Wound Healing and Hyper-Hydration: a Counter Intuitive Model

education

Wound healing and hyper-hydration: a counter intuitive model

Winters seminal work in the 1960s relating to providing an optimal level of moisture to aid wound healing (granulation and re-epithelialisation) has been the single most effective advance in wound care over many decades. As such the development of advanced wound dressings that manage the fuidic wound environment have provided signifcant benefts in terms of healing to both patient and clinician. Although moist wound healing provides the guiding management principle confusion may arise between what is deemed to be an adequate level of tissue hydration and the risk of developing maceration. In addition, the counter-intuitive model ‘hyper-hydration’ of tissue appears to frustrate the moist wound healing approach and advocate a course of intervention whereby tissue is hydrated beyond what is a normally acceptable therapeutic level. This paper discusses tissue hydration, the cause and effect of maceration and distinguishes these from hyper-hydration of tissue. The rationale is to provide the clinician with a knowledge base that allows optimisation of treatment and outcomes and explains the reasoning behind wound healing using hyper-hydration.. l Declaration of interest: K. Cutting is a clinical research consultant to Hartmann. M. Rippon is Medical marketing consultant for Hartmann, and K. Ousey provides consultancy for a range of companies through the University of Huddersfeld including consultancy services for Hartmann on Hydrotherapy.

hyper-hydration; hydration; moisture balance; maceration; skin; wound dressings

1 homeostatic moist wound environ- infux of infammatory cells and mediators that M. G. Rippon, PhD, Visiting Clinical Research ment is generally accepted as benefcial help to prevent infection through the open Fellow; to the healing process and co-exists wound. This is then followed by periods of cellular K. Ousey,1 PhD, Reader with an adequately hydrated wound. proliferation, extracellular matrix (ECM) deposi- Advancing Clinical Conversely, maceration of the peri- tion and fnally remodelling which leads to scar Practice; 2 wound skin is considered to have a far-reaching and formation.3 Underpinning these processes is ang- K. F. Cutting, M.N. A R.G.N, Clinical Research negative infuence which impacts adversely on the iogenesis, generally occurring in the proliferative Consultant; patient, clinician1,2 as a result of putative excessive phase of healing which leads to a temporary 1. School of Human and hydration. There is a lack of clarity regarding the increase in the number of blood vessels at the site Health Sciences, Institute optimal level of hydration required to support heal- of injury.4 Although remodelling is regarded as the of Skin Integrity and Infection Prevention. ing. Furthermore, the origin of fear associated with fnal phase of the repair process it is important to University of excessive hydration of the peri-wound skin (macera- remember that remodelling of tissue takes place Huddersfeld, tion) appears to be founded on anecdotal evidence.2 throughout the repair process and is not isolated Queensgate, Huddersfeld Here we try to clarify tissue hydration in relation to to the post-closure phase.3 2 Hertfordshire, UK wound healing, maceration and, rationalise the Wound hydration has been the basis of modern 5–8 Email: woundspecialist@ counter intuitive model of healing through hyper- wound care since the seminal papers of Winter in gmail.com hydration. Developing understanding, based on the the 1960s. Scientifc research in vitro and in vivo has available evidence, of wound/soft tissue hydration, supported this original premise9–15 and moist wound peri-wound maceration and the nuances of hyper- healing has become the recognised tenet of clini- hydration has the potential to improve not only cians working in the wound care feld.16 Studies patient outcomes but also clinicians’ appreciation have highlighted that moisture retained over the of topical wound dressings and the role they have to wound prevents desiccation of the wound surface play in support of healing. and/or deeper tissues allowing for an unimpeded migration of epithelial cells over the wound sur- Moisture and wound healing face.5,17–19 Cytokines and growth factors are also ena-

LTD Healing of the skin consists of four overlapping bled to exert their benefcial effect on wound con-

RE and integrated phases haemostasis, infammation, tracture and re-epithelialisation, through the

HCA 3 20,21

LT proliferation and remodelling. This initial hae- maintenace of a moist enviroment. Furthermore, EA mostatic response is characterised by platelet acti- there is improved cosmesis, the provision of an vation and coagulation, ensuring that blood loss is environment that supports autolysis22,23 and a minimised. The infammatory phase consists of an decrease in pain experienced for example in split- s © 2016 MA H

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Table 1. Some advantages of moist wound treatment over dry wound treatment Effect Experimental evidence Clinical evidence Up to 50% faster wound healing Winter 1962;5 Dyson 198890 Falanga, 1988;97 Beam et al. 2008;98 Varghese et al. 1986;99 Rubio et al. 1991;100 Madden et al. 1989101 Faster wound contraction Wigger-Alberti et al. 2009102 Enhanced and faster reepithelialisation Eaglstein 2001;17 Triller et al. 201291 Jones et al., 2007103 Generally increase cellular proliferation Romanelli et al 2004;104 Attinger et al. 2007;105 Harding, 2012106 Prolonged presence of growth factors and Svensjö et al. 2000;14 Hackl et al. 2014;15 cytokines Powers et al. 201392 Keratinocyte proliferation, fbroblast growth Korting et al. 201177 Promotes angiogenesis/revascularisation Svensjö et al. 2000;14 Rusak et al. 201393 Field and Kerstein 1994;107 Dowsett and Ayello 2004108 Greater quantity and quality of extracellular matrix Dyson, 1992;94 Mosti et al. 201321 Collagen synthesis Chen et al. 1992;95 Leung et al. 200796 Lower rate of infection Hutchinson and Lawrence 1991;109 Kannon and Garret, 1995;110 Thomas 2003;111 NICE, 2008112 Cleansing/irrigation Duleck et al. 2005;71 Hall 2007; 72 Tao et al. 2015 73 Painless removal of the dressing without Wiechulaet al. 2003;113 Metzger 2004;116 Leaper destroying newly formed tissue et al. 2012; Coutts et al., 2008 Less scarring and better cosmetic results Atiyeh et al. 2003;18 O’Shaughnessy et al. Metzger 2004;116 Atiyeh et al. 2004;117 Hoeksema 2009;114 Mustoe and Gurjala 2012;22 Tandara et al. 2013118 et al. 2007115 Enhance autolytic debridement Gray et al. 2005;119 King et al. 201423 Decrease in initial donor site pain and improved Weber et al. 199524 donor site healing

thickness graft donor sites in a moist enviroment.24 The epidermis provides a portal for insensible loss of The benefts resulting from maintaining a moist water termed trans epidermal water loss (TEWL). healing environment can be seen in Table 1. Good Here fuid (vapour) is lost to the atmosphere via hydration (of the wound) has been described as the evaporation and diffusion over which the organism single most important external factor responsible has little or no physiological control. for optimal wound healing.20 The skin therefore provides an interface between the body and the environment but does not main- Tissue hydration tain total control over water loss. Provided the skin All biological processes require water, it is essential remains intact and in conjunction with surface lip- for maintaining homeostasis, a universal solvent, ids and antimicrobial peptides the entry of poten- mediator of life’s chemical reactions, and has a tially harmful environmental substances and microstructure unlike that of any other liquid.25 From the organisms is prevented.28,29 time that primeval species ventured from the oceans In intact skin, the opposing forces of interstitial to live on land, a major key to survival has been the fuid pressure and capillary fltration pressure togeth- maintenance of hydration. Without water, humans er with the rate of lymphatic drainage control fuid can survive only for days. In man, water content infow from the local vasculature to the ECM30 and ranges from 75% body weight in infants, to 55% in thus maintain tissue hydration. However, when the elderly26 with the skin having a water content of wounding occurs this mechanism is compromised approximately 30%. The outermost layer of the epi- and fuid infow from the blood vessels increases due

dermis, the stratum corneum, prevents water loss. It to vascular leakiness triggered by infammation and is LTD

forms a water-impermeable barrier. Any structural observed on the wound surface as exudate because of RE HCA

defect of its integrity will result in uncontrolled the missing epidermal barrier. Not all of the fuid that LT water loss such as in ruptured blisters or more dra- results from this decrease in interstitial fuid pressure EA matically in burns. The noticeable water ‘loss’ e.g. resides on the wound surface as some ECM compo- sweating is the result of active water transport in nents such as hyaluronan absorb and hold this fuid 27 sweat glands regulated by ion and water channels. at a capacity greater than that achieved by the skin. © 2016 MA H

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extended water exposure had effects, which in Fig 1. Transient, hyper-hydration of the skin (wrinkling) following prolonged immersion in water. themselves were not considered overtly damaging, This is quickly reversed on exposure to air for example, swelling of stratum corneum with increased epidermal thickness and dilation of intra- cellular spaces41,42,43,32 increased stratum corneum suppleness44,45,46 enhanced mitotic rate,47 and reduced cytokine IL-1a mRNA levels.48,49 From the literature, its appears that reports on clinical observations and investigations that hyper- hydration of the skin is biologically limited, and does not necessarily result in sustained damage to the skin. Prolonged exposure of the skin to water results in a whitened or pearlescent appearance and is termed maceration.50

Maceration of the skin A number of defnitions of hydration exist, but in Maceration of peri-wound skin is defned as ‘the sof- relation to soft tissue, the most appropriate appears tening and breaking down of skin resulting from to be ‘the process of providing an adequate amount prolonged exposure to moisture’.51 Maceration is a of liquid to bodily tissues’.31 Naturally, the question common aversion and although many clinical arises—what is adequate? guidelines contain preventative recommendations2 the origin of this apprehension appears to be Hyper-hydration of the skin shrouded by history, although some consider it may Following prolonged exposure to water, swelling be related to the time when corrosive or irritating and absorption occur in the dead corneocytes in the agents were used on wounds.2 outermost layer of the stratum corneum.32 These The term Moisture Associated Skin Damage cells are stacked in layers like bricks and their swell- (MASD) is now accepted as the general term for ing is the key process by which their permeability infammation or skin erosion caused by prolonged and the mechanics of fuid interactions within the exposure to a source of moisture such as urine, stool, skin is controlled.32 These cells contain a network of sweat, wound exudate, saliva, or mucus.52 Moreover keratin flaments that interlock to form a three- in order for MASD to occur, complicating factors are dimensional lattice—which can increase its volume required in addition to moisture exposure, such as by fve times when the strands stretch out.32 The mechanical (friction), chemical (irritants contained interplay of these opposing forces ensures that the in the moisture source), microbial or in the case of skin can only absorb a certain amount of water, lim- chronic wounds a signifcant complicating factor is ited by the skin’s physical structure.32 the presence of wound exudate.50,53 Immersion in a moist/wet environment for pro- The synthesis of wound exudate is a normal part longed periods of time results in the skin becoming of wound healing, generally associated with the white and wrinkly (Fig 1). It is thought that this infammatory stage.54 It is an essential part of the wrinkling response may provide an evolutionary wound healing process in that it provides a moist beneft in terms of providing improved grip in wet environment conducive to healing. Acute wound conditions33 and a better grasp of wet objects.34 This exudate is a mixture of biochemical (including, wrinkling mechanism was investigated by Lewis growth factors, cytokines, electrolytes, proteases and Pickering (1936) who suggested that the phe- and nutrients) cellular components (such as infl- nomenon was not solely related to water absorption trating white cells such as leucocytes) and proteins but that the nervous system was also implicated.35 (including fbrinogen and fbrin) that enable heal- Recent fndings support this view and indicate that ing to occur.55 Chronic wounds, however, are char- sympathetic innervation is important in water- acterised by non-resolving infammation, under- immersion skin wrinkling.36 pinned by disruption to the ‘normal’ biochemistry Some authors have shown that prolonged expo- and cellular activity.56 Chronic wound exudate sure to water can lead to dermatitis37,38 but that contains an excess of protein degrading enzymes

LTD exposure of the skin to water for short periods of such as serine proteases such as plasmin and

RE time is generally deemed to be innocuous.39 This lat- elastase and matrix metalloproteases (MMPs) such HCA

LT ter fnding is supported by a study that evaluated as MMP-2 and MMP-9, increased numbers of neu- EA the effect of continuous exposure of human skin to trophils together with an elevated profle of pro- water for 72 hour and 144 hour. The results noted infammatory cytokines.57,56 In addition to endog- only a mild, transient dermatitis occurred in half of enous proteases some bacterial species can produce s 40 © 2016 MA H the test sites. Other report have demonstrated that powerful proteases and may contribute to the pro-

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References Fig 2. Maceration of a fnger as a result of inhibition of trans Fig 4. Grossly macerated peri-ulcer skin as a result of the 1 Cutting, K.F. The causes epidermal water loss. This is promptly reversed on removal combination of chronic wound exudate containing proteases and prevention of of occlusion maceration of the skin. and prolonged intervals between dressing change Journal of Wound Care 1999; 8: 4, 200–201. 2 Bolton, L.L., Monte, K., Pirone, L.A. Moisture and healing: beyond the jargon. Ostomy Wound Manage 2000; 46: 1A Suppl, 51S–62S. 3 Li, J., Chen, J., Kirsner, R. Pathophysiology of acute wound healing. Clin Dermatol 2007; 25: 1, 9–18. 4 Johnson, K.E., Wilgus, T.A. Vascular endothelial growth factor and angiogenesis in 58 the regulation of cutaneous teolytic damage of chronic wound exudate. This wound repair. Adv Wound results in a state that is not conducive with home- Care 2014; 3: 10, 647–661. ostasis as proteases degrade growth factors and white tissue. It is therefore important that the cli- 5 Winter, G.D. Formation of the scab and rate of fbroblasts resulting in defective remodelling of nician takes into account the context in which epithelialization in the skin the ECM.59 Nearly two decades ago, chronic suspected maceration occurs so that an accurate of the young domestic pig. wound exudate was described as ‘a wounding diagnosis is made.w Nature 1962; 193: 293–295. 60 6 Winter, G.D. Effect of air agent in its own right’. Thus, excessive fuid is Hyper-hydration of the skin (such as spending exposure and occlusion on not per se the cause of skin damage but it is the too long in the bath) can present as white wrinkly experimental human skin content of the fuid that is of major importance.27 skin (Fig 1). A similar situation occurs when a wounds. Nature 1963; 200; 4904, 378–379. The corrosive effect of chronic wound exudate wound dressing has not managed to maintain 7 Winter, G.D. A note on leads to breakdown of the peri-wound skin, which wound moisture balance such as when TEWL is wound healing under in turn, can lead to wound enlargement, delayed inhibited or when wound exudate remains in con- dressings with special reference to perforated- healing, a higher risk of infection and increased tact for extended periods of time with the peri- flm dressings. J Invest pain and discomfort that results in a reduction in wound skin. Fig 2 shows over-hydrated skin on a Dermatol 1965; 45: 4, quality of life for the patient.52,61 Patient morbidity fnger due to inhibition of TEWL. In these two 299–302. 8 Winter, G.D., Scales, J.T. and cost of treatment will inevitably increase with examples the ‘maceration’ is quickly and easily Effect of air drying and the potential for hospitalisation.62 reversed. In contrast, Fig 3 demonstrates a chronic dressings on the surface of Maceration that occurs as a result of both over- wound with a moderate to heavy level of exudate the wound. Nature 1963; 197: 91–92. hydration and the biochemical wound composi- presenting as whitened skin with swelling and 9 Kruse, C.R., Nuutila, K., tion is not only damaging but a challenging to where the surface of the skin is not smooth, but is Lee, C.C. et al. The external manage.63,64 Clinical practitioners need to be able laced with multiple networks of fne grooves called microenvironment of 50,65 healing skin wounds. to identify the differences between peri-wound sulci cutis. Fig 4 shows grossly macerated peri- Wound Repair Regen 2015; maceration and that of ‘normal’ hydration in ulcer skin as a result of a combination of chronic 23: 4, 456–464. order to achieve optimal outcomes. For example, wound exudate and prolonged dressing change 10 Junker, J.P,. Caterson, E.J., Eriksson, E. The newly formed (delicate) epithelial tissue can be intervals. Maceration may also be associated with microenvironment of mistaken for maceration as it often appears as pale dermatitis/eczema (Fig 5 and 6) and may present wound healing. J Craniofac with associated erythema, sloughy/necrotic tissue Surg 2013; 24: 1; 12–16. and extensive tissue breakdown of the wound/ 11 Junker, J.P., Kamel, R.A., Fig 3. Chronic wound with a moderate/heavy level of Caterson, E.J. et al. Clinical exudate with whitened skin, swelling and where the peri-wound skin. impact upon wound healing surface of the skin is laced with multiple networks of fne and infammation in moist, grooves called sulci cutis wet, and dry environments. Reversal of over-hydration of the skin Adv Wound Care 2013; 2: It is important to note that some authors have 7, 348–356. inferred that skin damage caused by excessive 12 Evans, N.D., Oreffo, 61 R.O., Healy E, et al. hydration is reversible. In support of this premise Epithelial mechanobiology, is data from a recent study62 that investigated the skin wound healing, and the hydration effects on skin microstructure and its stem cell niche. J Mech Behav Biomed Mater 2013; implications in relation to enhancing transcutane- 28: 397–409. ous delivery of biomacromolecules. In this study LTD

13 Vogt, P.M., Andree, C., cryo-scanning electron microscopy was used to RE

Breuing, K. et al. Dry, moist, HCA and wet skin wound repair. investigate how hydration changes to the stratum LT Ann Plast Surg 1995; 34: 5, corneum allowed penetration of macromolecules. EA 493–499. The results showed that extended hydration 14 Svensjo, T., Pomahac, B., Yao, F., et al. Accelerated (>8 hour) caused swelling of the corneocytes, cre-

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Fig 5. Maceration of venous leg ulcers with associated dermatitis/venous eczema.

a b

structural changes in lipid self-assembly. These Healing and hyper-hydration disruptions allowed penetration (of biomacromole- Although the term hyper-hydration is contempo- cules) through the barrier of the stratum corneum, rary the underlying principle has a notable histori- importantly the disruptions were reversible, as cal provenance. Junker (2013), records how Hebra, removing the hydration source enabled restoration who published in 1861 his experience of patients of the barrier.66 This is supported by data presented with extensive burns and how they were treated by in a study in which the skin membrane electrical immersion in a bath using ‘continuous baths’ for impedance properties under the infuence of a vary- months or years.10 Hebra claimed that the treatment, ing water gradient was investigated. The results using water, reduced patients’ pain, limited their from this study concluded that hydration/dehydra- weight loss and ensured their survival. When the con- tion induced reversible changes of membrane resist- tinuous baths were stopped none of the patients sur- ance and effective capacitance.67 vived. Later, during the Second World War John Bun-

Table 2. Comparative effects hydration versus maceration Hydration References Maceration References Benefcial to healing Kruse et al. 20159 Delays healing Cutting and White 200292,120 Aids debridement/cleansing Powers et al. 201387 Increases slough and tissue damage Mugita et al. 2015;121 Ichikawa- Shigeta et al. 201450 Lowers risk of infection Sarabahi 2012122 Increased tissue necrosis—higher Benbow and Stephens, 2010;123 risk of infection Charlesworth et al. 201462 Transient low grade dermatitis Rietschel and Allen 197740 High grade dermatitis, wet eczema Gray and Weir 2007;52 Colwell et al. 2011124 Less pain Morgan 2000;125 Metzger et al. 2004116 Increased discomfort, irritation Butcher 2000;126 Dini et al. 201488 pain and reduced quality of life

2 123 121 LTD

Less scarring Bolton et al.2000; Benbow 2008 Long term physiological changes Mugita et al. 2015

RE in skin with associated tissue

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75,76 77–79 80,81 wounds in a wet yan, a medical offcer in the Royal Navy treated flms, hydrocolloids, foams and hydrof- environment. Plast wounded soldiers using the ‘envelope’ method.68 A bres82,83 and new dressings and their components Reconstr Surg 2000; 106: 3, coated silk sheeting was used to envelope a large burn are still being developed with this aim in mind.84 602–612. 15 Hackl, F., Kiwanuka, E., wound area which acted as a trough into which a The use of a dressing that provides a high fuid Philip, J. et al. Moist dressing solution of electrolytically produced sodium content was introduced over ten years ago and has coverage supports hypochlorite was placed for 20 minutes three times since been further developed. The main characteris- proliferation and migration of transplanted skin each day. Bunyan claimed that this method improved tic of this wound dressing is that it maintains the micrografts in full-thickness healing, cosmesis and avoided the use of painful wound in a fuidic environment of isotonic Ringers porcine wounds. Burns dressing changes.68 +solution. This dressing technology has been shown 2014; 40: 2, 274–280. 16 Bryan, J. Moist wound In 1985 Stenn and Yan investigated the effect of a to be highly successfully in the treatment of healing: a concept that liquid covering for superfcial skin wounds and its acute76,85 and chronic wounds.86,87 changed our practice. J effect on wound closure in a guinea pig wound Maintaining a balanced moist environment for Wound Care 2004; 13: 6, 69 227–228. model. The results of this study showed that the wounds is highly important. Advanced dressings are 17 Eaglstein,W.H. Moist animals tolerated the liquid bandage well and that now able to cope with a full range of exudate levels. It wound healing with no bacterial contamination or wound maceration is this ability to effectively manage the balance occlusive dressings: a clinical focus. Dermatol was evident. The extent of re-epithelialisation with between excessive moisture/exudate presence at the Surg 2001; 27: 2, 175–181. time was measured histologically under three sepa- wound surface yet ensure a correct level of hydration 18 Atiyeh, B.S., El-Musa, rate conditions: wound exposed to air, wound cov- that can otherwise complicate clinical practice.88,89 K.A., Dham, R. Scar quality and physiologic barrier ered and kept moist, and wound covered with liq- However an imbalance of moisture in conjunction function restoration after uid and the results showed that the liquid cover with an acidic wound fuid will cause tissue damage moist and moist-exposed enhanced the rate of wound closure signifcantly.69 and maceration of the peri-wound skin. dressings of partial- 2 thickness wounds. In another experimental study, that investigated Bolton eloquently listed the dressing variables Dermatol Surg 2003; 29: 1, the healing of partial-thickness porcine skin that require investigation to clarify clinical practice 14–20. wounds, in a liquid environment, the healing of in relation to maceration: 19 Erfurt-Berge, C., Renner, R. Recent Developments in fuid-treated wounds occurred without tissue mac- l Wound dressings absorbency and adsorbency Topical Wound Therapy: eration and showed less infammation and less scar l Wound dressing wicking characteristics Impact of formation than healing of wounds exposed to air.70 l Wound dressing capacity to retain fuid. Antimicrobiological Changes and Rebalancing Topical wound irrigation (intermittent or continu- These variables cannot be effectively examined in the Wound Milieu. Biomed ous) with either saline, water or isotonic solutions is a isolation of: Res Int 2014; 2014:819525. technique that provides the wound with a fuidic l The type and amount of exudate 20 Atiyeh, B.S., Hayek, S.N. Intérêt d’un Onguent environment and has been used successfully as an aid l Pathology of peri-wound skin Chinois (MEBO) dans le to healing in many different wound types.71,72 A pilot l Potential sources of physical, chemical, metabolic, Maintient Local de study evaluated the effect of irrigation on two groups or vascular damage. l’Humidité. Journal des Plaies et Cicatrisation of patients, with severely infected wounds, treated 2005;9:7-11. Available at: with either a) continuous topical irrigation (n=17) or Conclusion bit.ly/1RSPhoa (accessed January 2016). b) with standard of care (no irrigation; n=15). Results Hydration is highly benefcial to wound healing 21 Mosti, G. Wound care in showed that irrigation improved severely infected but needs to be clearly differentiated from macera- venous ulcers. Phlebology wound healing through inhibition of pro-infammation (and the corrosive nature of chronic wound 2013; 28: Suppl 1, 79–85. tory cytokines and improving tissue regeneration exudate). This is because, the negative physiologi- 22 Mustoe, T.A., Gurjala, A. 73 The role of the epidermis when compared with the control group. Fluidic cal and clinical implications of maceration and its and the mechanism of therapy such as instillation combined with the use of treatment/prevention is far removed from that of action of occlusive dressings in scarring. adjunctive negative pressure wound therapy (NPWTi) hydration. Similarities in presentation may cause Wound Repair Regen 2011; has been shown to enhance exudate and debris confusion and unwarranted intervention that can 19: Suppl 1, s16–21. removal, provide regular cleansing of the wound bed, lead to a wrong treatment pathway and ultimately 23 King A, Stellar JJ, Blevins and add moisture to the wound. Positive results have be detrimental to the patient and the healing out- A, et al. Dressings and products in pediatric been demonstrated with this technique in assisting come of their wound. Healing through hyper- wound care. Adv Wound healing of static and painful wounds.74 hydration is a counter-intuitive model that at frst Care (New Rochelle) 2014; 3: 4, 324–334. These studies, uphold the view that innocuous sight may appear incongruent with the more 24 Weber, R.S., Hankins, P., fuid that remains in contact with the wound bed familiar moist healing paradigm. However, the Limitone, E. et al. for extended periods of time supports healing and is isotonic nature of the fuid used in hyper-hydra- Split-thickness skin graft donor site management. A well tolerated. Note—Hebra claimed his electrolytic tion together with the homeostatic mechanism of 68 randomized prospective sodium hypochlorite solution was non-toxic. soft tissue, ensure that this approach to healing LTD

trial comparing a Wound dressings that provide part or complete remains tenable. n RE

hydrophilic polyurethane HCA absorbent foam dressing occlusion and retain a degree of moisture content LT with a petrolatum gauze over the wound surface are de rigueur in the treat- EA dressing. Arch Otolaryngol ment of most acute and chronic wounds. These Head Neck Surg 1995; 121: 10, 1145–1149. have been developed in many forms for example,

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