Hydro-Responsive Wound Dressings in Clinical Practice

Hydro-Responsive Wound Dressings in Clinical PracticePodiatry

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INTRODUCTION

Podiatry in Wound Care: Podiatry is a specialty area of medicine that focuses on the diagnoses

and treatment of pathologies of the foot and lower limb. This covers many aspects including

musculoskeletal, sports injuries, surgical interventions and forensics to name a few. Furthermore,

Podiatrists have a specific knowledge regarding the diagnosis and management of acute and chronic

wounds of the foot and lower limb. There is a strong tradition of a focus on the management of

diabetic foot wound and in limb salvage. Due to their poor healing response, altered mechanics,

propensity to infection, poor vascularity, and lack of protective sensation the diabetic patient

population is particularly prone to developing chronic wounds that can deteriorate to such a

level that amputation is the only treatment option. Podiatrists are therefore involved in preventive

ulcer development strategies that include for example, regular monitoring for the development of

wounds, routine care of calluses, foot wear prescription, and orthoses recommendations for the

prevention and treatment of foot deformities. Surgically trained podiatrists can also undertake foot

surgery to reduce deformity and pressures. Additionally clinic-based ulcer care as well as surgery that

include prophylactic and acute intervention, can translate to the preservation of a functional limb.

Additionally, continuous podiatric management can prevent ulcer recurrence through offloading

strategies and diabetic foot education. Podiatrists also play an essential role in advanced assessment

using techniques such as Doppler and referring for modalities such as x- ray, ultrasound and

scans. They can therefore use clinical assessment skills and competencies including independent

prescribing, to identify the optimum treatment regimen (wound dressings, antibiotics, pain relief,

antimicrobial therapy, NPWT etc.,) that will enable healing to progress. Then reducing the recurrence

of wounds after the initial wound has healed, by addressing the biomechanical forces that were the

cause of the original wound. This booklet presents information relating to the use of HydroTherapy.

HydroTherapy; an innovative two step treatment using HydroClean® plus and HydroTac®, in the

treatment of (in some cases) very severe wounds of the lower leg and foot. This document has been

developed to exemplify how wounds that a podiatrist may come across, can be treated successfully

and may support limb salvage as an alternative to amputation.

Samantha Haycocks FFPM RCPS (Glasg)

Advanced Podiatrist

Dr Paul Chadwick FFPM RCPS (Glasg). FCPM

National Clinical Director at the College of Podiatry

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ACUTE AND CHRONIC WOUND HEALING

Physiology of wound healing: Wound healing is achieved through the completion of a number

of temporally and spatially overlapping phases: haemostasis, inflammation, proliferation and

remodelling (Han and Ceilley, 2017). Immediately after injury, haemostasis prevents excessive

blood loss by physically plugging the open wound. Following haemostasis, neutrophils and

monocytes/macrophages are attracted to the wound site and begin the process of cleansing

the wound of tissue debris and bacterial contamination via the production of protein-

degrading enzymes (proteases) and reactive oxygen species (ROS). Tissue macrophages

release a further wave of growth factors and cytokines that reinforces the recruitment to

the wound of fibroblasts, endothelial cells and epidermal cells. As the inflammatory phase

resolves (i.e., inflammatory cell numbers decrease) the proliferative phase of healing begins.

New granulation tissue (fibroblasts), the formation of new blood vessels (endothelial cells)

and epithelialisation (epithelial cells) of the wound takes place. Once the wound is closed,

remodelling of this new tissue takes place. Taking up to 1-2 years, the remodelling phase

results into a maturation of the wound granulation tissue into a more ‘normal’ dermis and

includes the organisation of dermal collagen bundles that increases the strength of the skin.

Chronic wound pathophysiology: Chronic wounds fail to progress through the phases of

wound healing and in many cases essentially ‘stall’ in the early inflammatory phase of the

healing response (Martin and Nunan, 2015). A combination of severe underlying pathologies

(e.g. chronic venous insufficiency, neuropathy, tissue ischaemia) and the persistent and elevated

levels of inflammatory mediators, together with the sustained presence of a significant bacterial

contamination of the wound, all contribute to a persistent stimulation of a local inflammatory

response that leads to high levels of tissue breakdown and ulceration. The inability of the wound

to progress through the phases of healing results in a failure to achieve wound epithelialisation.

Clinically addressing the underlying disease aetiologies that give rise to the onset of ulceration

(e.g. compression bandaging, offloading, etc.) and local wound care to address the

consequences of the sustained inflammatory response (e.g. elevated production of wound

exudate) by the use of appropriate wounds dressings (Han and Ceilley, 2017), contribute to

resolving the drivers that sustain the persistent, elevated inflammatory response and encourage

the wound to progress along the latter phases of the acute wound healing response.

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Wounds of the Foot, Ankle and Lower Leg: A wide variety of wounds can affect the foot

and lower leg. They can be caused by a number of problems including illness, trauma or

skin irritation. Without proper treatment these problems can quickly develop into serious,

even life-threatening complications. Wounds of the foot are complex and call for a multi-

disciplinary approach to care (Aumiller & Dollahite, 2015). Wounds of the lower leg, e.g. pre-

tibial lacerations are acute wounds caused by trauma but they may take on the appearance

of a chronic wound and become difficult to heal. The pre-tibial region is poorly vascularised

and the skin is very thin (Bradley, 2002). The foot and ankle are complex structures with many

tendons linking muscles and bones of the foot. These tendons that sit between the skin and

foot bones are prone to damage as the skin on the dorsum on the foot is thin. Any exposure

of the tendon to air – as a result of foot injury – will cause desiccation and subsequent tissue

loss (Geiger et al, 2016). Therefore, exposed tendons must be protected in order for them to

remain viable.

Patients with diabetic foot and complications associated with diabetes (e.g., peripheral

neuropathy) are particularly susceptible to serious wounds and foot ulcers. Diabetes is one of

the most common underlying factors associated with lower-extremity amputations (Chadwick

& McCardle, 2016) and the presence of an ulcer in a patient with diabetes is the most common

precursor to amputation (Armstrong et al, 1998). The quality of life of a patient who has a

foot ulcer and is at risk of amputation is significantly affected and can often result in extended

hospital stays, increased morbidity and mortality (Boulton, 2013). Dressing selection is one

important aspect of the effective management of wounds, including wounds of the foot.

Wound Debridement: Both acute and chronic wounds require the removal of devitalised

tissue. In the clinical treatment of wounds, the process of wound debridement is an important

step in the preparation of the wound bed and the promotion of wound healing (Strohal et al,

2013; Junker et al, 2013). In chronic wounds, there may be a build-up of devitalised tissue that

also contributes to the wound impairment seen in these wounds (Atkin & Ousey, 2016; Nunan

et al, 2014; Snyder et al, 2016). As well as being a physical barrier to healing, the devitalised

tissue – necrotic tissue (black, dry and leathery tissue) and slough (moist, loose and yellowish

material) – can also be reservoirs for high levels of bacterial contamination which can lead to

biofilm formation and infection (Percival & Suleman, 2015).

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Wound bed preparation is an important, systematic approach to aid wound progression. Once

devitalised tissue has been removed and a healthy granulation tissue wound bed has been

established, wound healing is promoted. The moist wound healing environment established

by many of today’s modern wound dressings, together with the optimised moisture balance,

provides the ideal environment for wound healing to progress (Ousey et al, 2016a-c). There

are a number of debridement methods used by clinicians to remove devitalised tissue including

surgical/sharp, mechanical, autolytic, enzymatic and biological (e.g., larval or maggot therapy).

Each method has its advantages and disadvantages, but autolytic debridement is of particular

interest as this method uses the body’s own debridement mechanisms to enhance the

removal of devitalised tissue. The provision of a moist wound environment using modern

wound dressings promotes autolytic debridement to occur using the proteases released by

inflammatory cells within the wound.

What is HydroTherapy?

HydroTherapy simplifies wound dressing choice for the management of wounds to deliver

effective healing by basing the therapy around two complementary Hydro-Responsive Wound

Dressings (HydroClean® plus and HydroTac®). Together, HydroClean® plus and HydroTac®

provide rapid wound cleansing action, healthy granulation tissue appearance and sustained

epithelialisation (Ousey et al, 2016b).

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HydroClean® plusHydroClean® plus is a Hydro-Responsive Wound Dressing (HRWD™) for rapid debridement

and reduced pain during wear time. It cleanses, debrides, desloughs and absorbs via a unique

cleansing-absorption mechanism. It achieves this by promoting an optimal level of hydration

and maximising autolytic debridement processes at the wound site. The dressing comprises

a soft and conformable pad, which contains a Hydro-Responsive matrix at its core. Super-

absorbent polyacrylate (SAP) particles containing Ringer’s solution form part of the matrix

and provide a continuous rinsing and absorption effect for supporting effective wound bed

preparation. Ringer’s solution is an isotonic salt solution

that is balanced relative to the body’s fluids that has

been reported to have clinical benefi ts (Colegrave et al,

2016). Pre-activation of the SAP with Ringer’s solution

allows for rapid and sustained cleansing of the wound

bed (König et al, 2005; Humbert et al, 2014; Spruce et

al, 2016b; Ousey et al, 2016c).

HydroTac®

HydroTac® is a HRWD™ with AquaClear™ Technology.

The dressing is made up of a hydrogel wound contact

layer that enhances re-epithelialisation, and is indicated

for wounds with nil - low levels of exudate, covered

by a foam, with an air-permeable, waterproof and

bacteria-proof fi lm backing. The wound side of the

dressing features AquaClear Technology that releases

moisture. AquaClear Technology is designed to increase growth factor concentration, thus

speeding up epithelial wound closure. (Ousey et al, 2016b). Laboratory studies have shown

that the AquaClear Technology used in HydroTac® concentrates growth factors, leading

to a stimulation of epithelial closure in a laboratory model system (Smola et al, 2016a)

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CLINICAL CASE STUDIES USINGHydroClean® plus and HydroTac®

Below is a summary of clinical cases where HydroClean® plus and HydroTac® have shown

effective and rapid wound debridement and wound healing progression in a variety of difficult-

to-heal podiatric wounds.

HydroClean® plusThere has been a number of recent studies providing evidence that HydroClean® plus supports

the efficient cleansing of chronic wounds, including wounds of the foot, ankle and lower

leg (Spruce et al, 2016b; Hodgson et al, 2017; Chadwick & Haycocks, 2017; Chadwick &

Haycocks, 2016; O’Brien & Clarke, 2016). The ability to gently rinse the wound bed and, at the

same time, manage wound exudate levels via fluid absorption results in the effective removal

of devitalised tissue via autolytic debridement (Ousey et al, 2016c). The preparation of the

wound bed for subsequent phases of wound healing promotes wound bed granulation tissue

formation. The balancing of wound moisture levels ensures an optimised healing response.

HydroClean® plus Case Study 1:

40 year old male with burn wound on foot (Chadwick and Haycocks, 2016)

Patient History

• A 40-year-old male presented with a necrotic wound that had become infected, caused by a burn from radiator whilst he was asleep

• Type 1 diabetes (with suboptimal control) and comorbidities including asthma and neuropathy

• Various IV antibiotic therapies showed limited success at controlling infection

At presentation

• HydroClean® plus applied to wound with 100% necrosis

• Extremely painful due to presence of painful neuropathy unable to tolerate sharp debridement

Day 2

• Wound had been actively debrided

• Necrosis reduced to 30% wound coverage

• Reduced pain

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HydroClean® plus Case Study 1 continued:

40 year old male with burn wound on foot (Chadwick and Haycocks, 2016)

Day 7

• Active wound debridement continued

• Wound bed: 50% slough and 50% granulation tissue

Reasons for Success

• Rapid wound debridement after HydroClean® plus application

• Dressing applied to infected wound

• Reduced pain


68 year old male with lower leg trauma (Hodgson et al, 2017)

Patient History

• A 68-year-old homeless male admitted with 4 week history of right lower leg trauma

• Patient had left this wound untreated

• Cellulitis and necrotic infected wound

At presentation

Post-treatment of 4 weeks with HydroClean® plus every 3 days

Reasons for Success

• Patient was unable to tolerate any sharp debridement HydroClean® plus was pain free to apply and tolerated well

• Larvae were applied for 1 week to main area of slough but wound became necrotic – so note final picture was after 1 week of reapplying HydroClean® plus

• HydroClean® plus applied and within first dressing change patient reported an improvement in pain from wound. Within a week the wound was hydrated and debrided

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54 year old male with toe amputation site wound (Chadwick and Haycocks, 2016)

Patient History

• A 54-year-old male with type 1 diabetes, retinopathy, neuropathy and hypertension with a toe amputation wound

• Wound had become sloughy

• Difficult to treat because of position and shape of the wound

At presentation

• HydroClean® plus applied to promote wound debridement

• 90% slough and 10% granulation tissue

Week 2

• Wound improvement seen with debridement of devitalised tissue visible

Week 4

• Size of wound decreased both in area and volume

• 80% slough and 20% granulation tissue

Reasons for Success

• Difficult to dress wound because of shape and position of wound. Conformability of dressing enabled effective treatment

• Tolerance of dressing rated as excellent

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HydroTac®

Once wound bed preparation has been achieved and the wound is in a state to progress to

healing, HydroTac is suitable to continue effective wound healing. During the granulation and

epithelialisation phases of healing, HydroTac creates a moist wound environment for optimal

healing. HydroTac supports epithelial wound closure by enhancing the activity of wound

epithelial cells. A recent observational study in 270 patients with a variety of chronic wounds,

including diabetic foot ulcers, showed enhanced wound epithelialisation (Smola et al, 2016b),

and another study also showed enhanced wound progression with a number of wounds

progressing to healing when treated with HydroTac (Spruce and Bullough, 2016). A number

of small-scale case studies have also provided evidence of the benefits of HydroTac in wound

healing progression (Spruce et al, 2016a; Cole, 2017; Wilde, 2016; Knowles et al, 2016a;

Bloomer et al, 2017).

HydroTac® Case Study 1:

69 year old male with lower leg wound with exposed tendon (Cole, 2017)

Patient History

• A 69-year-old male with rheumatoid arthritis who presented with destructive Arthropathy of metatarsophalangeal and metacarpophalangeal joints

• Patient previously admitted with critical limb ischaemia and extensive tissue loss with malodorous necrotic wound on left dorsal foot that was present for 6 weeks but patient failed to seek any advice

• Patient resistant to medical treatment and was re-admitted with extensive tissue necrosis and referred to plastic surgeons for surgical debridement

• Comorbidities include peripheral vascular disease and intermittent claudication

At presentation (21-Jun-2016)

• Extensive wound to forefoot following surgical debridement

• Several foot tendons exposed as well as muscle and fascia

• Moderate exudate levels and wound extremely painful requiring opiates

• Wound dressed with HydroTac®

29-Jun-2016

• Wound showed significant improvement in appearance of tendons and wound bed

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HydroTac® Case Study 1 continued:

69 year old male with lower leg wound with exposed tendon (Cole, 2017)

21-Jul-2016

• Significant amount on new granulation tissue formation

• Tendons completely recovered with healthy tissue

05-Aug-2016

• Continued improvement in wound bed with HydroTac®

Reasons for Success

• Desiccation and necrosis damage of tendons prevented using HydroTac®

• Exudate management good

• Dressing easy to apply and highly conformable

• Patient reported reduced wound and dressing change associated pain levels and less discomfort with HydroTac®

• Dressing reported to be soothing

• Patient compliance good


58 year old male with burn wound on foot (Bloomer et al, 2017)

Patient History

• A 58-year-old male with type 2 diabetes and neuropathy with a burn wound to dorsum of right foot and toes

• Attended emergency clinic where iodine-based dressing was applied and referred to acute diabetic foot clinic

• Iodine-based dressing was not able to manage high exudate levels

• Evidence of soft tissue infection

At presentation (06-Jan-2016)

• Wound size: 7.5cm x 5.0cm

• Dry black eschar and a granulation tissue/slough mix (60%/40%)

• High exudate levels, peri-wound redness and swelling of wound margins

• HydroTac® applied and retained with tubular dressing

• Dressing applied 3x weekly for first 2 weeks, reducing to 2x weekly thereafter

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58 year old male with burn wound on foot (Bloomer et al, 2017)

07-Mar-2017

• From initial presentation eschar and slough rapidly began to lift

• Subsequent de-sloughing of the wound bed resulted in 100% granulation tissue

28-Mar-2017

• Rapid wound size reduction was seen with continued HydroTac® treatment

06-Jun-2017

• Wound closure with minimal scarring achieved within 6 months of initial presentation

Reasons for Success

• Exudate levels were effectively managed

• Patient reported instant decrease in discomfort upon first application of HydroTac®

• Dressing comfortable and easy to change himself between assessment appointments

• Patient felt more involved with his own care


91 year old female with leg ulcer and exposed tendon (Jones, 2016)

Patient History

• A 91-year old female with a leg ulcer with wound bed exposed to tendon

• Leg ulcer present for less than 6 months

• Vascular insufficiency and comorbidities of heart failure, chronic kidney and thyroid disease

At presentation (05-Feb-2016)

• Ulcer size: 11.5cm x 11.5cm

• 30% slough and 70% granulation

• Too painful to tolerate compression

• Exudate levels moderate

• Peri-wound skin fragile and dry

• Aim: manage exudate, protect peri-wound skin, prevent infection, reduce trauma/pain and promote wound progression

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91 year old female with leg ulcer and exposed tendon (Jones, 2016)

30-Mar-2016

• After 7 days there was a reduction in wound size and an improvement in wound bed appearance

• After 55 days there was a reduction in level of tendon exposure and evidence of new granulation formation

05-May-2016

• After 92 days there was continued reduction of tendon exposed

• Increasing amounts of healthy granulation tissue continued to form during the treatment schedule

Reasons for Success

• Previous treatments showed poor healing response in the wound and HydroTac® treatment resulted in rapid wound improvement

• Pain levels were reduced and the dressing was well tolerated

HydroTherapyHydroTherapy is a novel approach to the treatment of chronic wounds. It is a simple two-step

process from wound cleansing to wound healing utilising the unique benefits of HydroClean

plus and HydroTac. Each dressing complements one another, supporting healing through the

delivery of rapid cleansing via autolytic debridement, early granulation tissue formation and

epithelialisation while maintaining a balanced moist environment at all stages of the healing

response. A number of case studies have shown effective wound progression in a number of

wound types requiring the removal of devitalised tissue in order to promote healing (Ousey et

al, 2016b; Knowles et al, 2016b-d; Chadwick & Haycocks, 2017).

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HydroTherapy Case Study 1: Patient with limb-threatening medial leg wound due to surgical

wound dehiscence and forefoot wound (Chadwick and Haycocks, 2017)

Patient History

• A male with type 2 diabetes and neuropathy presented with non-healing wound to the forefoot and open wounds on medial leg as a result of surgical wounds dehiscence

• Comorbidities include neuropathy and peripheral vascular disease

• Previously had amputations of right 5th toe and left hallux, a subsequent successful popliteal-pedal bypass to the right leg

• Non-healing ulcer to left 3rd and 5th metatarsal heads and a left popliteal-pedal bypass which occluded


• Open wound to medial leg due to surgical wounds dehiscing

• Large dorsal foot wound with bypass graft stitches visble

• Both wounds treated with HydroClean® plus

27-Jul-2016: after 4 weeks HydroClean® plus treatment the medial leg wounds debrided

02-Aug-2016: after 5 weeks HydroClean® plus treatment the dorsal foot wound debrided

Both wounds showed increased levels ofwound bed granulation tissue

Once wounds were debrided HydroTac® applied to promote wound progression

21-Sep-2016: Treatment with HRWDs of the medial leg wounds show good woundprogression with significant reduction inwound size

21-Sep-2016: dorsal foot wound also shows good wound progression

12-Oct-2016: Continued treatment with HRWDs of the medial wounds shows continued wound progression. Proximal leg wound now healed

31-Oct-2016: dorsal foot wound continues to show progression to healing

Reasons for Success

• HydroClean® plus promoted effective and rapid wound debridement

• Subsequent HydroTac® use supported healing of debrided wounds

• Both wounds healed • Amputation was prevented

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HydroTherapy Case Study 2:

Patient with limb-threatening neuroischaemic wounds (Chadwick and Haycocks, 2017)

Patient History

• A patient with type 2 diabetes presented with neuroischaemic foot wounds

• Previous episode of colon cancer

• Receiving haemodialysis 3x weekly

• Referred to diabetes team after severe and rapid deterioration of neuroischaemic wounds


• Extensive wound of right foot

• Significant levels of black necrotic tissue in wound bed

Week 2

• After 2 weeks treatment with HydroClean® plus necrotic tissue lifting from wound bed

• Extensive slough present on the wound bed

• HydroClean® plus applied to areas where there is slough and HydroTac® applied to granulating areas

Week 8

• Wound is significantly debrided

• Good healing progression observed with HRWDs

• Wound progression and well on the way to healing

Reasons for Success

• HydroClean® plus and HydroTac® treatment promoted rapid and effective wound debridement and subsequent wound progression

• Promotion of wound healing in potentially limb-threatening case

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HydroTherapy Case Study 3:

61 year old male with foot amputation wound (Knowles et al, 2016d)

Patient History

• A 61-year-old male with type 2 diabetes and comorbidities including peripheral arterial disease, neuropathy, chronic obstructive pulmonary disease and ischaemic heart disease

• Patient had necrotic infected blister present for 2 months

• Subsequent amputation of the 5th digit and metatarsal head and surgical debridement

• Wound failed to progress

At presentation (21-Jul-2016)

• Ulcer size: 8.0cm x 9.0cm

• 90% slough, 10% granulation and with minimal coverage of bone

• Wound was offloaded and a number of dressings had been used for debridement without success

• Aim: debride wound and initiate wound progression

25-Jul-2016

• Wound treated with HydroClean® plus

• Levels of visible slough reduced and granulation tissue increased

28-Jul-2016

• Over the course of the first week of treatment the wound bed appearance continued to improve

• Reduction in wound dimensions: 7.0cm x 8.0cm

8-Aug-2016

• After 19 days the wound had continued to improve with HydroClean® plus and subsequent HydroTac® treatment

• Wound size had continued to reduce in size: 5.5cm x 2.5cm

Reasons for Success

• Patient experienced high pain levels at beginning of treatment and levels of pain reduced over the treatment period such that opiate pain control was discontinued

• HydroClean® plus debrided and desloughed the wound bed where previously debridement had been difficult

• Once the wound bed had been prepared treatment was changed to HydroTac® and wound progression was maintained leading to a reduction in wound size

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CONCLUSIONS

There is a growing body of evidence supporting the use of Hydro-Responsive Wound Dressings

(HRWDs) in the management of a wide range of wound types. In addition to promoting

rapid and effective debridement of devitalised tissue found in wounds (HydroClean® plus),

HRWDs also promote the epithelialisation of wounds (HydroTac®) thus providing a beneficial

treatment programme enhancing wound progression from initial wound cleansing and wound

bed preparation through to wound closure.

Podiatrists are presented with a variety of difficult-to-heal wounds and there are a number of

clinical studies and case reports that support the use of HydroClean® plus and HydroTac® in the

management of these wounds. As well as promoting rapid and effective wound debridement

and the enhancement of wound progression, clinical experience with HRWDs document these

dressings as being less painful, have good exudate management/handling properties, are

easy to use (including being conformable) and comfortable. All these properties contribute

to providing environments that promote wound progression and have positive effects on the

patient experience.

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REFERENCES

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Hydro-Responsive Wound Dressings in Clinical Practice

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