What are the key challenges of hard-to-heal wounds in community settings?
Dr Illes: Hard-to-heal wounds are wounds that don’t heal within four to six weeks. The patient might have a lot of oedema and exudates, along with significant amounts of bacteria that form biofilms.
Unfortunately, we have an ageing population, including many people with comorbidities such as diabetes. We also have patients who have been smoking for many years, leading to peripheral artery disease. So these hard-to-heal wounds are becoming increasingly prevalent.
The longer a wound takes to heal, the more likely it is that a patient will experience complications, including the risk of hospitalisation and amputation. If the patient has recurrent infections, that means using a lot of antibiotics, which leads to increasingly resistant bacteria.
Patients with hard-to-heal wounds experience an impaired quality of life. They may not have much social life, they may have chronic pain, they may not be able to work. So it’s a very human burden, but an economic burden too. And not all countries have the same resources to deal with this problem.
What is the standard of care for hard-to-heal wounds?
When you have a hard-to-heal wound, the first and most important step is the cleaning and debridement of the wound. The nurse can do this mechanically at home, using tools to remove the necrosis and the biofilm. But this can be very painful, and after 24 hours, the biofilm reappears, because the bacteria are so abundant.
If you have a lot of exudate, you have bacteria like Pseudomonas aeruginosa, which is naturally resistant to many antibiotics. It will form like a blanket with the biofilm and protect all the other bacteria (Staphylococcus aureus, Streptococcus spp.), which can lead to sepsis and soft tissue infections. That’s why it’s so important to debride the wound and diminish the exudate. With venous ulcers, you also need to do compression.
It’s a very bad idea to use topical antibiotics because they’re not effective against biofilm bacteria but they can increase the antibiotic resistance for them. And the systemic antibiotics will heal only the skin infection, but will not diminish the bacterial burden of the biofilm. So we must fight against all these problems in the standard of care.
Why is the standard of care sometimes insufficient?
The problem is, often the nurse comes by only once a day. Today, we don’t have enough outpatient nurses. We also have patients with a lot of comorbidities. Patients with diabetes can have necrosis or gangrene, and if you don’t take care of that quickly, it can lead to sepsis. So it’s important to take really good care of the wound, and also to care for the patient holistically in terms of nutrition, hygiene etcetera. In an ideal world, we would very quickly find the patients whose wounds hadn’t healed in four weeks and refer them to a wound specialist. At that point, it would be sensible to consider active treatment.
PICO single-use Negative Pressure Wound Therapy (sNPWT) is emerging as a promising new approach. Why so? What does this treatment involve?
Negative pressure wound therapy (NPWT) is a therapeutic technique to promote healing in wounds. It uses suction to remove exudate, which leads to rapid wound contraction and better control over the exudate. You can manage the local infection and the biofilm, as well as enhancing blood flow and oxygenation. That promotes tissue granulation.
NPWT has been around for years. However, traditional devices weren’t portable and could only be used in hospital or homebased settings, which isn’t great for the patient or the economy.
This is why PICO single use NPWT (sNPWT) is such a great tool. The PICO system includes a portable pump, which delivers a constant negative pressure of -80mmHg, along with a dressing-canister that can handle up to 300ml of fluid. You can leave the dressing on the wound for up to a week if it is used without filler. It’s lightweight, so it can be used within community care settings and the patient can go to work or school.
How effective is PICO sNPWT?
What does the clinical data show? In a 2022 clinical trial, involving more than 323 patients, 52% of the patients’ wounds were healed at 12 weeks when they used the sNPWT compared to standard care dressings. They also required 1.7 fewer dressing changes per week (from 4.7 to three).1
Another study from 2020 found a healing rate of 84.6% for wounds of less than three months in duration (n=13), along with a reduction in dressing frequency and cost savings compared to standard care dressings.2 An earlier intervention with the PICO system in stalled wounds improved the proportion of healed wounds compared to late/ delayed treatment with PICO.1,2
With PICO sNPWT, you don’t have the same pressure on the wound as in traditional NPWT. So the question was, is it as effective? A 2019 study compared the two directly. It has been demonstrated that PICO sNPWT offers greater reductions in wound depth, area and volume over a 12-week treatment period for leg ulcers compared to traditional NPWT (n=161).
Thanks to its unique AIRLOCK technology, PICO sNPWT delivers a consistent and optimal negative pressure beyond the zone of injury.4 It offers significantly more mature collagen suggesting more advanced tissue formation compared to tNPWT (in upper wound tissue, as demonstrated in vivo; p<0.001)5 and should be “considered the first choice over other types of NPWT when possible”.
I’ll also add that, as a testimony to its safety, efficacy and costeffectiveness, PICO sNPWT is the only sNPWT to be reimbursed for outpatients in France.
What are the advantages of PICO sNPWT from the patient’s perspective?
The system is attached using a gentle silicone adhesive, which is very comfortable for the patient. It helps to minimise trauma and pain during dressing removal.6 The dressing comes in 10 different sizes so you can adapt it to your wound. It’s a lightweight design and has demonstrated to reduce the total wound care costs through a reduced number of dressing changes in the community compared to standard dressings.
What kind of difference could sNPWT make to the burden of hard-to-heal wounds?
If we can use this active type of treatment in our community, we will have less persistence of chronic wounds. We might have fewer acute infections, leading to a potential decrease in antibiotic treatments, as well as lower morbidity.
What does the future hold for sNPWT?
I think that this is the future for wound healing, not only for chronic and hard-to-heal wounds, but also for acute and post-surgical wounds. We don’t have a lot of nurses, we don’t have a lot of doctors. The population is ageing, which means we’ll have more and more wounds. If we had a system that allowed us to change the dressing only once a week, it would give us the time to take care of a lot more patients. It’s not so costly, frankly. So I think it’s a great revolution, and personally, I would always choose to use this type of treatment.
