ShapeShapeauthorShapecrossShapeShapeShapeGrouphamburgerhomeGroupmagnifyShapeShapeShapeShape

Wound management products: the emperor’s new clothes and other stories

by
01 June 2016, at 1:00am

Georgie Hollis discusses the products available for wound management in practices and the fact that thorough cleansing of wounds followed by moist wound healing principles remain the gold standard.

WITH THE HELP OF SOCIAL MEDIA AND Dr Google, the array of products and remedies being used for wound management is set to rise: from commercially packaged ointments and sprays to home-made recipes using household ingredients.

The promise of faster healing and reduced scarring is not only appealing to humans but is transferrable to veterinary patients. But what are the rules when producing products for animals and how do we know what we are using is legitimate?

The products available for wound management in veterinary practice vary from professional products transposed from human wound care to those that promise to aid healing using natural ingredients and scientific formulae.

What is new and what isn’t?

Many of the wound management techniques used throughout the 20th century were hundreds of years old, the only differentiation being packaging and production techniques. Only in 1962 did the NHS identify a cost burden associated with chronic wounds and commissioned the research that began to focus on optimising the wound environment. 

Winter’s research focused on the creation of the “ideal” wound environment where he noted that healing was more efficient and scarring reduced when the formation of an eschar was avoided by providing a moist environment. The experimental wounds appeared to heal 30-50% faster than those left to dry out and he set the foundation for the development of modern wound management products.

The science demonstrated that a moist environment has many benefits, not only assisting in autolytic debridement during the inflammatory phase but also supporting cell physiology and communication; the result being healthy angiogenesis, wound contraction and a timely maturation.

The moist wound healing principle is the biggest leap forward in wound management in centuries and has yet to catch on in many over-the-counter treatments. However, the marketing behind the products can lead to doubt where the story of natural ingredients and scientific formulae can be enchanting.

Medical devices for healing

Modern wound management products used in humans are in the most part licensed as medical devices. A CE mark ensures that any medical device is supported by correct regulatory and quality assurance and is governed by European conformity standards for use in open wounds. This will mean the product is sterile, does not damage healthy tissue and will include specific indications for the type of wounds it is designed to assist. In the USA, FDA approval should provide the equivalent recognition.

Many of the disposable dressings used today in veterinary practice are directly bought from human medicine. The commonly used hydrogels (e.g. Intrasite), dry dressings (e.g. Zorbopad), foams (e.g. Allevyn), medical grade Manuka honey (e.g. Activon) and silver impregnated dressings (e.g. Suprasorb Ag) are but a few examples. All these products are available in brands that have a CE mark and as such have guaranteed safety profiles for use in open wounds.

Why are human products not more readily adapted for animals? 

The most modern products for wound healing tend to be purely targeted for human use. This is entirely due to market value and the cost of product development. The human market will generate enough income for a company to justify research and development, manufacturing of different sizes and types and packaging whereas a veterinary equivalent may bring minimal income in comparison.

Compare the human products to what is then available for purchase over the counter for animal use. Here we have a different situation and a sharp contrast to the stringent regulation of devices for human use.

To date, ointments, tools, technologies and devices marketed to “support” or “promote” wound healing in animals are within the law as long as they do not claim a medicinal effect. Furthermore, the product may be promoted without a marketing licence and a CE mark is not required. 

As long as the product does not claim to treat a condition or have ingredients that are known to have a pharmaceutical effect (e.g. antibiotic components), it is free to be promoted for use.

As long as the product meets the criteria of being for topical use and does not claim medicinal effect, it is not required to undergo any testing to demonstrate cellular toxicity and the full range of ingredients may be withheld.

As with nutraceuticals, the addition of “natural” ingredients is often considered a bene t. It is often worth reminding those with a particular fixation on natural remedies that hemlock and arsenic are also naturally occurring.

Moist wound healing – the only real evidence we have? 

How many people do you hear saying, “Let the air get to it”? Alas, Dr George Winter has since set a precedent that has been surprisingly slow to catch on. His 1962 paper published in Nature discussed and proved his findings that wounds kept in a moist environment (following proper cleansing and debridement) will not only heal 30 to 50% faster but have less scar tissue and a better tensile strength once healed.

These figures may be associated with a product that provides a moist environment by either donating moisture (e.g. hydrogel) or a product that prevents dehydration of the wound through the use of a barrier such as a semi-permeable lm membrane (e.g. Opsite film) or through topical application of petroleum- based products (e.g. emollient creams, Vaseline).

If a new product is developed tomorrow that fits the description of maintaining a moist environment, it can ride on the back of Winter’s research and state that it helps to achieve 50% faster healing (compared to leaving the wound to dry out). At the same time this product requires no testing for cytotoxicity, does not need to be sterile and can be packaged anywhere in the world with no traceability of production standards or ingredients.

Add to the product a price that is artificially high: the phenomenon of price-quality signalling. The higher the price, the greater the trust in the brand. Unfortunately, the perception of animal owners is that doing something themselves prior to seeking veterinary intervention only makes them an easy target for premium-priced products that meet the need to “do the right thing” for their pet.

So what is this new product that revolutionises wound management? All these qualities can be found in nothing less than margarine. Priced highly to infer quality and labelled in a way that is appealing and scientific, we offer a winning formula that can claim to improve healing rates by 50%, help to maintain a moist environment, is a barrier to contamination and is soothing. 

Why not add a small amount of naturally derived tea-tree oil? In order to play by the rules we must not say it is antimicrobial, but we can be con dent that the buyer will have been exposed to similar claims elsewhere.

What we may not state is that oil-based products are known to inhibit broplasia and cell migration in open wounds and that tea-tree oil is a highly sensitising phenolic compound that is cytotoxic in the open wound.

Conclusion

Research continues to explore ways to manage wounds that improve healing rates and aid in progression of the wound from phase to phase. Any products used should avoid cytotoxicity and damage to healthy tissue.

To date there is no magic formulation that bypasses the proper cleansing of wounds which is critical for positive progression, and promotion of wound healing that will negate the need for proper management. Thorough cleansing of wounds followed by moist wound healing principles remain the gold standard.

The challenge comes in limiting factors that delay healing such as movement, compliance, contamination and interference. Whatever is promised on the label, be reassured that many wounds heal despite the products used.