<strong>Wound</strong> <strong>dressing</strong>s: 21st century<strong>performance</strong> requirementsA wide range of wound <strong>dressing</strong> <strong>performance</strong> parameters exist. This paper discussesthose <strong>dressing</strong> attributes that, within the constraints of current technology, favourablyinfluence the biological actions/processes that may occur within the wound so thatthey actively contribute to the healing process.Keith F Cutting, Visiting Professor, Buckinghamshire New University, Uxbridge, UKJSampson Gamgee’s (1828–1886) view thatwound <strong>dressing</strong>s should be dry, firm, absorbentand disturbed as infrequently as possible madehim a revolutionary clinician of his time. 1 Gamgeefound that placing absorbent cotton wool betweenlayers of absorbent gauze resulted in a firm butabsorbent <strong>dressing</strong> that perfectly suited his surgicalpractice. 1 Dressing changes were also less frequent.Following the advent of the concept of moistwound healing, 2 the focus shifted to a <strong>dressing</strong>’sability to maintain a moist wound/<strong>dressing</strong> interfaceand create an optimal environment that will supporthealing and improve scar cosmesis. Over thepast 40 years, there has been a transition from providingsimple protection, to the developmentof hi-tech synthetic or natural <strong>dressing</strong> materialsthat are biocompatible and actively support thehealing process.<strong>Wound</strong> <strong>dressing</strong> <strong>performance</strong>parametersIn the past, natural materials were used to protectthe wound from the external environment. <strong>Wound</strong>swere cleansed with water or milk and often dressedwith honey, lard or butter, which was kept in placewith leaves and/or grass and, later, with wool orlinen. 3 It appears that some of the ancients used treeresin to cover and protect the wound surface. Theresin would harden, providing a natural barrier orseal. 3 Resin does not decompose when the bark iscut, but oozes naturally from the surface. It is possiblethe ancients drew an analogy from this.In 1985, <strong>performance</strong> parameters were developedto ensure that a <strong>dressing</strong> will create a microenvironmentthat supports healing. 4 To comply with these,the <strong>dressing</strong> must:• Remove excess exudate and toxic components• Maintain high humidity at the wound/<strong>dressing</strong> interface• Allow gaseous exchange• Provide thermal insulation• Protect against secondary infection• Be free from particulate or toxic contamination• Not cause tissue trauma during removal.This inventory was extended by Morgan 5 in 1998but, surprisingly, was not extensively modified untilThomas 6 published the <strong>performance</strong> requirementsof the ideal <strong>dressing</strong> in 2008 (Table 1).Interestingly, the moist wound <strong>dressing</strong>s availablein 1985 would easily have met all of Turner’s criteria.However, not only is the 2008 list more complex butno single <strong>dressing</strong> currently available complies withall of the parameters. Clearly, <strong>dressing</strong> <strong>performance</strong>parameters have become more sophisticated as ourknowledge has increased, and the gap between therequirements of the ideal <strong>dressing</strong> and the capabilityof modern <strong>dressing</strong> technology to meet them all in asingle <strong>dressing</strong> has widened.This might have been the stimulus for the developmentof a range of durable medical devices, suchas negative pressure wound therapy (NPWT) andelectrical stimulation. While no single durable medicaldevice can fulfil all of the requirements of theideal wound <strong>dressing</strong>, these devices do appear to fillthe technology gap resulting from our dependenceon textiles as the foremost wound <strong>dressing</strong> modality.Nevertheless, it may be worth exploring whetherthere are any areas of overlap in <strong>performance</strong>between durable medical devices and textile-basedwound <strong>dressing</strong>s.When seeking the ideal <strong>dressing</strong> for a particularwound in the 21st century, the decision should bebased not on one main function or one woundfactor, but should embrace the patient, his or herwound and the associated multifactorial needs. 7Advanced wound care products have beendesigned with a specific function or functions inmind. These are governed largely by the properties4J O U R N A L O F W O U N D C A R E S O R B I O N S U P P L E M E N T 2 0 1 0
Table 1. Performance requirements of the ideal <strong>dressing</strong> 6 (Thomas 2008)6Primary requirementsType of feature1 Free of toxic or irritant extractables Design feature2 Does not release particles or non-biodegradable fibres into the wound Design feature345Forms an effective bacterial barrier (effectively contains exudate or cellulardebris to prevent the transmission of microorganisms into or out of thewound)If self-adhesive, forms an effective water-resistant seal to the periwound skin,but is easily removed without causing trauma or skin strippingMaintains the wound and the surrounding skin in an optimum state ofhydration (this implies it is able to function effectively under compression)Design featureDesign featureDesign/wound related6 Requires minimal disturbance or replacement Design/wound related78Protects the periwound skin from potentially irritant wound exudate andexcess moistureProduces minimal pain during application or removal as a result of adherenceto the wound surfaceDesign/wound relatedDesign/wound related9 Maintains the wound at the optimum temperature and pH Design/wound relatedSecondary requirements10Possesses antimicrobial activity — capable of combating localisedinfection11 Has odour-absorbing/combating propertiesType of featureDesign featureDesign feature12 Able to remove or inactivate proteolytic enzymes in chronic wound fluid Design feature13 Haemostatic propertiesDesign feature14 Exhibits effective wound cleansing (debriding) activity Design/wound relatedof the <strong>dressing</strong> ‘ingredients’. This has led to a popularclassification of wound <strong>dressing</strong>s based primarilyon their principal constituents such as films, hydrogelsand hydrocolloids. In other areas of health care,products are chosen or grouped on the basis of theirfunction e.g. orthotics, bronchodilators, mucolyticsand antifungals. van Rijswijk rightly points out thatthe focus on <strong>dressing</strong> ingredients, rather than ontheir function, appears outmoded or even counterproductiveto the development and clinical use ofadvanced <strong>dressing</strong> technology. 8Optimal wound management is dependent onacquisition of the necessary resources, plus the skillsof the attending clinician. Since the characteristicsof the ideal wound <strong>dressing</strong> remain at a superlativelevel, only <strong>dressing</strong> attributes that address widespreadneeds, especially those found in chronicwounds, are discussed here.Exudate managementEfficient exudate management is a vital ingredientof good wound care and an essential <strong>dressing</strong> per-J O U R N A L O F W O U N D C A R E S O R B I O N S U P P L E M E N T 2 0 1 05
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