Let’s begin with the following questions: Is wet-to-dry the best choice of dressing to facilitate moist wound healing? Should wet-to-dry be used to treat chronic wounds regardless of the phase of healing they are at? If a wound needs debridement, is wet-to-dry the best choice? Is wet-to-dry more cost-effective for treating chronic wounds than any other type of dressing?
Interesting enough, the answer to all of these questions is “No.”
Wet-to-dry dressings are a type of mechanical debridement that consists of damping a sterile gauze with normal saline, usually 0.9 percent and applying it to the wound bed. Once the gauze is dried up, the clinician forcibly removes the gauze along with devitalized tissue. The wound must be in the inflammatory phase should a wet-to-dry dressing is selected because its purpose is the removal of necrotic tissue.
Unfortunately, many clinicians choose to moisten the dressing before removing the gauze in order to decrease the amount of pain and tissue damage dealt with the patient. This defeats the purpose of mechanical debridement. In addition, wet-to-dry dressings do not facilitate moist wound healing because as the saline evaporates, wound drainage is trapped in the gauze, desiccating the tissue which impedes cell migration and proliferation. Not to mention that the dry gauze removal disperses a significant amount of bacteria into the air, increasing the risk for wound infection.
With the use of wet-to-dry wound healing is also delayed. On each dressing removal, healthy tissue is damaged which causes trauma and pain. Furthermore, the frequency of dressing change, which is as often as much as 3-4 times daily, causes a decrease in wound temperature which leads to vasoconstriction. Because of the decrease in blood perfusion, lack of oxygen impairs the ability of bacterial clearance from the wound bed, leading to a higher risk of tissue infectability.
Another important point of discussion is the cost-effectiveness of using wet-to-dry dressings in the current wound care practice. In many cases, clinicians believe that using a moistened gauze to treat a chronic wound is less expensive than advanced wound dressings such as foams, hydrocolloids or alginates. This cannot be further from the truth. Coyne[1] researched the cost-effectiveness of using a polyacrylate moist wound dressing in comparison with wet-to-dry.
He found a 26 percent savings annually in a 65-nationwide home care agency and remarked that wet-to-dry dressings increase pain, slowed wound healing and increased infection rate. Colwell et al.[2] found that the use of a more expensive semi-occlusive dressing requiring less frequent dressing changes had a faster healing outcome than wet-to-dry dressings.
In spite of all the scientific evidence discouraging the use of wet-to-dry dressings in the current wound management practice, these continue to be ordered. Cowan & Stechmiller[3] indicated that wet-to-dry dressings were improperly selected to treat chronic wounds 78 percent of the time. They are considered a “default” dressing, even when the wound is in the proliferative phase when no debridement is indicated. Cowan & Stechmiller indicated that wet-to-dry dressings can be appropriate only if the risk of destructing the healthy tissue is outweighed by the benefit of removing devitalized tissue, such as when the wound bed presents with 50 percent or more of necrotic tissue. However, clinicians were ordering this dressing for proliferating wounds with more than 75 percent of granulation tissue.
There are other types of debridement such as enzymatic, sharps, hydrotherapy, among others, that facilitate the removal of necrotic tissue without the challenges a wet-to-dry dressing cause in the wound bed.
If the use of wet-to-dry dressing is being challenged in the current wound practice, why its continued use? The main reasons are unfamiliarity with advanced wound dressings and their use; lack of time to learn about advanced wound dressings; clinician’s training and personal experience using wet-to-dry dressings; and the belief that wet-to-dry dressings are more cost-effective than other dressings.[1]
The use of advanced wound dressings for chronic wounds is well-documented in the literature. A clinician treating patients with wounds must rely on evidenced-based medicine for their clinical decision making to improve patient care, facilitate positive outcomes and cost-effective treatments.
Therefore, the best way to improve the current wound practice and limit the use of wet-to-dry dressings is education. Clinicians must follow wound management guidelines from white papers and expert panels such as the National Pressure Ulcer Advisory Panel, the Wound Healing Society, the Academy of Clinical Electrophysiology and Wound Management; and the American Professional Wound Care Association, among others.
Most importantly, there needs to be a collaboration with wound clinicians and board-certified wound specialists who have studied and researched the area of wound management and can make the best recommendations to treat a chronic wound and facilitate healing. Not only this will benefit the patient but healthcare as a whole.
Wound care is a science, is an art, is a love; with collaboration and expertise, wounds can heal.
Dr. Nilma Elias Santiago is a physical therapist with 15 years of experience. She is certified in wound care and ostomy specialist through the National Alliance of Wound Care and Ostomy. She is the owner of the Integumentary Physiotherapy Clinic in Altamonte Springs, FL. For more information, you can reach her at nelias@integumentarypt.com.
References:
- Coyne N. Eliminating wet-to-dry treatments. Remington Report. September/October
2003;(sup):8–11.
- Colwell JC, Foreman MD, Trotter JP. A comparison of the efficacy and
cost-effectiveness of two methods of managing pressure ulcers. Decubitus .
1993;6(4):28–36.
- Cowan LJ, Stechmiller J. Prevalence of wet-to-dry dressings in wound care. Adv Skin
Wound Care, 2009;22:567– 573.
- Wollheim D. Wet-to-dry dressings; the good...the bad...and the options. Wound Care
Education Institute. May 22nd, 2016. Available at:
http://www.shieldhealthcare.com/community/wp-content/uploads/2016/09/HandoutWetToDry_Final.pdf
