Hello, everyone, and welcome to the lecture on topical treatments based on moon bed characteristics. I'm Barbara Delmore, I'm the senior nurse scientist in Seat within the departments of nursing at NYU Langone Health. I'm also the clinical assistant professor on the Hartsburg Wyss Department of Plastic Surgery in the NYU Grossman School of Medicine. So our objectives for this lecture is to distinguish the basic principles for wound healing, also known as moon bed preparation. And once you prepare the moon bed, then you can choose the correct topical treatment. And we're going to do so using a case example. So let's start with principles for wound healing, also known as the moon bed preparation process. And so there's definitely principles that we want to think about before we even decide what topical treatment we're going to apply to the moon bed. First, we want to think about identifying the etiology and treating the cause. And this is a very important step, because if we don't heed this step, we are likely going to revisit this step somewhere down the line when our wound is not healing. So you want to think of things like, is there blood flow to the moon bed? What are the patient cofactors and comorbidities? Is the patient's A1C at 11? Or is it well controlled at 5.6? What about referrals that may be needed to help treat the cause? Then you want to think about the goals of care and the wound's ability to heal. Is it a healable wound, meaning you've identified the etiology, the cause has been treated, and you have the green light, and you're ready to find the perfect topical treatment to heal the wound? Or is it a maintenance or non-healing situation? The patient doesn't have the resources, such as insurance, or perhaps they don't have the support system, their circle of care is not existent, and they're going to need help and support. Or is it a non-healable palliative care wound? Right? We know the goals of care for this wound is not to heal it, but we are going to choose topical treatments that don't allow it to deteriorate. Now, once you've identified these first two steps, then you start to think about local wound care, and that's the wound bed characteristics themselves. Right? What does the wound bed look like? Is it dry? Is it moist? Wet? Is it a slough or eschar? Is it infected or inflamed? Is there exudate? Does the exudate have odor? Is there an edge effect that's going to impede wound healing? What about pain? How much pain is this causing the patient? And where is it located? Because not all topical treatments are amenable to all locations. But most importantly, from the very beginning, you want to have the patient and their circle of care involved. Right? They need to be on board. They need to be part of the planning, because you can develop and devise this perfect plan to heal a wound. But if the patient and the circle of care aren't on board, it's not going to succeed. So let's talk about that ideal dressing, right? It really isn't a perfect dressing, but we may have ideal dressings, right? And you want to think of ABCDEF for starters. You want to think about topical treatments that don't cause trauma to the wound bed as you remove them. They have to provide some kind of bacterial barrier. They need to control moisture. They need to eliminate dead space. So, if you have a cavity wound, you want something that's going to gently fill the cavity. You want it to absorb exudate when you need it to. And Fahrenheit temperature, right? Your ideal dressing should remain in place at least for 24 hours. The more you expose a wound bed to the external temperature, it starts to cool the wound bed down, and that slows down healing. So your ideal dressing should stay in place at best for 24 hours if your goal is to heal a wound. We talked about this on the previous slide about matching form to function, looking at the wound bed characteristics, knowing where it's located, and what topical treatments you may be able to use based on the anatomical area that the wound is. And you want to meet the patient's care goals and involve them throughout the whole process. And you want to remember that no one product treats all wounds. So what you start with may not be what you end with, because wounds change, you know, sometimes even as they're healing they change, or sometimes they can deteriorate. Right, so we constantly have to evaluate the wound bed and make those adjustments as necessary. And you want to remember that no product treats deep and surrounding infection. That is for antibiotics. You certainly can choose an antimicrobial that will reduce the bio burden on the wound bed itself. But antibiotics are needed for treating deep and surrounding infections. Some other tidbits to think about. You always want to use evidence-based treatment. You don't want to use home remedies. You don't want to do quenching. This is usually with your ointments and lotions, or perhaps you want to powder down first on the skin, and then you want to use an ointment to seal it in. But you don't take it in your hands and mix it all and then apply. You always layer your products. By doing so, you allow these products to do what they need to do. When you quench, you can actually destroy some of their properties and make them ineffective. And you always want to think of moist wound healing principles. So when you look at this wound, right, this venous ulcer, it reminds you of the soup on the left, right? So you don't want to add soup to soup. This wound is not going to heal as it is. Likewise, you don't want to have an overly dry wound bed. You know, think of a desert. A dry cell is a dead cell. So this needs moisture. So again, it's that perfect moisture balance that you're always striving for and you're matching form to function, right? Look at where these wounds are located. So you want those topical treatments that are amenable to these anatomical locations. All right, let's do our case study and start to think about how we're going to treat a wound using topical treatment categories. So you recognize this wound from the previous slide. It's a venous ulcer located on the left at a malleolus. It's five centimeters length, 2.5 centimeters in width and one centimeter in depth. It's deep red, which is never a good color for a wound bed to be. It's moist, actually overly moist, and it has depth. Now let's look at the periwound skin. That's also important to look at besides your wound bed. It is very macerated and there's small wounds. Well, the small wounds are likely because the skin has lost its tensile strength because it's overly moist. And so sometimes you see these like little satellite wounds around the main wound or you start to see extensions from the main wound. Again, it's an overly moist situation. The skin has lost its tensile strength. So you just get more damage. Now look at the forefront. See a lot of cirrhosis, right? So this whole picture needs a lot of care, right? We are probably going to have to employ a couple topical treatments in order to address all these areas. Because as you can see by the picture, the old dressing, which is located towards the upper right of the picture, is absolutely saturated. So it looks like the primary and the secondary dressings were just not adequate and they did not provide the adequate coverage. So. When we talk about treatment categories, right, this is where it sometimes can become very overwhelming to clinicians. Because there are so many topical treatments to choose from. So the good news about your topical treatments these days is that they can be very versatile. So that's the good news, right? You can apply them to different situations. The not so good news is you still have to figure out what your topical treatments are, what they do, what they can't do, and just know when to apply them. So. Given all the categories. It's sort of best and probably easiest way to think of your treatment categories in five categories. You have products that donate moisture. Such as in dry wounds, you have products that protect. And that could be primary, secondary dressings or the Perry wound skin. You have products that can absorb. Then that's that excess moisture and drainage. You have compression, right? That's really its own category. And you have those products that have limited capability. And so you never say never, and you never say always, but these products, you have to know them and you have to look at them with a bit of caution in use. So, again, the good news is the topical treatments can be very versatile. And they can fit different categories. The trick is, is just figuring it out when to use. In what circumstance, so let's start. With our donate moisture, and this is the category for dry wounds and there's the picture of our Venus ulcer in the top left. And certainly this category is not what we want. For our room, because our wound has plenty of moisture does not need anything donated. But as you look on the left hand side, you see various products and to the right. In four columns, you see surface deep cavity, antimicrobial debris, and then within the body of the table, you see yes. Depends no, maybe it lines a cavity. Right. And so this is the versatility of these products. And so, you know, let's take, for example, contact layers. You know, they're good for lining cavities, but they don't have antimicrobial. Right. So if you had a situation where you had a dry wound you want to donate moisture, and you need an antimicrobial effect. This would not be the product, or it would not do the job of an antimicrobial, it would help somewhere else. Foam dressings, but remember foam dressings are moisture retentive. So that's good for this situation, but not for our case, because there's enough moisture in that wound. And when you look at the selective enzymatic debriefer on the bottom. You know, this can donate moisture, but you have to know a bit about this product in that it requires the sear-sanguish drainage. You cannot donate moisture by sort of moistening the product with a saline or sterile water. Right. Again, so this is where it comes in, you have to know the products a bit. But again, very versatile. Let's go to the next category. And this is the protect the primary secondary dressings and your peri-wound skin. Well, this patient's peri-wound skin definitely needs help, right, it needs some healing, it needs protection. And we really should be addressing that forefoot too, because we know cirrhosis just invites bacteria, right, the cracks in the skin. So we need to address that as well. So maybe cirrhosis can be addressed by the ointment. Peri-wound skin, you know, we probably might want a product that has a little bit of an overlay and can help to sort of heal and absorb that excess moisture and may not be in this category. Right. So, this cirrhosis may be the only thing we can address at this moment, given the way the wound looks. So let's go to the next category. This is our absorb moisture excess drainage category. If you look in the top. This is where you get to the antimicrobials that may have a hydrofiber alginate component and have that ability to absorb the drainage when you need it to. You have wound fillers, you know, this wound isn't really a cavity wound, so you wouldn't need it in this situation. But then you even have foams with hydrofiber and alginate. So previously I'd said that foam is moisture-retentive, but when you add a hydrofiber or an alginate component to the dressing, you start to get that absorptive capacity. And some of the foams with the hydrofiber and alginate do have an antimicrobial property, and that may be what for this wound. Right. So this is sort of a good options for us here. But I also put compression on the screen because this patient has a venous ulcer, and patients should be evaluated not only for what we need to put on the wound bed, but is it feasible that this patient can be fitted for compression. Right. It is a form of bandaging, and it really is the mainstay for venous ulcer care management. All right, this is more our cautionary category, right? You never say never, you never say always. But these products do have caution with them, but they do have a place, possibly at some point. So let's start with transparent films, you know, transparent films are great to protect. They can have an autolytic property, but they can be very aggressive on the skin and they don't have absorbency. Right. They can provide moist wound healing, they can have an autolytic property, and they come in different foams. The form that is the most problematic probably in this category is the wafer form. Right. It's very aggressive. It has no absorbency. If the product itself has a pentylene component, you're going to see allergic contact dermatitis, and it is not good for infected wounds. However, the forms of the gel and the powder have a lot of those. So the gel itself has been used in radiation burns and the powder has an absorptive and a healing capacity. A lot of times you see this powder form in stoma powder. Betadine. Great for eradicating bacteria from dry egg scar. The problem is it's toxic to normal healthy tissue. Cephalosulfadazine. It's really only indicated for the treatment of burns. And it's a more anti-inflammatory property than an antimicrobial. Why is that? The silver in it is not ionized, it's AG0. The other thing is it contains sulfur, and we have patients who have sulfur allergies. And many times this product gets a bad rap because it's claimed that the silver is causing an allergy when it's actually the sulfur component. The problem with this product also, though, is it can be drying, and it does create pseudo-escorts, especially from improper use. And the pseudo-escorts can be so bad that it requires surgical incision. And the other thing overall is that this product really only needs to be used for burns. You cannot be using it for outside indications. Topical treatments or topical antibiotics. The problem with topical antibiotics is they really don't have a place near wounds. For the most part, with the exception of one, they are not broad spectrum. They only fight gram positive only. They can cause antibiotic resistance within one mutation. They have allergens, they do not degrade, and they do not offer moisture balance. Non-adherent pads, they're also great to protect, but more for structures, such as surgical sites or any kind of reconstructive efforts. The product itself has no absorbency, and it can stick. And it sticks so bad to dry blood or any kind of serosanguine drainage that it is very painful to remove from a patient. And then you have your abysmal impregnated causes. And this is a pretty strong astringent, which you may need at some point. But you've got to remember that strong astringents do dry out wounds, and you want to strive for that moisture balance. Now, again, not all products in this category are created equal, like as we talked about some of the others. So the product you choose may not have an antimicrobial property if that's what you were looking for in this product. Antiseptics, they are fantastic because they can eradicate bacteria from a wound bed like nobody's business. These are perfect for when you need to do surgery and you're going to do a flap or something as grafting, anything like that. However, they have a limitation because at some point they're going to destroy healthy tissue as well as all the slough and eschar that you're trying to get rid of. And then it starts to dry out the wound bed. And so then you don't have your moisture balance. So again, you use these until you don't need it anymore. All right. And with that, thank you for your attention during this lecture. And I wish you the best of luck.

wound healing

wound bed preparation

topical treatments

evidence-based treatment

venous ulcer