Enzymatic wound debridement.
BACKGROUND
Clinical experience and existing research strongly support debridement as a necessary component of wound bed preparation when slough or eschar is present. Multiple techniques are available, but the indications for each technique and their efficacy are not clearly established. There is little evidence to guide the clinician in the selection of a safe, effective debridement method for the patient with a chronic wound.


OBJECTIVE
We sought to identify evidence related to the efficacy of enzymatic debriding agents collagenase and papain-urea in the removal of necrotic tissue from the wound bed and its impact on wound healing.


METHODS
A systematic review of electronic databases was undertaken using key words: (1) debridement, (2) enzymatic debridement, (3) collagenases, (4) papain, (5) urea, and (6) papain-urea. All prospective and retrospective studies that compared enzymatic debridement using collagenase or papain-urea (with and without chlorophyllin) on pressure ulcers, leg ulcers, or burn wounds were included in the review. All studies that met inclusion criteria and were published between January 1960 and February 2008 were included.


RESULTS
Collagenase ointment is more effective than placebo (inactivated ointment or petrolatum ointment) for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence suggests that a papain-urea-based ointment removes necrotic material from pressure ulcers more rapidly than collagenase ointment, but progress toward wound healing appears to be equivocal. Limited evidence suggests that treatment of partial-thickness burn wounds in children with collagenase ointment may require an equivocal time to treatment with surgical excision and that combination treatment may reduce the need for surgical excision. Insufficient evidence was found to determine whether collagenase ointment removes necrotic tissue from leg ulcers more or less rapidly than autolytic debridement enhanced by a polyacrylate dressing.


CONCLUSIONS
Enzymatic debriding agents are an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. They may be used to debride both adherent slough and eschar. Enzymatic agents may be used as the primary technique for debridement in certain cases, especially when alternative methods such as surgical or conservative sharp wound debridement (CSWD) are not feasible owing to bleeding disorders or other considerations. Many clinicians will select enzymes when CSWD is not an option. Clinical experience strongly suggests that combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent or enzymatic debridement along with serial CSWD, is effective for many patients with chronic, indolent, or nonhealing wounds.
Ramundo
Janet
J
Houston, Texas, USA.
Gray
Mikel
M
D000279:Administration, Cutaneous; D001329:Autolysis; D001458:Bandages / Q000145:classification / Q000600:supply & distribution; D002908:Chronic Disease; D015400:Clinical Nursing Research; D017364:Collagenases / Q000494:pharmacology / Q000627:therapeutic use*; D003646:Debridement / Q000379:methods* / Q000451:nursing; D019317:Evidence-Based Medicine; D006801:Humans; D009336:Necrosis; D010206:Papain / Q000494:pharmacology / Q000627:therapeutic use*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D012107:Research Design; D017592:Skin Care / Q000379:methods* / Q000451:nursing; D016896:Treatment Outcome; D014508:Urea / Q000494:pharmacology / Q000627:therapeutic use*; D014945:Wound Healing / Q000187:drug effects*; D014947:Wounds and Injuries / Q000209:etiology / Q000473:pathology / Q000628:therapy
D014508:Urea; D010206:Papain; D017364:Collagenases