Company insight Healing innovation
Chronic wounds are a major challenge worldwide. This from an economic standpoint – as managing them expends time and resources – and from a patient outcome perspective, as wounds that aren’t managed effectively can lead to significant morbidity and mortality. Professor Joachim Dissemond, MD, Department of Dermatology, Venerology and Allergology, University of Essen, Germany, is one of several academics who believe bringing more standardisation to the care of chronic wounds will improve their management, and outcomes. He tells Practical Patient Care about the M.O.I.S.T. concept developed by him and his colleagues and how it improves upon the current framework for treating wounds.
What makes chronic wounds a challenge for healthcare professionals to manage? Prof. Joachim Dissemond: One major problem is the heterogeneous approach to patients with chronic wounds. Each patient with wounds must be considered individually because there are many individual cofactors and comorbidities that must be considered. This is true both for the diagnosis and therapy applied. Age is a common consideration, but there are also medical issues such as obesity and mobility restrictions, as well as the individual and combined impact of medications. All of these things can be compounding factors in impaired wound healing.
What are the most common reasons behind impaired wound healing? Worldwide, chronic wounds are most frequently caused by damage to the venous and/or arterial vascular system, either in the context of diabetes mellitus or by pressure damage.
In addition to these common causes there are numerous less-common factors that can contribute to impaired healing in chronic wounds – especially when they’re considered together as part of a holistic picture of patient health. Infectious diseases or autoimmune conditions are two relevant examples; in both cases, a difficult-to-control inflammation can be triggered that makes it harder for wounds to transition from the inflammatory to the proliferative phase. Inflammation is the immune system’s response to harmful stimuli, such as pathogens, damaged cells, toxic compounds, or irradiation. An inflammatory response is aimed at removing injurious stimuli and initiating the healing process. But if a wound doesn’t complete the transition from
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From T.I.M.E. to M.O.I.S.T. (Dissemond et al, 2017). T: Tissue
I: Infection and inflammation M: Moisture balance E: Edge of the wound
M: Moisture balance O: Oxygen balance I: Infection control
S: Supporting strategies T: Tissue management
The factors of the T.I.M.E. concept designated by ‘T’, ‘I’, and ‘M’ were deemed to be still highly applicable and important. They were, therefore, included, albeit slightly modified, in the M.O.I.S.T. concept.
The letter ‘E’ of the T.I.M.E. concept originally stood for epidermis and subsequently for edge (wound margins) (Schultz et al, 2003; 2004), and comprised very different concepts aimed at wound-bed preparation and promotion of re-epithelialisation, such as debridement, skin grafts, and biological wound therapies. In the M.O.I.S.T. concept, ‘E’ has now been replaced by the letters ‘O’ for oxygen balance and ‘S’ for supporting strategies, thus allowing for the inclusion of new treatment options for targeted therapy in a much more differentiated fashion.
inflammation to proliferation, prolonged inflammation can occur and may result in deregulated differentiation and activation of skin cells. This impedes the normal stages of wound healing and ultimately results in a wound that doesn’t heal, otherwise known as a chronic wound.
How do healthcare professionals currently decide on the appropriate treatment for wounds?
The most important component of therapy is always treating the cause behind a wound that isn’t healing. The basic principle of conservative treatment revolves around modern moist wound care, oriented toward the different phases of treatment. Individual products are typically selected based on the experience of healthcare professionals, the availability of products, costs and patient preferences. There is a wide range of wound dressings produced by the respective manufacturers for specific phases of wound care. Despite this, there are only a few high-quality clinical studies that validate the implementation of an evidence-based wound treatment concept.
How does the M.O.I.S.T. framework improve on the current standard of care? The M.O.I.S.T. concept was developed to give healthcare professionals a structured approach to follow for patients with chronic wounds. Here, the M (moisture balance) means that attention must be paid to good exudate management. The O (oxygen balance) aspect refers to the often-disturbed balance of oxygen supply. Hypoxia is present in most chronic wounds, and in recent years, more and more therapies have been developed that actively bring oxygen into wounds from the outside, for example via haemoglobin transport. The letter I (infection control) describes all measures that treat infections in wounds. It is therefore primarily concerned with combating bacteria. The letter S (supporting strategies) describes a very
heterogeneous group of wound products that are intended to actively influence and improve the wound healing process. The modulation of matrix
metalloproteinases is an example here. Finally, there is T (tissue management),
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