Study reference

Study characteristics

Patient characteristics

Intervention (I)

Comparison / control (C)

Follow-up

Outcome measures and effect size

Comments

Brown, 2018

Systematic review

Literature search up to 31 December 2016

1. Brölmann, 2013
2. Solanki, 2012

Study design:

Evidence-based review

Setting and Country:

Not specifically reported.

Source of funding and conflicts of interest:

Not reported.

Inclusion criteria SR:

• Papers from any country of origin and published in English;
• Full study published;
• Human studies;
• Study participants requiring a STSG;
• Study participants of all ages;
• Published after December 31, 2005;
• Moist and non-moist dressing materials.

Exclusion criteria SR:

• Papers published in a language other than English;
• Incomplete study published;
• Animal studies;
• Participants not requiring a STSG;
• Published before December 31, 2005.

17 studies included (15 studies in the SR of Brown were excluded for this particular guideline).

Important patient characteristics at baseline:

N, mean age

1. Hydrocolloid: 61 (17)

Hydrofibre: 60 (16)

Silicone: 62 (17)

Gauze: 62 (18)

Film: 61 (18)

Alginate: 60 (18)

2. DUODERM: 47.0 (median)

AWBAT-D: 49.5 (median)

Sex:

1. Hydrocolloid: 32/49 male

Hydrofibre: 27/47 male

Silicone: 36/48 male

Gauze: 30/50 male

Film: 37/49 male

Alginate: 36/45 male

2. Not reported.

Groups comparable at baseline?

Not reported.

Describe intervention:

1. Hydrocolloid/ antimicrobial hydrofiber (Aquacel) dressings /silicone/film/gauze/alginate treatment. Secondary dressings were cotton gauzes and bandages to ensure equal treatment in all groups.
2. DUODERM

Describe  control:

1. Compared to each other
2. AWBAT-D (new, purpose-designed biosynthetic material).

End-point of follow-up:

1. 12 weeks after complete wound healing
2. Not reported.

For how many participants were no complete outcome data available?

1. N=10 (3.5%) dropouts. Crossover varied from three times in the hydrocolloid group to ten times in the hydrofibre group, owing to unfamiliarity with the product (14), preference of the patient (12), infection (6), leakage (3) or logistical reasons (2). The effects of these dropouts and crossovers were avoided by means of the intention-to-treat analysis.
2. None.

Time to wound healing

Defined as

1. full re-epithalialization fo the donor site without any remaining scabs.
2. Time when the donor site no longer required a dressing.

Time to wound healing, mean (SD) (95% CI):

1. Hydrocolloid: 19.4 (11.5)

Hydrofibre: 26.0 (18.2)

Silicone: 29.2 (22.5)

Alginate: 27.1 (14.4)

Film: 32.9 (6.2)

Gauze: 27.9 (17.1)

Time to wound healing, median (IQR):

1. Hydrocolloid: 16 (12 to 21) days

Hydrofibre: 22 (15 to 27) days

Silicone: 26 (18 to 33) days

Alginate: 22 (19 to 28) days

Film: 23 (14 to 36) days

Gauze: 22 (18 to 33) days

2. DUODERM: 11 (not reported) days

AWBAT-D: 17 (not reported) days

Pain (VAS 0-10), median (IQR)

1. Hydrocolloid: 0.2 (0 to 1.1)

Hydrofibre:0.8 (0 to 1.5)

Silicone: 0.4 (0.1 to 1.1)

Alginate: 0.4 (0.0 to 1.9)

Film: 0.3 (0 to 1.0)

Gauze: 0.3 (0 to 1.5)

2. No data

Adverse events

Defined as:

1. Clinical infection

Allergic reaction

Hypergranulation

Other

2. Not described.

Clinical infection, n/N (%):

1. Hydrocolloid: 1/49 (2%)

Hydrofibre: 7/47 (15%)

Silicone: 2/48 (4%)

Alginate: 0/45 (0%)

Film: 8/49 (16%)

Gauze: 9/50 (18%)

Allergic reaction, n/N (%):

1. Hydrocolloid: 0/49 (0%)

Hydrofibre: 0/47 (0%)

Silicone: 0/48 (0%)

Alginate: 0/45 (0%)

Film: 0/49 (0%)

Gauze: 0/50 (0%)

Hypergranulation, n/N (%):

1. Hydrocolloid: 1/49 (2%)

Hydrofibre: 1/47 (2%)

Silicone: 2/48 (4%)

Alginate: 1/45 (2%)

Film: 1/49 (2%)

Gauze: 0/50 (0%)

Other, n/N (%):

1. Hydrocolloid: 0/49 (0%)

Hydrofibre: 0/47 (0%)

Silicone: 1/48 (2%)

Alginate: 0/45 (0%)

Film: 2/49 (4%)

Gauze: 2/50 (4%)

Adverse events

2. DUODERM: 0/8 (0%)

AWBAT-D: 0/8 (0%)

Patient satisfaction with dressing

Defined as:

1. A score of 1 indicates very dissatisfied and 10 indicates very satisfied.
2. Study does not report patient satisfaction

Patient satisfaction: Total POSAS score (patient), median (IQR)

1. Hydrocolloid: 10 (8 to 12)

Hydrofibre: 10 (7 to 15)

Silicone: 11 (9 to 14)

Alginate: 10 (7 to 13)

Film: 14 (11 to 15)

Gauze: 11 (8 to 15)

2. No data.

Patient satisfaction: Total POSAS score (observer), median (IQR)

1. Hydrocolloid: 10 (8 to 14)

Hydrofibre: 11 (9 to 15)

Silicone: 11 (8 to 13)

Alginate: 11 (8 to 14)

Film: 11 (10 to 15)

Gauze: 12 (8 to 14)

2. No data.

Patient satisfaction with dressing, median (IQR)

3. Hydrocolloid: 7.6 (1 to 10)

Hydrofibre: 7.3 ( 4 to 10)

Silicone: 7.7 (2 to 10)

Alginate: 7.7 (4 to 10)

Film: 7.5 (1 to 10)

Gauze: 8.0 (5 to 10)

4. No data.

Overall scar (patient) rating, median (IQR)

Defined as: for observer and patient a score of 1 indicates normal skin, and 10 indicates the worst possible results.

1. Hydrocolloid: 3 (2 to 5)

Hydrofibre: 3 (2 to 5)

Silicone: 2.5 (1 to 4)

Alginate: 2 (2 to 5)

Film: 4 (1 to 4)

Gauze: 2 (2 to 5)

Overall scar (observer) rating, median (IQR)

1. Hydrocolloid: 2 (2 to 3)

Hydrofibre: 2 (1 to 3)

Silicone: 2 (2 to 4)

Alginate: 3 (2 to 4)

Film: 3 (2 to 4)

Gauze: 3 (2 to 4)

2. No data.

Author’s conclusion

The aim of this evidence-based review was to provide a critical review of the evidence relating to the efficacy of dressing materials in relation to healing and pain reduction. Based on the current evidence, it was determined that moist wound healing dressing products have a clear clinical advantage over non-moist dressing products in the management of split-thickness skin graft donor site wounds. This advantage relates to healing and pain/comfort. Clinicians have identified these areas to be the most important in donor site wound care. The numerous dressing types did not allow for the detection of clear trends regarding the performance of each dressing type. To date, there has been limited discussion about the influence of secondary dressings as well as methods/techniques of primary dressing use on donor site wounds. Further research is clearly warranted in this area and should aim at examining the role of secondary dressing use and using more than one primary dressing product throughout the donor site wound-healing process should be considered. As highlighted by Holden,75 it is not practical or appropriate to leave many donor site wound dressings in situ for 2 weeks.

Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

Macharia, 2019

Type of study:

Randomized controlled trial

Setting and country:

Kenyatta National Hospital, a tertiary referral and teaching hospital in Kenya.

Funding and conflicts of interest:

None.

Inclusion criteria:

• Patients undergoing split-thickness skin graft.

Exclusion criteria:

• Patients who were on steroids;
• Patients who were using chemotherapeutic agents;
• Patients with poorly controlled diabetes;
• Patients who smoked;
• Patients with advanced stage HIV disease.

N total at baseline: n=88

Paraffin gauze (BACTIGRAS): n=22

Hydrocolloid (DUODERM): n=22

Antimicrobial hydrofiber (Aquacel): N=22

Antimicrobial foam (KENDAL): n=22

Important prognostic factors²:

age ± SD:

The age range for the patients was 19 to 49 years, with a mean of 35.4 years.

Sex:

Male-to-female ratio was 5:4.

Other characteristics: wound types

Burns: 56/88 (63.6%)

Trauma: 27/88 (30.7%)

Chronic wounds (cellulitis): 2/88 (2.3%)

Diabetic wounds, with cellulitis: 1/88 (1.1%)

Penile wounds (necrotizing fasciitis: 1/88 (1.1%)

Postmalignant excision: 1/88 (1.1%)

Groups comparable at baseline?

Not clearly reported, but probably yes.

Describe intervention:

Paraffin gauze (BACTIGRAS) , hydrocolloid (DUODERM), antimicrobial hydrofiber (Aquacel), or antimicrobial foam (KENDAL) was used to cover the donor site wound.

Describe  control:

Compared with each other

Length of follow-up:

10 days

Loss-to-follow-up:

None.

Wound healing

Mean epithelialization score (%)

Paraffin gauze: 73.4%

Hydrocolloid: 92.2%

Aquacel: 91.4%

Kendall: 11%

Pain

Defined as: measured on a scale of 0 to 10 using a pain visual analog score and then further categoriezed as no pain (0), mild (1-3), moderate (4-6), and severe (7-10).

Day 1: mild pain

Total: 52 patients had mild pain.

Paraffin gauze: 3.8% (n=2)

Hydrocolloid: 34.6% (n=18)

Aquacel: 28.8% (n=15)

Kendall: 32.7% (n=17)

Day 1: severe pain, n/N (%)  

Total: 24 patients had severe pain.

Paraffin gauze: 62.5% (n=15)

Hydrocolloid: not reported.

Aquacel: not reported

Kendall: not reported.

Day 1: mean pain scores (no SD reported)

Paraffin gauze: 6.7

Hydrocolloid: 2.5

Aquacel: 3.7

Kendall: 3.4

Day 3, mild pain

Total: 68 patients had mild pain

Paraffin gauze: not reported.

Hydrocolloid: 28.8% (n=20)

Aquacel: not reported.

Kendall: 31.4% (n=21)

Day 3: mean pain scores (no SD reported)

Paraffin gauze: 4.8

Hydrocolloid: 1.8

Aquacel: 2.5

Kendall: 2.0

Day 3, severe pain

Total: 8 patients had severe pain

Paraffin gauze: 87.5%)

Hydrocolloid: not reported.

Aquacel: not reported.

Kendall: not reported.

Day 10, mild pain

No data.

Day 10, severe pain

Total: not reported.

Paraffin gauze: not reported.

Hydrocolloid: 3.4%

Aquacel: not reported.

Kendall: 69.0%

Day 10: mean pain scores (no SD reported)

Paraffin gauze: 5.0

Hydrocolloid: 2.2

Aquacel: 4.3

Kendall: 8.0

Adverse events

Defined as infection.

Infection incidence (%)

Total: 6.8%

Paraffin gauze: 83%

Hydrocolloid: not reported  0%?

Aquacel: 0%

Kendall: 0%

Author’s conclusion

This study demonstrated that donor site wound healing and morbidity are influenced by the dressing material. There are no 2 dressing materials with similar properties. It is thus paramount for the physician to familiarize with the qualities of a given dressing material before deciding on which to use on the donor sites. Paraffin gauze dressing had high donor site morbidities and should thus be discouraged in day-to-day use of the donor site wounds. Hydrocolloids and the hydrofiber silver dressings had the least donor site morbidities and should probably be used more routinely. Antimicrobial foam dressings on the other hand adhere to the donor site resulting in excessive pain and disrupting the healing epithelium upon removal. They

Cadier, 1996

Type of study:

RCT.

Setting and country:

Not reported.

Funding and conflicts of interest:

Not reported.

Inclusion criteria:

• >12 years old;
• Burns not exceeding 40% body surface area.

Exclusion criteria:

• Presence of an inhalational element;
• Clinical infection;
• Steriod or immunosuppressant therapy.

N total at baseline: n=21

All patients were their own control

Important prognostic factors²:

age ± SD:

Not reported.

Sex:

Not reported.

Groups comparable at baseline?

Yes.

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Tulle dressing (Jellonet)

Length of follow-up:

14 days.

Loss-to-follow-up:

None.

Wound healing (reepithelialization), mean (SD)

Specific numbers not reported  hydrocolloid significantly less painful than the jellonet (P=0.056 on day 2, p<0.023 on days 4,7, and final assessment).

Author’s conclusion

We would strongly advocate the use of Dermasorb as a donor site dressings because it is relatively pain free and appears to promote rapid donor site re-epithelialization.

Smith (1993)

Type of study:

RCT

Setting and country:

Funding and conflicts of interest:

N total at baseline: n=30

Intervention: n=14

Control: n=16

Important prognostic factors²:

age ± SD:

Not reported.

Sex:

Not reported.

Groups comparable at baseline?

Unclear.

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Fine mesh gauze

Length of follow-up:

17 days.

Loss-to-follow-up:

N=3

Healing time, n (%)

5-8 days

I: 4/12 (33.3%)

C: 1/13 (7.7%)

9-12 days

I: 6/12 (50%)

C: 7/13 (53.8%)

13-17 days

I: 2/12 (16.7%)

C: 5/13 (38.5%)

Author’s conclusion

In conclusion, the biologic significance of this study was that the occlusive hydrocolloid dressing used was superior overall when compared with the conventional dressing. Occlusion of the wounds resulted in fewer infections, and donor sites healed more rapidly.

Tan (1993)

Type of study:

RCT

Setting and country:

New Zealand

Funding and conflicts of interest:

Not reported.

N total at baseline: n=60

Intervention: n=32

Control: n=28

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Zenoderm dressings

Length of follow-up:

10 days.

Loss-to-follow-up:

N=4

Wound healing (reepithelialization), mean (SD)

Complete wound healing day 10

I: 31/32 (97%)

C: 21/28 (75%)

Infection, n (%)

I: 0/32 (0%)

C:2/28 (7.1%)

Author’s conclusion

Two donor sites of the ZM group and none of the DE group developed clinical infection. although the incidence is not statistically significant. In neither of the two patients did the dressing slip. ZM was shown to be impermeable to various bacteria and Candida albicans (Nangia and Hung, 1990a) and it is presumed that in the absence of dressing slippage, donor site contamination occurred during harvesting of the skin graft or by haematogenous spread.

Feldman, 1991

Type of study:

RCT

Setting and country:

Not reported.

Funding and conflicts of interest:

Not reported.

N total at baseline: n=30

Hydrocolloid: n=10

Biobrane: n=10

Xeroform: n=10

Important prognostic factors²:

age ± SD:

Not reported.

Sex:

Not reported.

Groups comparable at baseline?

Unclear.

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Xeroform dressings

Length of follow-up:

Until complete wound healing

Loss-to-follow-up:

Not reported.

Pain, mean:

Hydrocolloid: 0.53

Xeroform: 2.41

Costs:

Hydrocolloid: $54.88

Xeroform: $1.16

Porter (1991)

Type of study:

RCT

Setting and country:

Not reported.

Funding and conflicts of interest:

Not reported.

N total at baseline: n=65

Intervention: n=31

Control: n=34

Important prognostic factors²:

age ± SD:

Not reported.

Sex:

30 F; 35 M

Groups comparable at baseline?

Yes.

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Alginate dressings

Length of follow-up:

Until complete wound healing

Loss-to-follow-up:

None.

Wound healing (reepithelialization), mean (SD)

Mean time to complete healing in days, mean (range)

I: 10.0 (6-15)

C: 15.5 (7-35)

Author’s conclusion

Hydrocolloid dressings have certain clear advantages in hospitalized patients. The time to complete healing of the donor area is rapid, the quality of the regenerated skin is excellent and the dressing is simple to change, due to the non-adherence between the wound and the hydrocolloid gel. As there is low friction between the wound surface and the dressing, hydrocolloid dressings are particularly suitable for awkwardly sited donor areas, which may rub against the bedclothes or have to take some of the patient’s weight. Leakage of wound exudate is the main practical problem in the clinical use of hydr eolloid dressings; this problem can be overcome for inpatients by changing the dressing but may be the cause of considerable difficulties in the management of outpatients. Alginate dressings are simple to apply in theatre and can safely be ignored until they separate spontaneously. In outpatients alginates are probably the dressing of choice, due to the absence of wound leakage.

Leicht (1989)

Type of study:

RCT

Setting and country:

Department of Plastic Surgery and Bums Unit, Kobenhavns Kommunes Hvidovre Hospital, University of Copenhagen, Denmark

Funding and conflicts of interest:

Not reported.

Inclusion criteria:

Exclusion criteria:

N total at baseline: n=

Intervention: n=

Control: n=

Important prognostic factors²:

age ± SD:

50.3 years (range 16-90)

Sex:

Not reported.

Groups comparable at baseline?

Yes.

Describe intervention (treatment/procedure/test):

Hydrocolloid dressings

Describe  control (treatment/procedure/test):

Omiderm dressings.

Length of follow-up:

Until complete wound healing.

Loss-to-follow-up:

None.

Wound healing (reepithelialization), mean (SD)

Mean healing time

I: 7.8 days (range 7-10 days)

C: 10.6 days (range 9-13 days)

Author’s conclusion

This trial with Omiderm and Duoderm dressings on comparable donor sites showed that neither fulfils the demands for the ideal temporary dressing material. Although resulting in extra dressing changes because of fluid accumulation beneath the dressing, Duoderm is recommendable since it provides fast and solid re-epithelialization and is comfortable for the patient.

Brown (2018)

Yes

Yes

Yes

Yes

Not applicable

Yes

Yes

Unclear

Unclear

Study reference

(first author, publication year)

Was the allocation sequence adequately generated? ^a

Definitely yes

Probably yes

Probably no

Definitely no

Was the allocation adequately concealed?^b

Definitely yes

Probably yes

Probably no

Definitely no

Blinding: Was knowledge of the allocated

interventions adequately prevented?^c

Were patients blinded?

Were healthcare providers blinded?

Were data collectors blinded?

Were outcome assessors blinded?

Were data analysts blinded?

Definitely yes

Probably yes

Probably no

Definitely no

Was loss to follow-up (missing outcome data) infrequent?^d

Definitely yes

Probably yes

Probably no

Definitely no

Are reports of the study free of selective outcome reporting?^e

Definitely yes

Probably yes

Probably no

Definitely no

Was the study apparently free of other problems that could put it at a risk of bias?^f

Definitely yes

Probably yes

Probably no

Definitely no

Overall risk of bias

If applicable/necessary, per outcome measure^g

LOW

Some concerns

HIGH

Macharia, 2019

Definitely yes;

Reason: Computer-generated randomization program.

Definitely yes;

Reason: Computer-generated randomization program.

Probably no;

Reason: Blinding of patients, data collectors, and data analysts not reported.

Definitely yes;

Reason: No loss to follow-up reported. 

Definitely yes;

Reason: All relevant outcomes were reported

Definitely yes;

Reason: No other problems noted

Some concerns (pain, healing time, infection not blinded)

Brölmann, 2013

Definitely yes;

Reason: This trial was stratified by centre, with a balanced allocation ratio for each treatment arm using a biased coin.

Definitely yes;

Reason: This trial was stratified by centre, with a balanced allocation ratio for each treatment arm using a biased coin.

Probably no;

Reason: Blinding of patients and care providers was obviously not possible. However, to avoid performance bias, patients were instructed only about how to use their wound dressing and wound care, without expressing any expectations regarding the effectiveness of the dressings in the trial.

Probably yes

Reason: Loss to follow-up was infrequent in the groups.

Definitely yes;

Reason: All relevant outcomes were reported

Definitely yes;

Reason: No other problems noted

Some concerns (pain, healing time, patient satisfaction not blinded)

Solanki, 2012

Probably yes;

Reason: Randomization was done using sealed envelopes opened in the operating theatre.

Reason: Randomization was done using sealed envelopes opened in the operating theatre.

Probably no;

Reason: Blinding of patients, data collectors, and data analysts not reported.

Definitely yes;

Reason: Loss to follow-up was infrequent in the groups.

Definitely yes;

Reason: All relevant outcomes were reported

Definitely yes;

Reason: No other problems noted

Some concerns (pain, wound size, healing time, scar formation not blinded)

Cadier, 1996

Probably yes;

Reason: The areas were randomly allocated, by use of sealed envelopes, to either regimen A or regimen B.

No information

Probably no;

Reason: Blinding of patients, data collectors, and data analysts not reported.

Probably yes;

Reason: Loss to follow-up was not reported in the groups.

Definitely yes;

Reason: All relevant outcomes were reported

Definitely yes;

Reason: No other problems noted

Some concerns (allocation concealment unclear, blinding unclear)

Tan (1993)

Probably yes;

Reason: The remaining 64 patients were randomly assigned to a dressing regime of either ZM or DE.

No information

Probably no;

Reason: Blinding of patients, data collectors, and data analysts not reported.

Probably no;

Reason: Two patients in the ZM group were excluded during the course of study due to violation of the protocol. A further 2 patients in this group developed clinical infection of their donor sites and had their dressing regime changed.

Definitely yes;

Reason: all relevant outcome measures were reported

Definitely yes;

Reason: No other problems noted

Some concerns (allocation concealment unclear, blinding unclear, bias due to loss to follow-up).

Smith (1993)

No information

No information

No information

Probably yes;

Reason: lost to follow-up almost equal in both groups.

Definitely yes;

Reason: all relevant outcome measures were reported

Definitely yes;

Reason: No other problems noted

Some concerns (no information regarding randomization, allocation concealment, and blinding).

Feldman (1991)

Probably yes;

Reason: Envelope containing one of the three dressing assignments was opened.

No information

No information

Probably yes;

Reason: Loss to follow-up was not reported in the groups.

Definitely yes;

Reason: all relevant outcome measures were reported

Definitely yes;

Reason: No other problems noted

Some concerns (no information regarding allocation concealment and blinding).

Porter (1991)

Probably yes;

Reason: Before the grafts were cut, the patients were randomised between the hydrocolloid and the alginate dressings, using cards in sealed envelopes.

No information

No information

Probably yes;

Reason: Loss to follow-up was not reported in the groups.

Definitely yes;

Reason: all relevant outcome measures were reported

Definitely yes;

Reason: No other problems noted

Some concerns (allocation concealment unclear, blinding unclear, bias due to loss to follow-up).

Leicht (1989)

No information

No information

No information

No information

Definitely yes;

Reason: all relevant outcome measures were reported

Definitely yes;

Reason: No other problems noted

Some concerns (no information regarding randomization, allocation concealment, and blinding).