How to Apply an Enzymatic Debrider?

Debridement is recognized as a major component of wound bed management to prepare the skin for the growth of new tissue. Here, we have a wound. In this case, there is limited evidence of debridement or granulation tissue. It may have been just post-complete debridement or there may have not been any debridement on it so far whatsoever. Either way, prior to application of the enzymatic debrider, you want to make sure the wound is cleaned with saline and the appropriate protocols. And, the skin around it is dry and there’s no loose debris. At that point, you want to apply the enzymatic debrider within the margins of the wound.

You want to apply the enzymatic debridement ointment to the base of the wound.  Now, the base of the wound could appear to be fairly clean with no visible necrotic tissue or minimal volume of necrotic tissue. Or, there could actually be some residual black eschar or necrosis which was not able to be removed at this particular visit due to pain, bleeding, or various other reasons. In which case, it’s possible to score it, which increases the surface area for the agent collagenase to work. Either way, the application is such that you apply it within the wound trying to avoid the wound edges. You generally try to provide a uniform coating of approximately 2 millimeters thick.

After the application of the enzymatic debrider, you’d like to make sure that the base is fully covered and that there’s not any of the enzymatic debrider with the agent collagenase on the wound edge and the periwound surface of intact skin because that will contribute to maceration, and you don’t want an adverse event.

The dressing that’s put on top of this is obviously dependent on the wound. If it’s a highly secretive wound the secretions will activate the enzymes within the ointment. In which case, you really don’t need a very moist dressing. However, if it’s a dry wound, a moist dressing is preferred because it will help activate the enzymes within the ointment and increase the efficacy of the treatment.

One thing also to make note of is that silver or iodine-containing dressings, silver and iodine will inactivate the enzymatic action and should not be used in combination or in conjunction with enzymatic debriders to prevent any adverse reaction.

After the dressing is applied, generally enzymatic debriders are changed once every day. If however, the wound is highly secretive you may increase the frequency so that you don’t incur maceration on the periwound surface. It’s not common to decrease the frequency much from Q-24 hours.

The reasons you may use enzymatic debridement as opposed to other forms are many. One is if you have debrided a wound but there’s still some residual necrosis, either black bio-film or gray necrosis or black eschar that’s residual and you’d like to without mechanically disrupting the base of the wound any further, or causing bleeding, have some continuous effect over the next week before you come back for your serial debridement in terms of removing necrotic debris.

The second reason post-debridement is that you might have some residual black eschar, which we mentioned earlier. You can score, increase the surface area and allow the collagenase to soften for the next time. This should never be used in place of sharp debridement as sharp debridement has many other advantages other than simply the removal of necrosis. But, there are many cases in which this can be used as an adjunct or might be preferable in cases where debridement might be too painful initially, the necrosis is too adherent initially because it’s such a chronic wound, and other situations similar to that.

In children, limited evidence suggests that treatment of partial-thickness burn wounds with collagenase ointment may require equivocal time to treatment with surgical excision. Still, combination treatment may reduce the requirement of surgical excision.

Regarding the choice of the debridement agent, collagenase ointment has been found more effective than inactivated ointment or petrolatum ointment for debridement of necrotic tissue from pressure ulcers, leg ulcers, and partial-thickness burn wounds. Limited evidence also suggests that agent papain-urea removes necrotic material from pressure ulcers more rapidly than collagenase ointment. However, there’s insufficient evidence comparing the performance of collagenase ointment and autolytic debridement in removing the volume of necrotic tissue from leg ulcers.