chapter 8 wound healing and its impact on dressings and
TRANSCRIPT
Chapter 8
Wound Healing and Its
Impact on Dressings and
Postoperative Care長庚皮膚科 R2 劉人鳳2015.12.11
Chapter summary
Dressing – cover the wound, absorb drainage, moist environment
Moist environment– epithelial migration, angiogenesis, growth factors
retention, autolytic debridement, fibrinolysis, protection, voltage gradient
Acute wounds healing
Chronic wounds –relieve pain, promote autolytic debridement, decrease
frequency of changes
Dressings, skin grafts and skin substitutes
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Functions of Dressings
Table 8.1
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Functions of Dressings -- Acute wounds
Heal in an orderly/timely fashion
Moist environment and occlusion -- 40% faster of healing than air exposed
Enhancement of epithelial migration: keratinocytes begin to migrate sooner
Stimulation of angiogenesis:
- angiogenesis-stimulating factors (TNF, heparin)
- steep oxygen gradient or hypoxia stimulates capillary growth
長庚皮膚科 R2 劉人鳳
Functions of Dressings -- Acute wounds
Retention of growth factors: platelet derived growth factor (PDGF), basic
fibroblast growth factor (bFGF), transforming growth factor (TGF-b),
epidermal growth factor (EGF), interleukin IL-1
Facilitation of autolytic debridement: retained water and proteolytic enzymes
Protection of exogenous organisms: physical barrier; neutrophils,
lysozymes/globulins; inhibitory to bacteria growth by mildly acidic pH
Maintenance of voltage gradients: keratinocyte migration, increase
synthesis of growth factors
長庚皮膚科 R2 劉人鳳
Functions of Dressings -- Chronic wounds
Chronic wounds – with underlying pathology (delay in the healing process)
Inhibitory to epithelialization, inhibit keratinocyte migration; fails to
stimulate DNA synthesis directly; considerably higher protease activity
Pain relief, painless wound debridement, containment of wound exudates,
reduction in the incidence of complications, and improved quality of life
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Box 8.1
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Non-adherent fabrics
Hydrophobic -- greater occlusive capability
Vaseline gauze (The Kendall Co, Mansfield, MA), Xeroform (The Kendall
Co), and Telfa (The Kendall Co)
Hydrophilic -- less occlusive, facilitate drainage of fluids and exudates
Xeroflo (The Kendall Co), Mepitel (Mö lnlycke Health Care, Gothenburg,
Sweden), Adaptic (Johnson & Johnson Medical, Arlington, TX), and N-
Terface (Winfield Laboratories, Dallas, TX)
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Non-adherent fabrics: Absorptive dressings
Gauze is one of the most common
Secondary dressing to fix
Foam dressings and alginates: both absorptive and occlusive/moisture-
retentive dressings
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Occlusive/moisture retentive
Moisture vapor transmission rate (MVTR) in 24 hrs
MVTR of intact normal skin: 200 g/m 2 per day
MVTR of wounded skin: 40X
MVTR of <35 g/m 2 per hour are defined as occlusive or moisture retentive.
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Non-biologic
occlusive
dressings
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Foam dressings
[Advantages]
Able to expand to conform to the size and shape of
the wound
Wounds with unusual configurations
Highly absorptive
Can be easily removed
[Disadvantages]
Opaque, require secondary dressing
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Foam dressings
[Indications]
Partial-thickness wounds
Moderately to heavily exudative wounds and infected wounds
Pressure relief and cushion bony prominences
Secondary dressings for additional absorption
[Examples]
Allevyn (Smith & Nephew United, Largo, FL), Biopatch (Johnson & Johnson Medical), Curafoam (The Kendall Co), Flexzan (Dow B Hickam, Inc, Sugarland, TX), Hydrasorb (The Kendall Co), Lyofoam (ConvaTec, Princeton, NJ), Mepilex (Mö ln-lycke Health Care), Polymem (Ferris Corp, Burr Ridge, IL)
[Technique] 2 cm margin, tape or gauze for non-adhesive foam dressing長庚皮膚科 R2 劉人鳳
Film dressings
[Advantages]
Transparent, bacterial barrier
Self-adhesive
[Disadvantages]
Non-absorptive fluid collection frequent
dressing changes
Strip away newly formed epidermis on removal
Wrinkle easily, hard to handle
Contact dermatitis
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Film dressings
[Indications]
Mildly exuding wounds, including lacerations, superficial surgical and burn wounds, donor sites, superficial ulcers, and catheter sites
Partial-thickness wounds with minimal exudates
Secondary dressings over alginates, foams, and hydrogels
NOT used in moderately to heavily exuding or infected wounds, sinus tracts, or cavities
[Examples]
Tegaderm (3M Healthcare, St Paul, MN), Bioclusive (Johnson & Johnson Medical), Blisterfilm(The Kendall Co), Polyskin II (Kendall Healthcare, Mansfield, MA), Mefilm (Mö lnlyckeHealth Care), Carrafilm (Carrington Lab, Irving, TX), and Transeal (DeRoyal, Powell, TN)
[Technique]
Intact periwound skin, 3–4 cm margin 長庚皮膚科 R2 劉人鳳
Hydrocolloids
[Advantages]
Absorbent, create bacterial and physical barrier
(waterproof)
Hydrophilic particles absorb and form a gel
autolytic debridement, enhance angiogenesis,
granulation tissue formation, and healing.
[Disadvantages]
Opaque, gel has unpleasant smell, expensive
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Hydrocolloids
[Indications]
Partial- or full-thickness wounds, mildly to moderately exudative wounds (NOT actively infected)
Pressure ulcers, venous ulcers
Burn wounds (NOT 3rd degree) and donor sites
Acute surgical wounds
[Examples]
Duoderm (ConvaTec), NuDerm (Johnson & Johnson Medical), Comfeel (Coloplast, Minneapolis, MN), Hydrocol (Dow Hickam/Bertek), Cutinova (Smith & Nephew), Tegasorb (3M, Minneapolis, MN), Replicare (Smith & Nephew United), and Restore (Hollister, Libertyville, IL)
[Technique] >2 cm margin, daily ~ 3-7 days, ZnO for peri-wound skin長庚皮膚科 R2 劉人鳳
Hydrogels
[Advantages]
Semitransparent, soothing& cooling
effect
Do not adhere to wounds, hydrating
[Disadvantages]
Require secondary dressing, frequent
dressing changes
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Hydrogels
[Indications]
Painful wounds
Partial-thickness wounds
Wounds after laser, dermabrasion or chemical peel
Donor sites
[Examples]
Vigilon (CR Bard, Murray Hill, NJ), Nu-gel (Johnson & Johnson Medical), Tegagel (3M), Flexi-Gel (Smith & Nephew), Curagel (The Kendall Co), Clear-Site (Conmed Corp, Utica, NY), Curafil (The Kendall Co), Curasol (Healthpoint), Carrasyn (Carrington Laborato-ries), Elasto-Gel (SW Technologies, North Kansas City, MO), Hypergel (Mö lnlycke Health Care), Normlgel (Mö lnlycke Health Care), SoloSite Wound Gel (Smith & Nephew), 2nd Skin (Spenco Medical, Ltd, Waco, TX), and Transigel (Smith & Nephew).
[Technique] changed every 3 days for necrotic wounds, 7 days for granulating wounds. Remove gently.
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Alginates
[Advantages]
Highly absorbent
Hemostatic, do not adhere to wounds
Fewer dressing changes
[Disadvantages]
Require secondary dressing, gel has unpleasant
smell
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Alginates
[Indications]
Highly exudative wounds
Deep wounds, sinuses and cavities (rope and ribbon forms)
Partial- or full-thickness wounds
After surgery
[Examples]
AlgiSite (Smith & Nephew), Algosteril (Johnson & Johnson Medical), Kaltostat (ConvaTec), Curasorb (The Kendall Co), Dermacea (The Kendall Co), Melgisorb (Mö lnlycke Health Care), SeaSorb (Coloplast, Holtedam, Denmark), Kalginate (DeRoyal), and Sorbsan (Dow B Hickam, Inc)
[Technique] at least 2 mm beyond the wound edges, secondary dressing is needed
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Non-biologic
occlusive
dressings
NEWER NON-BIOLOGIC
DRESSINGS ARE CLASSIFIED
INTO 3 BASIC CATEGORIES
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Hydrofibers
[Advantages]
Soft, absorbent
[Indications]
Moderately to heavily exuding wounds
Wounds that are prone to bleeding
Abrasions, lacerations, excisional wounds, pressure or leg ulcers, burns, and graft donor sites, wound cavities (hydrofiber ribbons)
[Examples] Aquacel
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Collagen dressings
[Advantages]
Available as particles, sheets, or gels
Providing a collagen matrix for cellular migration
[Disadvantages]
Cause irritation or initially increase drainage
[Indications]
Moderately exudative wounds and recalcitrant ulcers
[Examples] Fibracol (Johnson & Johnson, Skillman, NJ), Medifil (Biocore Medical
Technologies, Inc, Silver Spring, MD), and Nugel collagen wound gel (Johnson &
Johnson Medical)
長庚皮膚科 R2 劉人鳳
Hyaluronic acid dressings
[Advantages]
Biodegradable, absorbent
Accelerates granulation tissue formation and re-epithelialization
[Examples]
Hyalofil (ConvaTec)
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Biologic
dressings: grafts
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Biologic dressings: grafts
Grafts: local blood supply new blood supply from the recipient bed
Autografts: donor site to recipient site from the patient
Fractional skin harvesting: multiple full thickness cores of skin with small
diameter to minimize donor site morbidity
Allografts: donors of the same species -- cadaveric skin
Composite grafts: at least two different types of tissues, ex: skin and
cartilage
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Biologic/biosynt
hetic dressings:
skin substitutes
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Cultured epidermal grafts
Cultured epidermal autografts: serial subculture of human keratinocytes from the patient’s own skin large epidermal sheets sutured onto the
recipient’s tissue
Secondary dressing: mesh gauze for 7-10 days
Another outer dressing: absorb wound exudates, change QD or QOD
Disadvantages: require a 2–3-week period, fragile, lack a dermal
component. short-term stability
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Cultured epidermal grafts
Cultured epidermal allografts: Neonatal foreskin
Growth factors release stimulate migration and multiplication of the
recipient’s keratinocytes
Donor sites, partial-thickness burns, chronic leg ulcers, epidermolysis
bullosa, and wounds resulting from tattoo removal
長庚皮膚科 R2 劉人鳳
長庚皮膚科 R2 劉人鳳
Dermal replacements
Cadaveric allograft skin, Biobrane (Smith and Nephew), EZ Derm (Mö lnlycke),
Oasis (Healthpoint), and Dermagraft (Shire Regenerative Medicine, St Helier,
Jersey)
Human cadaver skin -- acellular collagen dermal matrix and an intact basement membrane
Can be used alone or in combination with other grafts
AlloDerm (Life Cell Co, Woodlands, TX) --
• used in combination with STSGs
• burn wounds and dermal defects, and for periodontal, and plastic and
reconstructive surgery長庚皮膚科 R2 劉人鳳
Dermal replacements
Biobrane -- bilaminate biosynthetic material made up of silicone film and nylon fabric containing porcine collagen peptides
• pain relief, healing time, and absorption of exudates
EZ Derm -- porcine collagen chemically cross-linked using an aldehyde
• temporary coverage of partial-thickness wounds (burns and ulcers)
Oasis -- porcine small intestinal submucosa
• longer shelf-life, requiring a secondary dressing for additional protection
Integra (Integra LifeSciences Corp, Plainsboro, NJ) -- bovine collagen and chondroitin-6-sulfate covered by a synthetic silicone elastomer
• approved by FDA for burns (severe burns, insufficient skin available for an FTSG)
長庚皮膚科 R2 劉人鳳
Dermal replacements
Dermagraft -- neonatal fibroblasts seeded on a 3D polyglactin
bioabsorbable mesh with no outer silicone membrane
• Full-thickness wounds, FDA approved for chronic diabetic ulcers
Avoiding the use of non-human tissue
Ready availability
Less chance of wound contracture and scarring
Mesh absorption in 60–90 days
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Dermagraft
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Composite skin substitutes
Contain both epidermal and dermal components
Apligraf (Organogenesis, Canton, MA; also known as Graftskin) --cultured human neonatal foreskin keratinocytes overlying fibroblasts
cultured on a dermal matrix of bovine type I collagen
• Lack immune cells no clinical rejection
• FDA-approved: venous leg ulcers or neuropathic diabetic foot ulcers
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Apligraf
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Composite skin substitutes
Bilayered cellular matrix (BCM) or OrCel (Forticell Bioscience Inc, New York,
NY) -- porous collagen sponge containing cultured keratinocytes and
fibroblasts derived from allogeneic cells harvested from neonatal foreskins
• FDA approved: split-thickness donor sites of burn; recessive dystrophic
epidermolysis bullosa
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Cell therapies
For healing of chronic wounds
Solution containing cells is sprayed onto the wound bed
Do not require in-vitro tissue engineering (unlike skin substitutes)
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Keratinocyte Spray
Spray-applied cell therapy
Growth-arrested allogeneic neonatal keratinocytes and
fibroblasts
Phase-2 double-blind randomized trial
Superiority of the active treatment over vehicle (p = 0.0446)
Lowest concentration and least frequent, administered
every 14 days showed the largest improvement (p = 0.0028)
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Mesenchymal stem cells derived from
bone marrow
Bone marrow aspirate in vitro multipotent mesenchymal stem cells
A fibrin polymer spray system used to apply the cultured autologous stem
cells
Difficult-to-heal wounds
Chronic lower extremity wounds
長庚皮膚科 R2 劉人鳳
Antimicrobial dressings
Silver-impregnated dressings
broad-spectrum action on bacteria, including against vancomycin-
resistant enterococci and methicillin-resistant Staphylococcus aureus
(MRSA)
• release antibacterial levels of silver for 3–7 days
against fungi and yeast
Aquacel Ag (ConvaTec), Contreet (Coloplast), Arglaes (Medline Industries,
Mundeline, IL), Acticoat (Smith & Nephew, London, UK), Silverlon
(Argentum Medical, Geneva, IL), and Silvasorb (AcryMed, Inc, Portland,
OR)
長庚皮膚科 R2 劉人鳳
Antimicrobial dressings
Cadexomer iodine -- a slow-release formulation of iodine
broad-spectrum antibiotic coverage
significantly decrease the bacterial load on the wound surface
Iodosorb -- a cadexomer iodine ointment
antibacterial and an effective debriding agent
pressure, venous, and diabetic ulcers
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DEBRIDEMENT
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Autolytic debridement
The body’s own enzymes and moisture liquefy necrotic tissue
Selective and painless
Enhanced with dressings (films, hydrogels, and hydrocolloid dressings)
Should be monitored for infection (particularly with anaerobes)
長庚皮膚科 R2 劉人鳳
Mechanical & Surgical debridement
Mechanical
Wet-to-dry dressings: moist dressing is applied to a wound and then
removed after drying
Non-selective (may traumatize healthy tissue), painful
Side-effects of infection with water-borne pathogens and tissue
maceration
Surgical
Rapid and selective
Significant amount of necrotic tissue
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Enzymatic debridement
Proteolytic enzymes
Enhance granulation tissue formation and epithelialization
No large, high-quality, published randomized controlled trials comparing
the efficacy
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Maggot therapy (biosurgery)
Lucilia sericata (green bottle fly) are the most commonly used maggots for
biosurgery
Secretion of proteolytic enzymes, digestion of necrotic tissue and bacteria,
increase in wound pH
Most efficacious in wounds infected with Gram-positive
bacteria, including MRSA
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POSTOPERATIVE
CARE AND
WOUND CARE
ACUTE WOUNDS
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Post-excision wounds healing by
primary intention
Simple low-or non-adherent gauze dressing secured with tape
Vaseline or Aquaphor ointment to make the patient more comfortable
Rarely require cleansing (care using saline )
1 week for sutured wounds to re-epithelialize
suture removal -- 4–6 days for the head and neck, 7 days for the upper
limbs, 10 days for the trunk and abdomen, and 14 days for the lower limbs
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Liquid adhesive bandages
Minor lacerations and abrasions, partial-thickness wounds, shave
biopsies
Traumatic lacerations especially in pediatric patients
Nexcare (3M), Band-Aid brand (Johnson & Johnson Medical), and
New-Skin (Medtech, Inc, Irvington, NY)
長庚皮膚科 R2 劉人鳳
Post-excision wounds healing by
secondary intention
“Shave” or tangential removal of skin
Randomized controlled trials -- white petrolatum is as safe and effective as
bacitracin with less risk for inducing allergy
Dressing -- left undisturbed for 48–72 h after surgery, to reduce incidental
trauma and contamination
Another alternative: occlusive dressings
• superficial wounds with minimal exudation -- films
• deeper wounds -- hydrogels or hydrocolloids
• highly exudative -- foams and alginates
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Postoperative care in laser resurfacing
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Postoperative care in laser resurfacing
Closed technique
Occlusive or semiocclusive dressing (such as Flexzan, Vigilon, 2nd Skin, N-
Terface)
More rapid epithelialization, less pain
Combination of the two approaches --
Closed technique being used for the first 48 h, then followed by the open
technique
長庚皮膚科 R2 劉人鳳
Uncomplicated partial-thickness and
full-thickness wounds
Moisture-retentive occlusive dressings -- facilitate healing and relieve pain
Biologic and biosynthetic skin grafts and skin substitutes
STSGs, FTSGs
cultured epidermal autografts, AlloDerm, Integra, and Apligraf
長庚皮膚科 R2 劉人鳳
POSTOPERATIVE
CARE AND
WOUND CARE
CHRONIC WOUNDS
長庚皮膚科 R2 劉人鳳
Venous ulcers
The most common form of leg ulcers
Compression, edema reduction, and improvement of venous return
Bed rest
Leg elevation
• Elevate the affected leg 18 cm above the level of the heart, 2–4 h during the day and night
Compression devices
• occlusive arterial disease should be excluded
• recommended ankle pressure: 30–40 mmHg
長庚皮膚科 R2 劉人鳳
Venous ulcers
Compression stockings
Difficult in elderly or arthritis patient
Compression bandages
Elastic bandages – the ACE type: reusable, but not self-adherent
• be applied in a spiral with 50% overlap between turns
長庚皮膚科 R2 劉人鳳
Venous ulcers
Compression bandages
Unna boot –
• semirigid paste bandage, applied with foot at a 90° angle
• replaced weekly
• https://www.youtube.com/watch?v
=vrGjhDwd5Mo
長庚皮膚科 R2 劉人鳳
Venous ulcers
Four-layer bandage –
• more flexible and absorbent than the Unna boot
• maintaining evenly distributed pressure
• long periods of time
• orthopedic wool layer, a crepe layer, an elastic layer applied in a figure-
of-eight pattern, and an elastic layer applied in a spiral pattern
長庚皮膚科 R2 劉人鳳
Venous ulcers
Orthotic device –
• useful in patients who cannot tolerate other
compression modalities or who require
frequent dressing changes
Pneumatic compression –
• For patients unresponsive to conventional
compression bandages or stockings
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長庚皮膚科 R2 劉人鳳
Venous ulcers
Moisture-retentive dressings combined with compression therapy may produce more rapid healing rates initially
But long-term follow-up has failed to demonstrate any statistically significant advantage over compression therapy alone
Meshing of STSGs
Shave therapy (excision of ulcers with lipodermatosclerotic tissue) & meshed STSGs
FDA approved: Apligraf -- in combination with compression therapy, > 6 months
長庚皮膚科 R2 劉人鳳
Arterial ulcers
Requires surgical re-establishment of an adequate vascular supply
Diabetes mellitus, cigarette smoking, hypertension, and hyperlipidemia
should be controlled
Moderate exercise may promote development of collateral circulation
Elevation of the head of the bed 10–15 cm improves gravity-dependent
arterial flow
Limbs should be kept warm
Good foot care
長庚皮膚科 R2 劉人鳳
Diabetic foot ulcers
Good wound care –
• proper footwear, the correct antibiotics when needed, avoidance of weight bearing, pressure-relieving aids, debridement as necessary
• Aggressive revascularization
• Control of the serum glucose levels
Topical antibacterials
Saline-moistened gauze
Occlusive dressings such as hydrogels, hydrocolloids, and polymers
Dermagraft and Apligraf ; Bilayered Cellular Matrix
長庚皮膚科 R2 劉人鳳
Pressure ulcers
Goal to enhances soft tissue viability and promotes healing of the pressure ulcers
Nutrition (espescially protein), immobility, comorbid disease, and protection from fecal or urine soiling
Debridement of devitalized tissue, wound cleansing, application of dressings
• Possible adjunctive therapy with electrical stimulation for stage III and IV unresponsive ulcers
• Alginates followed by hydrocolloid > hydrocolloid alone
• Foam dressings or wound fillers to eliminate dead space
長庚皮膚科 R2 劉人鳳
OPTIMIZING OUTCOMES
Avoid leakage
Control pain
Prevent maceration: apply zinc oxide paste on the periwound area
Minimize odor: odor-absorbing dressings
Remove necrotic tissue
Ensure patient compliance
Check intrinsic factors
Keep wound moist, but not wet
長庚皮膚科 R2 劉人鳳
PITFALLS AND THEIR MANAGEMENT
Infection: antibiotics, practice clean or aseptic techniques, irrigate under pressure, debride to remove necrotic tissue
Contact dermatitis
Seroma formation
Excessive pressure from dressing
Excessive granulation tissue: apply pressure, change dressing type, pare with curette, cauterize with silver nitrate
Pigmentary alteration
Milia or suture granuloma
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PRACTICAL APPLICATIONS
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SUMMARY
Extensive discussion of the different types of dressings currently available,
including their advantages, disadvantages, and indications
Reviews the technical aspects of applying some types of dressings as well
as specific dressings for venous ulcers and techniques for post laser
resurfacing care
長庚皮膚科 R2 劉人鳳
“
”Thank You For Your Attention
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