Optimizing Wound Bed Preparation With Collagenase Enzymatic Debridement

Abstract

Difficult-to-heal and chronic wounds affect tens of millions of people worldwide. In the U.S. alone, the direct cost for their treatment exceeds $25 billion. Yet despite advances in wound research and treatment that have markedly improved patient care, wound healing is often delayed for weeks or months. For venous and diabetic ulcers, complete wound closure is achieved in as few as 25%-50% of chronic or hard-to-heal wounds. Wound bed preparation and the consistent application of appropriate and effective debridement techniques are recommended for the optimized treatment of chronic wounds. The TIME paradigm (Tissue, Inflammation/infection, Moisture balance and Edge of wound) provides a model to remove barriers to healing and optimize the healing process. While we often think of debridement as an episodic event that occurs in specific care giver/patient interface. There is the possibility of a maintenance debridement in which the chronic application of a medication can assist in both the macroscopic and microscopic debridement of a wound. We review the various debridement therapies available to clinicians in the United States, and explore the characteristics and capabilities of clostridial collagenase ointment (CCO), a type of enzymatic debridement, that potentially allows for epithelialization while debriding. It appears that in the case of CCO it may exert this influences by removal of the necrotic plug while promoting granulation and sustaining epithelialization. It is also easily combined with other methods of debridement, is selective to necrotic tissue, and has been safely used in various populations. We review the body of evidence has indicated that this concept of maintenance debridement, especially when combined episodic debridement may add a cost an efficacious, safe and cost-effective choice for debridement of cutaneous ulcers and burn wounds and it will likely play an expanding role in all phases of wound bed preparation.

An overview on therapeutic potential and various applications of microbial collagenases

“…Facilitating maintenance debridement by collagenase can be used to complete wound closure [91]. Wound bed preparation optimization with collagenase enzymatic debridement offers opportunities to improve the management of chronic and difficult-to-heal wounds [92].…”

Autolysis: mechanisms of action in the removal of devitalised tissue

“…Debridement is an essential component of wound bed preparation and plays an important role in all four of the main stages of the TIME framework (McCallon et al, 2015). Traditionally, the term debridement has been used to describe the removal of devitalised tissue from a wound, or more generally, the removal of damaged and infected tissue (Vowden and Vowden, 2011).…”

“…Also, some procedures are not used or are unavailable in the UK (e.g., wet-to-dry dressings, enzymatic) and are highlighted where appropriate. Davies (2004), McCallon et al (2015) and Gray et al (2011) Generally, the various methods of debridement can be placed into two broad categories: nonselective and selective debridement. With non-selective debridement methods (e.g., mechanical (i.e., wet-to-dry dressings), aggressive surgical or sharp debridement), surrounding viable tissue may be removed along with the removal of devitalised tissue particularly if the devitalised tissue is tightly associated with the underlying viable tissue (e.g., wet-to-dry dressing mechanical debridement).…”

“…Debridement is thought to be necessary in order to help transform the chronic wound environment back to an acute wound (Panuncialman and Falanga, 2009;McCallon et al, 2015). That is, the removal of devitalised tissue with each repeated debridement helps reduce or negate the effects of chronicity by removing the local wound factors that contribute to maintaining the chronic wound (e.g., devitalised tissue, biofilm).…”

“…However, debridement can take longer than other methods, requiring multiple dressing applications and can take several weeks depending upon the extent of necrosis/slough (Davies, 2004;Mosher et al, 1999;Davies et al, 2005). Because autolytic debridement requires endogenous protein-degrading enzymes -many of them from inflammatory cells -for effective removal of devitalised tissue, patients with impaired immune and inflammatory responses (due to medications or disease) may not show an effective autolytic response (McCallon et al, 2015).…”