Wound Dressings: Why Not Wet-to-Dry?

Wet-to-dry dressings have been a mainstay in wound care for years in the U.S.—even though research shows that this method doesn’t allow wounds to heal properly. In this article, we’ll take a closer look at the problems with wet-to-dry dressings and why they should no longer be used.

Why Moist Wound Healing Is a Better Approach

A wet-to-dry dressing consists of moistened gauze placed or packed into a wound, left in place until dry and then removed. While this type of dressing can be applied as a form of mechanical debridement, it’s being used even when that isn’t the goal.¹Wet-to-dry dressings continue to be a primary treatment for wounds despite many better options that promote a moist wound environment and are less harmful to the patient.

We have known for many decades that moist wound healing is superior to letting a wound dry out,² and research-based evidence along with clinical practice guidelines state that a moist wound environment is the primary factor for wound healing to occur.³ Not only do wet-to-dry dressings allow the wound base to dry and healing cells to desiccate within the wound, but they can also be painful, impede wound healing, and act as a medium for bacterial growth, leading to infection.^4,5,6

Research Supports Moving Away from Wet-to-Dry Dressings

In the past three decades, randomized controlled trials have repeatedly demonstrated that wet-to-dry dressings are not appropriate in any healthcare setting.^4,7,8 Wet-to-dry dressings remove healthy tissue as well as necrotic tissue (non-selective debridement), are painful to the patient, impede healing through local tissue cooling, prolong the inflammatory response, and increase risk for infection.^6,9,10

Benefits of Moist Wound Healing

A moist wound environment mimics the function of the epidermis to trap moisture and promote healing. The body is composed mainly of water, and the natural cell environment is moist. A dry cell is considered a dead cell. Moisture in the wound environment promotes cell hydration and survival. Neutrophils, macrophages, and fibroblasts, all key cells in the inflammatory and proliferative healing phases, cannot thrive in a dry environment.^11,12 They need moisture and oxygen to survive and function to progress wound healing through each phase toward closure. A moist wound environment increases angiogenesis, the formation of blood flow to newly formed tissues, and enhances autolytic debridement, the body’s process of producing endogenous enzymes to break down necrotic tissue for removal from the wound bed.

Moist wound healing also promotes final closure of the wound, or re-epithelialization, enabling epithelial cells to close the wound across the surface. Dry crusted wound debris acts as a barrier to cell migration and slows epithelialization.¹¹ When surface cells dry and die, more necrotic tissue is present in the wound bed, causing a delay in closure and an increased risk for infection.¹² Finally, there is less pain for the patient because a moist wound bed insulates and protects nerve endings.

Other Options Besides Wet-to-Dry Dressings

What can be used instead? Raw wounds will heal with appropriate blood supply as long as they are not allowed to “dry and die,” supporting the concept of a moist wound environment. For clinicians who perform wound care, recommendations include keeping raw wounds “clean and greasy.” This means simply washing with soap and water then applying simple white petroleum topicals like Aquaphor or Vaseline with a light covering to keep the environment moist. Bacitracin, a commonly used medicated ointment, when used on wounds likely heals them due to keeping them greasy, not necessarily for its antibiotic factor.¹³

Many other dressing types exist that also provide a moist wound environment and promote autolytic debridement. Some of these dressings include:

• Hydrogels—hydrophilic (water-loving) amorphous gels that regulate fluid exchange from the wound and can absorb or donate moisture to the wound.^12,14
• Hydrocolloids—opaque, occlusive, wafer dressings that turn to gel upon contact with wound exudate and stay in place for three to seven days.¹²
• Foams—open-cell polyurethane coverings that insulate the wound and stay in place for four to seven days.¹²

The advantage of these dressings is that they can stay in place for several days, promoting an undisturbed wound environment to maintain moisture and accomplish autolytic debridement for removal and cleansing every four to seven days.¹⁵The disadvantages include additional upfront cost (although fewer dressing changes can potentially reduce pain for the patient and the cost for wound care providers performing the dressing changes¹²) and some inconvenience, as the dressings must remain dry, which precludes showering or getting the area wet.

The specific needs of each patient should help determine the best choice for each individual case. Regardless, moist wound healing principles must be prioritized, and wet-to-dry dressings should not be an option.

References

1. Cowan LJ & Stechmiller J. (2009.) Prevalence of wet-to-dry dressings wound wound care. Advances in Skin & Wound Care, 22(12): 567-573.
2. Winter GD. (1962). Formation of scab and the rate of epithelialization of superficial wound in the skin of the young domestic pig. Nature, 193, 293-294.
3. Bergstrom N, Bennell MA & Carlson. (1994). Treatment of pressure ulcers (Clinical Practice Guidelines No. 15). Rockville, MD: US Department of Health and Human Service, Public Health Service. Agency for Healthcare Policy and Research. Publication No. 95-0562.
4. Dale BA & Wright HD. (2011). Say goodbye to wet-to-dry wound care dressings. Home Healthcare Nurse, 29(7), 429-440.
5. Armstrong MH & Price P. (2004). Wet-to-dry gauze dressings: fact and fiction. Published 3/3/2004. http://www.medscape.com/viewarticle/470257.
6. Spear M. (2008). Wet-to-dry dressings: Evaluating the evidence. Plastic Surgical Nursing, 28(2), 92-95.
7. Ovington LG. (2001). Hanging wet-to-dry dressings out to dry. Home Healthcare Nurse, 19(8), 477-483.
8. Lee JC, Kandula S & Sherber NS. (2009). Beyond wet-to-dry: A rationale to treating chronic wounds. Journal of Plastic Surgery, 9, 131-137.
9. Fleck CA. (2009). Why wet to dry. Journal of the American College of Clinical Wound Specialists, 1: 109-113.
10. Ovington LG. (2002). Hanging wet-to-dry dressings out to dry. Advances in Skin & Wound Care, 15(2), 79-84.
11. Holloway S, Tate S, Stechmiller JK & Schultz G. (2020). Acute and Chronic Wound Healing. In: S Baranoski & EA Ayello (Eds.), Wound Care Essentials: Practice Principles,.5th ed. Wolters Kluwer: 79-101.
12. Niezgoda JA, Baranoski S, Ayello EA, McIntosh A, Montoya L & Ostler M. (2020.) Wound Treatment Options. In: S Baranoski & EA Ayello (Eds.), Wound Care Essentials: Practice Principles. 5th ed. Wolters Kluwer: 185-241.
13. Lalonde D, Joukhadar N & Janis J. (2019). Simple effective ways to care for skin wounds and incisions. Plastic & Reconstructive Surgery, 7(10): e2471.
14. Parrish KP & Barrett NE. (2021). Wound Classification and Management. In: TM Skirven, AL Osterman, JM Fedorczyk, PC Amadio, SB Feldscher & EK Shin, (Eds.), Rehabilitation of the Hand and Upper Extremity. 7th ed. Philadelphia, PA: Elsevier: 196-209.
15. Sibbald RG, Niezgoda JA & Ayello EA. (2020). Wound Debridement. In: S Baranoski & EA Ayello (Eds.), Wound Care Essentials: Practice Principles. 5th ed. Wolters Kluwer: 163-184.