Caring for Minor Wounds

W. Steven Pray, PhD, DPh

Disclosures

US Pharmacist. 2006;31(4):16-23. 

When to Refer Wounds

The pharmacist should refer wounds to a physician in several instances, including the following:

  • Puncture wounds or animal bites.

  • Burns that are more severe than minor second degree.

  • Gaping wounds that may require stitches.

  • Wounds that have exposed fatty tissue, white tissue, or muscle.

  • Wounds with visible foreign material (dirt, plant material, glass, metal, or gravel).

  • Wounds with blood spurting from them.

  • Wounds causing severe pain or resulting in a numb feeling or inability to move structures below the wound.

  • New wounds in patients with diabetes or bleeding problems.

  • Chronic wounds that do not heal.

  • Infected wounds.[1,2,3,4,5]

Chronicity of Wounds

The pharmacist should ask about the duration of the wound. The FDA requires wound care antiseptics and antibiotics to be labeled with the warning that they should not be used beyond one week. Thus, a wound persisting longer than one week requires referral. This ensures that these products will be used only on minor wounds and not on those that are serious and chronic, such as pressure ulcers or wounds on the legs of a diabetic patient.

Moist Versus Dry Wound Healing

Recent medical wisdom states that a moist wound will heal more rapidly and favorably than one that is dry.[6] If the wound is allowed to fully dry during healing, cells on the leading edges may lose viability. Cells in lower tissues are left to heal the wound from the moist tissues on the bottom upward to dead tissues.[7] This is the reason for the proliferation of wound dressings that can keep the wound moist.

First Aid

One of the first matters to address with minor wounds is cleansing the wound.[3,8] Cleansing is important for incisions that are caused by sharp objects, such as knives or broken glass. However, it is even more critical in abrasion injuries, in which the skin's outer layers have been scraped away by abrasion against a rough object, such as when elbows and arms scrape against pavement during a skateboard fall. If the abrasion occurred on a surface that contains loose materials, the wound is likely to be contaminated with gravel, dirt, grass, and other foreign substances. Each foreign object remaining may serve as a source of infection and should be removed.

The wound can be washed with tap water under enough pressure to thoroughly cleanse the wound of foreign materials. Wound Wash Saline is a pressurized sterile 0.9% sodium chloride product that can accomplish this cleansing for minor wounds.

Antiseptics/Antibiotics

Application of an antiseptic/antibiotic can help prevent infection in a minor wound. (These products are not appropriate for an infected wound; self-treatment of any type of bacterial skin infection [e.g., boils, folliculitis, impetigo] is inappropriate and delays the patient from making a physician appointment.) The FDA requires the following labeling on these products: "Stop use and consult a doctor if the condition persists or gets worse. Do not use for longer than one week unless directed by a doctor."[9] Product labeling will also caution patients against use in the eyes or over large areas of the body. Safe and effective local antiseptics that are readily available include denatured ethyl alcohol 48% to 95%, isopropyl alcohol 50% to 91.3%, hydrogen peroxide 3% solution, tincture of iodine, povidone-iodine, and creams and ointments containing polymyxin and bacitracin (e.g., Polysporin). Products containing neomycin (e.g., Neosporin) should be avoided, as neomycin is a potential cause of allergic dermatitis.[10] Band-Aid Antiseptic Foam is a one-step product for cleaning and disinfecting; its antiseptic ingredient is 0.13% benzalkonium chloride. A note of caution is necessary for the ingredient triclosan. Its popularity is unparalleled among antimicrobial hand cleansers, but it can cause resistance in such organisms as Staphylococcus aureus.[11,12,13]

Local Anesthetics

Patients may request relief for the minor pain of scratches, scrapes, and minor burns. Some antibiotic ointments incorporate local anesthetics in neomycin-free formulas (e.g., Betadine Plus First Aid Antibiotics + Pain Reliever Ointment, with polymyxin, bacitracin, and pramoxine). Patients could also choose a polymyxin/bacitracin cream or ointment and use a separate local anesthetic product. An innovative method to prevent pain is the application of tissue adhesives. These "superadhesive" cyanoacrylate polymers have been used in surgical procedures since the late 1990s and are superior to sutures in closing wounds. A leading product is Band-Aid Liquid Bandage. The patient applies it to a minor laceration, abrasion, friction blister, hangnail, paper cut, or cracked finger using the activator provided. The product reduces the time of wound closure, provides instant hemostasis, and seals off damaged nerve endings, which reduces pain. The adhesive serves as a barrier to wound contamination during its five- to 10-day duration on the skin before it is shed along with the surface layer of skin cells.

Types of Wound Dressings

Nonadherent Dressings. An abrasion may have exudate issuing from it. If the patient applies most types of dressings directly over the area, exudate may become encrusted in the bandage. Subsequent removal can damage the healing wound. The pharmacist can recommend a nonadherent dressing over a minor wound with drainage. The nonadherent nature is achieved through impregnation with petrolatum or the use of a specially constructed rayon-polyethylene laminate. Such products as Adaptic Non-Adhering Dressing, Vaseline Gauze, Nexcare Non-Stick Pads, Release Non-Adhering Dressing, and Telfa Pads are easily removed when the dressing needs to be changed but do not absorb exudates from draining wounds.

Primary Dressings. Wounds can be covered with a primary dressing—a type of bandage with a small degree of absorbency for lightly draining wounds or those with no drainage. Their absorbency wicks drainage away from wounds to minimize the risk of exudate adherence. They also provide some protection for the wound and cover it for purposes of aesthetics. Primary dressings include the Kerlix Sponge, Sof-Wick Drain Sponge, Sof-Wick Dressing Sponge, Steri-Pad, and Topper Dressing Sponge. The set of products marketed under the Band-Aid trade name is a veritable cornucopia of primary dressings. A major advantage of Band-Aid products is that they are manufactured with the tape needed to secure them to the wound, while most other primary dressings require separate tape. Band-Aid products range from standard sizes (e.g., rectangular or round pads) to those with pads impregnated with polymyxin and bacitracin (Band-Aid Plus Antibiotic). Other products have waterproof seals to speed wound healing (Band-Aid Activ Flex).

Secondary Dressings. These dressings are advisable when a wound is producing moderate to heavy drainage. They are absorbent materials (e.g., gauze or cotton) and cannot be placed directly over a wound, since they will yield fibers that could hamper wound healing. However, when placed over a primary dressing, they provide added absorbency, increased compression, and enhanced protection from environmental contaminants.

Most minor wounds would not produce drainage heavy enough to require a secondary dressing; thus, secondary dressings are seldom necessary for accidental wounds for which self-care is appropriate. However, the trend to discharge surgical patients on the day of surgery, or very soon thereafter, has created a compelling need for them. The individual changing the postsurgical wound dressing may be a family member with no medical training or understanding of even the most basic principles of wound care. The pharmacist must stress the need to wash hands thoroughly before applying the dressing, to keep all dressings wrapped prior to application, and to not touch the side of any primary dressing that will face the wound before applying the secondary dressing.

Tapes

Dressings that do not have a self-contained adhesive will require tape to secure them to the skin. Patients should be advised against the use of old "adhesive" tapes, as they have a stiff backing that can damage skin during removal and are prone to be allergenic. Rather, the patient should choose any of several hypoallergenic tapes. These have light adhesives that are gentler on skin with repeated bouts of application and removal. An allergic reaction on broken skin may also retard healing.

Silver as an Antiseptic

Silver nitrate and other silver products, such as colloidal silver, have been traditionally used as antiseptics for many years. The FDA, in its sweeping review of nonprescription products, addressed the safety and efficacy of silver products for self-care in a final rule published in the Federal Register in 1999.[14] The agency stated that many products containing colloidal silver or silver salts were being marketed to treat numerous serious disease conditions, and the FDA was unaware of any evidence to support these therapeutic claims. It ruled that products containing silver would be subject to regulatory action after September 16, 1999. In addition, the agency explained that topical silver products cannot be marketed as dietary supplements under the Dietary Supplement Health and Education Act of 1994, since this law pertains only to orally ingested products. Yet, silver products continue to be marketed. Even now, in 2006, a Google search of the Internet using the term "colloidal silver" returns over two million hits, many directing the reader to sites still promoting unproven claims. Furthermore, a product known as Curad Silver Bandages is being promoted as an effective antibacterial for wound care. Until topical silver products are ruled to be safe and effective for wound care by the FDA, this product should not be recommended.

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