EDAs aren’t first choice, but they have their place

The key is knowing when to use them

Given a choice in debridement techniques, surgery is still the method preferred by Lawrence Kollenberg, DPM, medical director of the Garland Count Foot Clinic in Hot Springs, AR, and a licensed pharmacist. But he also recognizes the importance of chemical debridement using enzymatic debridement agents (EDAs). The most well-known EDAs include collagenase, sutilains, Accuzyne, and Panafil.

"As a surgeon, I feel I can get better results in general with surgery assuming the patient meets certain requirements. Surgery is quicker, cleaner, and faster, and patients want to get back to normal life as fast as possible," he says. "But some patients, because of medical or financial necessity, must be treated with EDAs or wet-to-dry dressings."

Typically, patients with stage II wounds are not yet surgical candidates and can often benefit from chemical debridement. Chemical debridement also may be preferable for patients with vascular compromise, such as arterial sclerosis, who are therefore high surgical risks and unsuitable for mechanical debridement, Kollenberg says.

Robert Kirsner, MD, assistant professor of dermatology at the University of Miami School of Medicine and co-director of the Cutaneous Ulcer Rehabilitation and Education program at Columbia Cedars Medical Center in Miami, will consider chemical debridement in several situations:

• for hospitalized patients in which occlusive dressings are not working optimally;

• when personnel are available to change dressings frequently;

• when occlusive dressings have been ineffective, and the patient is reluctant to have surgery, or medical problems preclude surgical intervention.

Kirsner finds that, as with occlusive dressings, some chemical agents sometimes work better than others, but as yet he hasn’t determined any pattern that would help to select one over another. "Sometimes changing an occlusive dressing frequently will improve results in one wound while in another that same action will result in a steady state," he says. "I’ve found the same type of situation with chemical debridement in which one will work better than another for no apparent reason."

EDAs are contraindicated in a number of situations. For instance, their use is dicey when bone is infected or exposed. "You want to preserve any periosteal cover that is present at the bony level, and if you can get the bone to stimulate bleeding, then you want it to grow granulation tissue directly off the bone," explains Kollenberg. "My concern is that the enzymatic agent may end up inhibiting that process."

Kollenberg emphasizes that once healthy tissue appears around the wound, EDA use should be discontinued. "I don’t like to use enzymatic agents for epithelialization because they’re too slow," he explains. "There’s a whole host of wound care products that can be used and will assist once the wound bed is no longer necrotic." Glycosaminoglycans (GAGs), collagens, and cytokines are some examples.

Kollenberg also says that new methods to aid epithelial growth are under investigation, such as dermal grafting systems, which have shown promise during clinical trials but are still some time from reaching the market. "When they do become available, I’d like to see cost-effectiveness compared with treatments such as a combination of GAGs and collagens," he says. n