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Using Endoform as a Protease Indicator to Standardize Wound Management

Wound Care in the First Person

Using Endoform as a Protease Indicator to Standardize Wound Management

Every wound is different. To achieve the best healing outcome, an individually tailored approach to care is best. Even the same wound can change over time, requiring modification of the wound management strategy over the course of care. This varied and dynamic nature of wounds and particularly chronic wounds makes for a difficult learning curve when training staff on best wound care practices. In my role as Program Manager for a large health care organization, it is critically important that wound care practitioners are adequately trained to perform best-practice wound care for every patient, on every wound, and at every visit. 

Endoform (Aroa Biosurgery, Auckland, New Zealand) is an extracellular matrix (ECM) with the composition and function of native tissue ECM.1,2 Endoform modulates protease activity,3 facilitating resolution of the stalled inflammatory phase of chronic wounds and progression to the proliferative phase where Endoform provides a scaffold for healing tissue. An antimicrobial variant of Endoform that contains ionic silver and provides broad-spectrum antimicrobial activity also is available. This makes it ideal for wounds at risk of infection.4 

We recently performed a study evaluating the use of Endoform as a surrogate marker of wound protease levels5,6 that showed Endoform could be used as a visual cue to identify highly proteolytic wounds and monitor wound protease levels throughout the period of care. This approach can provide useful information to tailor care to the wound simply by observing the presence of Endoform in the wound bed at dressing change and determining the amount of product reapplication required (see Figure 1 and Figure 2). 

Wounds should be assessed as follows:

  • If no Endoform is present, the wound is highly proteolytic and requires increased application of Endoform (multiple layers) to control excessive protease activity. 
  • If minor remnants of Endoform are present, the wound is still in an inflammatory phase with elevated protease activity. Reapplication of Endoform is required to correct the protease imbalance. 
  • If substantial residual Endoform is present, protease levels are lower and the wound is transitioning to the proliferative phase. Reapplication should be continued at a reduced rate to scaffold granulation tissue until wound closure is achieved.

We have implemented this unique feature of Endoform in our approach to best-practice wound management. Applying the optimal amount of Endoform at each visit is a cost-effective way to achieve better healing outcomes, allow wound proteases to be quickly controlled, decrease time to closure, and minimize unnecessary applications. By dynamically tailoring the care approach to the wound, consistent results are achieved and patient outcomes are improved.

Additionally, we have found in our practice that this simple algorithm is easy to teach and to implement. We have adapted our wound care staff training to include this protease indication and Endoform application algorithm. From a trainer’s perspective, it is easy to teach how to determine the optimal amount of Endoform to apply. All that is required is a record of how much was applied at the last visit and the observation of residual Endoform in the wound bed. I now teach staff to utilize this approach with each patient visit to standardize care and optimize the use of Endoform. 


Wound Care in the First Person is made possible through the support of Aroa Biosurgery Limited and Appulse ( The opinions and statements of the clinicians providing Wound Care in the First Person are specific to the respective authors and not necessarily those of Appulse, Wound Management & Prevention, or HMP. This article was not subject to the Wound Management & Prevention peer-review process.