By the WoundSource Editors

Wound chronicity is a major concern, and removing barriers with each stage of healing is paramount. Debridement may occur naturally by the body’s own ability to slough off dead tissue; however, often this tissue needs to be removed medically. The goal of wound debridement is to provide consistent wound bed preparation along with good healing outcomes. Removing non-viable tissue and foreign material is the first goal of debridement. Non-viable tissue not only inhibits the development of healthy new tissue but also increases the risk of infection. Non-viable tissue includes slough and eschar, which create the perfect recipe for bacterial growth and infection. Viable tissue is granulation and epithelial tissue, which is beneficial to normal healing. Wounds that present devitalized tissue and/or biofilm warrant one or more of the debridement methods to promote healing. Since 2006, debridement has been found to be advantageous in managing complex wounds.¹

Combination Debridement Methods: Sharp and Enzymatic

Sharp debridement is normally performed weekly. This procedure immediately stimulates platelets, and they begin to occupy the wound space. This is called the inflammatory process, and it begins transforming a chronic wound into an acute wound. During the first 48 hours, healing is managed by platelet-derived growth factors (PDGFs) and modifying growth factors. Circulating monocytes later become tissue macrophages and then supply multiple growth factors for healing.³ Aggressive debridement transforms chronic wounds into acute wounds toward healing.⁴

Enzymatic debridement is usually used either by itself or in combination with another method, such as sharp debridement, to removed devitalized tissue and enhance healing.⁵ Enzymatic ointment can serve as maintenance while removing macroscopic and microscopic devitalized tissue from the wound bed surface. Once granulation tissue is established, the enzymatic debriding agent can be discontinued, but it is safe to use until wound closure.⁶ This ointment is ideal for patients receiving anticoagulant therapy for whom surgical debridement is not feasible. The ointment is sterile and contains 250 collagenase units per gram of white petrolatum USP. This enzyme is derived from fermentation by Clostridium histolyticum. Enzymatic debridement is suggested to be applied nickel thick, and use is daily unless the ointment is used in an area where the dressing may become soiled by incontinence. If the wound is covered by eschar, it is advised to use the cross-hatching technique to assist the enzymatic ointment in penetrating beneath the necrotic tissue layer.^6,7

Other Debridement Considerations

• Epibole can be a common problem in full-thickness wounds. Wounds normally fill in from the bottom up while the wound edges pull together as epithelial cells migrate across the wound surface from all sides and meet in the middle. When the epidermal cells move sideways instead of across the wound, the edges are then rolled or curled under, this condition is considered epibole. Epibole-type wound edges can be treated several ways, to jump start the healing process.
• Silver nitrate application to the wound edges
• Sharp debridement of wound edges
• Mechanical debridement, by abrading with a gauze dressing to the edges

• The silver nitrate stick is considered an antimicrobial and is used in enhancing anti-inflammatory healing. A silver nitrate stick uses a chemical cautery agent made up of 75% silver nitrate and 25% potassium nitrate. When the tip of the applicator stick is moistened by wound fluid, a chemical reaction occurs: killing bacteria, removing necrotic tissue, reducing hypergranulation, reducing fibroblast proliferation, and coagulating tissue.
• Hypergranulation, known as “proud flesh,” is overgrown granulation tissue above the normal wound bed surface level. It is identified as red, friable, moist, and shiny tissue. A silver nitrate stick can be used to reduce hypergranulation by rolling the tip of the silver nitrite stick over the wound tissue. This application process will jump start the healing cascade over again as an acute wound.
• Patient education should be first and foremost to reduce anxiety, manage expectations, and promote good outcomes with the treatment plan. Discuss the procedure and any local or topical anesthetics being used for pain control during the debridement procedure. Anesthetic agents such as lidocaine (with and without epinephrine) injectables, topical gels, sprays, and ointments are available to control pain at the wound site for clinic or bedside debridement procedures. Independent providers may have their own preferences or may follow the health care facility protocol.

Conclusion

Utilize a combination of debridement methods to promote faster healing times when possible. Not all wounds are appropriate for debridement. Sharp debridement is the most aggressive method, whereas autolytic is less aggressive. The enzymatic method assists stalled wounds through the inflammatory phase. The patient’s health status, wound infection, wound size, wound exudate, and wound location should all be considered when deciding on the best plan of care to achieve treatment goals. Debridement and wound healing can occur together, so measures to expedite the healing process should always be engaged.

References
1. Anderson I. Debridement methods in wound care. Nurse Stand. 2006; 20(24):65–70.
2. Leaper D. Sharp technique for wound debridement. World Wide Wounds. 2002. http://www.worldwidewounds.com/2002/december/Leaper/Sharp-Debridement.h…. Accessed April 11, 2018.
3. Steed DL. Debridement. Am J Surg. 2004;187(5A Suppl):71S–4S.
4. Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K. Clinical approach to wounds: débridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg. 2006;117(7 Suppl):72S–109S.
5. Moore Z. The important role of debridement in wound bed preparation. Wounds Int. 2012;3(2):19–23. https://www.woundsinternational.com/resources/details/the-important-rol… Accessed April 11, 2018
6. Collagenase Santyl Ointment. Ongoing, daily debridement can help break the cycle of inflammation. Smith & Nephew. https://www.santyl.com/hcp/ongoing-daily-debridement. Accessed on April 3, 2019.
7. RxList. Santyl. Last reviewed on RxList: July 28, 2017. https://www.rxlist.com/santyl-drug.htm#description. Accessed on April 3, 2019.

Suggested Reading
Ayello EA, Cuddigan JE. Debridement: controlling the necrotic/cellular burden. Adv Skin Wound Care. 2004;17(2):66–75.
Kirshen C, Woo K, Ayello EA, Sibbald RG. Debridement: a vital component of wound bed preparation. Adv Skin Wound Care. 2006;19(9):506–17.
Moore Z. The important role of debridement in wound bed preparation. Wounds Int. 2012;3(2):19–23. https://www.woundsinternational.com/resources/details/the-important-rol…. Accessed April 11, 2018.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.