Hydrocolloid Wound Dressing for Sealing Periwound With Poor Normal Skin: Negative Pressure Wound Therapy for Deep Limb Burns With Extensive Burns

Recently, negative pressure wound therapy (NPWT) has been used not only for chronic wounds and acute trauma but also for burns. NPWT is effective for wound bed preparation (WBP) with exposed limb bones and tendons, but sealing is challenging when the wound is accompanied by extensive burns because the periwound area is not in good condition.¹ Here, we report a simple sealing method using a hydrocolloid wound dressing in NPWT for extremities with extensive burns.  

Our dressing method. Karayahesive (ALCARE Co, Ltd) was used as the hydrocolloid wound dressing. The hydrocolloid wound dressing is wrapped around the proximal and distal aspects of a deep wound. Even if the normal skin is poor and there is a skin defect due to burns, the hydrocolloid wound dressing is applied over the skin defect. The width of the dressing is 5 cm for all sizes. For the length, a dressing that can wrap around the limb with an overlap of about 5 cm is selected. If necessary, it is cut or 2 sheets are connected and attached (Figure 1A). Foam is placed on the deep wound with exposed bones and tendons. According to the sandwich method using 2 film dressings,² the limbs are sandwiched from the front and back and sealed with the film dressing including the hydrocolloid (Figure 1B, C). A suction tube is attached and negative pressure is applied to the foam. The foam, film dressing, and connection port used are those of the VAC system (KCI) or RENASYS NPWT system (Smith & Nephew). The dressing is changed every few days as with normal NPWT, depending on the condition of the wound and the exudate.

Case. A 61-year-old woman was burned in a fire at her home. The burn sites were the lower limbs, the anterior chest and abdomen, the hands, and the face. The total body surface area affected was 42% (Figure 2A). Debridement was performed and artificial dermis were applied on post-injury day 4. Split-thickness skin grafting was performed on post-injury days 14 and 35, but exposure of the right patella and patellar tendon became apparent (Figure 2B).

NPWT using wall suction was performed between days 53 and 87 after the injury. The skin defects proximal and distal to the patella remained but were sealed with the hydrocolloid wound dressing. The foam used was black foam (VAC; KCI). The suction pressure was ‐20 kPa. Skin grafting was performed on post-injury day 88 because good granulation had formed on the bone (Figure 2C). The skin grafts were almost completely engrafted, and epithelialization was obtained promptly (Figure 2D).

NPWT is effective for WBP with exposed limb bones and tendons. Although the indication of NPWT for deep burns with exposed bones and tendons has been controversial, it is an effective option in situations where flap surgery is not possible or as a means of waiting until flap surgery.³ However, if the burn wound is around an exposed bone or tendon, it will be difficult to seal. Especially in the case of extensive burns, the lack of normal surrounding skin will increase the difficulty. As an effective method for preventing leaks, fixing a large number of staples in 2 rows at the dressing edge has been reported but with the disadvantages of pain incurred by the staples and the difficulty of frequent dressing replacement.¹

We performed sealing with a hydrocolloid wound dressing on limb burns. With this method, even if a burn wound surrounds an exposed tendon or bone, a dry part can be made by wrapping the hydrocolloid dressing around the entire circumference of the limbs, and a base for attaching the film dressing can be made. In addition to retaining the exudate, the hydrocolloid wound dressing prevents air leaks between the colloid and the skin by gelling and swelling (Figure 3). The frequency of dressing changes depends on the amount of exudate that the hydrocolloid wound dressing can hold, but in our case effective negative pressure was applied without air leaks for 3 to 4 days.

The hydrocolloid wound dressing can be used as a substitute if it is a long one that can wrap around the limbs. Products are manufactured, but they are not widespread and are difficult to obtain immediately. On the other hand, hydrocolloid wound dressing is widely used for covering suture wounds in general surgery and is easily available. Stoma paste has also been used, but it is difficult to handle and to wrap around the limbs. We used the sandwich methodto attach the film dressing.² The sandwich method is often used for digit or thumb NPWT, but it is also effective for limb NPWT because the procedure is simple and it is easy to find the leak.

In this case we used wall suction as the device to apply the suction. Previously, we reported a case of NPWT for an upper limb with extensive burns.⁴ Our dressing method was also used for the previous case, owing to the poor normal skin periwound. In previous cases, NPWT was used not only for WBP but also for skin graft fixation. Although effective negative pressure was applied by using either wall suction or a specific device, it is better to use a specific device to keep a constant pressure applied while the skin graft is fixed.

The appropriate pressure to use for NPWT of burn wounds is controversial. When using wall suction, we set a slightly higher pressure (-20 kPA ≈ -150 mm Hg) in consideration of the length of the tube and the negative pressure actually applied to the wound surface, but even with suction at 100 mm Hg, leakage did not occur.⁴ Although NPWT was not discontinued for reasons of excessive pain, it may be better to set a slightly lower pressure when treating fingers or toes.²

It is necessary to consider the indication of NPWT for deep burns in terms of the total treatment period and cost-effectiveness, but our method permits NPWT to be easily and effectively performed for deep limb burns with poor normal skin periwound.

The limitations of this report are that it only reported 1 case and was not compared with other cases. In addition, since it is important to consider the cost-effectiveness and treatment period for NPWT, this is an issue for future consideration.

By wrapping the hydrocolloid wound dressing all around the extremities, sealing was possible even when the normal skin was poor and there was a skin defect due to burns. Our method is considered to be an inexpensive, easy, and effective method when performing NPWT for deep extremity burns accompanied by extensive burns.

1. Kantak NA, Mistry R, Varon DE, Halvorson EG. Negative pressure wound therapy for burns. Clin Plast Surg. 2017;44(3):671-677. doi:10.1016/j.cps.2017.02.023
2. Niimi Y, Ito H, Sakurai H. Negative-pressure wound therapy for fixing full-thickness skin graft on the thumb [published correction appears in JPRAS Open. 2021 Sep 02;30:155-156]. JPRAS Open. 2018;18:22-27. Published 2018 Aug 23. doi:10.1016/j.jpra.2018.08.0013
3. Sahin I, Eski M, Acikel C, Kapaj R, Alhan D, Isik S. The role of negative pressure wound therapy in the treatment of fourth-degree burns. Trends and new horizons. Ann Burns Fire Disasters. 2012;25(2):92-97
4. Oshima J, Sasaki K, Aihara Y, et al. Combination of three different negative pressure wound therapy applications and free flap for open elbow joint injury with extensive burns. J Burn Care Res. 2022;43(2):479-482. doi:10.1093/jbcr/irab228

¹Department of Plastic, Reconstructive, and Hand Surgery, University of Tsukuba, Japan
²Department of Emergency and Critical Care Medicine, University of Tsukuba, Japan

Junya Oshima, MD; Department of Plastic, Reconstructive, and Hand Surgery, University of Tsukuba; 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan; ooshima-tuk@umin.ac.jp; Tel/Fax: +81-29-853-3122