An updated overview and clarifi cation of the principle role of debridement



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EWMA Document:

Debridement

An updated overview and clarifi cation 

of the principle role of debridement

     

  

     



  

A EWMA Document



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© EWMA 2013

All rights reserved. No reproduction, transmission or copying of this publication is allowed without written 

permission. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or 

by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission 

of the European Wound Management Association (EWMA) or in accordance with the relevant copyright legislation.

Although the editor, MA Healthcare Ltd. and EWMA have taken great care to ensure accuracy, neither MA 

Healthcare Ltd. nor EWMA will be liable for any errors of omission or inaccuracies in this publication.

Published on behalf of EWMA by MA Healthcare Ltd.

Publisher: Anthony Kerr 

Editor: Daniel Shanahan 

Designer: Alison Cutler 

Published by: MA Healthcare Ltd, St Jude’s Church, Dulwich Road, London, SE24 0PB, UK

Tel: +44 (0)20 7738 5454 Email: anthony.kerr@markallengroup.com Web: www.markallengroup.com



R. Strohal (Editor);

1

J. Dissemond;

2

J. Jordan O’Brien;

3

A. Piaggesi;

4

R. Rimdeika;

5,6


T. Young;

7

J. Apelqvist (Co-editor);

8

1 Department of Dermatology and Venerology, Federal University Teaching Hospital Feldkirch, Feldkirch, Austria;



2 Clinic of Dermatology, Venerology and Allercology, Essen University Hospital, Germany;

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: robert.strohal@lkhf.at  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.


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Contents

Introduction 

4

Method


6

Patientconsentfordebridement

8

Mechanical debridement 



10

Wet-to-drydebridement

10

Paraffintulle



10

Gauze


11

Monofilamentfibrepad

12

Conclusions



12

Autolytic dressings, enzymatic dressings, absorptive dressings and honey 

13

Autolyticdressings



13

Enzymaticdressings

17

Absorptivedressings



20

Honey


20

larvae debridement therapy 

22

technical solutions 



26

Directdebridementtechnologies

26

Jetlavage/hydrosurgery



26

Ultrasound

27

Indirectdebridementtechnologies



28

Negativepressure

28

Low-frequencyultrasound



29

Conclusions

30

Surgical and sharp debridement 



31

Health economics: Wound management and debridement 

35

Healtheconomicsandfactorsrelatedtohealingofnon-healingwounds



35

Costofwoundmanagement:Existingevidence

36

Thehealtheconomyofdebridement



37

Needforstudiesonthecost-effectivenessofdebridement

37

Debridement algorithm 



39

References 

42

Appendices 



46

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R

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.

1

However, despite the central role of debridement 



in the fi eld of wound healing, there is still no 

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.

Definitionofdebridement

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 

tension.

2

 Today, debridement refers to deeply 



removing adherent, dead or contaminated tissue 

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).

3



Furthermore, debridement does not encompass 



revision of a wound, resection of functional tissue 

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;

4

 however, from a global 



perspective it becomes clear that not only the 

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 

wound healing.

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 

Introduction


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Fig 1.Woundmargincoveredbydriedexudate

andhyperkeratosiswhichmayimpairthe

physiologicalprocessofwoundhealing

Fig 2.Lowerlegwithwidelydisseminated,adherentcrusts

ofexudate,largeskinscales,hyperkeratosisanddebris,

whichmayimpairthephysiologicalprocessofwoundhealing.

Nodefinedulcer.

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.

Indicationsfordebridement

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 


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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).

Remove


Necrosis

Slough


Eschar

Impairedtissue

Sourcesofinflammation

Sourcesofinfection

Exudate

Serocrusts



Hyperkeratosis

Slough


Pus

Haematomas

Foreignbodies

Debris


Bonefragments

Othertypesofbioburden/

barriersofhealing

Decrease


Odour

Excessmoisture

Riskofinfection

Stimulate

Woundedges

Epithelialisation

Improve

Qualityoflife



Table1.Targetsofdebridement

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.

Method

The methodology of this document comprises 



of a general literature review with the addition 

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), 



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Fig 3.Dryfibrin;thewoundedgesshowthat

fibrinrepresentsabarriertohealing.

Fig 4.Adherent,dryblacknecrosis

Fig 5.Wetslough

Fig 6.Localinfectionofthewoundandwound

edges,withthepotentialpresenceofabiofilm

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.


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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.

5

Informed consent must be obtained before 



commencing any treatment or investigation, or 

in providing personal care.

6

 For consent to be 



valid, the person giving consent must be capable 

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.

7

It should be noted that a parent or guardian 



can initiate consent if the person receiving the 

debridement treatment is too young (< 16 years 

old) or is incapable of making the decision for 

themselves (due to physical or mental illness).

8



It is important that parents and their children 



are informed about the proposed treatment and 

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.

9

Informed consent maybe expressed or implied. 



Implied consent may be inferred by the patient’s 

actions, for example voluntary attendance to the 

clinic for larval therapy dressings.

10

 Expressed 



consent can be either written or verbal.

11

 In the 



USA and UK, for example, it is common practice 

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 

Decision parameters

Pain


Skillofthecaregiver

Patientsenvironment

Resourcesofthecaregiver

Patientschoiceandconsent

Regulations

Biologicalageandcomorbidities

Guidelines

Qualityoflife



Table2.Additionalparametersinfluencingthedecisionfordebridement

andthechoiceoftechnique

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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 

debridement technique.

12

Regardless of debridement technique it is essential 



that patients are given adequate information in 

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,

13

 it is an active participation of the 



patient in the decisions about their own health care.

An example of a debridement consent form can 

be found in Appendix 3.

Theobjectiveistoprovideanupdated



overviewwithregardtodebridement

anditsmethods,togetherwitha

suggestionforanoverallclinical

algorithmwhichdefinesthewhy,

whenandhowofdebridement



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M

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).

Wet-to-dry debridement

Background

Mechanical debridement has been reported to be 

the most commonly used debridement technique 

in the USA

14

 and is a method that has been used 



for decades.

15,16


 A wet-to-dry method of wound 

cleansing has also been decribed,

17

 but should 



not be confused with the traditional wet-to-dry 

method of debridement.

Action

One technique used to achieve mechanical 



debridement is the wet-to-dry method. A moist 

Mechanicaldebridement

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. 

Indications

Wet to dry dressings are recommended only as a 

short-term therapy for infected necrotic wounds.

15,18


One case study reports using wet-to-dry as a 

debridement method in a patient with a category III 

pressure ulcer.

19

 In addition, there is one case 



reporting success in using wet-to-dry gauze as one 

component of a debridement regimen.

20

Limitations



The wet-to-dry debridement method often 

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 

dressing changes.

15

 In addition, while cost of 



the gauze is low, application is said to be time 

consuming and costly.

15,18

Paraffin tulle



Donati and Vigano

21

 provide anecdotal reports of 



paraffin tulle dressings causing pain and damage 

to new tissue, bleeding at the wound bed on 

removal, as well as an increased risk of infection 

and a delay in re-epithelialisation.

21

 Barnea et 



al.,

22

 in a study comparing a 



Hydrofiber dressing 

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  

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).

Gauze 

Background



Traditionally, gauze has been used as the basis 

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.

23,24


Indications

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.



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