Wound care seems simple enough - wounds that are treated correctly seem like they should also heal correctly, and in a timely fashion. But what happens when this isn’t the case? What if wounds don’t heal when they should or the way they should?
Unfortunately, some wounds can persist in a nonhealing fashion. We call these chronic wounds because they don’t move through the typical wound healing phases. As a result, chronic wounds can take much longer to heal. Treating chronic wounds often requires additional measures, one of the most effective of which is enzymatic debridement.
What is Debridement?
Debridement is the removal of dead (necrotic) or infected skin tissue until surrounding, healthy tissues are exposed, ultimately helping the wound to heal. Multiple technique styles are used to debride wounds: surgical, conservative sharp, mechanical, high-pressure fluid irrigation, ultrasonic mist, autolysis, enzymatic, and larval therapy are all different debridement techniques, and each has its place in practice.
Debridement is a necessary part of wound bed preparation, especially in chronic, nonhealing, or otherwise indolent wounds. For wounds that are stuck in the first stage of healing, are not getting better, or are stalled in the inflammatory phase, debridement is the best possible solution.
It’s important to note that while debridement isn’t required for all wounds, it’s often an essential component of treating chronic wounds, wounds that are infected, or wounds that are simply not improving.
What is Enzymatic Debridement?
Enzymatic debridement is defined as “the application of exogenous enzymes to the wound bed in order to degrade necrotic tissue without harming viable, granulation tissue.” The procedure includes the application of an ointment or gel containing enzymes directly into the wound, while avoiding the wound’s margins. This essentially softens unhealthy tissue, increasing the sloughing off of necrotic tissue.
Enzymatic debridement is often used when the patient is at a high risk for surgery or has bleeding problems. While it’s useful in many chronic wound scenarios, it is not recommended for large and severely-infected wounds.
How Does Enzymatic Debridement Work?
Enzymatic debridement does three things: reduces the inflammatory cytokines, fibronectin, and metalloproteinases produced when a wound is chronically inflamed owing to the presence of necrotic tissue; promotes DNA synthesis and growth of keratinocytes that are inhibited by production of these inflammatory products; and reduces bacterial bioburden associated with necrotic tissue in the wound bed. Ultimately, the removal of dead tissue is the goal of all debridement.
The enzymes used in enzymatic debridement procedures may come from an animal, plant, or bacteria, and are applied once or twice a day. The wound is then covered with a dressing, which, when removed, will also remove the dead tissue.
Preparing the wound bed is a critical component of wound care. There are four factors that must be adhered to when preparing any wound bed:
Nonviable or deficient tissue must be removed.
Infection of inflammation must be treated.
Moisture imbalances must be attended to.
A non-advancing or undetermined wound edge must be addressed.
By removing slough or eschar from the wound, addressing the underlying infection and bacterial bioburden, reducing inflammation, enzymatic debridement helps to move the wound through the healing process by removing the factors that inhibit the growth of new, healthy tissue.
What Does This Mean for Wound Care?
While expert opinion and clinical experience overwhelmingly support enzymatic wound debridement, especially when the wound bed contains necrotic tissue in the form of yellow slough or black eschar, there are a number of other reasons enzymatic debridement is a preferred method of chronic wound treatment today.
For example, when a wound is debrided through some other method but some residual necrosis is present, enzymatic debridement offers the physician the ability to further debride the wound without mechanically disrupting the base of the wound any further. These disruptions can cause bleeding or other continuous effects which may not be able to be addressed before the next visit, so enzymatic debridement is preferred in these cases.
Enzymatic debridement can also be used as an additional treatment, particularly in cases where debridement might be too painful.
There are many important implications for enzymatic debridement in wound care. For one, it can be used as primary treatment in cases where surgical removal is not feasible, or as an effective alternative for removing necrotic material from pressure ulcers, leg ulcers, and partial-thickness wounds. It can even be used as a combined therapy along with surgical debridement, or some other combination of treatments.
In the modern medical landscape, debridement is a requisite component of effective wound care. While enzymatic debridement isn’t the only debridement option, it is particularly effective when necrotic tissue remains post-debridement, when surgical debridement is not possible, or simply to advance wound healing alongside other debridement therapies.
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