An updated overview and clarifi cation
of the principle role of debridement
A EWMA Document
© EWMA 2013
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permission. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or
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J. Jordan O’Brien;
J. Apelqvist (Co-editor);
1 Department of Dermatology and Venerology, Federal University Teaching Hospital Feldkirch, Feldkirch, Austria;
3 Centre of Education,Beaumont Hospital,Beaumont Road, Dublin, Ireland;
4 Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy;
5 Kaunas University Hospital, Department of Plastic and Reconstructive Surgery, Lithuania;
6 Lithuanian University of Health Sciences , Faculty of Medicine, Lithuania;
7 Bangor University, North Wales, United Kingdom;
8 Department of Endocrinology, University Hospital of Malmö, Sweden.
Editorial support and coordination: Julie Bjerregaard, EWMA Secretariat
Email: firstname.lastname@example.org Web: www.ewma.org
The document is supported by an unrestricted grant from Ferris Healthcare, FlenPharma, Lohmann & Rauscher,
Sorbion and Söring.
This article has not undergone double-blind peer review;
This article should be referenced as: Strohal, R., Apelqvist, J., Dissemond, J. et al. EWMA Document: Debridement.
J Wound Care. 2013; 22 (Suppl. 1): S1–S52.
Autolytic dressings, enzymatic dressings, absorptive dressings and honey
larvae debridement therapy
Surgical and sharp debridement
Health economics: Wound management and debridement
outine care of non-healing acute and
chronic wounds often comprises either
cleaning or debridement. Consequently,
debridement is a basic necessity to induce the
functional process of tissue repair, which makes it a
central medical intervention in the management of
acute and chronic, non-healing wounds.
The last years many different new debridement
techniques have been introduced; primarily
applying physical principles and forces to promote
the development from acute infl ammatory phase to
the reparative condition.
However, despite the central role of debridement
document that gathers this information. With this
document, the European Wound Management
Association (EWMA) aims to provide an overview
of the various options, including a clarifi cation of
the principal role of debridement (why and when to
debride, evidence for debridement), the defi nition
of possibilities and limitations for standard and new
debridement options with specifi c potentials in
their practical use, health-economic aspects and an
algorithm for the clinical routine.
The word debridement derives from the French
débridement, which means to remove a constraint.
In clinical medicine this term was fi rst used by
Henri Le Dran (1685–1770), in the context of
an incision to promote drainage and relieve of
Today, debridement refers to deeply
from a wound and must be clearly separated from
the act of cleansing, defi ned as the removal of
dirt (loose metabolic waste or foreign material).
Furthermore, debridement does not encompass
or amputation. Thus, we defi ne debridement as
the act of removing necrotic material, eschar,
devitalised tissue, serocrusts, infected tissue,
hyperkeratosis, slough, pus, haematomas, foreign
bodies, debris, bone fragments or any other type
of bioburden from a wound with the objective to
promote wound healing.
Debridement is sometimes referred to as a form of
wound bed preparation;
however, from a global
wound bed but also the wound edges and the
peri-wound skin are important for the successful
healing of a wound. This supports a defi nition
of debridement that does not only refer to the
removal of bioburden from the wound bed, but
also the liberation of wound edges as well as of
peri-wound skin. This document will show that
this broader view on debridement opens new
possibilities and perspectives within the fi eld of
When adapting a global approach to wound
healing, debridement must be understood as
a process, possibly used in conjunction with
other treatment approaches, with the aim to
create a benefi cial situation supporting various
clinical goals related to wound management.
We believe that this approach increases the
probability to achieve clinical benefi ts such as
increased quality of life of the patient, fewer
odours, improved microcirculation, normalised
biochemistry including normalising the matrix
metalloproteinase (MMP) balance, decreased
access of moisture and stimulated wound edges. A
global approach to debridement offers advantages
with regards to the possibility to clearly defi ne
wound phase targets for debridement and review
whether these targets have been achieved.
Primary targets for debridement have been
summarised in Table 1.
As debridement represents a central step in the
management of wounds it can be applied to all kinds
of wounds, irrespective of their diagnoses and origin.
The question arises with regards to the indication
for debridement and timing of the procedure. A
clear indication can be generated via the diagnosis
of different kinds of tissue types and bioburden
which cover the wound bed, the state of the wound
edges and the peri-wound skin. A tissue type related
defi nition of debridement allows the clinicians to
defi ne the right time point for debridement and to
identify the most appropriate method. Therefore, an
appropriate diagnosis must fi rst defi ne the problem
(necrosis, eschar, slough, sources of infection) and
secondly, defi ne the exudate levels of the wound bed
ranging from dry to wet (Fig 3–6).
Many additional parameters exist, which have the
capacity to infl uence the decision for debridement
and especially the choice of the appropriate
method. Such parameters comprise pain, the
patient’s environment, patient’s choice, age, skill
and resources of the care giver, patient’s quality of
life, regulations and guidelines (Table 2).
To summarise, we understand debridement as
an integrated part of the management of an
individual with a wound, achieving certain goals
and, thus, creating a healthy wound bed, edges and
peri-wound skin, with the objective of promoting
and accelerating healing. The indication for
debridement and choice of technique does not
relate to the diagnoses of the wound but to the
defi nition of certain tissue types covering the
wound, as well as their state of humidity and
relevant factors related to the patient situation.
The methodology of this document comprises
of the authors’ clinical expertise. The objective
is to provide an updated overview with regard
to debridement and its methods together with a
suggestion for an overall clinical algorithm which
defi nes the why, when and how of debridement.
Thus, this paper is not purely evidence based or
evaluating existing products, as this would lead to a
compromise with the primary objective: To describe
the substantial amount of available debridement
technologies, which all have potential advantages
and limitations related to the various wound types
and treatment settings.
The literature search strategy was instigated to
allow for the identifi cation of a broad range of
methods and results of using different techniques
in the debridement of wounds. Three databases
were searched: Medline, Embase and the Cochrane
Database. The search was conducted in December
2011 and search terms used are listed in Appendix 1.
The authors responsible for the various sections
of the document selected the relevant literature to
include in their sections, based primarily on the
literature identifi ed in the database search. Literature
used includes debridement studies of various types:
Reviews, randomised controlled studies (RCTs),
comparative studies and cohort studies were given
priority, but in many cases non-comparative studies,
case studies, in vitro studies and animal studies have
been included, as RCTs and comparative studies were
not available, with regards to the techniques/topics
described in the document.
A list of references, including information on
the study and document type, can be found at
www.ewma.org (Appendix 2).
As a general conclusion with regards to the
literature search we acknowledge that more
high-level evidence is needed to further support
the content of this document. However, until this
has been provided, we have to rely on existing
information and experience to define existing
methods of debridement.
Patient consent for debridement
A comprehensive and holistic patient assessment
is a necessary pre-requisite to evaluate the most
appropriate method of debridement. Patient
involvement in the assessment and planning of
treatment will optimise success, as the patient will
be more informed and more likely to accept and
comply with treatment resulting in greater success
in removing necrotic tissue.
Informed consent must be obtained before
in providing personal care.
For consent to be
of making the decision or deemed competent.
The consent should be given voluntarily, without
coercion and the person should be provided with
adequate information to make that decision.
Information should be available regarding the
type of debridement treatment, including benefits
and risks, implications of having treatment and
alternatives that maybe available.
It should be noted that a parent or guardian
debridement treatment is too young (< 16 years
old) or is incapable of making the decision for
themselves (due to physical or mental illness).
It is important that parents and their children
that children are listened to so that they can be
involved in the decision making. Ensuring consent
is legally and ethically obtained will reduce risk of
litigation and improve patient satisfaction.
Informed consent maybe expressed or implied.
actions, for example voluntary attendance to the
clinic for larval therapy dressings.
for patients to sign a consent form, indicating
that they have been given information and that
they are consciously giving their permission to
receive care, for example, sharp debridement of a
necrotic diabetic foot ulcer.
Documentation of consent provides evidence that
processes involved in obtaining consent have
been adhered to. It can also provide evidence of
information given to patients and clarification of
treatment, for example, amputation of lower limb
in theatre under general anaesthetic. However,
patients do have a right to withdraw their consent
at any stage before, or during the course of the
Regardless of debridement technique it is essential
order to reach an informed decision and consent
to treatment. Focus should be on all methods
of debridement and not just surgical and sharp
debridement. Consent is not just a signature on a
piece of paper,
it is an active participation of the
An example of a debridement consent form can
be found in Appendix 3.
echanical wound debridement involves
the use of dry gauze dressings, wet
to dry gauze dressings, impregnated
gauze/tulle dressings or a monofilament fibre pad
to remove non-viable tissue from the wound bed.
Following a review of the literature, a large
proportion of the articles were excluded, as they
did not contain specific information on the ability
to debride non-viable tissue (Edsrtom et al., 1979;
Xakellis and Chrischilles, 1992; Brown, 2000; Piaggesi
et al., 2000; Caravaggio et al., 2003; Eginton et al.,
2003; Wanner et al., 2003; Allie et al., 2004; Cohn et
al., 2004; Mouës, 2004; Brigido et al., 2006; Huang et
al., 2006; Yao et al., 2006; Mouës et al., 2007; Koller et
al., 2008; Wang and Teng, 2008; El-Nahas et al., 2009;
Saba et al., 2009; Martin et al., 2010; Perez et al.,
2010; Solway et al., 2010; Brenes et al., 2011; Uccioli
et al., 2011; Warriner et al., 2011; Zhen et al., 2011.
Full references can be found in Appendix 4).
Mechanical debridement has been reported to be
the most commonly used debridement technique
in the USA
and is a method that has been used
cleansing has also been decribed,
method of debridement.
One technique used to achieve mechanical
gauze pad is applied to the wound. As the
devitalised tissue dries, it re-hardens and becomes
attached to the gauze; when the dressing is
removed, the adhered material is pulled free.
Wet to dry dressings are recommended only as a
short-term therapy for infected necrotic wounds.
debridement method in a patient with a category III
In addition, there is one case
component of a debridement regimen.
results in a lack of procedural concordance, with
an increased risk of infection; also, the gauze
remnants can potentially act as foreign bodies
within the wound bed. The disadvantages of this
method are described as injury to normal tissue
and pain, along with the necessity for frequent
In addition, while cost of
consuming and costly.
provide anecdotal reports of
to new tissue, bleeding at the wound bed on
removal, as well as an increased risk of infection
and a delay in re-epithelialisation.
in a study comparing a
S 1 1
with paraffin gauze, found patients with split-skin
donor sites treated with the latter experienced
significantly more pain and a less rapid rate of
epithelialisation (p < 0.01).
dressing in wound management and is frequently
used as a comparator in wound studies. However,
there is limited information and support available
with regards to its use as a debridement agent.
A Cochrane systematic review identified 10 trials
in which gauze was used as a comparator, in
studies investigating dressings and topical
agents for surgical wounds healing by secondary
intention. However, they did not use time to
debridement as an outcome, instead using time to
healing. In four of the trials, gauze was associated
with significantly more pain for patients compared
with use of other dressings.