Jwc ewma final indd

J O U R N A L  O F WO U N D  C A R E   Vo l   2 2 .  N o   1 .  E W M A   D o c u M E N t   2 0 1 3  

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Moreover, certain topical, antimicrobial agents have 

been associated with cytotoxicity, delayed healing, 

emergence of bacterial strains resistant to common 

antimicrobial agents and contact dermatitis.

49,50

Costeffectiveness

Only a few studies have thoroughly evaluated the 

cost effectiveness of autolytic debridement methods. 

A cost efficacy analysis of cadexomer-iodine 

dressings, compared with hydrocolloid dressings 

and paraffin gauze dressings, indicate that while 

material costs were higher in the cadexomer-

iodine group, the total weekly costs were similar 

for all treatments, due to the need for less frequent 

changes with cadexomer iodine. Primary costs were 

related to cost of staff resources and transportation, 

in relation to dressing changes.

41,44,51

A randomised clinical study by Caruso,

37

 including 

a cost-effectiveness analysis, suggests potential 

cost benefits related to fewer dressing changes, 

less nursing time and fewer procedural and opiate 

medications during dressing changes. 

Some general comments with regards to possible 

cost indicators are:

• 

Autolytic debridement can be considered one 

of the easiest and safest methods of debriding 

wounds. Therefore, it may be appropriate to use 

in long-term care facilities and in the home-care 

setting, thereby possibly saving costs. 

• 

However, achieving cost effectiveness may  

be difficult, as a prolonged period of time  

may be needed to achieve complete removal 

of nonviable tissue. Therefore, costs associated 

with dressings and repeated visits need to 

be considered. 

• 

Another problem may occur as the hygienic 

specification for hydrogels are usually 

determined for single use. Thus, the tube should 

be discarded after a single use, regardless of the 

remaining stock.

Enzymatic dressings

Background

For a few hundreds of years, patients with 

chronic wounds have been treated topically with 

proteolytic enzymes, for example in the form of 

fruit juices. Since 1960, the first scientific records 

exist on the effective use of proteolytic enzymes 

in the treatment of patients with chronic wounds 

(Table 3). Enzymatic debridement is a specific 

wound-debridement option using proteolytic 

enzymes in gels or ointments, which should work 

synergistically with endogenous enzymes.

36

Indications

Enzymatic debridement can be useful in patients 

with wounds where mechanical debridement 

options are not available or are contraindicated; for 

example, in patients with bleeding problems.

Mechanismofaction

During debridement, proteolytic enzymes are 

used to hydrolyse peptide bonds, in order to 

facilitate the removal of non-viable tissue from 

a wound. These enzymes can be divided in exo- 

and endopeptidases. Exopeptidases hydrolyse 

the amino or carboxy terminal protein, whereas 

endopeptidases degrade peptide bonds within the 

protein molecules.

34

Matrix metalloproteases (MMPs) are 

zinc-dependent endopeptidases, with a sub-

group of metalloenzymes called collagenases. 

Humans generate endogenous collagenases to 

facilitate the physiological balance between 

the assembly and degradation of collagen. 

Collagenases are the only endoproteases that 

can degrade human triple helical collagen, but 

do not attack keratin, fat, fibrin or haemoglobin.

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