Evidenz in der lokalen Therapie chronischer Wunden: Was ist gesichert?

ZUSAMMENFASSUNG

Chronische Wunden sind ein komplexes Symptom verschiedener Grunderkrankungen. Sie können bspw. vaskulärer, metabolischer oder immunologischer Genese sein. Auch wenn die Therapie dieser Grunderkrankungen im Vordergrund steht und zielführend ist, so beeinflussen diese Wunden die Lebensqualität der einzelnen Patienten oder Patientinnen stark. Zur Lokaltherapie chronischer Wunden steht ein breites Portfolio an Möglichkeiten zur Verfügung. Anders als in anderen Bereichen der Medizin ist die Evidenz für die verschiedenen Lokaltherapeutika meist gering. Deshalb rücken Experten-Empfehlungen und Leitlinien an ihre Stelle, die sinnvolle Behandlungspfade aufzeigen. Die wichtigsten Fragestellungen in der täglichen Praxis betreffen die Wahl und Effektivität der Wundspülung und des Wunddebridements, das Exsudatmanagement, den Einsatz von antimikrobiellen Wirkstoffen in Lösungen und Wundauflagen, die Unterdruck-Wundtherapie (NPWT) und die Indikationsstellung zur Kompressionstherapie. Trotz des Mangels an Evidenz folgt die Behandlung chronischer Wunde einigen grundlegenden Prinzipien, die im folgenden Artikel inklusive der dazugehörigen Behandlungsempfehlungen dargestellt werden.

ABSTRACT

Chronic wounds are a comprehensive symptom of various underlying diseases. For example, they can be vascular, metabolic or immunological in nature. Even if the therapy of these underlying diseases is in the focus, these wounds have a great impact on the quality of life of the individual patient. A broad portfolio of choices is available for the local therapy of chronic wounds. In contrast to other fields of medicine, the evidence for the various local therapeutic options is mostly limited. Therefore, expert recommendations, guidelines, and directives are replacing them to provide reasonable treatment pathways. The most important issues in daily practice relate to the choice and efficacy of wound irrigation and debridement, exudate management, the use of antimicrobial agents in solutions and wound dressings, negative pressure wound therapy (NPWT), and the indications for compression therapy. Despite the lack of evidence, the management of chronic wounds adheres to some fundamental principles, which are outlined in the following article, including the related treatment recommendations.

Schlüsselwörter

Chronische Wunden - Wundtherapie - Kompressionstherapie - Antiseptik - Unterdruck-Wundtherapie

Keywords

Chronic wounds - wound therapy - compression therapy - antiseptics - negative pressure wound therapy

Publication History

Article published online:
13 April 2022

• Literatur

• 1 Dissemond J, Armstrong DG, Stang A. et al. WUWHS Position document – Evidence in wound care. Wounds Int 2020; 1-25 www.woundsinternational.com
• 2 AWMF S3-Leitlinie 091–001 „Lokaltherapie chronischer Wunden bei den Risiken CVI, PAVK und Diabetes mellitus“. Deutsche Gesellschaft für Wundheilung und Wundbehandlung e.V. (DGfW); 2012. www.awmf.org
• 3 Nolan M, Carroll A, Wynne M. SE National Wound Management Guidelines 2018. https://healthservice.hse.ie/filelibrary/onmsd/hse-national-wound-management-guidelines-2018.pdf
• 4 Price P, Gottrup F, Abel M. EWMA Study recommendations: For clinical investigations in leg ulcers and wound care. J Wound Care 2014; 23 (Suppl. 05) 1-36
• 5 Sackett DL, Rosenberg WM, Gray JA. et al. Evidence based medicine: what it is and what it isnʼt. BMJ 1996; 312: 71-72
• 6 Driver VR, Gould LJ, Dotson P. et al. Identification and content validation of wound therapy clinical endpoints relevant to clinical practice and patient values for FDA approval. Part 1. Survey of the wound care community. Wound Repair Regen 2017; 25: 454-465
• 7 Kyaw BM, Järbrink K, Martinengo L. et al. Need for improved definition of “chronic wounds” in clinical studies. Acta Derm Venereol 2018; 98: 157-158
• 8 Kramer A, Assadian O. Wallhäußers Praxis der Sterilisation, Desinfektion, Antiseptik und Konservierung, Qualitätssicherung der Hygiene in Industrie, Pharmazie und Medizin. 6th ed.. Stuttgart: Thieme; 2008
• 9 Kramer A, Dissemond J, Willy C. et al. Auswahl von Wundantiseptika: Aktualisierung des Expertenkonsensus 2018. Wundmanagement 2019; 13 (Suppl. 01) 3-23
• 10 Assadian O, Kammerlander G, Geyrhofer C. et al. Use of wet-to-moist cleansing with different irrigation solutions to reduce bacterial bioburden in chronic wounds. J Wound Care 2018; 27 (Suppl. 10) S10-S16
• 11 Schupp CJ, Holland-Cunz S. Persistent subcutaneous oedema and aseptic fatty tissue necrosis after using octenisept. Eur J Pediatr Surg 2009; 19: 179-183
• 12 Zhu G, Wang Q, Lu S. et al. Hydrogen peroxide: A potential wound therapeutic target?. Med Princ Pract 2017; 26: 301-308
• 13 Main RC. Should chlorhexidine gluconate be used in wound cleansing?. J Wound Care 2008; 17: 112-114
• 14 Whaley S. Tap water or normal saline for cleansing traumatic wounds?. Br J Community Nurs 2004; 9: 471-478
• 15 Schwarzkopf A, Assenheimer B, Bültemann A. et al. Hygienefachliche und -rechtliche Bewertung der Anwendung von Leitungswasser als Wundspüllösung. Wundmanagement 2012; 6: 195-197
• 16 Edwards J, Stapley S. Debridement of diabetic foot ulcers. Cochrane Database Syst Rev 2010; 1: CD003556
• 17 Dumville JC, Worthy G, Bland JM. et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ 2009; 338: b773
• 18 Koenig M, Vanscheidt W, Augustin M. et al. Enzymatic versus autolytic debridement of chronic leg ulcers: a prospective randomised trial. J Wound Care 2005; 14: 320-323
• 19 Malone M, Bjarnsholt T, McBain AJ. et al. The prevalence of biofilms in chronic wounds: a systematic review and meta-analysis of published data. J Wound Care 2017; 26: 20-25
• 20 Dissemond J, Gerber V, Lobmann R. et al. TILI (Therapeutischer Index für lokale Infektionen) – Score für die Diagnostik lokaler Wundinfektionen. Wundmanagement 2019; 6: 36-41
• 21 Dissemond J, Augustin M, Eming S. et al. Moderne Wundtherapie – praktische Aspekte der lokalen, nicht-interventionellen Behandlung chronischer Wunden. J Dtsch Dermatol Ges 2014; 12: 541-554
• 22 Dissemond J, Assenheimer B, Engels P. et al. M.O.I.S.T. – ein Konzept für die Lokaltherapie chronischer Wunden. J Dtsch Dermatol Ges 2017; 15: 443-445
• 23 Harding K, Carville K, Chadwick P. et al. WUWHS Consensus Document: Wound Exudate, effective assessment and management. Wounds UK; 2019. https://www.woundsinternational.com/resources/details/wuwhs-consensus-document-wound-exudate-effective-assessment-and-management
• 24 Dissemond J, Bültemann A, Gerber V. et al. Diagnosis and treatment of chronic wounds: current standards of Germanyʼs Initiative for Chronic Wounds e.V. J Wound Care 2017; 26: 727-732
• 25 Rayala BZ. Skin ulcers: Pharmacotherapy. FP Essent 2020; 499: 25-28
• 26 Bodmann KF, Grabein B, Kresken M. et al. Kalkulierte parenterale Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2018. AWMF-Register Nr. 082–006. https://www.awmf.org/uploads/tx_szleitlinien/082–006l_S2k_Parenterale_Antibiotika_2019–08.pdf
• 27 Edmonds M, Lázaro-Martínez JL, Alfayate-García JM. et al. Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): An international, multicentre, double-blind, randomised, controlled trial. Lancet Diabetes Endocrinol 2018; 6: 186-196
• 28 Game F, Jeffcoate W, Tarnow L. et al. LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomised controlled trial. Lancet Diabetes Endocrinol 2018; 6: 870-878
• 29 Seidel D, Storck M, Lawall H. et al. Negative wound pressure therapy compared with standard moist care for diabetic foot ulcers in real-life clinical practice: results of the German DiaFu-RCT. BMJ Open 2020; 10: e026345
• 30 Zens Y, Barth M, Bucher HC. et al. Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials. Syst Rev 2020; 9: 238
• 31 Maybaum T, Beerheide R. Vakuumversiegelungstherapie kommt in die Regelversorgung. Dtsch Arztebl 2020; 117: A-156/B-140/C-136.
• 32 Rabe E, Földi E, Gerlach H. et al. Medizinische Kompressionstherapie der Extremitäten mit Medizinischem Kompressionsstrumpf (MKS), Phlebologischen Kompressionsverband (PKV) und medizinische adaptiven Kompressionssystemen (MAK). AMWF Register Nr. 37/005. 2018. www.awmf.org
• 33 Heyer K, Protz K, Augustin M. Compression therapy – cross-sectional observational survey about knowledge and practical treatment of specialised and non-specialised nurses and therapists. Int Wound J 2017; 14: 1148-1153
• 34 Juenger M, Haase H, Schwenke L. et al. Macro- and microperfusion during application of a new compression system, designed for patients with leg ulcer and concomitant peripheral arterial occlusive disease. Clin Hemorheol Microcirc 2013; 53: 281-293
• 35 Rabe E, Partsch H, Morrison N. et al. Risks and contraindications of medical compression treatment – A critical reappraisal. An international consensus statement. Phlebology 2020; 35: 447-460
• 36 Brehmer F, Haenssle HA, Daeschlein G. et al. Alleviation of chronic venous leg ulcers with a hand-held dielectric barrier discharge plasma generator (PlasmaDerm VU-2010): results of a monocentric, two-armed, open, prospective, randomized and controlled trial (NCT01415622). J Eur Acad Dermatol Venereol 2015; 29: 148-155
• 37 Stratmann B, Costea TC, Nolte C. et al. Effect of cold atmospheric plasma therapy vs standard therapy placebo on wound healing in patients with diabetic foot ulcers: A randomized clinical trial. JAMA Netw Open 2020; 3: e2010411
• 38 Moelleken M, Jockenhöfer F, Wiegand C. et al. Pilot study on the influence of cold atmospheric plasma on bacterial contamination and healing tendency of chronic wounds. J Dtsch Dermatol Ges 2020; 18: 1094-1101
• 39 Strauch B, Herman C, Dabb R. et al. Evidence-based use of pulsed electromagnetic field therapie in clinical plastic surgery. Aesthetic Surg J 2009; 29: 135-143
• 40 Tata D, Waynant RW. Laser therapy: A review of its mechanism of action and potential medical applications. Laser Photonics Rev 2011; 5: 1-12
• 41 Taradaj J, Halski T, Kucharzewski M. et al. Effect of laser irradiation at different wavelengths (940, 808, and 658 nm) on pressure ulcer healing: Results from a clinical study. Evid Based Complement Alternat Med 2013; 2013: 960240
• 42 Percival SL, Francolini I, Donelli G. Low-level laser therapy as an antimicrobial and antibiofilm technology and its relevance to wound healing. Future Microbiol 2015; 10: 255-272
• 43 Ingram JR, Woo PN, Chua SL. et al. Interventions for hidradenitis suppurativa. Cochrane Database Syst Rev 2015; 2015 (10) CD010081
• 44 Scott AM, Stehlik P, Clark J. et al. Blue-Light therapy for acne vulgaris: A systematic review and meta-analysis. Ann Fam Med 2019; 17: 545-553