What is the ideal wound product?

The previously accepted wisdom was that a wound healed best when it was kept as dry as possible. In 1962, George Winter, a British-born physician, published his ground-breaking wound care research. His paper, (Nature 193:293. 1962), entitled, “Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig,” demonstrated that wounds kept moist healed faster than those exposed to the air or covered with a traditional dressing and kept dry. Dr. Winter’s work began the development of modern wound dressings which are used to promote moist wound healing.

Natural skin is considered the ideal wound dressing, and therefore wound dressings have been designed to try to reproduce the advantages of natural skin. Today, experts feel that a wound dressing should have several characteristics if it is to serve its purpose. A wound dressing should:

  • Provide the optimal moisture needs for the particular wound
  • Have the capacity to provide thermal insulation, gaseous exchange, and to help drainage and debris removal, which promotes tissue reconstruction
  • Be biocompatible without causing any allergic or immune response reaction
  • Protect the wound from secondary infections
  • Be easily removable without causing any trauma to the delicate healing tissues.

There are hundreds of dressings to choose from, but they all fall into one of a few categories. The healthcare provider will select a dressing by category, according to availability and familiarity of using that particular dressing.

Occlusive dressings are those which are air- and water-tight. An occlusive dressing is frequently made with some kind of waxy coating to ensure a totally water-tight bandage. It may also consist of a thin sheet of plastic affixed to the skin with tape. An occlusive dressing retains moisture, heat, body fluids and medication in the wound. There are several types of occlusive dressings, which are discussed below.

It should be remembered that proper wound care, especially of a chronic wound, is a complex process, as much art as science; a trained healthcare provider assesses the wound as it goes through various stages, and applies the appropriate wound dressings as the need arises. Unfortunately, the most appropriate dressing is not always used, due perhaps to confusion around which type of dressing to apply, or because certain dressings—especially advanced dressings—either may not be available in the facility, or may not be reimbursed by the country’s healthcare system, or may simply be too expensive. This remains true even in some of the developed countries.

The following table summarizes potential applications for various types of wound care products, with selected examples. This summary is meant as a guideline and an illustration of the fact that different dressing types may find use in various types of wounds. In addition, as a wound heals, it may need a different type of dressing. Here again the wound care professional’s judgment and training come into play.

Dressing categoryProduct examplesDescriptionPotential applications
FilmHydrofilm, Release, Tegaderm, BioclusiveComes as adhesive, thin transparent polyurethane film, and as a dressing with a low adherent pad attached to the film.Clean, dry wounds, minimal exudate; also used to cover and secure underlying absorptive dressing, and on hard-to-bandage locations, such as heel.
FoamPermaFoam, PolyMem, BiatainPolyurethane foam dressing available in sheets or in cavity filling shapes. Some foam dressing have a semipermeable, waterproof layer as the outer layer of the dressingFacilitates a moist wound environment for healing. Used to clean granulating wounds which have minimal exudate.
HydrogelHydrosorb Gel Sheet, Purilon, Aquasorb, DuoDerm, Intrasite Gel, Granugel,Colloids which consist of polymers that expand in water. Available in gels, sheets, hydrogel-impregnated dressings.Provides moist wound environment for cell migration, reduces pain, helps to rehydrate eschar. Used on dry, sloughy or necrotic wounds.
HydrocolloidCombiDERM, Hydrocoll, Comfeel, DuoDerm CGF Extra Thin, Granuflex, TegasorbÕ Nu-DermMade of hydroactive or hydrophilic particles attached to a hydrophobic polymer. The hydrophilic particles absorb moisture from the wound, convert it to a gel at the interface with the wound. Conforms to wound surface; waterproof and bacteria proof.Gel formation at wound interface provides moist wound environment. Dry necrotic wounds, or for wounds with minimal exudate. Also used for granulating wounds.
AlginateAlgiSite, Sorbalgon Curasorb, Kaltogel, Kaltostat, SeaSorb, TegagelA natural polysaccharide derived from seaweed; available in a range of sizes, as well as in ribbons and ropes.Because highly absorbent, used for wounds with copious exudate. Can be used in rope form for packing exudative wound cavities or sinus tracts.
AntimicrobialBiatain Ag, Atrauman Ag, MediHoneyBoth silver and honey are used as antimicrobial elements in dressings.Silver: Requires wound to be moderately exudative to activate the silver, in order to be effective
NPWDSNaP, V.A.C. Ulta, PICO, Renasys (not in USA), Prospera PRO series, Invia LibertyComputerized vacuum device applies continuous or intermittent negative or sub-atmospheric pressure to the wound surface. NPWT accelerates wound healing, reduces time to wound closure. Comes in both stationary and portable versions.May be used for traumatic acute wound, open amputations, open abdomen, etc. Seems to increase burn wound perfusion. Also used in management of DFUs. Contraindicated for arterial insufficiency ulcers. Not to be used if necrotic tissue is present in over 30% of the wound.
Bioengineered Skin and Skin SubstitutesAlloDerm, AlloMax, FlexHD, DermACELL, DermaMatrix, DermaPure, Graftjacket Regenerative Tissue Matrix, PriMatrix, SurgiMend PRS, Strattice Reconstructive Tissue Matrix, Permacol, EpiFix, OASIS Wound Matrix, Apligraf, Dermagraft, Integra Dermal Regeneration Template, TransCyteBio-engineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic), xenographic, synthetic materials, or a composite of these materials.Burns, trauma wounds, DFUs, VLUs, pressure ulcers, postsurgical breast reconstruction, bullous diseases

Source: MedMarket Diligence, LLC; Report #S251.

Wound prevalence and wound management

(Update, March 2013:  MedMarket Diligence has published its 2013 report #S249 on the Worldwide Wound Management Market.)

Wound management encompasses a wide range of products: fabric dressings, first aid dressings, dressings and internal wound management products for surgery, advanced wound management products, active pharmaceutical wound care products, tissue engineering, physical therapies for wound care, and pressure relief products and skin treatments, for preventative wound management.

Following is an excerpt on wound prevalence from the 2007 MedMarket Diligence report #S245, “Worldwide Wound Management, 2007-2016: Established and Emerging Products, Technologies and Markets in the U.S., Europe, Japan and Rest of World.”  See also the related report #S175 on “Worldwide Surgical Sealants, Glues and Wound Closure, 2009-2013.”


Wound prevalence

Surgical Wounds

Surgical wounds account for the vast majority of skin injuries. We estimate that there are over 100 million surgical incisions a year, which require some wound management treatment. Approximately 80% of these wounds use some form of closure product (sutures, staples, and tapes). Many employ hemostasis products, and use fabric bandages and surgical dressings.

Surgical wounds are projected to increase in number at an annual rate of 3.1%, but overall the severity and size of surgical wounds will continue to decrease over the next ten years as a result of the continuing trend toward minimally invasive surgery.

Surgical procedures generate a preponderance of acute wounds with uneventful healing and a lower number of chronic wounds, such as those generated by wound dehiscence or post-operative infection. Surgical wounds are most often closed by primary intention, using products such as sutures, staples, or glues, where the two sides across the incision line are brought close and mechanically held together. Surgical wounds that involve substantial tissue loss or may be infected are allowed to heal by secondary intention where the wound is left open under dressings and allowed to fill by granulation and close by epithelialization. Some surgical wounds may be closed through delayed primary intention where they are left open until such time as it is felt it is safe to suture or glue the wound closed.

A significant feature of all wounds is the likelihood of pathological infection occurring. Surgical wounds are no exception, and average levels of infection of surgical wounds are 7 to 10 percent dependent on the procedure. These infections can be prevented by appropriate cleanliness, surgical discipline and skill, wound care therapy, and antibiotic prophylaxis. Infections usually lead to more extensive wound care time, the use of more expensive products and drugs, significantly increased therapist time, and increased morbidity and rehabilitation time. A large number of wounds will also be sutured to accelerate closure, and a proportion of these will undergo dehiscence and require aftercare for healing to occur.

Traumatic Wounds

There are estimated to be 1.5 million cases of traumatic wounding every year. These wounds required cleansing and treatment with low adherent dressings to cover them, prevent infection, and allow healing by primary intention. Lacerations are a specific type of trauma wound that are generally more minor in nature and require cleansing and dressing for a shorter period of healing. Lacerations occur frequently (approximately 19 million cases a year) as a result of cuts and grazes and can usually be treated within the doctor’s surgery and outpatient medical center and hospital accident and emergency department.

Burns

Burn wounds can be divided into minor burns, medically treated, and hospitalized cases. Out-patient burn wounds are often treated at home, at the doctor’s surgery, or at outpatient clinics. As a result a large number of these wounds never enter the formal health service system. We estimate that approximately 3.3 million burns in this category do enter the outpatient health service system and receive some level of medical attention. These burns use hydrogels and advanced wound care products, and may even be treated with consumer based products for wound healing. Medically treated burn wounds usually get more informed care to remove heat from the tissue, maintain hydration, and prevent infection. Advanced wound care products are used on these wounds. Approximately 6.3 million burns like this are treated medically every year. Hospitalized burn wounds are rarer and require more advanced and expensive care. These victims require significant care, nutrition, debridement, tissue grafting and often tissue engineering where available. They also require significant aftercare and rehabilitation to mobilize new tissue, and physiotherapy to address changes in physiology.

Chronic Wounds
Chronic wounds generally take longer to heal and care is enormously variable, as is the time to healing. There are approximately 7.4 million pressure ulcers in the world that require treatment every year. Many chronic wounds around the world are treated sub-optimally with general wound care products designed to cover and absorb some exudate. The optimal treatment for these wounds is to receive advanced wound management products and appropriate care to address the underlying defect that has caused the chronic wound; in the case of pressure ulcers the causal effect is pressure and a number of advanced devices exist to reduce pressure for patients. There are approximately 11 million venous ulcers, and 11.3 million diabetic ulcers in the world requiring treatment. Chronic wounds are growing in incidence due to the growing age of the population, and due mostly to awareness and improved diagnosis. At present these factors are contributing to growth of this pool of patients faster than the new technologies are reducing the incidence of wounds by healing them.

Wound management products are also used for a number of other conditions including amputations, carcinomas, melanomas, and other complicated skin cancers, which are all on the increase.

Worldwide Wound Prevalence by Etiology, 2007

wound-prevalence

Source:  MedMarket Diligence report #S245.


See the 2013 Worldwide Wound Management Market report #S249.


Wound care technology balance is shifting

The global market for wound management includes many products that fall into more than one category. For simplicity sake, however, product-based revenues can be assembled into categories including fabric dressings, first aid dressings, dressings and internal wound management products for surgery, advanced wound management products, active pharmaceutical wound care products, tissue engineering, physical therapies for wound care, and pressure relief products and skin treatments, for preventative wound management.

The total wound management market worldwide yields revenues in the range $13-14 billion. The aggregate market is forecast to grow at a modest annual rate through 2016. While some well established wound care product segments will grow at barely more than inflationary rates, the aggregate market growth will be driven predominantly through exceptional growth in advanced wound management (roughly $5 billion in 2005) and in active therapy areas (roughly only $900 million in 2005).

The charts below illustrate the size and evolution of the Advanced Wound Care market from 2007 to 2016.

Advanced Wound Care Market, by Segment, 2007 & 2016

 Source:  See Report #S245, "Worldwide Wound Management, 2007-2016."

Wound Management Product Growth, Up and Down, to 2016

Excerpt from MedMarket Diligence report #S245, “Worldwide Wound Management, 2007-2016.” See link for more information. Available for purchase online.

Wound Management Market Growth by Segments, 2007-2016Technologies developed and in use for the management of acute and chronic wounds have diversified from traditional dressings, bandages and wound closure techniques to include an increasing number of diverse technologies ranging from tissue engineering, growth factors, physical therapies (e.g., negative pressure) and others. Traditional dressings and bandages have evolved to contain more active elements contributing to wound healing, with products including films, hydrocolloids, foams, alginates, hydrogels, non-adherents and antimicrobials. Wound closure is a specific area of intense development and market growth beyond traditional suturing and more recent stapling technologies and has seen proliferation and high market growth for surgical sealants, glues and hemostasis products.

The size of the worldwide wound management market is ultimately driven by the clinical need for advanced wound management products. That need is most clearly reflected in the prevalence of chronic wounds and burns. Current estimates put the total annual incidence of chronic wounds at almost 9 million worldwide, and there are 177 million cases of diabetes worldwide; 10-15% of diabetic patients will develop ulcers at some point. The market for products used in the management of venous stasis (as in chronic venous ulcers) is put at over $3 billion, while the decubitus ulcer (e.g., bedsores) market is in excess of $2 billion. Sales of products used to treat diabetic foot ulcers are estimated around $1.5 billion, and the market for burns dressings is approximately $60 million.

It should be noted that a large proportion of worldwide wound product sales are accounted for by traditional types of wound management products. An estimated two-thirds of the world’s physicians are not making routine use of advanced wound management products, with availability playing only a minor role in limiting their use. Conversely, while the U.S. healthcare market is characterized by an almost overindulgent attitude toward new technologies, U.S. physicians are much more conservative in their approach to advanced wound healing technologies than their European counterparts. For this reason, the European share of the advanced wound care market is significantly higher than the U.S. share.

Market Growth in Wound Management Product Segments
Until recently, the product categories with most growth potential were alginates and foams; both have substantial shares of the total market and both are set to increase their shares substantially between 2007 and 2016. Hydrocolloids had a considerable market share in 2007 but their star is in decline; it is anticipated that they will lose several percentage points in the market share table by 2016. (Segment growth in chart from MedMarket Diligence report #S245, “Worldwide Wound Management, 2007-2016,” publishing November 2007. See link for description, table of contents.)

The most significant market entrants are growth factors and, even more dramatically, physical therapies – specifically, negative pressure (also known as VAC therapy) devices. This market sector grew from a small base to gain $1.2 billion by 2007 and is set to capture an estimated 20% of the advanced woundcare market by 2016.

Films, antimicrobials and non-adherent dressings will maintain steady growth although their shares of a vigorously expanding market will decline.


Report #S245, “Worldwide Wound Management” is available for purchase online or via Google Checkout, below.