Addressing the Pain: Use of an Atraumatic Dressing in the Treatment of a Painful Wound Resulting from Herpes Zoster

  The overwhelming focus of the wound care specialist is on healing. However, the patient’s greatest concern may be the pain associated with his or her wound; therefore, the prescribed treatment must promote healing while minimizing pain. Despite evidence that patients experience the greatest pain with dressing removal,¹ some practitioners continue to employ dressings that exacerbate the patient’s pain, such as saline wet-to-dry dressings and topical silver sulfadiazine dressing (SSD). These dressings adhere to the wound surface and surrounding periwound skin, traumatizing the skin and wound bed and causing great discomfort. Moreover, frequent dressing changes cause wound trauma. These dressings are painful to remove and difficult to clean from the wound surface and at least twice-daily dressing changes are required.

  Newer atraumatic dressings have been shown to be effective in the treatment of painful wounds.² They reduce pain, promote healing, and may be changed once or twice a week. The following case demonstrates the use of a silicone non-adherent dressing in the treatment of a painful wound that resulted from herpes zoster.

Case Study

  Mr. P, a 54-year-old man with diabetes and end-stage hepatic failure, presented to his primary care physician with a painful lesion on his left hip. A diagnosis of herpes zoster was made and antiviral agents were initiated. Mr. P reported the severity of his pain at 8 on a scale of 1 to 10; he described the pain as continuous with cyclical spikes and he was having difficulty sleeping. Narcotic analgesics were used judiciously because of his liver disease; they did little to control his discomfort. The lesion had a crusted surface with a small amount of serosanguineous drainage. Initial wound care consisted of twice-daily application of SSD. Mr. P refused many of his dressing changes due to discomfort. The pain persisted. Infection in the wound was suspected and Mr. P received two courses of antibiotic therapy. Oral antibiotics had little effect on his discomfort and the wound worsened. The visiting nurses reduced their visits to once daily. At this point, Mr. P was referred to the wound care center.

  Mr. P presented to the wound clinic in January 2006. His non-insulin dependent diabetes was under fair control but his hepatic failure was complicated by tense abdominal ascites and peripheral muscular wasting. He was best described as “weathered” in appearance. A large, necrotic ulceration with moderate drainage was present on the left hip (see Figures 1 and 2). Surrounding erythema was minimal. He continued to report pain levels of 8 on a scale of 10; his pain prevented debridement of the ulcer at the first visit. The wound was treated with a silicone absorbent dressing, derived from a polyurethane foam (Mepilex Lite [Mölnlycke Health Care, Norcross, Ga]) (see Figure 3). The exterior lining helps prevent the passage of fluids and micro-organisms; the interior surface is a soft silicone that does not adhere to the wound surface.³ The dressing was changed every 3 days by the visiting nurses.

  After 2 days’ treatment, Mr. P reported his pain was reduced to 6 on a scale of 10. The drainage was well controlled by the dressing. On Mr. P’s second visit, the wound was debrided using local anesthetic (see Figure 4). The soft silicone dressing was changed twice weekly for the next 3 weeks. At this time, Mr. P’s pain had resolved and he no longer required narcotic analgesics. Four weeks after presentation, visiting nurse services were discontinued and Mr. P’s spouse replaced the dressing weekly. The wound continued to improve and in May 2006 was completely healed (see Figures 5, 6, and 7).

Discussion

  This case demonstrates the importance of pain control in the healing process. Once the physician’s goal of wound closure was aligned with patient’s desire for pain control, healing this complex wound in a patient whose health was compromised by severe hepatic failure became possible. The patient’s original dressing exacerbated his pain, leading to poor compliance with dressing change. Once the pain was controlled with an atraumatic dressing, basic wound care treatment, such as debridement, was acceptable. The dressing eliminated the need for narcotic analgesia, which in Mr. P’s case not only was ineffective, but also carried the risk of serious side effects. Moreover, the dressing change regimen allowed for better utilization of visiting nursing services.

Conclusion

  Soft silicone dressings provide wound care specialists a dressing alternative that reduces pain and wound trauma. When pain and trauma are addressed, other healing measures can be implemented to enhance chances for healing.

Addressing the Pain is made possible through the support of Mölnlycke Health Care, Norcross, Ga.

This article was not subject to the Ostomy Wound Management peer-review process.

1. Moffatt CJ, Franks PJ, Hollinworth H. Understanding wound pain and trauma: an international perspective. EWMA Position Document: Pain at Wound Dressing Changes. 2002:2-7.

2. Thomas S. Low adherence dressings. J Wound Care. 1994;3(1);27-30.

3. Thomas S. Atraumatic dressings. World Wide Wounds. Available at: www.worldwidewounds.com/2003/january/thomas/atraumatic-dressings.html.