Enzymatic Debriding Agents: An Evaluation of the Medical Literature

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Author(s): 
Robert G. Smith, DPM, MSc, RPh, CPed

Index: Ostomy Wound Manage. 2008;54(8):16-34.

     Debridement — the process by which devitalized tissue is softened or liquefied and removed — is an essential part of effective wound care. Debridement prepares the wound bed for healing.1-3 Results from a 55-patient venous leg ulcer study2 showed that, compared to ulcers that were not debrided, one session of sharp debridement significantly increases the rate of ulcer healing (P <0.05).

     The intention of clinical debridement is the removal of devitalized or infected, contaminated tissue from a wound until surrounding healthy tissue is exposed. Wound care specialists may select from a variety of debridement methods.1,4-11 Ayello and Cuddigan7 review four methods of debridement: surgical/sharp, mechanical, autolytic, and enzymatic. A fifth method — biological — is also available and involves larval or maggot therapy.

     The literature contains several reviews of the advantages and disadvantages of each method of debridement.7-10 A particular technique may be selected based on evaluation and consideration of the following: clinician experience and skill, cost of the interventional method, the presence of exudate or infection, tissue selectivity, and a patient’s tolerance to a particular intervention.4-11 In addition, the most appropriate method can be selected following critical appraisal of the evidence in the literature.

     The conventional and customary practice of wound debridement as described in the literature is based on tradition and anecdotal experience, often referred to as best practice approach.8 This concept is supported by Ryan et al’s12 observation that evidence-based wound care is still in the developmental stages and the information available has been left to interpretation. From this observation, it can be inferred that the selection of a particular debridement method is generally based on interpretive evaluation rather than evidence-based medicine. Further, Bradley et al13 assert that compelling clinical evidence comparing one method of debridement with another is scant. Thus, clinical evidence-based information specific to debridement methods is not easy to find. In addition, Beitz8 has identified the ominous problems related to conducting randomized controlled trials comparing debridement methods — ie, investigation of this nature may create substantial ethical dilemmas for researchers.

     The purpose of this literature review is to evaluate the validity and usefulness of enzymatic debridement and provide an evidence base to justify current practice. Enzymatic debridement was chosen not because this method is more effective or preferred compared to other options but because it was presumed that these pharmaceutical products should be associated with a myriad of readily available data from the literature. To serve as a foundation, enzyme products commercially available in the US are reviewed emphasizing functional components, mechanisms of action, and patient considerations. Relevant literature is defined with regards to search determinants and clinimetric definitions, and results are integrated for assessment.

Enzymatic Debridement Agents

     Enzymatic debridement is a highly selective method of wound debridement that uses naturally occurring proteolytic enzymes manufactured by the pharmaceutical and healthcare industry specifically for eliminating devitalized tissue.

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