Hydrogel: An Overused Wound Care Modality?

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by Jeffrey Levine MD

While I’m on rounds with students I like to ask, "What is the active ingredient of hydrogel?" My query is usually met with puzzled looks. It's a trick question, because the term "active ingredient" generally applies to pharmacologic agents that undergo metabolic change in biologic systems. The active ingredient of hydrogel which gives this substance its name is water. Compounds are added to thicken the mixture and provide viscosity, such as glycerine. Other ingredients common in cosmetics, such as aloe vera, methyl paraben, hydrogenated castor oil, and propyl paraben, are added to hydrogel depending on the manufacturer.

An Overview of Hydrogel Dressings

Hydrogel is supplied in an amorphous form in tubes, impregnated into gauze, or in a gel-saturated fiber mesh. Because hydrogel is not a pharmaceutical as defined by the FDA, it does not require a physician prescription. Due to its classification, the FDA does not require controlled clinical trials that prove its efficacy, and there is no reliable research comparing it to other wound care modalities, or even its predecessor, moist gauze.

Hydrogel is a popular treatment for sacral and buttocks wounds which always has me puzzled, as these are areas prone to moisture-associated skin damage (MASD) and incontinence-associated dermatitis (IAD). Adding moisture to the perineal area not only increases the risk of IAD, but adds to the propensity to develop yeast and other infections. Moisture balance is an important component of wound bed preparation, but if a wound is too moist the skin becomes fragile and prone to bacterial colonization and infection.

When to Use Hydrogel

I understand the rationale for application of hydrogel, as it renders the wound bed moist which promotes epithelialization and other aspects of healing. It is also marketed to reduce wound pain and fill dead space. Despite the marketing claims, I often wonder if this modality is overused, particularly in areas that are already moisture-prone such as the perineum.

Hydrogel is often used on eschar with the intent of adding moisture, thereby making the eschar easier to remove. This could be a form of autolytic debridement, however eschar is essentially dead tissue. Hydrating this tissue can render it a desirable substrate for proliferation of pathogenic bacteria.

As with any wound care modality, topical treatment must be accompanied by frequent visual inspection and documentation of the wound as it evolves. Any sign of worsening such as pain, increased drainage, purulence, odor, slough, or systemic symptoms such as fever should result in re-evaluation of treatment in progress. Hydrogel certainly has its place in the wound care armamentarium, but we need to exercise caution when using it in moisture prone areas. The last thing we want is to worsen a wound by causing maceration or promoting infection.

About the Author

Dr. Jeffrey Levine is a board-certified internist and geriatrician with over thirty years of experience in wound care in hospitals, nursing homes, and home care environments. He is a voluntary attending physician at the Mount Sinai Medical Center in Manhattan, and Associate Professor of Geriatrics and Palliative Care at the Icahn School of Medicine at Mount Sinai. He received his fellowship training in geriatrics at the Mount Sinai Medical Center where he began his interest in chronic wounds. He is an elected board member of the National Pressure Ulcer Advisory Panel (NPUAP).

Dr. Levine’s interest in pressure ulcers began in the 1980s during his geriatric training when he noticed that many of his nursing home patients had pressure ulcers but there was little reliable information on treatment methods. This motivated him to study not just prevention and treatment of chronic wounds, but to delve into the rich history of wound care over the centuries. He has since published a number of articles on historical topics ranging from wound care in ancient Egypt through the 20th Century.

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.

Comments

Interested in your recent articles on Skin Failure. Have you made any headway in documentation considerations with coding ICD-10

Dr. Levine,

Thank you for writing this article. As a Nationally Board Certified Wound and Ostomy Nurse, I often see hydrogel misused or overused. I believe your article is a confirmation as to those in charge of wound care need to ensure they are trained on determining such decisions for this product. In my practice, I tend to use it on dry wounds (arterial) but always ensure that the periwound is first protected with a skin barrier and that the dressing is not oversaturated with the goal to avoid maceration to wound edges. You provided some great points to think about. Thank you for sharing!

Brenda Goss, BSN, RN, CWON
Certified Wound Ostomy Nurse
Masters in Nursing Administration/Education (Student)
University of Arkansas for Medical Sciences

I am probably an idiot, but I typically do not consider the possibility of disseminating pathogenic bacteria while using a hydrogel. The necrotic tissue itself always concerns me as a chronic source of infection that is not effectively reduced with systemic antibiotics. Also, I tend to use hydrogels that are silver impregnated, or have some other antimicrobial properties. Another point, I think the use of any enzymatic, autolytic, or sharp debridement can introduce bacteria into the blood or local surrounding tissue. Hydrogels come in many mixtures and will continue to be one of my first choices in treating wounds.

Saying that, I definitely agree with Dr.Levine regarding the avoidance of hydrogels on macerated wounds. Dr. Howard Lewis, my old attending use to say, "if is wet, dry it. If it is dry, moisten it". A wound too wet or too dry will not heal correctly. Wound beds need to moist.

I also agree with Dr. Levine that wounds require frequent educated "eyes on". The wound and wound bed can change from day to day. It takes a person trained in wound care to follow the various changes and adapt their wound care strategy accordingly. Thank you Dr. Levine!

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