Comparison of “Semiocclusive Dressing” Treatment Using Plastic Wrap or Low-Adherent Absorbent Wound Dressings Versus Occlusive Dressing Treatment for Stage III/IV Pressure Injuries in the Inflammatory Phase: A Randomized Controlled Trial

Abstract

Objective:

To compare the effectiveness of “semiocclusive dressing (SOD)” treatment using plastic wrap or low-adherent absorbent wound dressings with that of occlusive dressing (OD) treatment for National Pressure Injury Advisory Panel stage III/IV pressure injuries in the inflammatory phase.

Approach:

This 12-week, open-label, randomized controlled trial was conducted at one hospital and three care facilities. Seventy-seven participants were enrolled; 40 comprised the SOD group and 37 comprised the OD group. The primary outcome was the surface area reduction. Secondary outcomes included the Bates-Jensen Wound Assessment Tool (BWAT) score reductions, incidence of adverse events, and material cost. This trial met the recommendations of the CONSORT 2010 statement.

Results:

The surface area reduction of the SOD group was greater than that of the OD group throughout the study period. The significant interaction was revealed between treatment and time course (p < 0.0001). The 95% confidence interval of the difference at 12 weeks was 3.4 to 21.9. The median BWAT score reduction of the SOD group at 12 weeks was 23, and that of the OD group was 18.5 (p = 0.0077). The incidence of adverse events was comparable between groups. The OD treatment cost was 3.0 times higher than the SOD treatment cost (p = 0.0012).

Innovation:

Because the SOD does not completely occlude the wound, excess exudate drains from the wound. Therefore, SOD can treat the wound with abundant exudate effectively and safely.

Conclusion:

SOD treatment is more effective and less expensive than OD treatment for stage III/IV pressure injuries.

Clinical Trial Registration:

UMIN Clinical Trials Registry [UMIN000023412]. Registered on July 31, 2016.

Keywords

food wrap plastic wrap pressure injury pressure ulcer randomized controlled trial semiocclusive dressing

INTRODUCTION

Although not well-known worldwide, the use of food wrap as a dressing material to treat pressure injuries is widespread in several countries. The effectiveness of plastic wrap dressing (PWD) for National Pressure Injury/Ulcer Advisory Panel (NPIAP)^1,2 stages II, III, and IV pressure injuries has been reported.^3–8 Because PWD treatment involves only nonmedical and low-cost materials, some experts regard it as a strange folk remedy or cheap alternative to medical treatment and dismiss it. Whereas many medical professionals view that it is rational treatment^3–5,9,10 based on the modern concepts of moist healing^11–13 and wound bed preparation^14–16 with the unique mechanism that differs from conventional treatments.

The most crucial feature of PWD treatment is that the dressing material does not tightly adhere to the wound. Thus, the part of the dressing detaches from the wound when abundant exudate is generated and excess exudate drains outside the wound. This mechanism that the dressing material does not completely occlude the wound prevents wound deterioration following increased intrawound pressure and maintains an adequately moist environment to facilitate wound healing. Because the wound was not sealed, the lack of air permeability of the PWD caused no clinical problems.

The frequent adverse event associated with PWD treatment is periwound skin maceration due to overflowing exudate. To prevent it, several modified methods of PWD treatment have been developed to manage the exudate more effectively. One such method involves to use a PWD punched with many small holes and place an absorbent pad over it. Another is to place an absorbent pad inside a polyethylene bag with many small holes (sold as food waste bags).^17,18

In addition, medical materials have been used, such as low-adherent absorbent wound dressings (for burns and postoperative wounds).¹⁸ These products consist of some different layers, including an inner layer of low-adherent perforated film that prevents sticking to the skin, an absorbent layer made of cotton, resin, or polyester fiber pad, and a hydrophobic backing layer. The mechanism of these modified methods that the dressing material incompletely occludes the wound and allows excess exudate to drain from the wound is identical to that of PWD treatment. We call the treatments based on this mechanism “semiocclusive dressing (SOD)” treatment.

CLINICAL PROBLEM ADDRESSED

We hypothesized that SOD treatment involving PWD treatment and its modified treatments would improve severe pressure injuries faster than standard occlusive dressing (OD) treatment because of the results of previous reports.^5–7 These reports suggested that PWD treatment was superior to standard treatment for the management of stage III/IV pressure injuries in the acute inflammatory phase^9,10 with much exudate and necrotic tissue, however, the level of evidence was inadequate. Furthermore, few articles are available on SOD treatment other than PWD treatment. Thus, we compared the effectiveness of SOD treatment with that of OD treatment for NPIAP stage III/IV pressure injuries in the inflammatory phase.

MATERIALS AND METHODS

Trial design and participants

This 12-week, prospective, randomized controlled trial involved 10 wards of a Japanese psychiatric/geriatric hospital and three care facilities between August 2016 and March 2019. This study had an open-label design because it was impossible to mask the intervention. The Minakuchi Hospital Clinical Review Board approved the study protocol. This trial was registered on UMIN Clinical Trials Registry [UMIN000023412], and performed in accordance with the Declaration of Helsinki and its amendments. Study design and reporting followed the recommendations of the CONSORT 2010 guidelines.¹⁹ Written informed consent was obtained from all participants or their family members.

Patients who were 20 years or older and had stage III or IV pressure injuries according to the NPIAP Pressure Injury Staging System^1,2 were considered for inclusion in this study. Eligible participants had pressure injuries within 3 weeks of onset, ranging from 4 to 80 cm² (Bates-Jensen wound assessment tool [BWAT]^20,21 score of 2–4 for size), and at least 50% of the surface area was covered by necrotic tissue (BWAT score of 4–5 for necrotic tissue amount). If patients had wounds covered with black hard eschars, we included them after surgically removing the eschars. When patients had multiple wounds, the largest wound was selected. Participants were excluded for the following reasons: the skin ulcer was attributable to other causes, such as peripheral arterial occlusive disease or skin cancer; poorly controlled diabetes (HbA1c >10.0% measured at the time of registration); or treatment with cytotoxic agents or immunosuppressants.

The baseline parameters included age, sex, mental disorders, systemic diseases (including infectious diseases, diabetes, and malignancy), hemoglobin level, body mass index, serum albumin level, Braden Scale^22,23 score, location and surface area of the wound, and BWAT score. After obtaining these baseline characteristics, simple randomization was performed to allocate the consenting participants to SOD or OD treatment in a 1:1 ratio. For this randomization, a researcher affiliated with the registrar’s office who was not involved in the treatment or evaluation assigned treatments using a random number table created in Excel 2010 for Windows (Microsoft Japan Co., Ltd., Tokyo, Japan) and recorded the result on the registration form. An electronic laboratory notebook platform was not used.

Intervention

Procedure for SOD treatment

This study used unsterilized PWD or low-adherent absorbent wound dressing for SOD treatment. The low-adherent absorbent wound dressing was the first choice of treatment. The PWD was preferentially used when the wound was too large or when the wound with less exudate tended to dry out.¹⁸ Unlike OD treatment, SOD treatment did not require the type of dressing material to be changed based on the wound condition and could be implemented in the same manner from wound development to healing.

After cleansing with saline solution, the wound was covered with the dressing material. To allow loose adherence to the wound, nonwoven or plastic tape with weak adhesive strength was used^5,6; this is one of the most critical points of SOD treatment. After treatment initiation, a foul odor or copious yellow exudate might be observed. These signs indicated good performance of autolysis of devitalized tissue promoted by a moist environment, rather than wound infection or deterioration in most cases.^5,6 Changing the dressing materials, removing the autolyzed necrotic tissue, and cleansing the wound two to four times daily resulted in translucent and odorless exudate after one to two weeks without antibiotic use. Subsequently, the amount of exudate decreased. Thereafter, changing the dressings once or twice daily was sufficient.

Procedure for OD treatment

After cleansing with saline solution, the polyurethane foam dressing was applied to the wound with extensive exudate, whereas the hydrocolloid dressing was applied to the wound with less exudate.^24–27 Infected wounds were treated with the silver-impregnated dressing or calcium sodium alginate dressing.^24,25 One physician decided which dressing to use depending on the depth of the wound, nature and volume of exudate, and presence of wound infection. The frequency of dressing changes was determined based on the amount of exudate. If the exudate was controlled, then the dressing was changed several times per week. For wounds with excess exudate or infection, the dressing was changed once or twice daily.

Common procedures

No disinfectants such as iodine or topical antibiotics were used.^5–8 Debridement of necrotic tissue was primarily performed by autolysis. Surgical debridement and/or skin incision were performed for wounds with extensive necrosis, advanced cellulitis, and large abscesses.^26,27 Calcium sodium alginate dressings were occasionally used to manage bleeding after surgical procedures.²⁸ Systemic antibiotics were administered to treat cellulitis or bacteremia/sepsis.

Depending on the risk level indicated by the Braden Scale, prevention protocols were implemented^29–32 by a trial-independent pressure injury prevention and management committee. An alternating air pressure mattress, high-specification reactive foam mattress, nonpowered pressure redistribution support surface, seat cushions, and overlays were applied to enhance pressure redistribution, shear reduction, and proper posture.^33–38

Outcome measures

The primary outcome measure was the difference in absolute surface area reduction (SAR) of both treatment groups throughout the study period observed when the baseline surface area was compared with the surface area after treatment (SAR = baseline surface area − actual surface area). Surface area measurements were performed as follows; after cleansing the wound and debridement, a ruler was placed vertically on the wound and photographed using a digital camera. Using these images and Leaf Area Counter Plus software (Vector Inc., Tokyo, Japan), the same investigator who was unaware of treatment allocation measured the surface area at baseline and every week.

The secondary outcomes included SAR value and BWAT score reduction comparison at 4, 8, and 12 weeks resulting from both treatments (BWAT score reduction = baseline BWAT score − actual BWAT score). A physician and nurse who were aware of treatment allocation examined the wound together and recorded BWAT scores for all wounds at baseline and every week. In addition, the incidence of adverse events, including wound infection and maceration, the frequency of wound deterioration as assessed by SAR values or BWAT score, material cost, and frequency of dressing changes were compared. The material cost was calculated by the number of each used item and unit price at which the hospital purchased the item. Nurses recorded the number of dressings, gauze, absorbent pads, gloves, and amount of saline used for each procedure.

Statistical analyses

Based on the results of previous studies,^5,6 59 patients were needed in each arm of the study to detect a mean difference of 6.0 cm² (standard deviation [SD], ±10.0 cm²) in the SAR between groups at 12 weeks and ensure an alpha risk of 0.0167 (to maintain an overall alpha level of 0.05 based on the Bonferroni adjustment) and study power of 0.80. Allowing for 10% loss to follow-up and unbalanced allocation, a minimum sample size of 150 (75 per group) was determined. We used EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan)³⁹ for sample size planning.

Statistical analyses were performed on an intention-to-treat basis. All statistical tests were two sided, with an alpha level of 0.05. All analyses were performed using Stat View version 5.0 (SAS Institute Inc., Cary, NC, USA) and EZR. The difference in SAR for both treatment groups during the study period was evaluated by a linear mixed-model. The SAR value and BWAT score reduction comparison at 4, 8, and 12 weeks were analyzed using the unpaired Student’s t-test and the Mann–Whitney U test, respectively; for multiple comparisons, the Bonferroni adjustment was applied. For patients lost to follow-up but who were observed at least once after randomization, the last data observed were carried forward. Fisher’s exact test was used to analyze the incidence of adverse events and the frequency of wound deterioration. The material cost and frequency of dressing changes of both treatment groups were compared using unpaired Student’s t-test.

RESULTS

Eighty-six patients with deep skin ulcers were screened. Of those patients, 77 were enrolled and randomized to the SOD group (n = 40) or OD group (n = 37). Although the estimated number of necessary participants was not achieved, patient recruitment was terminated because changes in the practice structure of the research facility caused difficulties in the acceptance of more patients with pressure injuries. Figure 1 summarizes the flow of participants through the trial. Their baseline demographics and wound characteristics are shown in Table 1. The two groups were well-balanced.

Figure 1.

Flow of participants during the trial. BWAT, Bates-Jensen Wound Assessment Tool; OD, occlusive dressing; SOD, semiocclusive dressing.

Table 1.

Baseline patient demographics and wound characteristics

Characteristics	SOD Group (n = 40)	OD Group (n = 37)	p value
Sex, female	19 (48%)	19 (51%)	0.82^a
Age, mean ± SD [year]	81.2 ± 10.5	79.9 ± 11.7	0.60^b
Hemoglobin, mean ± SD [g/dl]	10.5 ± 1.6	10.7 ± 1.9	0.69^b
Albumin, mean ± SD [g/dl]	2.9 ± 0.5	2.8 ± 0.5	0.94^b
Body mass index, mean ± SD	19.8 ± 3.2	18.8 ± 2.6	0.13^b
Braden Scale score, mean ± SD,	14.5 ± 3.1	13.3 ± 2.9	0.10^b
Median (interquartile range)	15 (12–16.25)	14 (11–15)	0.09^c
Type of mental disorder:			0.15^d
Alzheimer’s disease	8 (20%)	15 (41%)
Vascular dementia	9 (23%)	5 (14%)
Dementia with Lewy bodies/ Parkinson disease with dementia	4 (10%)	2 (5%)
Mixed dementia	4 (10%)	3 (8%)
Other dementia	7 (18%)	2 (5%)
Schizophrenia	2 (5%)	7 (19%)
Mental retardation	3 (8%)	1 (3%)
Others	3 (8%)	2 (5%)
Systemic disease:
Systemic infectious disease	8 (20%)	9 (24%)	0.78^a
Diabetes mellitus	9 (23%)	12 (32%)	0.44^a
Malignancy	3 (8%)	3 (8%)	0.99^a
Others^e	7 (18%)	7 (19%)	0.99^a
Surface area of pressure injuries, mean ± SD [cm²]	22.7 ± 18.1	19.0 ± 17.1	0.36^b
Stage III/IV	16/24	23/14	0.07^a
Cellulitis	12 (30%)	9 (24%)	0.62^a
Sepsis due to wound infection	5 (13%)	3 (8%)	0.71^a
BWAT score, median (interquartile range)	43.5 (38.75–48)	40 (36–46)	0.07^c
Location of pressure injuries:			0.57^d
Sacrum	10 (25%)	13 (35%)
Greater trochanter	5 (13%)	1 (3%)
Ilium	2 (5%)	1 (3%)
Back	1 (3%)	3 (8%)
Heel/feet	14 (35%)	8 (22%)
Arm	2 (5%)	3 (8%)
Leg	3 (8%)	3 (8%)
Hip	2 (5%)	3 (8%)
Others^f	1 (3%)	2 (5%)

Fisher’s exact test.

Unpaired Student’s t-test.

Mann–Whitney U test.

Chi-square test. To compare categorical variables in descriptive data between two groups, a Fisher’s exact test or chi-square test was performed. The unpaired Student’s t-test was applied for parametric variables, and Mann–Whitney U test for nonparametric variables.

Systemic disease other than those listed included one patient with liver cirrhosis, one with pemphigoid, one with pulmonary embolism, and four with moderate congestive heart failure in the SOD group, and one with femoral neck fracture, one with chronic rheumatoid arthritis, one with neuroleptic malignant syndrome, and four with moderate congestive heart failure in the OD group.

In the SOD group, one pressure injury was on the head. In the OD group, one was on the scrotum, and one was on the coccyx.

p < 0.05 was accepted as significant.

BWAT, Bates-Jensen Wound Assessment Tool; OD, occlusive dressing; SD, standard deviation; SOD, semiocclusive dressing.

Initially, 29 patients and 11 patients in the SOD group were treated with the low-adherent absorbent wound dressing and PWD, respectively. In the OD group, 10 patients and 27 patients were initially treated with the hydrocolloid dressing and polyurethane foam dressing, respectively. During the trial, the treatment of nine patients was changed from the OD to SOD because of excessive exudate. The treatment of one patient was switched from the SOD to OD because SOD treatment could not be performed at the facility where he would be transferred.

Outcome measures

Figure 2 shows the SAR of both groups. The SAR of the SOD group was greater than that of the OD group during the study period. The significant interaction was revealed between treatment and time course (p < 0.0001). The mean SAR values of the SOD group at 4, 8, and 12 weeks were 7.4 cm² (SD, ±16.6 cm²), 12.1 cm² (SD, ±19.2 cm²), and 14.0 cm² (SD, ±19.9 cm²), respectively, whereas those of the OD group were −0.4 cm² (SD, ±18.6 cm²), −0.1 cm² (SD, ±22.2 cm²), and 1.3 cm² (SD, ±20.0 cm²), respectively. The differences between groups were statistically significant at 8 and 12 weeks. The 95% confidence intervals of the differences at 4, 8, and 12 weeks were −0.3 to 16.0, 2.6 to 21.8, and 3.4 to 21.9, respectively.

Figure 2.

SAR of the SOD and OD treatment groups. The linear mixed model revealed a significant interaction between treatment and time course (p < 0.0001*). The comparisons of SAR values at 4, 8, and 12 weeks resulting from both treatments were performed using the unpaired Student’s t-test and Bonferroni adjustment for multiple comparisons. *Statistically significant. SAR, surface area reduction.

Figure 3 shows the BWAT score reductions of both groups. The median BWAT score reductions of the SOD group at 4, 8, and 12 weeks were 14 (interquartile range [IQR], 10.25–20), 18 (IQR, 13.25–26.75), and 23 (IQR, 14.25–29.75), respectively. The corresponding values of the OD group were 12 (IQR, 0–21), 16 (IQR, 8.5–22), and 18.5 (IQR, 9.75–22). At every assessment point, the BWAT score reduction of the SOD group was greater than that of the OD group, with a statistically significant difference observed at 12 weeks.

Figure 3.

BWAT score reduction of the SOD and OD treatment groups. The horizontal bar in each box represents the median. Horizontal boundaries of the boxes represent the first and third quartiles. Vertical bars indicate the values of the 10th and 90th percentiles. p Values were based on the Mann–Whitney U test, and the Bonferroni adjustment was used for multiple comparisons. *Statistically significant.

The incidence of adverse events and the frequency of wound deterioration with both treatments were approximately equal (Table 2). Table 3 shows the material cost and frequency of dressing changes. The cost associated with OD treatment was significantly higher (3.0 times higher) than that associated with SOD treatment. Conversely, the frequency of dressing changes of the SOD group was significantly higher (2.4 times higher) than that of the OD group.

Table 2.

Incidence of adverse events and frequency of wound deterioration

	SOD Group (n = 38)	OD Group (n = 36)	p value
Wound infection	4 (11%)	6 (17%)	0.51
Maceration	5 (13%)	2 (6%)	0.43
Enlargement of the surface area	5 (13%)	8 (22%)	0.37
Not improved in BWAT score	2 (5%)	7 (19%)	0.08

Fisher’s exact test was performed.

p < 0.05 was considered significant.

Table 3.

Material costs and frequency of dressing changes

	SOD Group (n = 38)	OD Group (n = 36)	p value
Total material cost	547748	1619853	<0.01*
Cost of dressing materials	98676	1401091
Plastic wrap	2772	686
Low-adherent absorbent dressing	90735	23063
Hydrocolloid dressing	990	83779
Polyurethane foam dressing	0	1257944
Calcium sodium alginate dressing	4179	35619
Cost of supplies used in the procedure	449072	218762
Gauze	131785	54362
Absorption pad	60786	16038
Glove	44925	18618
Saline solution	211576	129744
Frequency of dressing changes	4965	2044	<0.01*

The unit of cost was the Japanese yen. p Values were based on unpaired Student’s t-test.

p < 0.05 was considered significant. The analysis was performed on an intention-to-treat basis.

DISCUSSION

By performing SAR and BWAT score reduction comparisons, this trial demonstrated that SOD treatment improved stage III/IV pressure injuries in the inflammatory phase faster than OD treatment. No apparent difference in the incidence of adverse events was observed between groups. In addition, SOD treatment was significantly less expensive than OD treatment. Many participants were older with poor general conditions, and some were terminally ill. Some patients had systemic illnesses that impeded wound healing. Infected wounds were included in this study. SOD treatment was beneficial for such patients often encountered in the clinical setting of pressure injury treatment.

Our results are in agreement with those of prior studies, including one randomized controlled trial,⁶ one nonrandomized controlled trial,⁵ and one comparative study of the same patient,⁷ suggesting that SOD treatment is more effective than conventional treatment for stage III/IV pressure injuries in the inflammatory phase. The superiority of SOD over conventional treatment can be attributed to the difference in their treatment mechanisms. Because excess exudate drains outside the wound, SOD treatment can manage abundant exudate. Whereas with conventional treatment, the wound is occluded and dressing materials or ointments absorb the exudate, resulting in a limited amount of exudate that can be managed even though modern polyurethane foam dressings, which can absorb much exudate, are used. Unabsorbed excess exudate increases the intrawound pressure and deteriorates the wound.

Conversely, regarding treatments of mild pressure injuries, two randomized controlled studies^3,8 and one comparative study of the same patient⁷ showed no significant difference in the efficacy of SOD and conventional treatments. Because mild wounds do not typically generate abundant exudate and can be managed with conventional treatment, the effectiveness of both treatments may be equivalent for such wounds. Therefore, when conducting studies, deep wounds and shallow wounds should be considered separately, or results may be confusing.

Regarding the burden of medical practitioners, OD treatment was more advantageous than SOD treatment because fewer dressing changes were required. However, the caregiver workload required for SOD treatment was not high because the treatment procedure was simple. Changing dressings could be performed easily while providing other care, such as diaper changes and bathing. Moreover, frequent dressing changes, although burdensome, were also beneficial because they allowed more opportunities to observe wound conditions. Conversely, OD treatment required skilled medical professionals to select the type of dressings depending on the wound condition, which was not necessary with SOD treatment. In this respect, SOD treatment had an advantage over OD treatment.

SOD treatment can be easily implemented; however, the correct therapeutic procedures must be followed.^9,10 Wounds could worsen attributable to improper treatment by medical practitioners who were unskilled in wound care or nonmedical professionals.⁴⁰ For example, severe wound infection occurred when the dressing material was not changed for several days, the wound was sealed by a food wrap, or wound infection in the early stages was not appropriately managed.

This study had some limitations. First, the small sample size limited the strength of evidence. It may have also introduced some bias, affecting the equality of the underlying background characteristics between the two groups and the results. Moreover, the significance of the differences in some endpoints, including the incidence of adverse events, may have been underestimated because of insufficient statistical power. Second, the labor cost was not considered when calculating the treatment cost. Arguably, the labor cost associated with SOD treatment was higher than that associated with OD treatment because of the frequency of dressing changes. However, because the time and effort required to change dressings are not great, the difference in the labor cost between groups may be insignificant. Finally, long-term safety was not investigated. As this study does not provide sufficient findings to confirm the effectiveness and safety of SOD treatment, further studies of more patients over longer periods are required.

Key Findings

SOD treatment was more effective and less expensive than OD treatment for NPIAP stage III/IV pressure injuries in the inflammatory phase.

The incidence of adverse events associated with SOD and OD treatment was comparable.

The crucial feature of SOD treatment is that the low-adhesive dressing incompletely occludes the wound and allows excess exudate to drain from the wound while a moist environment is adequately maintained.

INNOVATION

The SOD does not completely occlude the wound and allows excess exudate to drain outside the wound; thus, wound deterioration following increased intrawound pressure is prevented while a moist environment is adequately maintained to facilitate wound healing. Due to this unique and rational mechanism, the SOD can treat severe pressure injuries with abundant exudate effectively and safely. In addition, SOD treatment is easy to implement and inexpensive. Therefore, SOD treatment can be a useful option at medical facilities and patients’ homes.

ACKNOWLEDGMENTS AND FUNDING SOURCES

This work was partially supported by a research grant from Minakuchi Hospital (RGM2406 to JT) and Minamikusatsu Keyaki Clinic (MK2-2300011).

AUTHORS’ CONTRIBUTIONS

J.T., K.N., R.N., and H.H. collected the data; R.N. carried out the randomization; J.T., K.N., and R.N. analyzed the data; J.T. drafted the article; O.Y. and M.M. provided edits to the article; J.T., O.Y., and M.M. designed the study.

Footnotes

AUTHOR DISCLOSURE AND GHOSTWRITING

The authors declare no financial interests or no conflict of interest to disclose. No ghostwriters were employed.

ABOUT THE AUTHORS

Jun Takahashi, MD, is a chief medical director of Minakuchi Hospital, and one of his research interests is the treatment of pressure injuries. Kayoko Nakae, RN, is a ward chief nurse of Minakuchi Hospital. Osamu Yokota, MD, PhD, is a director of Kinoko Espoir Hospital. He is also a researcher of Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Department of Neuropsychiatry. Rena Nakata is a chief medical clerk of Minakuchi Hospital. Hayato Hasegawa, MD, is a stuff doctor of Minakuchi Hospital. Masaharu Miyagawa, MD, is a director of Minamikusatsu Keyaki Clinic. He is a specialist in geriatric medicine.

Abbreviations and Acronyms

References

Edsberg

, Black

, Goldberg

, et al. Revised national pressure ulcer advisory panel pressure injury staging system: Revised pressure injury staging system. J Wound Ostomy Continence Nurs, 2016; 43(6):585–597; doi: 10.1097/WON.0000000000000281

National Pressure Injury Advisory Panel. NPIAP pressure injury stages. Available from: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf [Last accessed: May 26, 2024].

Bito

, Mizuhara

, Oonishi

, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open, 2012; 2(1):e000371; doi: 10.1136/bmjopen-2011-000371

Lee

, Min

, Kim

, et al. Control study evaluating the efficacy of wrap therapy for national pressure ulcer advisory panel stage II, III, and IV pressure ulcer. Korean J Fam Pract, 2015; 5:71–76. Retrieved from https://www.kjfp.or.kr/main.html

Takahashi

, Yokota

, Fujisawa

, et al. An evaluation of polyvinylidene film dressing for treatment of pressure ulcers in older people. J Wound Care, 2006; 15(10):449–452–454; doi: 10.12968/jowc.2006.15.10.26971

Takahashi

, Nakae

, Miyagawa

, et al. Plastic wrap as a dressing material to treat stage III/IV pressure ulcers in the inflammatory phase: A Randomized Controlled Trial. Int J Clin Exp Med, 2017; 10:5586–5594. Retrieved from http://www.ijcem.com

Takahashi

, Miyagawa

, Yokota

, et al. Plastic wrap versus occlusive dressings for the management of skin ulcers: Comparison of two symmetrical wounds in two individual patients. Dermatol Case Rep, 2017; 02(01):118. Retrieved from https://www.iomcworld.com/dermatology-case-reports.html

Takahashi

, Nakae

, Miyagawa

, et al. Plastic wrap as a dressing material to treat stage II pressure ulcers: A Randomized Controlled Trial to evaluate plastic wrap dressing treatment versus standard treatment. Int J Clin Exp Med, 2020; 13:7154–7161. Retrieved from http://www.ijcem.com

Fujiwara

, Isogai

, Irisawa

, et al. Wound, pressure ulcer and burn guidelines – 2: Guidelines for the diagnosis and treatment of pressure ulcers, second edition. J Dermatol, 2020; 47(9):929–978; doi: 10.1111/1346-8138.14587

10.

Kadono

, Furuta

, Kurashige

, et al. Guideline for prevention and management of pressure ulcers, fifth edition. Jpn J PU, 2022; 24:29–85. Retrieved from https://www.jspu.org/medical/journal/

11.

Liang

, Lai

, Zhang

, et al. Impact of moist wound dressing on wound healing time: A meta-analysis. Int Wound J, 2023; 20(10):4410–4421; doi: 10.1111/iwj.14319

12.

Nuutila

, Eriksson

. Moist wound healing with commonly available dressings. Adv Wound Care (New Rochelle), 2021; 10(12):685–698; doi: 10.1089/wound.2020.1232

13.

Souliotis

, Kalemikerakis

, Saridi

, et al. A cost and clinical effectiveness analysis among moist wound healing dressings versus traditional methods in home care patients with pressure ulcers. Wound Repair Regen, 2016; 24(3):596–601; doi: 10.1111/wrr.12433

14.

Harries

, Bosanquet

, Harding

. Wound bed preparation: Time for an update. Int Wound J, 2016; 13(Suppl 3):8–14; doi: 10.1111/iwj.12662

15.

Shamsian

. Wound bed preparation: An overview. Br J Community Nurs, 2021; 26(Sup9):S6–S11; doi: 10.12968/bjcn.2021.26.Sup9.S6

16.

Sibbald

, Elliott

, Persaud-Jaimangal

, et al. Wound bed preparation 2021. Adv Skin Wound Care, 2021; 34(4):183–195; doi: 10.1097/01.ASW.0000733724.87630.d6

17.

Konno

, Hamada

, Hatakeyama

, et al. Present status and issues in wrap therapy in our hospital revealed by a hospital questionnaire. J Jpn WOCM, 2021; 25:703–709; doi: 10.32201/jpnwocm.25.4_703

18.

Mizuhara

, Taguchi

, Sato

, et al. Useful wound management at home. Gan to Kagaku Ryoho, 2014; 41 Suppl 1:69–71.

19.

Schulz

, Altman

, Moher

, et al. CONSORT 2010 statement: Updated guidelines for reporting parallel group randomized trials. BMC Med, 2010; 8:18; doi: 10.1186/1741-7015-8-18

20.

Bates-Jensen

, McCreath

, Harputlu

, et al. Reliability of the Bates-Jensen wound assessment tool for pressure injury assessment: The Pressure Ulcer Detection Study. Wound Repair Regen, 2019; 27(4):386–395; doi: 10.1111/wrr.12714

21.

Wounds Canada. Bates-Jensen wound assessment tool, instructions for use. Available from: https://www.woundscanada.ca/docman/public/health-care-professional/1428-bwat/file [Last accessed: May 26, 2024].

22.

Braden Scale II, predicting pressure injuries. Available from: https://www.bradenscale.com [Last accessed: May 26, 2024].

23.

Huang

, Ma

, Wang

, et al. Predictive validity of the braden scale for pressure injury risk assessment in adults: A systematic review and meta-analysis. Nurs Open, 2021; 8(5):2194–2207; doi: 10.1002/nop2.792

24.

European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Haesler

Emily

(Ed.). EPUAP/NPIAP/PPPIA: 2019. Retrieved from. Available from: https://epuap.org/pu-guideline/.

25.

Gould

, Stuntz

, Giovannelli

, et al. Wound healing society 2015 update on guidelines for pressure ulcers. Wound Repair Regen, 2016; 24(1):145–162; doi: 10.1111/wrr.12396

26.

Tachibana

, Imafuku

, Irisawa

, et al. The wound/burn guidelines-2: Guidelines for the diagnosis and treatment for pressure ulcers. J Dermatol, 2016; 43(5):469–506; doi: 10.1111/1346-8138.13274

27.

The Japanese Society of Pressure Ulcers Guideline Revision Committee. JSPU guidelines for the prevention and management of pressure ulcers. (Jpn J PU, 2016; 18:455–544. 4th Ed.). Retrieved from https://www.jspu.org/medical/journal/

28.

Matsubara

, Banshodani

, Takahashi

, et al. Vascular access management after percutaneous transluminal angioplasty using a calcium alginate sheet: A Randomized Controlled Trial. Nephrol Dial Transplant, 2019; 34(9):1592–1596; doi: 10.1093/ndt/gfy143

29.

Dealey

, Brindle

, Black

, et al. Challenges in pressure ulcer prevention. Int Wound J, 2015; 12(3):309–312; doi: 10.1111/iwj.12107

30.

Mitchell

. Adult pressure area care: Preventing pressure ulcers. Br J Nurs, 2018; 27(18):1050–1052; doi: 10.12968/bjon.2018.27.18.1050

31.

Munoz

, Posthauer

, Cereda

, et al. The role of nutrition for pressure injury prevention and healing: The 2019 international clinical practice guideline recommendations. Adv Skin Wound Care, 2020; 33(3):123–136; doi: 10.1097/01.ASW.0000653144.90739.ad

32.

Ousey

, Stephenson

, Blackburn

. Sub-epidermal moisture assessment as an adjunct to visual assessment in the reduction of pressure ulcer incidence. J Wound Care, 2022; 31(3):208–216; doi: 10.12968/jowc.2022.31.3.208

33.

Tomova-Simitchieva

, Lichterfeld-Kottner

, Blume-Peytavi

, et al. Comparing the effects of 3 different pressure ulcer prevention support surfaces on the structure and function of heel and sacral skin: An Exploratory Cross-Over Trial. Int Wound J, 2018; 15(3):429–437; doi: 10.1111/iwj.12883

34.

Kim

, Kim

, An

, et al. Effects of alternating pressure air mattresses on pressure injury prevention: A Systematic Review Of Randomized Controlled Trials. Worldviews Evid Based Nurs, 2022; 19(2):94–99; doi: 10.1111/wvn.12570

35.

Nixon

, Brown

, Smith

, et al. Comparing alternating pressure mattresses and high-specification foam mattresses to prevent pressure ulcers in high-risk patients: The pressure 2 RCT. Health Technol Assess, 2019; 23(52):1–176; doi: 10.3310/hta23520

36.

Raepsaet

, Zwaenepoel

, Manderlier

, et al. A fully automated pulsating support system for pressure injury prevention and treatment in 10 Belgium nursing homes: An Observational Study. J Wound Ostomy Continence Nurs, 2021; 48(2):115–123; doi: 10.1097/WON.0000000000000746

37.

Shi

, Dumville

, Cullum

, et al. Alternating pressure (active) air surfaces for preventing pressure ulcers. Cochrane Database Syst Rev, 2021; 5(5):CD013620; doi: 10.1002/14651858.CD013620.pub2

38.

tfmkShi

, Dumville

, Cullum

, et al. Beds, overlays and mattresses for preventing and treating pressure ulcers: An overview of Cochrane reviews and network meta-analysis. Cochrane Database Syst Rev, 2021; 8(8):CD013761; doi: 10.1002/14651858.CD013761.pub2

39.

Kanda

. Statistical analysis using freely-available “EZR (Easy R)” software. Rinsho Ketsueki, 2015; 56(10):2258–2266; doi: 10.11406/rinketsu.56.2258

40.

Kunieda

, Minakata

, Kakudo

, et al. Two cases of severe pressure ulcer infection caused by inappropriate cling wrap therapy. Jpn J Plast Surg, 2020; 63:1055–1062.