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InFocus

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

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.

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