Product REVIEW A review of Debrisoft in the management of a variety of dermatological conditions
Debbie Lorenzelli, Alberto Barea, Clare Morris
This product review examines Debrisoft utilising Monofilament Fibre Technology. Debrisoft is known for its ability to remove dry skin and for the removal debris and barriers to healing from acute and chronic wounds during a process known as wound bed preparation. Debrisoft has recently had its clinical indication extended to include dermatological conditions such as eczema and psoriasis.
Lorenzelli D, Barea A, Morris C. A review of Debrisoft in the management of a variety of dermatological conditions. Dermatological Nursing 2018. 17(2): 33-38
Skin problems represent a big slice of Product focus – Debrisoft of the skin or wound bed (Figure 2) and NHS activity. Indeed, in 2006, it was Debrisoft utilises Monofilament Fibre will not damage new granulating tissue reported that in England and Wales Technology (Figure 1) in the form of or epithelial cells. around 24% of the population (12.9 a debridement pad and debridement million) seek medical advice about a device or lolly. The pad comprises of 18 Debrisoft has a unique technology skin condition each year, with the most million special monofilament fibres that and mode of action for wounds and common reasons being skin infection have angled tips to reach uneven areas skin, lifting debris, including biofilm, and eczema.1
In the UK, it is estimated that 70% of older people have a skin condition and eczema is one of the most common conditions.2 In more recent publications³ it has been suggested that 23-33% of the population have a skin problem, and in surveys3 around 54% of the UK population experience a skin condition in a given twelve month period.
Skin conditions cause physical discomfort, psychological distress and generally are long-term chronic conditions. Skin diseases remain a major cause of disability worldwide.4
Debbie Lorenzelli is a Dermatology Nurse Specialist at St Helens and Knowsley Teaching Hospital NHS Trust. Alberto Barea is Lead Clinical Nurse Specialist at Plastic Surgery and Dermatology, Kingston Hospital NHS Figure 1. Figure 2. Foundation Trust. Clare Morris is Senior Monofilament Fibre TechnologyTM 18 million special monofilament fibres which have angled Clinical Services Manager, L&R Medical UK Ltd. tips to reach uneven areas of the skin or wound bedTM www.bdng.org.uk Dermatological Nursing, 2018, Vol 17, No 2 33 Product REVIEW
superficial slough and exudate quickly, After examining clinical evidence, Following the products launch in binding it within the fibres (Figure 2) NICE concluded: “The likely benefits of 2011, it quickly became established for and removing barriers to healing. using the Debrisoft pad on appropriate use in acute and chronic wound care,6 wounds are that they will be fully and in the management of skin conditions It is soft and conformable and gentle debrided more quickly, with fewer nurse associated with chronic venous disease7 on patients. It is also safe and easy to visits needed, compared with other and lymphedema.8 In recent years, use and can also be used by patients for debridement methods. In addition, the Debrisoft has also been used more in the self-care. Debrisoft pad is convenient and easy to field of dermatology. use, and is well tolerated by patients”.5
How to use Debrisoft
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Review of the dermatology related evidence Weindorf and Dissemond10 discuss The authors concluded that whilst Flinton7 describes the use of Debrisoft the challenges of debridement of painful acknowledging limitations of the study, in varicose eczema following 3 years of chronic wounds in dermatological patients they believed that the evidence indicates unsuccessful management associated such as pyoderma gangrenous and that the use of Debrisoft on psoriasis or with high costs. Five Debrisoft treatments epidermolysis bullosa. Debrisoft proved dry, scaly skin would not cause harm and over a two week period resulted in the to be a useful, non-invasive and therefore may, in longer term testing, show benefits. wounds and varicose eczema healing at safe alternative, especially for chronic the end of the two week period (Figures wounds covered in fibrin and slough. A multicenter case series evaluating 3-5). Debrisoft was continued to prevent Debrisoft in the management of the build-up of hyperkeratosis. Girip and McLoughlin11 report in a childhood atopic eczema and psoriasis case study the management of a lady was undertaken.13 Denyer9 reports on the use of with a three year history of venous leg Debrisoft in the management of children ulcer, recurrent cellulitis and chronic The primary aim of this clinical with severe epidermolysis bullosa. eczema that was successfully managed evaluation was to investigate if Debrisoft This condition is extremely challenging, with debridement of the wound and skin would benefit the skin care regime of with wound management often being with Debrisoft in her own home. It was children suffering from atopic eczema painful and time consuming. Denyer important for this patient that a hospital and psoriasis compared with their recommends that Debrisoft is introduced admission was prevented, not only to current regime and if that benefit led to from infancy as it can be difficult to prevent the distress a hospital admission preservation of the epidermal barrier introduce new products later in life. would have caused her, but to prevent the by improving penetration of creams and Denyer states that Debrisoft will hopefully costs associated with admission. emollients. help in early detection of squamous cell carcinoma, as these tumours are often An interim report12 described the The intervention was offered to the concealed beneath crusts and debris. use of Debrisoft in the management of parents and was compared with their psoriasis and dry, scaly skin on two healthy current regime of gauze, flannel and volunteers. The basis of the study was to sponge. examine if it is possible to use Debrisoft in the management of skin conditions such Key results with Debrisoft were that as psoriasis and dry, scaly skin without in all 33 cases the condition was not adverse effect on the skin, and to establish made worse and in 31/33 cases no pain whether there was sufficient basis for a or discomfort was experienced. This more extensive study. was compared with 23/33 cases with their previous regime causing pain and Two volunteer subjects participated 22/33 cases where the condition was in this short study. Measurements were made worse due to increased itching and made using different measurement bleeding. In 31/33 cases dry skin came techniques including the Tissue Viability away more easily with the Debrisoft than Imager, Visioscan, Corneometer, with standard practice. There were many Tewameter, Mexameter, Colorimeter and positive comments received from parents, Skin Thermometer. Following baseline children and clinicians during the study. measurements Debrisoft was moistened and applied using a wiping motion to Key results with Debrisoft affected areas of skin. Twenty minutes after were that in all 33 cases the treatment a further set of measurements condition was not made were made. worse and in 31/33 cases In most cases the erythema no pain or discomfort was measurements were increased, which experienced may indicate an increased blood flow to the area. This is most likely due to In all parameters Debrisoft led to the massaging effect of Debrisoft. The an improved skin care regime when hydration figures were mostly increased. compared to their usual practice. Parents If the Debrisoft was causing damage to found it easier to apply creams and the skin the hydration figures would be emollients, and the affected area felt decreased. Initial TEWL results would smoother. It was pain and trauma free, and indicate that the monofilament pad does they would continue to use the product not impair the barrier function of the skin. as part of the daily management of their Figures 3,4 and 5. child’s skin condition. www.bdng.org.uk Dermatological Nursing, 2018, Vol 17, No 2 35 Product REVIEW
In 2014, the first national guidance mainstay of treatment in these situations confidence.25 Debrisoft is outlined as a document was produced,14 outlining the are based on four main components; wound and skin debridement technique management of hyperkeratosis of the skin care, exercise, lymphatic drainage which requires minimal training and being lower limb. This was followed in 2015 and external compression and support. convenient and easy to use in patient’s by a UK consensus document.15 Both Greaves20 and Harding21 both report on home, GP surgery or an inpatient setting.5 documents acknowledge the role of the devastating psychological and social Debrisoft in the management of lower impact of these conditions and how the Debrisoft is outlined limb hyperkeratosis and how it can be management of the skin changes with as a wound and skin used by all health care professionals Debrisoft along with management of debridement technique working in hospital or community and by the other mainstay components led to patients and carers. Its ease of use may considerable improvements in quality of which requires minimal encourage patients to take an active role life, organisational cost savings. training in their care and undertake exfoliation of their own hyperkeratosis and dry skin.15 Whiteside and McIntyre22 describe Young26 describes the introduction of how they utilised the role of the band a skin care regimen in an elderly inpatient It is very important that hyperkeratosis 3 health care assistant in providing skin population. The elderly often suffer from is removed in a safe, atraumatic, way as care for lymphoedema patients in a dry skin when in hospital due to the any disruption of the skin integrity, for clinic setting under the direction of the aging process, frequent cleansing and the example by using forceps, increases the lymphoedema specialist. They utilised temperature and lack of humidity in the risk of cellulitis.16 Removing the dry scaly Debrisoft to manage and prevent hospital environment. Young used Debrisoft skin also allows emollients to penetrate, hyperkeratosis keeping the skin in good which facilitated the skin being in the and so rehydrates the skin.16 Whitaker condition and allowing emollients to optimal condition to benefit from the describes a case study of a female patients penetrate the skin, preventing cracks subsequent application of the emollient who had previously experienced leg ulcers appearing and preventing cellulitis. therapy. This led to anecdotally fewer and was managed in ill-fitting compression incidence of skin tears to limbs potentially hosiery giving less than therapeutic Elwell23 explains that until recently to improved integrity of the skin. compression levels. An accumulation of there was no clear consensus for the emollients, coupled with the ill-fitting management of hyperkeratosis. This has Actinic Keratosis (AK) are red or hosiery and hyperkeratosis had led to led to time consuming practice that is brown flat, scaly lesions that are rough to cellulitis.16 Debrisoft was used over a two- sub-optimal, often ineffective and time the touch.27 Heron28 describes the care week period along with new compression consuming for patients and services. She of a patient aged 73 years who presented hosiery and light emollient therapy. describes the impact of the publication of with a history of AK on his scalp which the consensus recommendations15 and was extremely sensitive and at risk, due Pidcock and Jones report on a case how it led to service improvements and to a history of a squamous cell carcinoma study that illustrates the important of the patient satisfaction. excised from the area and then grafted. removal of hyperkeratosis with Debrisoft He was successfully managed with to facilitate effective compression therapy.17 Freeman et al24 outlines how In cases of chronic oedema, hyperkeratosis important it is to ensure the barrier needs to be reduced as this leads to a function of the skin is maintained in softening of the skin and tissues. When the patients with lymphoedema. As such, skin and tissues are softer you can achieve good skin care is one of the cornerstones reduction in limb volumes.18 of treatment; for example, the removal of hyperkeratosis and meticulous cleaning of Johnson et al19 describe a multi-centre papillomatosis, including cleaning between observational study examining the effects skin folds and toes. She describes how of Debrisoft in chronic wounds and she uses Debrisoft Lolly on these types hyperkeratosis. During the evaluation, of patients and examines the care of one Debrisoft was found to be very easy to particular patient with excellent results. use and easily transferable into practice; not only does it look simple but it Skin problems can exist in diabetic actually is simple to use in hospitals and patients and within diabetic foot community settings requiring very little management, debridement of callus tissue educational input or training for use. is a general but important component in both prevention and management Several secondary skin changes of ulceration. A document was written develop as a result of chronic oedema and developed by Foot in Diabetes UK, and lymphoedema such as thickening of and provides a framework outlining the the skin, skin folds and papillomatosis. The competencies and skills to practice with Figures 6 and 7.
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Debrisoft (Figures 6 and 7) following a psoriasis-form eczema of the hands and paramount to achieving optimal results holistic review leading to pain free, safe feet to determine if it would be more and can be achieved by removing the and effective treatment regime improving cost effective and patient friendly than surface crust of scale by gently removing concordance and quality of life and standard local protocol. Patients were using gentle curettage or abrasion with reduced treatment costs and specialist monitored for an eight-week period and a scalpel. hospital intervention. reviewed at weeks 1, 4 and 8. A data collection form was used to document Barea33 identified a scope for using The mother of a young male patient the findings with photography and Debrisoft during lesion preparation prior who suffers from hyperkeratosis as DLQ Index.³¹ This initial evaluation has to PDT, with particular interest in: part of his epidermolytic ichthyosis its limitations due to the number of Potential reduction of time for used Debrisoft as part of his skin patients involved but gave the author debridement, and management.29 She was impressed with the confidence to continue using the Improved patient’s experience the softness and, most importantly, he Debrisoft pad in the future. tolerated her wiping his skin with the In the 20 cases of PDT sessions, Debrisoft. She commented that he had This study had an enormously positive Debrisoft provided: never tolerated any sort of cloth or towel, impact to the patients who suffer from 100% lesion debridement in 17 out of or anything rubbing his skin while washing. these chronic, debilitating skin conditions 20 episodes (Figures 11 and 12) of the hands and feet in terms of comfort, Between 75% to 100% debridement Lorenzelli30 undertook an evaluation occupation and employment and their in 3 episodes in lesions with firm in a nurse led hand and foot PUVA overall ability to self-manage their condition scaling dermatology clinic using Debrisoft in (Figures 8-10). One patient stated “I can Shortest time for debridement with the management of eight patients with now do what I couldn’t do before”. the monofilament fibre debridement hyperkeratotic psoriasis, hyperkeratotic pad was 10 seconds eczema, palmar plantar pustulosis and The use of Debrisoft has been Longest time for debridement with shown in this small service evaluation to the monofilament fibre debridement potentially reduce the costs of treatment pad was 3 minutes and 23 seconds by reducing the clinical input of a band 7 Average time spent for debridement specialist nurse in an acute hospital setting was 69 seconds and reducing the number of treatments Average pain score was 2.5. A pain required to manage the conditions. scale of zero to 10 had been used for each session allowing for the total Edwards32 describes the management number of pain points recorded for of three patients with psoriatic arthritis each regimen to be calculated. The and burn scars. Management of total was then divided by the number hypertrophic burn scar hyperkeratosis of sessions for each individual, allowing is extremely difficult and can be a pain score ratio to be formulated. psychologically very distressing for patients as they do not feel they are making any progress, and therapeutic treatments often have to be stopped to allow wounds to re-heal. Given the psychological impact of a burn, even minor setbacks can often be viewed as catastrophic, so any adjunct that can help prevent this can have a significant impact.
In terms of the patient with psoriatic arthritis, there was resistance during her inpatient care to undertake use of Debrisoft at every dressing change, but once they could see an improvement in the wound, increased range of movement and decrease in pain they became much more involved with the treatment.
Photodynamic Therapy (PDT) is a recognised, well-established treatment. Figures 8,9 and 10. Figures 11 and 12. Preparation of the area to be treated is www.bdng.org.uk Dermatological Nursing, 2018, Vol 17, No 2 37 Product REVIEW
Barea concluded that Debrisoft References debridement system. Journal of Community Nursing 2012. 26(6):43-46 can be used in conjunction with PDT 1. RCGP weekly returns service annual report 2006 by offering a quick and easy, manageable 20. Greaves T. The value of collaborative working 2. Van Onselen J. Eczema and older people: with industry in a community setting. Wounds UK debridement, allowing potentially introducing the Talking Eczema tool. British Journal conference, Harrogate, UK 2013 extra treatment time for sessions of Community Nursing 2017. 22(2):62 with other patients. 21. Harding C. The management of a patient with 3. Skin conditions in the UK: a health care needs bilateral lymphoedema and papillomatosis. Wounds assessment (2009) Centre of Evidence Based UK conference, Harrogate, UK 2013 Acne Vulgaris is a common problem Dermatology, University of Nottingham, UK in youth and early adolescence and 22. Whiteside L, McIntyre T. Providing a holistic 4. Karimkhani C et al. Global skin disease is characterised by areas of skin approach to skin care. BLS conference, Birmingham, morbidity and mortality: an update from the global UK 2013 with increased oil-sebum secretion burden of disease study 2013. JAMA Dermatology (seborrhoea) and the formation 2017. 153(5):406-412 23. Elwell R. Consensus and action: the impact of of comedones (blackheads and the new UK hyperkeratosis Best Practice document 5. National Institute for Health and Care Excellence in lymphoedema care. Tissue Viability conference, whiteheads), papules, as well as nodules. (NICE) (2014). The Debrisoft monofilament Cardiff, UK 2016 Scarring is often the result of the debridement pad for use in acute or chronic wounds. inflammatory processes within the London: NICE. Available at: guidance.nice.org.uk/ 24. Freeman N et al. A case study supplement: dermis. There are many pharmacological mtg17 [Last accessed May 2018] Real-life perspectives on use of Monofilament Fibre Technology in practice. Wounds UK 2016: 12-13 and non-pharmacological therapies 6. Bahr S et al. Clinical efficacy of a new to remove the sebaceous clogging. monofilament fibre containing wound debridement 25. Foot in Diabetes UK of behalf of College of Reduction of microbial burden is one product. Journal of Wound Care 2011. 20(5) Podiatry. The Principles of Debridement: The Diabetic Foot. Developing a Scope of Practice for such therapeutic option. Recent evidence 7. Flinton R. A new solution to an old problem Podiatrists in the UK. SB Communications Group is emerging that Debrisoft can have a – an innovative active debridement system. Poster 2014. London, UK role to play in the removal of excessive presentation, Wounds UK conference, Harrogate, sebum and microbial burden. UK 2011 26. Young T. The introduction of a novel skin care regimen in an elderly inpatient population. EWMA 8. Management of hyperkeratosis of the lower conference. London UK, 2015 Wiegand34 was able to demonstrate limb: consensus recommendations. London: the efficiency in cleaning by using a Wounds UK 2015. 11(4). Supplement 27. Bower C. Actinic Keratosis – Guidelines and management. Dermatological Nursing 2015. debridement model with artificial sebum. 9. Denyer J. The use of debridement pads in the 14(2):(suppl) s4-s8 This led to Eberlein et al35 undertaking management of children with severe Epidermolysis a semi-systematic case series in seven Bullosa. Poster presentation. EWMA conference, 28. Heron A. The impact of a monofilament young people suffering from retentive Copenhagen, Denmark 2013 debridement pad in the management of Actinic Keratosis. Wounds UK conference. Harrogate, manifestation of acne vulgaris to 10. Weindorf M, Dissemond J. Wound debridement UK 2014 collect practical findings of Debrisoft with a new debrider: A case report series about in combination with typical doses of dermatological patients with chronic painful 29. Unpublished data on file ulcerations of differing aetiology. EWMA polyhexanide and sodium-hypochlorite conference, Vienna, Austria 2012 30. Lorenzelli D. The management of skin based solutions. The overall results of conditions with monofilament fibre technology. this first clinical experience were very 11. Girip L, McLoughlin A. Safe debridement at Wounds UK conference. Harrogate, UK 2015 home – a case study. Wounds UK conference, encouraging and the user satisfaction Harrogate, UK 2013 31. Finlay AY, Khan GK. Dermatology Life Quality was very positive. Index (DLQI): A simple practical measure for 12. Unpublished data on file routine clinical use. Clinical and Experimental Dermatology 1994. 19: 210–216 13. Unpublished data on file Scarring is often the 32. Edwards J. Novel uses for a Monofilament 14. Wounds UK. The all Wales guidance for the Fibre Debridement pad. Wounds UK conference. result of the inflammatory management of hyperkeratosis of the lower limb. Harrogate, UK 2015 processes within the dermis Wounds UK, London 2014 33. Barea A. Safety and efficacy of a monofilament 15. Wounds UK. Management of hyperkeratosis fibre pad for superficial debridement prior to of the lower limb: Consensus recommendations. photodynamic therapy: a review of 20 cases. BDNG Conclusion London: Wounds UK, 11(4) Supplement 2015 conference. Bournemouth, UK 2016 This review of the dermatology related 16. Whitaker J. Self-management in combating 34. Wiegand C et al. Evaluation of the cleaning evidence to date using Debrisoft chronic skin disorders. Journal of Lymphoedema capacity of a monofilament debrider devise compared shows great promise for the treatment 2012. 7(1):46-50 to conventional cosmetic pads in a sebum model. of a number of dermatological skin 17. Pidcock L, Jones H. Use of a monofilament fibre Wounds UK conference. Harrogate, UK 2017 conditions as well as the management debridement pad to treat chronic oedema-related 35. Eberlein T et al. First experiences in use of a of acute and chronic wounds such as hyperkeratosis. Wounds UK 2013. 9(3) 89-92 leg ulcers. It is acknowledged that the monofilament fibre pad in the treatment of patients 18. Williams A. Chronic oedema in patients with suffering from retentive and cystic manifestation of studies comprise of small case series and CVI and ulceration of the lower limb. British acne. Wounds UK conference. Harrogate, UK 2017. case studies and it would be beneficial Journal of Community Nursing 2009. 14(10): S4-8 to extend this to much larger studies This article is a promotional item 19. Johnson S et al. A multi-centre observational DN commissioned by L&R UK Limited. with greater patient numbers. study examining the effects of a mechanical
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