The Development of the Available Technology Dressing, an Evidence-Based, Sustainable Solution for Wound Management in Low-Resource Settings

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Today’s Wound Clinic or HMP Global, their employees, and affiliates.

This article has been adapted with permission from the May 2024 issue of Wounds.

At any given time, as many as one in five adults in rural areas of tropical developing countries are incapacitated by a wound.^1,2 When populations are otherwise equivalent, a tropical climate is associated with five times more bacterial-infected skin wounds than a temperate environment.³ In addition, poor nutrition, poor hygiene, and lack of knowledge frequently cause delayed healing of wounds in rural areas of developing countries.⁴ The most common cause of a chronic wound in the developing world is a poorly managed acute wound (eg, injuries, insect bites).^5,6

Health care professionals are scarce in rural areas of developing countries, and they rarely manage wounds.^7,8 When villager family or self-care (VSC) fails, traditional health practitioners (THPs) and village health workers (VHWs) provide wound management.^9–11 The few published research articles about wounds in this setting have found that outcomes are poor and costs are high; none of the three groups of lay healthcare providers are able to manage wounds effectively.^4–6,9,12

The Benskin Research Group has been working since 1999 to develop a safe, effective, affordable, available, and acceptable wound management method to teach lay health care providers in low-resource settings.¹³ This article summarizes these 20+ years of research, culminating with testing Available Technology Dressings (ATDs), a very specific sustainable moist dressing technique which can be taught to patients and lay health care providers.

A Closer Look at the Foundational Research

During five years of working in a remote clinic in northern Ghana, the authors found that local wound remedies were often ineffective, sometimes caused serious complications, and were surprisingly expensive.^2,14 In contrast, in this setting, polymeric membrane dressings (PMDs) provided results far superior to those of any of the many other donated advanced dressings, continuously cleansing wounds, balancing moisture, controlling inflammation, and supporting wound closure in virtually every wound situation.¹⁴ Over 100 case studies were documented in detail, many of which have been presented at educational conferences. However, it was apparent that lay health providers who live in remote and conflict areas are best served if they can be taught to meet wound goals using only dressing materials that can be readily obtained from the local market or natural environment.^4,13 The quest to find a solution for this formidable challenge had begun. 

An extensive 2013 review of the literature found only four improvised moist dressing solutions that could be sustainable in the tropical village setting, of which banana leaves  and thin plastic were the most promising.⁹ However, banana leaves carry such a high bioburden that they must be autoclaved, which can be done in a hospital setting, but is untenable in the environments of our target populations.^15,16 The initial studies of thin plastic improvised dressings were conducted in a temperate climate (Japan), where perforated plastic food wrap (PW) proved to be safe and effective for even the most challenging pressure injuries.^17–21 A research team in India substituted plastic surgical drapes for PW on split thickness skin grafts, finding thin plastic superior to banana leaves.²² PW and surgical drapes are not available in most rural markets. However, thin clear food-grade plastic bags are used to carry soup, water, rice, and other prepared foods to the fields. Such bags, which are semi-permeable membranes, are ubiquitous in rural markets throughout the tropics.^23–25

Usual practice data, which is essential for designing a comparison study, was completely absent from the published literature.⁹ The “Story Completion” survey method was developed to address four identified cultural barriers to obtaining accurate descriptions of usual topical wound management practice, which were evaluated using standard quantitative statistical tools.^4,9 The initial survey took place in 25 villages across all four ecosystems of Ghana, West Africa in 2012.^4,26 A VHW, THP, and VSC from each of these villages completed the story for each of the seven cases, yielding 525 response narratives.^4,26,27 The study was replicated less formally later in East Africa and Southeast Asia with similar results, confirming that the essence of the usual practice data found in the initial study is likely to be broadly representative.²⁶ Almost all of the study participants stated that although they have confidence in managing many other health conditions, they felt that their wound management was inadequate.⁴

By far the most common method of debridement for all seven wound types was autolytic, described by study participants as applying occlusive dressings, crushed leaves, or moist herbal poultices in an attempt to keep the wound moist.⁴ However, these interventions could not consistently retain moisture overnight.^4,26 The few participants who mentioned papaya usually volunteered that it must be carefully monitored, making it unsuitable for outpatients who may not reliably return for follow-up.⁴

None of the participants mentioned using honey, which is unsurprising because the quality is often inferior in tropical environments.²⁸ Maggots were universally described as harmful.⁴ This is consistent with the authors’ experience: Patients whose wounds had attracted maggots inadvertently invariably complained of excruciating pain. Although Phaenicia (Lucilia) sericata (medical maggots) feed exclusively on necrotic tissue, virtually all other species of flies are non-selective, and many are invasive.^29–33

Summary of findings from foundational research: A wound dressing solution to meet the needs of lay health care providers in tropical developing countries should reliably keep wounds moist, promoting healing and keeping wounds clean via autolytic debridement. Thin food-grade plastic showed promise as a primary dressing. A study was needed to ensure that the proposed improvised wound dressing technique, using only materials that are widely available, was safe, effective, affordable, and culturally acceptable to patients and providers. The study site needed to have sufficient numbers of patients with fairly homogeneous wounds, and they needed to live in a true tropical (not climate-controlled) setting to ensure ecological validity.³⁴ The study team needed to be dedicated to following a rigorous study protocol exactly.

The Available Technology Dressing (ATD) Randomized Controlled Trial

Knowledge of the basic science of wound healing guided the development of an improvised wound dressing for resource-limited settings in the tropics. The FW dressings used in Japan were modified significantly to accommodate the special needs of patients in a much warmer environment with fewer resources.^19,20,35 A Wound Healing Foundation small grant helped fund a three-armed, 12-week, evaluator-blinded, non-inferiority RCT.36 The study, conducted at the University Hospital of the West Indies in 2021, was registered on ClinicalTrials.gov prior to the first patient visit.³⁵ Sickle cell leg ulcers (SCLUs) were chosen for their relative homogeneity, relative abundance in Jamaica, and the critical need for a more effective wound dressing solution for these patients.^37–40 The added challenge of ischemia helps explain why SCLUs heal 3 to 16 times more slowly than VLUs.^39,41,42 SCLUs tend to be recurrent, and are often so painful that opioids are insufficient.^39–42

Technology is the application of scientific knowledge for practical purposes.^43,44 The improvised dressing was named the Available Technology Dressing (ATD) technique because the study participants demonstrated that accurate implementation is not intuitive to untrained wound patients, and it is critical to its success; careful teaching and demonstration/return demonstration is required.^35,45

The ATD technique consists of: (1) thorough wound irrigation with strong squeeze on a homemade device (a ~500mL soda bottle with a hole from a hot bicycle spoke in the cap) filled with homemade saline; (2) drying the periwound, then protecting it with a non-toxic moisture barrier (eg, zinc oxide paste); (3) a cut-to-fit piece of food-grade clear plastic bag (a clean semipermeable membrane), with slits to allow excess fluid to escape, gently conformed to the wound bed and the moisture barrier; (4) fluffed clean absorbent material placed over the slits to absorb the excess fluid; (5) all of this held in place (and, when tolerated, compression applied) with a snug wrap.^9,35 Daily, the ATD was removed, the wounds were irrigated thoroughly, the periwound was dried, and a new ATD was applied.^35,45–47 Exact dressing components can vary based upon availability.

Comparator dressings: Because other wound management methods have not led to superior outcomes, standard of care for SCLUs world-wide is wet-to-dry gauze or dry gauze over an ointment.^41,48 However, these dry and adhere to the wound-bed, which is not congruent with the goals of lay health practitioners in village settings or modern wound theory.^4,49 Therefore, the researchers chose saline-soaked (wet-to-moist) gauze, or WTM, for the usual practice (negative control) arm of the study, fluffing the gauze to help keep it moist.⁴ The wound was irrigated well daily, at dressing changes.

The Sickle Cell Unit in Mona, Jamaica had trialed many advanced dressings, including honey, Unna boots, FW (used circumferentially, as in Japan), and hydrocolloid dressings, which all failed to produce superior results and/or were not accepted by patients, in part due to the warm climate.³⁵ However, comparing the ATD only to WTM dressings would assure the impending obsolescence of the study results, because saline-soaked gauze is widely regarded as inferior to advanced dressings.^50–53

The only advanced wound dressing type with a strong record of success in the tropics is polymeric membrane dressings, or PMDs (PolyMem^®, Ferris Mfg. Corp., Ft Worth, TX, USA).14,54 PMDs do not melt, break apart, or adhere to wound-beds in a warm environment, and they are well tolerated in the tropical heat.^14,55,56 The continuous cleansing system that is an integral function of PMDs mitigates the problem of increased wound infections in the tropics.^14,55 PMDs also control inflammation and decrease pain, two key influencers of healing important for SCLUs.^14,54,57 When used on VLUs, even without compression, PMD use led to increased wound closure rates and decreased pain.^56,57 PMDs are among the very few advanced wound dressings mentioned favorably in the sickle cell scientific literature.^41,58 This made PMDs the logical choice for a positive control.^{14,55,59–63}

Study results: Due to the pandemic, the 40 study participants tended to be older, with large, long-standing SCLUs - all predictors of ulcers increasing, rather than decreasing, in size.^35,42 Statistical results were obtained and evaluated by three statisticians to ensure accuracy of interpretation of this small, heterogeneous data set. Participants in all three groups saw improvement in both ulcer closure and quality of life compared with their previous practice. Overall, the ATDs (13 participants) were clinically superior to WTMs (16 participants), and only modestly clinically inferior to PMDs (11 participants) with respect to decreased wound size and pain. ATDs proved to be safe: the only study complications were in the WTM group, with four (25%) patients developing Pseudomonas infections. These resolved quickly when irrigated with 0.5% vinegar, per the study protocol.³⁵

Although Wound Quality of Life and ASCQ-Me Pain scores improved most with PMDs, ASCQ-Me Pain scores improved more in participants using the ATDs than WTMs. Wounds decreased in size much more often with ATDs than with WTMs as well (92% vs 50%). PMDs were by far the least time consuming to use, but ATDs were far less expensive (daily ATD materials costs were half that of WTM costs). Participants in all three groups gave ATDs high marks for acceptability. WTMs, which are commonly used worldwide, were not superior to ATDs by any metric.

Conclusions

Rigorous surveys confirmed that moist wound management is preferred, even in a tropical environment. However, until now, cost and availability has made it difficult for lay health care providers to provide a moist wound environment. The ATD technique proved safe, effective, affordable, and acceptable on sickle cell leg ulcers in Jamaica, and their use dramatically improved pain scores when compared with WTMs. Although PMDs outperformed ATDs for both pain relief and healing, ATDs were not dramatically inferior, they are far less expensive, and they are far more available. Study participants were able to master the dressing technique quickly, and preferred the ATD technique over other choices. WTMs were inferior to ATDs in every respect. The ATD technique finally provides a sustainable evidence-based solution for wound management in remote and conflict areas of tropical developing countries, and it shows promise for use in other resource-limited environments as well. 

This study demonstrated that the proposed ATD concept is sound. All materials (the irrigation device, periwound protectant, primary dressing, absorbent, and wrap) should be chosen for their functional properties and be readily available (which implies affordability) in the setting of the learners. Because the technique must be rigorously followed for the dressing to provide optimal benefits while minimizing risk of complications, the reason for each aspect of the dressing technique must be taught. This will empower the learners with the basic scientific knowledge to know which aspects of each material and which aspects of each step in the technique are critical.

Acknowledgements

Given that this project spanned multiple continents and multiple decades, it is impossible to adequately acknowledge all those who contributed to this effort. However, the authors would like to generically thank the many supporters, interpreters, collaborators, study participants, and prayer warriors who made our work successful. Special thanks to Linda Benskin's employer, Ferris Mfg. Corp., for their generous donations of travel funds and dressings. 
 
Linda Benskin is the Research, Education, & Charity Liaison at Ferris Mfg. Corp., a participant in ISTAP, uPGrade, and the WHS Educational Committee, a prolific peer-reviewer, and a WOCN Fellow. She provides e-consulting to missionaries and patients with especially challenging wounds world-wide. 

References
1.         Gibbs S. Skin disease and socioeconomic conditions in rural Africa: Tanzania. Int J Dermatol. 1996;35(9):633-639.
2.         Mahe A, Hay RJ. Epidemiology and Management of Common Skin Diseases in Children in Developing Countries. World Health Organization; 2005. Accessed February 5, 2015.
3.         Taplin D, Lansdell L, Allen AM, Rodriguez R, Cortes A. Prevalence of streptococcal pyoderma in relation to climate and hygiene. Lancet. 1973;1(7802):501-503.
4.         Benskin L 1959. Discovering the Current Wound Management Practices of Rural Africans: A Pilot Study. Dissertation. University of Texas Medical Branch; 2013. Accessed December 29, 2020.
5.         Gupta N, Gupta SK, Shukla VK, Singh SP. An Indian community-based epidemiological study of wounds. J Wound Care. 2004;13(8):323-325. doi:10.12968/jowc.2004.13.8.26657
6.         Oluwatosin OM. Wound care practices and challenges in Nigeria. Adv Skin Wound Care. 2007;20(7):375-378. doi:10.1097/01.ASW.0000280208.98163.1b
7.         Ryan TJ. Public health dermatology: regeneration and repair of the skin in the developed transitional and developing world. Int J Dermatol. 2006;45(10):1233-1237. doi:10.1111/j.1365-4632.2006.02671.x
8.         Keast DH, ed. Wound and Lymphoedema Management - Focus on Resource-Limited Settings. 2nd ed. World Alliance for Wound and Lymphedema Care; 2020.
9.         Benskin LLL. A review of the literature informing affordable, available wound management choices for rural areas of tropical developing countries. Ostomy Wound Manage. 2013;59(10):20-41.
10.       Bender DE, Pitkin K. Bridging the gap: The village health worker as the cornerstone of the primary health care model. Social Sci Med. 1987;24(6):515-528. doi:10.1016/0277-9536(87)90341-8
11.       Benskin LLL. A Concept Development of the Village Health Worker. Nursing Forum. 2012;47(3):173-182. doi:10.1111/j.1744-6198.2012.00270.x
12.       Belcher DW, Afoakwa SN, Osei-Tutu E, Wurapa FK, Osei L. Endemic pyoderma in Ghana: a survey in rural villages. Trans R Soc Trop Med Hyg. 1977;71(3):204-209.
13.       Benskin L. Incorporating Wound Care in a Christian Village Health Worker Training Program. Poster #2 presented at: 8th Annual American Professional Wound Care Association; April 2, 2009; Philadelphia, PA USA.
14.       Benskin LL. Polymeric Membrane Dressings for Topical Wound Management of Patients With Infected Wounds in a Challenging Environment: A Protocol With 3 Case Examples. Ostomy Wound Manage. 2016;62(6):42-50.
15.       Guenova E, Hoetzenecker W, Kisuze G, et al. Banana Leaves As an Alternative Wound Dressing. Dermatologic Surgery. 2013;39(2):290-297. doi:10.1111/dsu.12067
16.       Hoetzenecker W, Guenova E, Moehrle M. Banana leaves: an alternative wound dressing material? Expert Rev Dermatol. 2013;8(5):439-440. doi:10.1586/17469872.2013.835925
17.       Toriyabe S, Saito H, Sakurai K. Use of a Food Wrap as a Dressing Material. Adv Skin Wound Care. 1999;12(8):405-406.
18.       Takahashi J, Yokota O, Fujisawa Y, et al. An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people. J Wound Care. 2006;15(10):449-450, 452-454. doi:10.12968/jowc.2006.15.10.26971
19.       Takahashi J, Nakae K, Miyagawa M, et al. Plastic wrap as a dressing material to treat stage III/IV pressure ulcers in the inflammatory phase: a randomized controlled trial. Int J Clin Exp Med. 2017;10(3):5586-5594.
20.       Bito S, Mizuhara A, Oonishi S, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open. 2012;2(1):e000371. doi:10.1136/bmjopen-2011-000371
21.       Takafumi K, Katsunori F, Yayoi N, et al. JSPU Guidelines for the Prevention and Management of Pressure Ulcers (4th Ed.) | Article Information | J-GLOBAL. 日本褥瘡学会誌. 2016;18(4):455-544.
22.       Gore MA, Umakumar K, Iyer SP. Polyethylene Surgical Drape Dressing for Split Thickness Skin Graft Donor Areas. In: Gore MA, ed. Skin Grafts. InTech; 2013. doi:10.5772/54195
23.       Plastic Bags, Straw and Polystyrene Ban. Jamaica Information Service. Accessed May 31, 2019.
24.       ruth. Jamaica’s Scandal Bag Ban Explained —. diG Jamaica. Published September 17, 2018. Accessed May 31, 2019. http://digjamaica.com/m/blog/jamaicas-scandal-bag-ban-explained/
25.       Parker L. Plastic bag bans are spreading. But are they truly effective? National Geographic. Published April 2019. Accessed May 31, 2019.
26.       Benskin LLL. The Quest for a Sustainable Wound Management Solution for Rural Areas of Tropical Developing Countries: What We Have Learned So Far. Poster #18 presented at: 29th Annual Nursing & Midwifery Research Conference and 30th Mary J. Seivwright Day; May 30, 2019; Kingston, Jamaica. doi:10.13140/RG.2.2.28503.14247
27.       Benskin LLL. A Unique “Story Completion” Research Method For Obtaining Accurate Survey Data. Poster #32 presented at: 29th Annual Nursing & Midwifery Research Conference and 30th Mary J. Seivwright Day; May 30, 2019; Kingston, Jamaica.
28.       Rosiak E, Madras-Majewska B, Teper D, Łepecka A, Zielińska D. Cluster Analysis Classification of Honey from Two Different Climatic Zones Based on Selected Physicochemical and of Microbiological Parameters. Molecules. 2021;26(8):2361. doi:10.3390/molecules26082361
29.       Sunny B, Sulthana L, James A, Sivakumar T. Maggot Infestation: Various Treatment Modalities. J Am Coll Clinical Wound Specialists. 2016;8(1-3):51. doi:10.1016/j.jccw.2018.03.002
30.       Whitaker IS, Twine C, Whitaker MJ, Welck M, Brown CS, Shandall A. Larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. Postgrad Med J. 2007;83(980):409-413. doi:10.1136/pgmj.2006.055905
31.       Patel BC, Ostwal S, Sanghavi PR, Joshi G, Singh R. Management of Malignant Wound Myiasis with Ivermectin, Albendazole, and Clindamycin (Triple Therapy) in Advanced Head-and-Neck Cancer Patients: A Prospective Observational Study. Ind J Palliative Care. 2018;24(4):459-464. doi:10.4103/IJPC.IJPC_112_18
32.       Blechman AB, Wilson BB, Norris R. Myiasis. Medscape Emergency Medicine. Published online February 8, 2019. Accessed November 29, 2023.
33.       Deluca G. Wound Myiasis Management: What Works, What Doesn’t. BROWN EMERGENCY MEDICINE. Published October 28, 2022. Accessed November 29, 2023.
34.       Gliner JA, Morgan GA, Leech NL. Research Methods in Applied Settings: An Integrated Approach to Design and Analysis, 2nd Ed. Routledge/Taylor & Francis Group; 2009:xvii, 469.
35.       Benskin L. A Test of the Safety, Effectiveness, and Acceptability of an Improvised Dressing for Sickle Cell Leg Ulcers in a Tropical Climate. clinicaltrials.gov; 2021. Accessed November 29, 2021.
36.       Grants | Wound Healing Foundation. Published 2023. Accessed December 2, 2023.
37.       Cumming V, King L, Fraser R, Serjeant G, Reid M. Venous incompetence, poverty and lactate dehydrogenase in Jamaica are important predictors of leg ulceration in sickle cell anaemia. Br J Haematol. 2008;142(1):119-125. doi:10.1111/j.1365-2141.2008.07115.x
38.       Serjeant GR. The Natural History of Sickle Cell Disease. Cold Spring Harb Perspect Med. 2013;3(10). doi:10.1101/cshperspect.a011783
39.       Singh AP, Minniti CP. Leg Ulceration in Sickle Cell Disease: An Early and Visible Sign of End‐Organ Disease. In: Inusa BPD, ed. Sickle Cell Disease - Pain and Common Chronic Complications. InTech; 2016. doi:10.5772/64234
40.       Serjeant GR, Serjeant BE, Mohan JS, Clare A. Leg Ulceration in Sickle Cell Disease: Medieval Medicine in a Modern World. Hematology/Oncology Clin N Am. 2005;19(5):943-956. doi:10.1016/j.hoc.2005.08.005
41.       Minniti CP, Eckman J, Sebastiani P, Steinberg MH, Ballas SK. Leg Ulcers in Sickle Cell Disease. Am J Hematol. 2010;85(10):831-833. doi:10.1002/ajh.21838
42.       Flattau A, Gordon H, Vinces G, Ennis WJ, Minniti CP. Use of a National Electronic Health Record Network to Describe Characteristics and Healing Patterns of Sickle Cell Ulcers. Adv Wound Care (New Rochelle). 2018;7(8):276-282. doi:10.1089/wound.2018.0788
43.       Britannica.com. Technology. Published October 16, 2023. Accessed December 1, 2023.
44.       CODATA, The Committee on Data for Science and Technology. Technology. CODATA, The Committee on Data for Science and Technology. Accessed December 1, 2023.
45.       Benskin L. Trial of an Improvised Dressing for Remote and Conflict Areas of Tropical Developing Countries. Presented at: Technology in Wound Care Conference: AAWC 2022; 2022; Salt Lake City, Utah USA. Accessed February 27, 2023.
46.       Benskin LL. Trial of an Available Technology Dressing for Resource Limited Settings. Poster #204 presented at: NCCHC Spring 2023; May 1, 2023; New Orleans, LA, USA.
47.       Venugopal R, Benskin L, Barton-Gooden A. Trial of an Available Technology Dressing for Resource Limited Settings. e-Poster presented at: Wild On Wounds 2023; September 14, 2023; Hollywood, FL, USA.
48.       Martí-Carvajal AJ, Knight-Madden JM, Martinez-Zapata MJ. Interventions for treating leg ulcers in people with sickle cell disease. Cochrane Database Syst Rev. 2021;2021(1):CD008394. doi:10.1002/14651858.CD008394.pub4
49.       Bolton LL. Common Nonsense: Rediscovering Moist Wound Healing. Wound Manage Prevention. Published 2012. Accessed May 26, 2019.
50.       Flint L. Invited commentary on “Modern wound care for the poor: a randomized clinical trial comparing the vacuum system with conventional saline-soaked gauze dressings” by Perez et al. Am J Surg. 2010;199(1):21. doi:10.1016/j.amjsurg.2009.01.030
51.       Jones AM, San Miguel L. Are modern wound dressings a clinical and cost-effective alternative to the use of gauze? J Wound Care. 2006;15(2):65-69. doi:10.12968/jowc.2006.15.2.26886
52.       Sadati L, Froozesh R, Beyrami A, et al. A Comparison of Three Dressing Methods for Pilonidal Sinus Surgery Wound Healing. Adv Skin Wound Care. 2019;32(7):1-5. doi:10.1097/01.ASW.0000558268.59745.d2
53.       Yastrub DJ. Relationship between type of treatment and degree of wound healing among institutionalized geriatric patients with stage II pressure ulcers. Care Manag J. 2004;5(4):213-218.
54.       Benskin LL. Evidence for Polymeric Membrane Dressings as a Unique Dressing Subcategory, Using Pressure Ulcers as an Example. Adv Wound Care (New Rochelle). 2018;7(12):419-426. doi:10.1089/wound.2018.0822
55.       Feliciano I, Castillo R. Blast Injuries Successfully Managed with PolyMeric Membrane Dressing*. Poster presented at: Philippine Wound Care Society (PWCS); October 22, 2014; Manila, Philippines.
56.       Benskin L. Deep Ulceration Treated with Polymeric Membrane Dressings Until Complete Wound Closure. Poster #0727 presented at: 3rd Congress of the World Union of Wound Healing Societies; June 4, 2008; Toronto, Ontario Canada.
57.       Agathangelou C. How We Resolved the Problem of Poor Compliance with 20 Chronic Ulcers Patients by Using PolyMeric Membrane Dressings. Poster presented at: European Wound Management Association (EWMA); May 15, 2013; Copenhagen, Denmark.
58.       Campton-Johnston S, Wilson J, Ramundo JM. Treatment of painful lower extremity ulcers in a patient with sickle cell disease. J Wound Ostomy Continence Nurs. 1999;26(2):98-104.
59.       Benskin L. Excellent healing of pediatric wounds using polymeric membrane dressings... 41st Annual Wound, Ostomy and Continence Nurses Annual Conference, St. Louis, Missouri, June 6-10, 2009. J Wound Ostomy Continence Nursing. 2009;36(3S):S14-S14.
60.       Benskin LL. Dissecting Hand Abcess Wound Treated with Polymeric Membrane Dressings* Until Complete Wound Closure. Poster #31 presented at: 19th Annual Symposium on Advanced Wound Care (SAWC); May 30, 2006; San Antonio, TX.
61.       Benskin L. Diabetic foot salvaged, wounds closed in only two months using polymeric membrane cavity filler* and polymeric membrane dressings. Poster presented at: 39th annual meeting of the Wound Ostomy Continence Nurses Society (WOCN); June 10, 2007; Salt Lake City, UT.
62.       Benskin L. Extensive tunneling lower leg wounds with exposed tendons closed quickly using various polymeric membrane dressing configurations. Poster #41 presented at: 23rd Annual Clinical Symposium on Advances in Skin & Wound Care; October 26, 2008; Las Vegas, NV USA.
63.       Benskin LL. Spreading the Revolutionary Message of Modern Wound Management Principles: Facilitating Change Among Surgeons. Poster # CS16-031 presented at: WOCN Society & CAET Joint Conference; June 4, 2016; Montreal, Canada.