side of that dressing will interact with the wound exudate and form a gel. So it slowly absorbs the exudate. It can't absorb a lot. But then when you take the dressing off, the gel stays behind so you're not disrupting the surface of the wound. Again, we use them more as a final dressing if we're just trying to protect an area like we do with sometimes film dressings. They're available at just retail pharmacies. And there's often many times what we might suggest to a family member or somebody who has a blister or some little small thing that needs to be covered and kept clean. They can stay in place for up to a week. These next three categories help us to meet the needs of a wound based on our assessment. So if we do a wound assessment and we find that the wound bed is dry, a category of dressing that can help us to hydrate that are the hydrogels. Again, not something that's used very often because we don't find a lot of wounds, frankly, that are that dry. But they're usually water or glycerin based. They may contain antimicrobials such as silver. They're available in either amorphous, meaning they are a gel-like that squeezes out of a tube, or they are also available in a sheet form, which is nice for covering and protecting. But again, they don't provide any kind or very minimal absorption. When we need to manage exudate, we have the calcium alginates and the gelling fiber dressings. Now these are different types of dressings. The calcium alginates are, they both look the same. They look kind of like a fiber. Calcium alginates are derived from a seaweed, but they work on a calcium-sodium ion exchange, meaning that in the wound bed, they go on as a calcium alginate. They exchange the calcium ions for sodium ions out of the wound exudate, and then it becomes a sodium alginate, which is a gel. And so they absorb exudate. They become nice and soft once they absorb the exudate, and should come off without sticking or leaving anything behind, as long as there is adequate exudate to support the need for this much absorption. Then there's others that look similar called gelling fiber dressings, and they are made from different materials such as carboxymethylcellulose. Some are made of a polyvinyl alcohol fiber that does a very good job of moving exudate into the secondary dressing. Nonetheless, even though they are different, they still meet the same need in a wound, and that is to absorb exudate, hold onto that exudate, and hopefully transfer that exudate into the secondary dressing. Now the calcium alginates also have a bit of hemostatic properties. If we have a little bit of a punctate bleeding after we, say, have finished a debridement. And then lastly, but not least, is the foam category. This category of dressings is by far the largest, has a lot of different options. They can be used as primary or secondary dressings. Say you're using that calcium alginate, and you need to absorb exudate that is passing through that alginate or fiber dressing, then the foams would be a good choice. They come in different anatomic shapes. They come with or without a border. Some of them are just plain polyurethane foams that just absorb. Others are multi-layered, super-absorbent foams that help to lift exudate up and move it out into the body of the dressing. And again, you may have some that have silver. They may have pigmented organic pigments that help to reduce bacteria. There is one that includes a surfactant, so that as the exudate hits the dressing, it releases a surfactant, which helps us in cleaning the wound. So again, these are sort of our workhorse dressings when we're helping or working towards getting that exudate amount under control. And then we have some advanced categories. Another large one are the super absorbent dressings. These are multi-layered fibrous or particle filled dressings that again do a better job than standard dressings of absorbing exudate. They lift the exudate up and move it laterally out into the dressing and trap that exudate. So it works kind of like diaper technology so it's not moisture exudate that's sitting against the skin. So they can be a primary but often are a secondary dressing also. Then we have collagen. Collagen is not a moisture management dressing. Collagen as you know is the primary structural tissue structural component of our tissues and using collagen on the surface of the womb does a few different things. One, it does not become the the collagen of the wound bed but it does provide a sort of a scaffolding as it interacts with the wound exudate and so it's very favorable or conducive to fibroblasts migrating in and attaching to the temporary scaffolding. Another important thing that it does is that collagen dressings can act as sort of a sacrificial substrate. If you have a hostile wound environment and many times this is just trial and error but if you have a hostile wound environment and you use a collagen dressing then the matrix metalloproteases that now have become destructive and could be causing off-target destruction of some of the important proteins in the womb will preferentially go to the collagen, a sort of low-hanging fruit, and leave the protein components of the wound bed such as the collagen, the growth factors, the integrins, the cell surface receptors alone. So it helps to improve healing in that way and it's a great dressing. If you're thinking that you're dealing with a wound that's of such a chronic nature that you may want to move on to a cellular and tissue-based product, collagen is a good first place to start because it could help to create that nice environment that makes that wound bed not so hostile and you may see that the wound begins to close without the need to go on to more expensive therapies. And then there's a whole variety of other kinds of dressings that are multi-purpose that combine the attributes of say a collagen dressing with a foam and if you understand the basic categories, then when you see a combination or multi-purpose dressing, you can usually identify what it's going to be able to do for you or for your wound. So as we close out on the standard dressings, there's four questions that we can ask ourselves. Is the wound bed dry? Then we need to hydrate it and we can do that with some of these dressings, the hydrogel dressings, concentrated surfactants, hydrocolloids, and films. If the wound is draining, then we need to absorb it and we can do that with calcium alginates, gelling fiber dressings, foam, super absorbers, as well as negative pressure which I know is covered in another session. If there's space, then we must fill that space. We don't want to cover a dressing and leave undermining sinus tracts, tunneling, because if we do it's just they're just gonna fill with fluid and then it could be conducive to bacterial growth. So if there is space then we definitely want to fill it in. Again, we can use moist glass packing temporarily, calcium alginate, gelling fibers, different super absorbers, as well as, as I've already mentioned, negative pressure wound therapy. And then if it's all filled in and it's nicely granulated, this is when we want to practice undisturbed wound healing. We want to cover it, meet the moisture needs, because it still may be draining some, and then leave it alone. That's when we need these wounds to be epithelializing, especially with full thickness wounds. We need them to be epithelializing from the edges. So the more, the less we disturb it, the more conducive that it's going to be to that epithelialization. But we're still going to need the, to meet the moisture dressing. So that's where all of our dressings pretty much can still come into play. So let's switch gears and talk about those wounds that have an issue with bacteria. So I will also connect you to this source. This is also from the International Wound Infection Institute. These were our clinical practice, wound infection and clinical practice guidelines that were published in 2022 and won a, won an award at the World Union of Wound Healing Societies meeting. Inside, and these are free by the way, so you can go to our website and download not only the guidelines, but you can also download different charts and like this continuum that I'm getting ready to talk about in a PDF form to use in your own presentations. But inside the wound infection guideline is something that we call the wound infection continuum. And this is just looking at the level of microbial burden in open wounds. And I'm sure that infection is covered in a different module here. But just looking across the continuum, we know that all wounds are contaminated. There's bacteria sitting there and they're not causing the host or the wound any kind of challenges. There's not going to have any kind of a host reaction evoked and it should not interfere with wound healing. Once those bacteria begin to replicate, then the wound may become colonized, but still it doesn't evoke a host response and it usually will not delay wound healing. So this is a lot of our wounds and so we just want to observe them and make sure that they're not changing in a way that we think the bacterial burden is growing. What used to be in the literature and how we talked about this was we called it critical colonization, meaning there was a critical level of bacteria that now did evoke a host response and needed attention. The IWII has broken this down into covert, meaning less obvious sort of subtle changes, to overt signs of infection, which leads on into more spreading infection and unfortunately systemic infection. This is when we're going to use topical antimicrobials. So the covert signs would be hypergranulation tissue, maybe the tissue seems more friable, it's more painful, we may see pocketing in the granulation tissue. The wound will begin to exudate more as the body tries to clear out toxins from the wound environment and we start to see a change in the wound healing. It might have been on a nice trajectory and now it's not. What we're trying to do now is to institute topical therapy because the next thing it's going to do is go into more of our classic signs of infection, erythema, warmth, induration, swelling. We may see purulent discharge, meaning the body's reacting to it and it's sending white blood cells to the area. The wound may be getting larger, the periwound skin may be getting eroded, the patient often will complain of more pain, and we may begin to smell an odor that wasn't or notice an odor that wasn't there before. So again this is where our intervention topically will help to reduce this bioburden hopefully so that it doesn't go on to spreading infection which would require systemic antibiotic therapies. And so I'm going to go through the current antimicrobial dressings that are on the market, albeit rather briefly, but there are choices out there and we want to be able to have choices. I think our materials management folks would be very happy if we only had one silver, but we need to not only different antimicrobials, but we need them in different delivery systems. So we'll look at all these various ones. So silver is unquestionably one of the largest categories, if you will, of antimicrobial dressings. It's available in all dressing categories and historically the way silver supposedly was just found to be antimicrobial is when big ships were coming over to discover new lands they put silver coins into their big barrels of water to keep bacteria and stuff from growing in the water. I don't know if that's true, that's probably urban myth. But anyway, silver is a good agent. It's antimicrobial, it has a broad spectrum of antimicrobial action, it's effective against gram-positive, negatives, anaerobes, aerobes, resistant bacteria, and fungus. So it works really well and there is some concern because in vitro you can show some tolerance or resistance to silver, but again that's in vitro not necessarily in vivo. So again, but we need to respect that and use it for the length of time that we need it and then stop using it when we don't need it anymore. I mentioned organic pigments. These are some pigmented foam dressings that contain small amounts of methylene blue and ginseng or crystal violet in low enough amounts to not be conducive to harm to the tissues, but high enough so that they are antimicrobial or bactericidal in nature. Most of them are polyurethane, excuse me, the more classic one is a polyvinyl alcohol foam which needs to be moistened in order for it to be soft and malleable, but they also come impregnated into polyurethane foams. So they have been found to be effective against most common wound pathogens. When you take these dressings off and you'll find this with iodine based dressings also, what you'll find is that when it comes in contact with human wound fluid or serum that it does change in color and so it will blanch out. Doesn't mean that it's dumping the pigments onto the wound bed, it simply means that they have come in contact and it is an indication to change. The polyvinyl alcohol version of these also because of the they have a nice capillary action so they adhere to or the exudates will adhere to the back of the dressing. But they're generally changed, they can be left in place up to seven days, but depends on the amount of exudate and again when you see this color change that is indicative of needing a new dressing. So PHMB poly hexamethylene biguanide is a derivative, it's a biguanide. You're familiar with chlorhexidine as a wound cleanser, skin cleanser I would say like Hibiclens prior to surgery for example, but that's exquisitely toxic to the wound bed. And so chlorhexidine is a more is a more tissue friendly, a safer biguanide that is more biocompatible. We find PHMB in dressings, they're a really effective barrier to bacterial contamination, very effective against most common wound pathogens. And in some of the more recent literature and papers looking at therapeutic index, PHMB has a fairly high therapeutic index as a cleansing solution. So we find it in cleansers, we find it in foams, hydrogel dressings. The early ones were in gauze pads that were found to provide a nice bacterial barrier. In fact if you've ever used a negative pressure device that had a foam as the interface, it had PHMB in it. And so it's also in an advanced biologic that is made with native collagen and has PHMB as an antimicrobial. Then there's iodine which has been around for centuries, but iodine is toxic at the cellular level, but we do have safe delivery systems for iodine. Povidone iodine is so readily available but a useful strength onto a wound bed. It is toxic as well as you have to worry about the thyroid, any pre-existing thyroid disease. So we have two delivery systems for iodine that are safe and non-toxic to the wound bed. One is codexamer iodine and what that means is just that the codexamer piece are starch-based little beads that when the exudate comes up into the dressing then the codexamer opens up and releases that iodine in a slow controlled release so it's not going to be overwhelming or toxic to the wound bed. Again iodine like the organic pigments will turn white blanched out to white when the iodine has come in contact with the wound exudate and so that's an indication to change. But it is not going to inhibit or impair fibroblasts and some of the important cells that we need in the wound as full strength povidone iodine would. Another delivery system for iodine is in a foam polymer. It's a polyvinyl alcohol foam that also contains iodine similar to codexamer iodine but it's not starch-based it's foam based and so like iodine and like the organic pigments it will turn white when it is delivered. The native foam itself is white and so the iodophore is black and so it's going to blanch out when it has released the and it doesn't release it's not dumping iodine onto the wound bed but it's effectively managing the bacteria in the exudate when the exudate goes into the dressing. So same advantages has a lower toxicity a longer release duration and certainly a better efficacy than straight povidone iodine and also I don't think I said this with codexamer iodine it does has shown to have an in vitro effect on biofilm. So honey, honey has also been around for centuries as mentioned in many early writings used in plasters and by the early Egyptians so it's been around for a long time. There's a couple of types of honey that have been found to be more effective such as manuka honey depending on the the bee in the flower that it comes from. As we look at the mechanism of action of honey first and foremost it is antibacterial not bactericidal. It doesn't support bacterial growth because of the high concentration of sugar. Just the same reason that you don't have to keep your honey at home in the refrigerator you can keep it in your pantry which obviously makes it easier to flow out of the container. But it does prevent provide a barrier and because of the high concentration of sugar it simply does not support bacterial growth. The other thing about the high concentration of sugar it does cause a bit of a fluid shift from the surface of the wound so it helps to reduce some little bit of peri-wound edema as well as be very soothing and comforting so it does help to reduce pain. It creates a very nice moist wound healing environment because of that osmotic effect and so consequently will support autolytic debridement. Another antimicrobial dressing that's relatively new in the United States are copper dressings. It's been found that copper ions by themselves or in some sort of a complex have been used for centuries to disinfect liquids, solids, human tissue. So these dressings are impregnated with a copper oxide microparticles so it helps to provide some protection to the wound from bacterial contamination. There's a reported to have a potent wide spectrum of biocidal properties so it inhibits the biological assembly and activity of the bacterial proteins. And tolerance to copper particles by the microbes is rare or so far has been shown to be rare. There is another sort unique, very unique actually, biofilm disruption gel that helps to deconstruct the biofilm extrapolymeric substance. So I didn't, that's in another module I'm sure, bacterial growth and bacteria can grow into these communities called biofilm and they're held together with metallic bonds. These extrapolymeric substance, a bunch of polysaccharides and sugars and different things make up the film of the biofilm. So one of the things that this biofilm disruption gel will do is help to deconstruct those metallic bonds and so it breaks down the film of the biofilm releasing the pathogen and then they become free floating or planktonic again so that the gel can then kill the bacteria without cytotoxicity to the host cell. It isn't a, they do have a cleanser, it is also and is primarily in a gel form. So then it creates a physical environment then we that doesn't, is not conducive, it doesn't support the attachment of the planktonic organisms to reform that biofilm. And then last but not least is addressing that's considered to be a pathogen bio binding mesh. It's called DAC, that's the easy way to say it's diacocarbamyl chloride. So it's not technically antimicrobial because it doesn't really kill anything. What it is is it's a fatty acid derivative that is hydrophobic and because bacteria are inherently hydrophobic, they push water out in order to adhere to each other, adhere to surfaces, they now will adhere to this fatty acid derivative which is also hydrophobic. What's interesting is once the bacteria are bound on to the surface of the dressing, then they're inactivated and what we do, what happens is then when you take the dressing out of the wound, then the you're removing the bacteria alive. So we're not killing anything and it is doesn't cause any kind of toxins to be produced because of the killing of the bacteria. At first you have to change it every day but then many times you can decrease the frequency of the dressing change. So the pictures that you're looking at are scanning electron microscope photographs of the bacteria attached to the fibers of the dressing. It's sort of a Where's Waldo of bacteria. The purple are Pseudomonas, Staph aureus is yellow, Klebsiella is green. That's about the only ones that I see there. So interesting dressing. So in closing, I've given a lot of information about various dressings today and it's a lot to keep up with or try to learn, but a couple of important points. One is I want to give you some resources that you can have to look up different dressings and more learning on dressings. The WoundCareLearningNetwork.com is a site that you can just find all kinds of short and full-length presentations. Some are for CE, a lot of them, some of them are company-sponsored, but it's just a lot of good variety in terms of learning about various dressings and about various modalities. But one that I would definitely commit to memory and to actually look up and sign up and register for is WoundSource.com. WoundSource.com. So let's say you wanted to find out what did she say about that biofilm busting gel. You could go to WoundSource.com and in their keywords you could put biofilm busting gel or go in and put silver dressings and you will get a laundry list of every type of silver dressing and every manufacturer of silver dressing. So it really helps you look for dressings, it helps you find dressings that might be within the formulary that your institution, your hospital uses, as well as WoundSource puts on a twice yearly free conference, a virtual conference, called WoundCon. It's free, you just sign up for it. There's usually thousands of people logged in for this and actually that there's usually one in the spring and one in the fall. And then last but not least, it's important to remember that Medicare Part B and most insurance payers that follow Medicare guidelines do cover these dressings. I hate it when patients come in and they've been buying dressings on Amazon. They're just too expensive. There are some guidelines and some rules to follow that for utilization and what you can mix with what. But again, this is information that's available at WoundSource and you can just, they'll give you the actual, the code that you can use for for any kind of dressing if you do your own billing. But it also could list many, will list many of the companies that are able to do this billing for you. So with that, again, I thank you for your attention today. I appreciate the American Academy of Dermatology allowing me to spend time with you talking about one of my favorite topics. Thank you and goodbye.

wound management

venous leg ulcers

diabetic foot ulcers

pressure injuries

fluorescence imaging

wound dressings

antimicrobial dressings

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