Randomised, comparative study of three primary dressings for the treatment of venous ulcers

Dressings and topical agents for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality.

SEARCH METHODS

In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.

Wounds research for patient benefit: a 5-year programme of research

Background

Complex wounds are those that heal by secondary intention and include lower-limb ulcers, pressure ulcers and some surgical wounds. The care of people with complex wounds is costly, with care mainly being delivered by community nurses. There is a lack of current, high-quality data regarding the numbers and types of people affected, care received and outcomes achieved.

Objectives

To (1) assess how high-quality data about complex wounds can be captured effectively for use in both service planning and research while ensuring integration with current clinical data collection systems and minimal impact on staff time; (2) investigate whether or not a clinical register of people with complex wounds could give valid estimates of treatment effects, thus reducing dependence on large-scale randomised controlled trials (RCTs); (3) identify the most important research questions and outcomes for people with complex wounds from the perspectives of patients, carers and health-care professionals; (4) evaluate the potential contributions to decision-making of individual patient data meta-analysis and mixed treatment comparison meta-analysis; and (5) complete and update systematic reviews in topic areas of high priority.

Methods

To meet objectives 1 and 2 we conducted a prevalence survey and developed and piloted a longitudinal disease register. A consultative, deliberative method and in-depth interviews were undertaken to address objective 3. To address objectives 4 and 5 we conducted systematic reviews including mixed treatment comparison meta-analysis.

Results

From the prevalence survey we estimated the point prevalence of all complex wounds to be 1.47 per 1000 people (95% confidence interval 1.38 to 1.56 per 1000 people). Pressure ulcers and venous leg ulcers were the most common type of complex wound. A total of 195 people with a complex wound were recruited to a complex wounds register pilot. We established the feasibility of correctly identifying, extracting and transferring routine NHS data into the register; however, participant recruitment, data collection and tracking individual wounds in people with multiple wounds were challenging. Most patients and health professionals regarded healing of the wound as the primary treatment goal. Patients were greatly troubled by the social consequences of having a complex wound. Complex wounds are frequently a consequence of, and are themselves, a long-term condition but treatment is usually focused on healing the wound. Consultative, deliberative research agenda setting on pressure ulcer prevention and treatment with patients, carers and clinicians yielded 960 treatment uncertainties and a top 12 list of research priorities. Of 167 RCTs of complex wound treatments in a systematic review of study quality, 41% did not specify a primary outcome and the overall quality of the conduct and reporting of the research was poor. Mixed-treatment comparison meta-analysis in areas of high priority identified that matrix hydrocolloid dressings had the highest probability (70%) of being the most effective dressing for diabetic foot ulcers, whereas a hyaluronan fleece dressing had the highest probability (35%) of being the most effective dressing for venous ulcers; however, the quality of this evidence was low and uncertainty is high.

Conclusions

Complex wounds are common and costly with a poor evidence base for many frequent clinical decisions. There is little routine clinical data collection in community nursing. A prospective complex wounds register has the potential to both assist clinical decision-making and provide important research evidence but would be challenging to implement without investment in information technology in NHS community services. Future work should focus on developing insights into typical wound healing trajectories, identifying factors that are prognostic for healing and assessing the cost-effectiveness of selected wound treatments.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

A multi-center, randomized, clinical trial comparing adhesive polyurethane foam dressing and adhesive hydrocolloid dressing in patients with grade II pressure ulcers in primary care and nursing homes

Background

Pressure ulcers (PrUs) are ischemic wounds in the skin and underlying tissues caused by long-standing pressure force over an external bone or cartilaginous surface. PrUs are an important challenge for the overall health system because can prolong patient hospitalization and reduce quality of life. Moreover, 95% of PrUs are avoidable, suggesting they are caused by poor quality care assistance. PrUs are also costly, increasing national costs. For example, they represent about 5% of overall annual health expenses in Spain. Stages I and II PrUs have a combined prevalence of 65%. According main clinical guidelines, stage II PrUs (PrU-IIs) are usually treated by applying special dressings (polyurethane or hydrocolloid). However, little scientific evidence regarding their efficacy has been identified in scientific literature. Our aim is to assess the comparative efficacy of adhesive polyurethane foam and hydrocolloid dressings in the treatment of PrU-IIs in terms of healed ulcer after 8 weeks of follow-up.

Methods/design

This paper describes the development and evaluation protocol of a randomized clinical trial of two parallel treatment arms. A total of 820 patients with at least 1 PrU-II will be recruited from primary health care and home care centers. All patients will receive standardized healing procedures and preventive measures (e.g. positional changes and pressure-relieving support surfaces), following standardized procedures. The main outcome will be the percentage of wounds healed after 8 weeks. Secondary outcomes will include cost-effectiveness, as evaluated by cost per healed ulcer and cost per treated patient and safety evaluated by adverse events.

Discussion

This trial will address the hypothesis that hydrocolloid dressings will heal at least 10% more stage II PrUs and be more cost-effective than polyurethane foam dressings after 8 weeks.

Trial registration

This trial has been registered with controlled-trials number ISCRCTN57842461 and EudraCT 2012-003945-14.

Foam dressings for venous leg ulcers

BACKGROUND

Venous leg ulcers are a common and recurring type of chronic or complex wound that are associated with considerable cost to patients and to healthcare providers. Primary wound contact dressings are usually applied beneath compression devices with the aim of aiding healing. Foam dressings are used frequently, and a variety of foam products is available on the market. The evidence base to guide dressing choice, however, is sparse. 

OBJECTIVES

To determine the effects of foam dressings on the healing of venous leg ulcers.

SEARCH METHODS

In October 2012 we searched The Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); the Economic Evaluation Database (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL. There were no restrictions based on language or date of publication.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any type of foam dressing in the treatment of venous ulcers.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction and risk of bias assessment. Meta-analysis was undertaken when deemed feasible and appropriate.

MAIN RESULTS

Twelve RCTs (1023 participants) reporting 14 comparisons were included in this review. There was no difference in healing outcomes between hydrocellular foam dressings and polyurethane foam dressings (three RCTs). Pooled data across five RCTs (418 participants) showed no statistically significant difference between foam dressings and hydrocolloid dressings in the proportion of ulcers healed at 12 to 16 weeks (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.81 to 1.22). No statistically significant between-group differences in healing outcomes were detected when foam dressings were compared with: paraffin gauze (two RCTs); hydrocapillary dressing (one RCT); knitted viscose dressing (one RCT); and protease modulating matrix (one RCT). No statistically significant between-group differences in the proportion of participants experiencing adverse events were detected when hydrocellular foam dressings were compared with polyurethane foam dressings, or when foam dressings were compared with hydrocapillary, hydrocolloid, or knitted viscose dressings (one RCT for each comparison). Six RCTs were considered as being at overall high risk of bias, and the remaining six RCTs were considered to be at overall unclear risk of bias. No included RCT had an overall low risk of bias.

AUTHORS' CONCLUSIONS

The current evidence base does not suggest that foam dressings are more effective in the healing of venous leg ulcers than other wound dressing treatments. The evidence in this area is of low quality. Further evidence is required from well-designed and rigorously-conducted RCTs, that employ methods to minimise bias and report them clearly, before any definitive conclusions can be made regarding the efficacy of foam dressings in the management of venous leg ulcers.

Managing painful chronic wounds: the Wound Pain Management Model

Chronic wound pain is not well understood and the literature is limited. Six of 10 patients venous leg ulcer experience pain with their ulcer, and similar trends are observed for other chronic wounds. Chronic wound pain can lead to depression and the feeling of constant tiredness. Pain related to the wound should be handled as one of the main priorities in chronic wound management together with addressing the cause. Management of pain in chronic wounds depends on proper assessment, reporting and documenting patient experiences of pain. Assessment should be based on six critical dimensions of the pain experience: location, duration, intensity, quality, onset and impact on activities of daily living. Holistic management must be based on a safe and effective mix of psychosocial approaches together with local and systemic pain management. It is no longer acceptable to ignore or inadequately document persistent wound pain and not to develop a treatment and monitoring strategy to improve the lives of persons with chronic wounds. Unless wound pain is optimally managed, patient suffering and costs to health care systems will increase.

A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer

OBJECTIVE

To determine whether more "modern" complex wound dressings further improve the healing of venous ulcers over that with simple wound dressings, we conducted a systematic review of randomized controlled trials (RCTs) of wound dressing trials that were published from October 1, 1997, through September 1, 2005.

METHODS

We searched MEDLINE, CINAHL, and the Cochrane Controlled Trials Registry Database to identify RCTs. Criteria for ultimate selection included treatment with compression and an objective outcome describing the proportion of wounds healed. Twenty RCTs were identified that satisfied these criteria and were classified into three wound dressing classes: semiocclusive/occlusive group (n = 8), growth factor group (n = 7), and human skin equivalent group (n = 5).

RESULTS

Assessment of study design quality for the 20 RCTs showed a low percentage (<49%) of RCTs that incorporated at least 3 of 7 indicators of trial quality, but it seemed better in the 5 RCTs that showed significance for ulcer healing; 4 of the studies used at least 6 of the 7 characteristics of adequate study design. Five (25%) of the 20 RCTs had a statistically significantly improved proportion of ulcers healed in the experimental dressing group over control values: zinc oxide paste bandage (79% vs 56%) and Tegasorb (59% vs 15%) in the semiocclusive/occlusive group and perilesional injection of granulocyte-macrophage colony-stimulating factor (57% vs 19%) and porcine collagen derived from small-intestine submucosa (Oasis; 55% vs 34%) in the growth factor group. In the sole significant RCT from the human skin equivalent group, Apligraf (63%) was superior to Tegapore (48%). Four of these five studies also showed an improved time to complete healing by Kaplan-Meier estimate.

CONCLUSIONS

Certain wound dressings can improve both the proportion of ulcers healed and the time to healing over that achieved with adequate compression and a simple wound dressing. The selection of a specific dressing, however, will depend on the dressing characteristics for ease of application, patient comfort, wound drainage absorption, and expense.

Dressings for healing venous leg ulcers

BACKGROUND

Venous leg ulcers, sometimes called varicose or stasis ulcers, are a consequence of damage to the valves in the veins of the legs, leading to raised venous pressure. Venous ulcers are characterised by a cyclical pattern of healing and recurrence. The main treatment is the application of compression, either in the form of compression bandages or hosiery. Dressings are usually applied beneath the compression to aid healing, comfort and to control exudate. Wounds heal quicker in a moist environment and dressings are used to absorb excess fluid or retain fluid in an otherwise dry wound in order to achieve a 'moist wound environment'. There are a large number of dressing products and types available. It is unclear whether particular dressings aid healing of leg ulcers.

OBJECTIVES

To assess the effectiveness of wound dressings for the treatment of venous leg ulcers.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (April 2006) and CENTRAL (issue 1, 2006) and several other electronic databases (up to April 2005). Manufacturers of dressing products were contacted for unpublished studies.

SELECTION CRITERIA

Randomised controlled trials that evaluated dressings for the treatment of venous leg ulcers. There was no restriction in terms of source, date of publication or language. Ulcer healing was the primary endpoint.

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted and summarised using a data extraction sheet by two authors independently.

MAIN RESULTS

42 randomised controlled studies were identified that met the inclusion criteria. The main dressing types that were evaluated were hydrocolloids (n = 23), foams (n = 6), alginates (n = 4), hydrogel dressings (n = 6) and a group of miscellaneous dressings (n = 3). In none of the comparisons was there evidence that any one dressing type was better than others in terms of number of ulcers healed. Current evidence does not suggest that hydrocolloids are more effective than simple low adherent dressings used beneath compression (9 trials; relative risk for healing with hydrocolloid 1.09 (95% CI 0.89 to 1.34)). For other comparisons there was insufficient evidence.

AUTHORS' CONCLUSIONS

The type of dressing applied beneath compression has not been shown to affect ulcer healing. For the majority of dressing types there was insufficient data to allow us to draw strong conclusions except for hydrocolloid compared with a low adherent dressing. The result of the meta-analysis indicate no significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression. Decisions regarding which dressing to apply should be based on local costs of dressings and practitioner or patient preferences.

Leg ulcers: a review of their impact on daily life

BACKGROUND

Current nursing care for leg ulcer patients often focuses on wound care and providing compression therapy. Nurses perceive leg ulcer patients as 'under-served' with regard to problems patients experience in daily life. An overview of patient problems is a first and essential step in the development of comprehensive nursing care.

AIMS AND OBJECTIVES

To gather information about the impact of leg ulcers on patient's daily life as described in quantitative and qualitative studies.

DESIGN

Systematic literature review.

METHODS

Medline and Cinahl databases were searched for venous leg ulcer studies, up to 2002; this was followed by the 'snowball method'. Studies were selected in accordance with preset criteria.

RESULTS

A total of 37 studies was included. All studies report that leg ulcers pose a threat to physical functioning. Furthermore, a negative impact on psychological functioning is reported and, to a lesser degree, on social functioning. Major limitations are pain and immobility, followed by sleep disturbance, lack of energy, limitations in work and leisure activities, worries and frustrations and a lack of self-esteem. Patients have a significantly poorer quality of life compared with healthy people. Finally, patients report problems with regard to follow-up treatment.

CONCLUSIONS

Having a leg ulcer has a major impact on a patient's life. There are indications of under-treatment of pain.

RELEVANCE TO CLINICAL PRACTICE

Keeping in mind that leg ulceration is notorious for its chronic character, the negative impact on patient's life implies that many patients suffer over longer periods of time. This emphasizes the need to focus on quality of life aspects in patient care. There is much to gain, especially concerning pain and mobility. The development of comprehensive care programmes is essential.

Cohesive short stretch bandages in the treatment of venous leg ulceration

These two case studies report how a cohesive short-stretch bandage was employed to promote venous leg ulcer healing. The two patients were obese and in addition had champagne bottle shaped legs. The cohesive short-stretch bandage was applied following the shape of the leg. By using a cohesive short-stretch bandage this provided bandage stability. This sustained compression resulted in oedema and pain reduction and promoted wound healing.