This is the fifth article in the series on dressings in wound management, examining the role of a variety of wound care products used in clinical practice. Low/non-adherent dressings come in many different guises and can be used on a variety of wounds, especially in relation to reducing pain during dressing change and preventing trauma to the wound on removal. The most commonly used low/non-adherent dressings to be discussed are N-A™ dressing, N-A Ultra™, Tricotex™, Melolin™, Release™, Skintact™, Paraffin tulle dressings, Mepitel™, Mepilex™, and Tegapore™. This article will first examine the properties of all the dressings and indications for use, and then discuss the techniques of application and removal and finally discuss some of the clinical studies that have been undertaken. All dressings discussed in this article are available on FP10 in a range of sizes, except Tegapore™.
Properties of low/non adherent dressings
Although many of these products are called non-adherent dressings, it is important to note that many of these dressings are low adherent rather than non-adherent (Morgan, 2000). They are also classed as primary wound contact materials, as the majority of the dressings have limited absorbency and will require a secondary dressing. All of the dressings have perforations to enable the passage of exudate into the absorbent layer or secondary dressing.
N-A™, N-A Ultra™, and Tricotex™ dressings appear to look the same, however, there are slight differences in their composition. N-A™ and Tricotex™ are sterile knitted viscose primary dressings, while N-A Ultra™ has been coated with silicone, which should make the dressing non-adherent. Exudate from the wound is able to pass through to the secondary absorbent dressing, due to the knitted open structure of the fibres (Morgan, 2000).
Melolin™, Release™, and Skintact™ are all described by Morgan (2000) as absorbent, perforated plastic film-faced dressings. Melolin™ is a low adherent dressing incorporating three layers of material. The first layer is a perforated polyester film wound contact layer, with an absorbent pad made from 80 per cent cotton and 20 per cent viscose, and a non woven backing material (Morgan, 2000). The author has noted in her clinical practice that some patients can become sensitised to the perforated polyester film layer of this dressing, and so this dressing should be avoided in those patients who have sensitivities to a number of wound dressing products.
Absorbent padding
Release™ is another low adherent dressing, consisting of an ethylene methyl acrylate film that surrounds an absorbent core of viscose rayon sandwiched between two layers of non-woven fabric (Morgan, 2000). Skintact™ is also a low adherent dressing, consisting of an apertured film on both sides and a cotton absorbent pad in the middle (Morgan, 2000). All these dressings should not require a secondary dressing, as their absorbent padding should absorb minimal exudate from the wound. Although these dressings should not adhere to the wound bed, there may be some adherence if the exudate dries in the holes of the apertured film layer.
Jelonet™, Paranet™, Paratulle™, and Unitulle™ are all paraffin gauze or tulle gras dressings, which were first developed in the First World War (Thomas, 1990). They all consist of a bleached cotton or rayon cloth impregnated with white or yellow soft paraffin. Jelonet™ contains a ‘normal loading’ of 175–220g of white soft paraffin per square metre of cloth, while Paranet™, Paratulle™, and Unitulle™ contain a ‘light loading’ of 90–130gm2 (Thomas, 1994; Morgan, 2000). Unitulle™ also contains lanolin, and so should be avoided if the patient has a known allergy to lanolin. The soft paraffin in the dressing should reduce adherence to the wound bed if applied in sufficient layers.
However, in the author’s own experience this often depends on the type of paraffin gauze dressing used and the number of layers applied to the wound. These dressings will require frequent changing in order to prevent drying out and incorporation into granulation tissue in the wound (Morgan, 2000). Those paraffin gauze dressings that have a ‘light loading’ of paraffin are less occlusive and therefore less likely to cause maceration of the skin in heavily exuding wounds (Thomas, 1990), although they are also more likely to dry out and adhere to the wound bed if not changed daily.
The paraffin gauze dressings can also be impregnated with antiseptics, e.g. Bactigras™, Serotulle™, or antibiotics e.g. Sofra-tulle™ and Fucidine-Intertulle™, although these products are not advised for routine use nowadays. The antiseptic impregnated paraffin gauze dressings both contain chlorhexidine 0.5 per cent w/w, which is active against a wide range of gram positive and gram negative organisms, although acquired resistance and sensitivity can occur (Lawrence, 1993; Morgan, 2000). The antibiotic impregnated paraffin gauze dressings are rarely used nowadays due to problems of bacterial resistance and skin sensitivity. Sofra-tulle™ contains 1 per cent w/w Framycetin and 10 per cent lanolin, both of which can cause hypersensitivies. Fucidin-Intertulle™ contains two per cent sodium fusidate and lanolin and is not recommended for wound care (Morgan 2000).
Membranes
Mepitel™ and Mepilex™ are soft silicone wound contact dressings that are non-adherent, while Tegapore™ is classed as a membrane (Morgan, 2000). Mepitel™ is a non-adhesive dressing made from medical grade silicone gel that is bound to a soft and pliable polyamide net. The netting spaces’ in the dressing allows exudate to pass through into the secondary dressing, while maintaining a moist environment. The dressing will not adhere to the wound bed, but will adhere to adjacent dry, healthy skin. This ensures lateral fluid impermeability and prevents maceration of the surrounding skin (Williams, 1995). Mepilex™ is a recent addition to the Drug Tariff, and consists of a soft silicone wound contact layer with a polyurethane foam film backing (Morgan, 2000), making it a highly absorbent, conformable, non-adherent dressing. Tegapore™ is a very
thin membrane dressing and is made from a virtually non-adherent woven, hypoallergenic polyamide net (Morgan, 2000). The woven, polyamide net is hot rolled to produce a smooth ‘silk-like’ material that has a precisely defined fibre diameter and pore size, allowing the contact layer to act as an interface between the wound and absorbent dressing, as well as allowing exudate to pass through the pores into the secondary dressing. It is chemically inert and will not shed any fibres into the wound. The dressing creates a moist wound environment and becomes transparent when wet with exudate or saline, so allowing monitoring of the wound at dressing change, without having to remove the dressing itself.
Indications for use
The majority of low/non-adherent dressings can be used in any granulating or epithelialising wound with minimal amounts of exudate, although Melolin™, Release™, Skintact™ and Mepilex™ should be able to cope with low to moderate amounts of exudate as they contain an absorbent material. All the low/non-adherent dressings can be used on leg ulcers, abrasions and lacerations. Although the paraffin gauze dressings are frequently used on fingertip injuries because of their conformability to wrap around the finger, they frequently adhere to the wound bed due to the blood drying hard in the dressing and gauze. This means that the patient may have to soak their injured finger in warmed tap water for a prolonged period of time, so as to remove the dressing without causing pain or trauma to the wound bed.
Mepitel™ is a non-adherent dressing and is particularly of value if patient’s have painful wounds, especially at dressing change e.g. fingertip injuries, following nail bed surgery, burns or for those patients who have fragile surrounding skin e.g. pre-tibial lacerations, steroidal skin or following radiotherapy. It is used in the treatment of children with epidermolysis bullosa, and can also be used around pin sites and on skin grafts (Williams, 1995). Tegapore™ is particularly of value in those patients who experience severe pain at dressing change, as the dressing can be left on the wound bed for prolonged periods of time with only the secondary dressing being changed as needed. As the wound bed is left undisturbed, this reduces any pain when the secondary dressing is changed. The antiseptic impregnated paraffin gauze dressings are often used in minor traumatic wounds and abrasions, where there is contamination of the wound and possible risk of infection, while the antibiotic impregnated paraffin gauze dressings are rarely used nowadays except in exceptional circumstances.
Application of the dressings
N-A™, N-A Ultra™ and Tricotex™: The dressing should be removed from the packaging and applied to the wound, ensuring that all the wound is covered by the dressing. An appropriate secondary absorbent dressing is required. The dressing should be changed as required, but they can be left in place for up to seven days.
Paraffin gauze dressings: The protective backing sheets should first be removed, and sufficient layers of the dressing applied to the wound to prevent adherence to the wound bed. The dressings can be cut or folded to the shape of the wound, as the dressing should only be applied to the wound surface and not the surrounding skin, as maceration of the skin edges can then occur. An appropriate absorbent secondary dressing is required and secured in place. The dressing should be changed daily so as to prevent adherence to the wound surface.
Melolin™: The shiny side of the dressing should be applied to the wound, and the dressing secured with adhesive tape or a bandage. The dressing should be changed as required.
Release™ and Skintact™: As both sides of the dressing are covered with an apertured film, there should be no concern of the dressing being applied incorrectly. The dressing should be secured with adhesive tape or bandage, and changed as required i.e. once the dressing is saturated.
Mepitel™: Before the dressing is applied the surrounding healthy skin must be dry, to ensure the dressing stays in place and does not slip. An appropriately sized dressing should be chosen, to ensure that the dressing overlaps the wound on to the surrounding skin. Mepitel™ can be cut to size if required with no risk of shedding of fibres, and when dressing large areas, several pieces can be used with an overlap onto itself of 1-2cm. The large backing sheet should be removed from the dressing and the dressing can then be applied to the wound and the smaller backing sheets removed afterwards. For some wounds e.g. fingertip injuries, toes and cavity wounds, it may be easier to remove both backing sheets prior to applying the dressing to the wound. As the dressing is very sticky it will stick to gloves, making application rather difficult.
One way of avoiding this sticky situation, is to dampen gloved hands and the dressing will not stick to the gloves. An appropriate secondary dressing should then be applied and secured in place. Mepitel™ can be left in place for up to seven days and the secondary dressing changed as required. If Mepitel™ is used on skin graft sites, the dressing should be left intact for five days, to allow for ‘take’ of the skin graft.
Mepilex™: The tacky side of the dressing should be applied to the wound, ensuring that there is an overlap on to the surrounding skin of 1-2cm. As the dressing does not require a secondary dressing, it can be secured in place with adhesive tape or a bandage. The dressing can be left in place for up to seven days or changed when it becomes saturated with exudate.
Tegapore™: The dressing is applied to the wound, either dry or moistened with normal saline 0.9 per cent, and should overlap the edges of the wound by at least 1cm. If the dressing does not conform to the shape of the limb or body, the dressing can be cut to size, as it is important that this contact layer conforms exactly to the wound surface. The wound contact layer should then be covered with an absorbent secondary dressing and secured in place with either adhesive tape or bandage. Tegapore™ can be left in place for extended periods of time i.e. fourteen days, depending on the condition of the wound, as the secondary absorbent dressing can be changed as required.
Removal of the dressings
All the dressings should be gently removed from the wound. If any of the dressings adhere to the wound surface, the area can be soaked in warmed normal saline 0.9 per cent or tap water until the dressing is freed from the wound bed, hopefully allowing atraumatic removal of the dressing. If this situation arises, the wound should be reassessed and a different, more appropriate dressing should be applied i.e. one that will not adhere to the wound surface.
Research studies
Several studies have been undertaken comparing low-adherent dressings and Mepitel™, which will now be discussed to illustrate the appropriate use of the dressings. Terrill and Varughese (2000) undertook a prospective randomised control study comparing the use of three primary non-adherent dressings (Jelonet™, Adaptic™ and Mepitel™) applied to 99 patients with hand surgery wounds. These wounds are often very painful at dressing change and are also time-consuming for both the nurse and patient. They found that Adaptic™ was significantly easier to remove, required less soaking to remove the dressing, caused less maceration and caused less pain on removal of the dressing than Jelonet™, although it was harder to apply. They also found that Mepitel™ was easier to remove than Jelonet™.
Platt et al. (1996) compared the use of Jelonet™ and Mepitel™ in a comparative prospective randomised study of 38 patients with newly grafted burn wounds. They found that pain scores were significantly lower in the Mepitel™ group and more than half of this group registered no pain on removal of the dressing from the grafted site. They also found that the Mepitel™ dressing was easier to remove from the skin graft sites, required less soaking than the Jelonet™ dressing and offered advantages over the conventional paraffin gauze dressing in reducing patient comfort during dressing changes.
Gotschall et al. (1998) compared the use of Mepitel™ and silver sulfadiazine in a randomized trial of 63 children with partial-thickness scalds. They felt that Mepitel™ was a significant advance in the treatment of children with partial-thickness scald wounds as those wounds treated with Mepitel™ healed significantly faster than the control group i.e. those treated with silver sulfadiazine, showed less eschar formation, and experienced less pain at dressing change.
Taylor (1999) describes the case study of a lady with mycosis fungoides, a rare, cutaneous form of T-cell lymphoma, whereby the cutaneous lesions are often extensive and frequently infected with herpes simplex viruses. The main problem for this lady was severe wound pain at all times, and had found it difficult to tolerate any dressings. Mepitel™ was used and the patients’ pain was greatly reduced, allowing her to be discharged home and enjoy an improved quality of life before her subsequent death. Another case study that illustrates the use of Mepitel™ in reducing pain and improving a patient’s quality of life is that described by Gates (2000) of a lady with a painful arterial leg ulcer. Her pain was significantly reduced, maceration of the surrounding skin was resolved and re-epithelialisation had taken place. A full cost analysis of the care of this patient showed that labour costs had reduced by two-thirds and dressing costs by one-third.
Conclusion
Low/non-adherent dressings are of value in granulating and epithelialising wounds as a primary wound contact layer. It can hopefully be seen that low/non-adherent dressings come in many different guises and that only a few are truly non-adherent. The issue of adherence and pain at dressing change is a very important nursing matter, as it can cause great distress for the patient and nurse. Hollinworth (1995) identified that although a dressing change may seem minor by clinicians, the patients may find the experience traumatic, both physically and psychologically. Hollinworth and Collier (2000) have also found from their survey of specialist nurses (n = 373), that the need to prevent trauma to the wound and to avoid causing the patient pain, are nurses’ main considerations during dressing changes. Eighty-one per cent of the nurses surveyed noticed that patients experienced pain on removal of dressing products, but sadly the survey also highlighted the fact that there was confusion about the properties and availability of many dressing products, perhaps meaning that inappropriate dressings have been applied at times. From a nursing perspective it is paramount to assess the patient and their wound and apply an appropriate wound dressing that will provide the optimum wound healing environment.
References
Gates, A. (2000) ‘The use of a non-adherent silicone dressing in arterial leg ulceration’ Journal of Wound Care 9; 2: 79–81.
Gotschall, C.S., Morrison, M.I.S., Eichelberger, M.R. (1998) ‘Prospective, randomized study of the efficacy of Mepitel™ on children with partial-thickness scalds’, Journal of Burn Care & Rehabilitation. 19: 279–283.
Hollinworth, H. (1995) ‘Nurses’ assessment and management of pain at wound dressing changes’, Journal of Wound Care 4; 2: 77–83.
Hollinworth, H., Collier, M. (2000) ‘Nurses’ views about pain and trauma at dressing changes: results of a national survey’, Journal of Wound Care, 9; 8: 369–373.
Lawrence, J. (1993) ‘Medicated tulle dressings’, Journal of Wound Care, 2; 4: 240–243.
Morgan, D. (2000) ‘Formulary of Wound Management Products’. 8th Ed. Haslemere. Euromed Communications Ltd.
Platt, A.J., Phipps, A., Judkins, K. (1996) ‘A comparative study of silicone net dressing and paraffin gauze dressing in skin-grafted sites’, Burns, 22; 7: 543–545.
Taylor, R. (1999) ‘Use of a silicone net dressing in severe mycosis fungoides’, Journal of Wound Care, 8; 9: 429–430.
Terrill, P.J., Varughese, G. (2000) ‘A comparison of three primary non-adherent dressings applied to hand surgery wounds’, Journal of Wound Care, 9; 8: 359–363.
Thomas, S. (1990) ‘Primary wound contact materials’, In: Wound Management and Dressings. London. The Pharmaceutical Press.
Thomas, S. (1994) ‘Low-adherence dressings’, Journal of Wound Care, 3; 1: 27–30.
Williams, C. (1995) ‘Mepitel’, British Journal of Nursing, 4; 1: 51–52, 54–55.