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. 2017 Jun 22;6(6):CD011947.
doi: 10.1002/14651858.CD011947.pub2.

Dressings and topical agents for treating pressure ulcers

Maggie J Westby  1 , Jo C Dumville, Marta O Soares, Nikki Stubbs, Gill Norman
Affiliations

Dressings and topical agents for treating pressure ulcers

Maggie J Westby et al. Cochrane Database Syst Rev. .

Abstract

Background: Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. Dressings are widely used to treat pressure ulcers and promote healing, and there are many options to choose from including alginate, hydrocolloid and protease-modulating dressings. Topical agents have also been used as alternatives to dressings in order to promote healing.A clear and current overview of all the evidence is required to facilitate decision-making regarding the use of dressings or topical agents for the treatment of pressure ulcers. Such a review would ideally help people with pressure ulcers and health professionals assess the best treatment options. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

Objectives: To assess the effects of dressings and topical agents for healing pressure ulcers in any care setting. We aimed to examine this evidence base as a whole, determining probabilities that each treatment is the best, with full assessment of uncertainty and evidence quality.

Search methods: In July 2016 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

Selection criteria: Published or unpublished randomised controlled trials (RCTs) comparing the effects of at least one of the following interventions with any other intervention in the treatment of pressure ulcers (Stage 2 or above): any dressing, or any topical agent applied directly to an open pressure ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factor treatments, platelet gels and larval therapy.

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment and data extraction. We conducted network meta-analysis using frequentist mega-regression methods for the efficacy outcome, probability of complete healing. We modelled the relative effectiveness of any two treatments as a function of each treatment relative to the reference treatment (saline gauze). We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals for individual treatments compared with every other, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

Main results: We included 51 studies (2947 participants) in this review and carried out NMA in a network of linked interventions for the sole outcome of probability of complete healing. The network included 21 different interventions (13 dressings, 6 topical agents and 2 supplementary linking interventions) and was informed by 39 studies in 2127 participants, of whom 783 had completely healed wounds.We judged the network to be sparse: overall, there were relatively few participants, with few events, both for the number of interventions and the number of mixed treatment contrasts; most studies were small or very small. The consequence of this sparseness is high imprecision in the evidence, and this, coupled with the (mainly) high risk of bias in the studies informing the network, means that we judged the vast majority of the evidence to be of low or very low certainty. We have no confidence in the findings regarding the rank order of interventions in this review (very low-certainty evidence), but we report here a summary of results for some comparisons of interventions compared with saline gauze. We present here only the findings from evidence which we did not consider to be very low certainty, but these reported results should still be interpreted in the context of the very low certainty of the network as a whole.It is not clear whether regimens involving protease-modulating dressings increase the probability of pressure ulcer healing compared with saline gauze (risk ratio (RR) 1.65, 95% confidence interval (CI) 0.92 to 2.94) (moderate-certainty evidence: low risk of bias, downgraded for imprecision). This risk ratio of 1.65 corresponds to an absolute difference of 102 more people healed with protease modulating dressings per 1000 people treated than with saline gauze alone (95% CI 13 fewer to 302 more). It is unclear whether the following interventions increase the probability of healing compared with saline gauze (low-certainty evidence): collagenase ointment (RR 2.12, 95% CI 1.06 to 4.22); foam dressings (RR 1.52, 95% CI 1.03 to 2.26); basic wound contact dressings (RR 1.30, 95% CI 0.65 to 2.58) and polyvinylpyrrolidone plus zinc oxide (RR 1.31, 95% CI 0.37 to 4.62); the latter two interventions both had confidence intervals consistent with both a clinically important benefit and a clinically important harm, and the former two interventions each had high risk of bias as well as imprecision.

Authors' conclusions: A network meta-analysis (NMA) of data from 39 studies (evaluating 21 dressings and topical agents for pressure ulcers) is sparse and the evidence is of low or very low certainty (due mainly to risk of bias and imprecision). Consequently we are unable to determine which dressings or topical agents are the most likely to heal pressure ulcers, and it is generally unclear whether the treatments examined are more effective than saline gauze.More research is needed to determine whether particular dressings or topical agents improve the probability of healing of pressure ulcers. The NMA is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference and cost.

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Conflict of interest statement

Maggie Westby: my employment at the University of Manchester is funded by National Institute for Health Research (NIHR) and focuses on high priority Cochrane Reviews in the prevention and treatment of wounds.

Jo Dumville: I receive research funding from the National Institute for Health Research (NIHR) for the production of systematic reviews focusing on high priority Cochrane Reviews in the prevention and treatment of wounds. This work was also partly funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester.

Marta Soares: none known.

Nikki Stubbs: funding from pharmaceutical companies has supported training and educational events, and payments have been received by the author for non‐product‐related educational sessions. These have been unrelated to the subject matter of the review and have never been in support or in pursuit of the promotion of products.

Gill Norman: my employment at the University of Manchester is funded by the National Institute for Health Research (NIHR) and focuses on high priority Cochrane Reviews in the prevention and treatment of wounds.

Figures

1
1
Study flow diagram
2
2
Network diagram ‐ individual interventions, by risk of bias (3 categories) Key: green = low/unclear; yellow = high; red = very high overall risk of bias for the contrast. The number of studies for each contrast is given in Table 3.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study
4
4
NMA results: individual intervention 1 versus individual intervention 2 
 Key for overall risk of bias for the contrast: green = low/unclear; one red = high; two reds = very high
5
5
Rankograms for each intervention ‐ individual network
6
6
Funnel plot ‐ individual network Key to interventions: 1: saline gauze; 2: alginate dressing; 3: sequential hydrocolloid alginate dressings; 4: basic wound contact dressing; 5: collagenase ointment; 6: dextranomer; 7: foam dressing; 8: hydrocolloid dressing; 9: hydrocolloid +/‐ alginate (hydrocolloid dressing with/without alginate filler); 10: hydrogel dressing; 11: ineligible radiant heat; 12: ineligible skin substitute; 13: iodine‐containing dressing; 14: phenytoin; 15: protease‐modulating dressing; 16: PVP + zinc oxide 17: silicone + foam dressing; 18: soft polymer dressing; 19: sugar + egg white; 20: tripeptide copper gel; 21: vapour‐permeable dressing
7
7
Intervention 1 versus intervention 2 ‐ group network 
 Key for overall risk of bias for the contrast: green = low/unclear; one red = high; two reds = very high
8
8
Rankograms combined ‐ group network
9
9
Funnel plot ‐ group network Key to interventions: 1: basic dressing; 2: advanced dressing; 3: advanced or antimicrobial dressing; 4: antimicrobial dressing;
 5: collagenase ointment; 6: dextranomer; 7: phenytoin; 8: protease‐modulating dressing; 9: sugar + egg white; 10: tripeptide copper gel
10
10
Key: green = low/unclear risk of bias; yellow = high risk of bias; red = very high overall risk of bias for the contrast. The number of studies for each contrast is given in Table 11.
11
11
Risk of bias summary ‐ group network: review authors' judgements about each risk of bias item for each included study
12
12
Group network ‐ rankograms
13
13
Network diagram ‐ all interventions 
 Key: red = isolated interventions; blue = ineligible interventions joined to only one eligible intervention. Line and node weights not to scale
14
14
Contributions matrix ‐ interventions versus saline gauze (independent network) Key: 1 = saline gauze dressing; 2 = alginate dressing; 3 = sequential hydrocolloid alginate dressings; 4 = basic wound contact dressing; 5 = collagenase ointment; 6 = dextranomer; 7 = foam dressing; 8 = hydrocolloid dressing; 9 = hydrocolloid +/‐ alginate (hydrocolloid with/without alginate filler); 10 = hydrogel dressing; 11 = ineligible intervention: radiant heat; 12 = ineligible intervention: skin substitute; 13 = iodine‐containing dressing; 14 = phenytoin; 15 = protease‐modulating dressing; 16 = PVP + zinc oxide; 17 = silicone + foam dressing; 18 = soft polymer dressing; 19 = sugar + egg white; 20 = tripeptide copper gel; 21 = vapour‐permeable dressing.
15
15
Rankograms combined ‐ individual network 
 Key to interventions: 1: saline gauze; 2: alginate dressing; 3: sequential hydrocolloid alginate dressings; 4: basic wound contact dressing; 5: collagenase ointment; 6: dextranomer; 7: foam dressing; 8: hydrocolloid dressing; 9: hydrocolloid +/‐ alginate (hydrocolloid dressing with/without alginate filler); 10: hydrogel dressing; 11: ineligible radiant heat; 12: ineligible skin substitute; 13: iodine‐containing dressing; 14: phenytoin; 15: protease‐modulating dressing; 16: PVP + zinc oxide
 17: silicone + foam dressing; 18: soft polymer dressing; 19: sugar + egg white; 20: tripeptide copper gel; 21: vapour‐permeable dressing
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD011947

References

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Van De Looverbosch 2004 {published data only}
    1. Looverbosch D, Heyman H, Dierick AM. Explorative, comparative study with enamel matrix protein in pressure ulcer stage II. Second World Union of Wound Healing Societies Meeting; 2004 July 8‐13; Paris, France. 2004:X014.
Xakellis 1992 {published data only}
    1. Xakellis GC, Chrischilles EA. Hydrocolloid versus saline‐gauze dressings in treating pressure ulcers: a cost‐effectiveness analysis. Archives of Physical Medicine and Rehabilitation 1992;73(5):463‐9. - PubMed
Yapucu Güneş 2007 {published data only}
    1. Yapucu Güneş U, Eşer I. Effectiveness of a honey dressing for healing pressure ulcers. Journal of Wound Ostomy and Continence Nursing 2007;34(2):184‐90. - PubMed
Zeron 2007 {published data only}
    1. Zeron HM, Krotzsch Gomez FE, Hernandez Munoz RE. Pressure ulcers: a pilot study for treatment with collagen polyvinylpyrrolidone. International Journal of Dermatology 2007;46(3):314‐7. - PubMed

References to studies excluded from this review

Abbott 1968 {published data only}
    1. Abbott DF, Exton‐Smith AN, Millard PH, Temperley JM. Zinc sulphate and bedsores. British Medical Journal 1968;2(5607):763. - PMC - PubMed
Agren 1985 {published data only}
    1. Agren MS, Stromberg HE. Topical treatment of pressure ulcers. Scandinavian Journal of Plastic and Reconstructive Surgery 1985;19(1):97‐100. - PubMed
Ahmad 2008 {published data only}
    1. Ahmad ET. High voltage pulsed galvanic stimulation: effect of treatment durations on healing of chronic pressure ulcers. Indian Journal of Physiotherapy and Occupational Therapy 2008;2(3):1‐5. - PMC - PubMed
Alvarez 1999 {published data only}
    1. Alvarez OM, Fernandez‐Obregon A, Davis SC, Cazzaniga AL, Pacheco H. A prospective randomized clinical trial of papain‐urea for the debridement of pressure ulcers. 31st Annual Wound, Ostomy and Continence Conference; 1999 June 19‐23; Minneapolis (MN). 1999:488.
Alvarez 2000a {published data only}
    1. Alvarez OM, Fernandez‐Obregon A, Rogers RS, Bergamo L, Masso J, Black M. Chemical debridement of pressure ulcers: a prospective, randomized, comparative trial of collagenase and papain/urea formulations. Wounds 2000;12(2):15‐25.
Alvarez 2000b {published data only}
    1. Alvarez OM, Fernandez‐Obregon A, Hoboken NJ, Rogers RR, Masso J, Davis SC, et al. Enzymatic debridement of pressure ulcers: a prospective randomized comparative clinical trial. 13th Annual Symposium on Advanced Wound Care and 10th Annual Medical Research Forum on Wound Repair; 2000 April 1‐4; Dallas (TX). 2000:C69.
Alvarez 2002 {published data only}
    1. Alvarez OM, Fernandez‐Obregon A, Rogers RS, Bergamo L, Masso J, Black M. A prospective, randomized, comparative study of collagenase and papain‐urea for pressure ulcer debridement. Wounds 2002;14(8):293‐301.
Alvarez Vázquez 2014 {published data only}
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Aminian 1999 {published data only}
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Amione 2005 {published data only}
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Anonymous 2000 {published data only}
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Avanzi 1998a {published data only}
    1. Avanzi A, Martinelli R, Accardi S, Giraudi C, Peroli P, Rowan S. An adhesive hydrocellular dressing versus a hydrocolloid dressing in the treatment of 2nd and 3rd degree pressure sores. Eighth European Conference on Advances in Wound Management; 1998 April 26‐28; Madrid, Spain. 1998:116.
Avanzi 1998b {published data only}
    1. Avanzi R, Martinelli R, Accardi S, Giraudi C, Peroli P, Andriessen A, et al. Adhesive hydrocellular dressing versus hydrocolloid dressing in the treatment of stage II and III pressure sores. European Wound Management Association Conference; 1998 November; Harrogate, UK. 1998:11.
Avanzi 2000a {published data only}
    1. Avanzi A, Martinelli M, Accardi S, Giraudi C, Peroli P, Andriessen A. Adhesive hydrocellular dressing vs hydrocolloid dressing in the treatment of 2nd and 3rd degree pressure sores. 10th Conference of the European Wound Management Association; 2000 May 18‐20; Stockholm, Sweden. 2000:29.
Avanzi 2000b {published data only}
    1. Avanzi A, Martinelli R, Accardi S, Giraudi C, Peroli P, Rowan S, et al. Adhesive hydrocellular dressing vs hydrocolloid dressing in the treatment of pressure sores. First World Wound Healing Congress; 2000 September 10‐13; Melbourne, Australia. 2000:90.
Avanzi 2000c {published data only}
    1. Avanzi A, Martinelli M, Accardi S, Giraudi C, Peroli P, Andriessen A, et al. Adhesive hydrocellular dressing vs hydrocolloid dressing in the treatment of 2nd and 3rd degree pressure sores. A prospective, controlled randomised comparative multi‐centre clinical evaluation. Wound Repair and Regeneration 2000;8:A406.
Avanzi 2001 {published data only}
    1. Avanzi A, Martinelli M, Accardi S, Giraudi C, Peroli P, Andreissen A, et al. Adhesive hydrocellular dressing vs hydrocolloid dressing in the management of stage 2 and stage 3 pressure ulcers. 11th European Tissue Repair Society Annual Conference; 2001 September 5‐8; Cardiff, Wales. 2001:43.
Baade 1965 {published data only}
    1. Baade S. Local application of an anabolically active steroid to promote wound healing. Die Medizinische Welt 1965;32:1828‐30. - PubMed
Baatenburg de Jong 2004 {published data only}
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Baker 1981 {published data only}
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Bale 1997b {published data only}
    1. Bale S, Banks V, Hagelstein S, Harding KG. A randomized, controlled parallel‐group clinical trial to compare two amorphous hydrogels in the debridement of pressure sores. Sixth European Conference on Advances in Wound Management; 1996 October 1‐4; Amsterdam, the Netherlands. 1997:244‐8.
Bale 1997c {published data only}
    1. Bale S, Crook H. The preliminary results of a comparative study on the performance characteristics of a new hydrogel versus an existing hydrogel on necrotic pressure ulcers. European Wound Management Association Conference; 1997 April 27‐29; Milan, Italy. 1997:66‐8.
Bale 1998a {published data only}
    1. Bale S, Hagelstein S, Banks V, Harding KG. Costs of dressings in the community. Journal of Wound Care 1998;7(7):327‐30. - PubMed
    1. Harding KG, Bale S, Banks V, Orpin J. A cost effectiveness study using Allevyn hydrocellular dressings. Fourth European Conference on Advances in Wound Management; 1994 September 6‐9; Copenhagen, Denmark. 1995:57‐9.
Bale 1998b {published data only}
    1. Bale S, Banks V, Haglestein S, Harding KG. A comparison of two amorphous hydrogels in the debridement of pressure sores. Journal of Wound Care 1998;7(2):65‐8. - PubMed
Bale 2004 {published data only}
    1. Bale S, Tebbie N, Price P. A topical metronidazole gel used to treat malodorous wounds. British Journal of Nursing 2004;13(11):S4‐11. - PubMed
Banks 1997a {published data only}
    1. Banks V, Bale S, Harding K, Harding EF. Evaluation of a new polyurethane foam dressing. Journal of Wound Care 1997;6(6):266‐9. - PubMed
    1. Banks V, Bale S, Harding KG, Harding EF. A randomized, stratified, controlled, parallel‐group clinical trial of a new polyurethane foam dressing (Lyofoam Extra) versus a hydrocellular dressing in the treatment of moderate to heavily exuding wounds. Sixth European Conference on Advances in Wound Management; 1996 October 1‐4; Amsterdam, the Netherlands. 1997:235‐3.
    1. Banks V, Bale S, Harding KG, Harding EF. An interim analysis of a randomized stratified controlled parallel‐group clinical trial of a new polyurethane foam dressing versus a hydrocellular dressing in the treatment of moderate to heavily exuding wounds. Fifth European Conference on Advances in Wound Management; 1995, November 21‐24; Harrogate, UK. 1996:177‐80.
    1. Banks V, Fear M, Orpin J, Hagelstein S, Thomas N, Colgate G, et al. A comparative open multi‐center trial of hydropolymer dressing and hydrocolloid. Ninth Annual Symposium on Advanced Wound Care and Sixth Annual Medical Research Forum on Wound Repair; 1996 April 20‐24; Atlanta (GA). 1996:113.
    1. Banks V, Hagelstein S, Bale S, Harding KG. A comparison of a new polyurethane dressing versus a hydrocellular dressing in the treatment of moderate to heavily exudating wounds. Ninth Annual Symposium on Advanced Wound Care and Sixth Annual Medical Research Forum on Wound Repair; 1996 April 20‐24; Atlanta (GA). 1996:113.
Banks 1997b {published data only}
    1. Banks, Fear M, Hagelstein S, Bale S, Thomas S, Harding KG. A randomized controlled community comparison of Duoderm Extra Thin with an adhesive film as a secondary dressing. Sixth European Conference on Advances in Wound Management; 1996 October 1‐4; Amsterdam, the Netherlands. 1997:238‐41.
Barnes 1992 {published data only}
    1. Barnes J, Burns K. Management of pressure sores: a comparison of Granuflex hydrocolloid dressing and Granuflex E hydrocolloid dressing. Euroservices Communication: Going into the '90s: the Pharmacist and Wound Care 1992:19‐21.
Bazzigaluppi 1991 {published data only}
    1. Bazzigaluppi F, Biraghi MG, Fano M, Moschin AM, Toscani P, Cervone C, et al. Cadexomer iodine in the treatment of cutaneous ulcers: open, multicentric trial. Gazetta Medica Italiana 1991;150(11):471‐80.
Becker 1984 {published data only}
    1. Becker L, Goodemote C. Treating pressure sores with or without antacid. American Journal of Nursing 1984;84(3):351‐2. - PubMed
Beele 2010 {published data only}
    1. Beele H, Meuleneir F, Nahuys M, Percival SL. A prospective randomised open label study to evaluate the potential of a new silver alginate/carboxymethylcellulose antimicrobial wound dressing to promote wound healing. International Wound Journal 2010;7(4):262‐70. - PMC - PubMed
Berard 1986 {published data only}
    1. Berard P, Montandon S, Jedynak D, Saubier EC. Trial of a hydrocolloid in occlusive dressings in the treatment of skin wounds, "Duoderm". Revista de Enfermeria 1986;9(1):17‐20. - PubMed
Bigolari 1991 {published data only}
    1. Bigolari M, Mosca P, Astengo F, Biraghi M, Balestreri R. Randomized clinical trial with Cadexomer iodine in decubitus ulcers [Studio clinico randomizzato con cadexomero iodico nelle ulcere da decubito]. Gazzetta Medica Italiana 1991;150(5):177‐85.
Bito 2012 {published data only}
    1. Bito S, Mizuhara A, Oonishi S, Takeuchi K, Suzuki M, Akiyama K, et al. Randomised controlled trial evaluating the efficacy of wrap therapy for wound healing acceleration in patients with NPUAP stage II and III pressure ulcer. BMJ Open 2012;2:e000371. - PMC - PubMed
Blanco Blanco 2002 {published data only}
    1. Blanco Blanco J, Ballester Torralba J, Rueda Lopez J, Torra i Bou JE. Comparative study of the use of a heel protecting bandage and a special hydrocellular dressing in the prevention of pressure ulcers in elderly participants. 12th Conference of the European Wound Management Association; 2002 May 23‐25; Granada, Spain. 2002:114.
Blum 1973 {published data only}
    1. Blum G. Therapeutic results with Iruxol in ulcus cruris, decubitus ulcer and burns. Schweizerische Rundschau für Medizin Praxis 1973;62(26):820‐6. - PubMed
Boxer 1969 {published data only}
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Boykin 1989 {published data only}
    1. Boykin A, Winland‐Brown J. Pressure sores: nursing management. National League for Nursing Publications 1989;15(2232):252‐6.
Brady 1987 {published data only}
    1. Brady SM. Management of pressure sores with occlusive dressings in a select population. Nursing Management 1987;18:47‐50. - PubMed
Brem 2000 {published data only}
    1. Brem H, Kirsner RS. Use of Graftskin (APLIGRAF) in the treatment of pressure ulcers and acute wounds. Wounds 2000;12(5 (Suppl)):72A‐77A.
Brett 2003 {published data only}
    1. Brett DW, Alvarez OM, Fernandez‐Obregon AC. March 2003 Letters to the Editor. Wounds 2003;15(3):available from: www.woundsresearch.com/article/1368.
Brown‐Etris 1999a {published data only}
    1. Brown‐Etris M, Punchello M, Shields D, Bateman D, Stanfield J, Edvalson J, et al. Final report: a comparison clinical study to evaluate the efficacy of 20% hypertonic wound gel vs collagenase ointment for the debridement of nonviable tissue in dermal wounds. 31st Annual Wound, Ostomy and Continence Conference; 1999 June 19‐23; Minneapolis (MN). 1999:245.
Brown‐Etris 1999b {published data only}
    1. Brown‐Etris M, Punchello M, Shields D, Barnes H, Galluzzi K, Whalen A, et al. Interim analysis of a randomized prospective multi‐centred 20‐week comparison of two wound management systems on pressure ulcers. 31st Annual Wound, Ostomy and Continence Conference; 1999 June 19‐23; Minneapolis (MN). 1999.
Burgos 2000 {published data only}
    1. Burgos A, Gimenez J, Moreno E, Campos J, Ardanaz J, Talaero C, et al. Collagenase ointment application at 24‐ versus 48‐hour intervals in the treatment of pressure ulcers. A randomised multicentre study. Clinical Drug Investigation 2000;19(6):399‐407.
Burke 1998 {published data only}
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    1. Burke DT, Ho CH, Saucier MA, Stewart G. Effects of hydrotherapy on pressure ulcer healing. American Journal of Physical Medicine and Rehabilitation 1998;77(5):394‐8. - PubMed
Capillas Pérez 2000 {published data only}
    1. Capillas Pérez R, Cabre Aguilar V, Gil Colome AM, Gaitano Garcia A, Torra i Bou JE. Comparison of the effectiveness and cost of treatment with humid environment as compared to traditional cure. Clinical trial on primary care patients with venous leg ulcers and pressure ulcers. Revista de Enfermería 2000;23(1):17‐24. - PubMed
Carusone 2001 {published data only}
    1. Carusone A, Carella GR, Coppini R, Lorenzo E, Mancuso M, Mazzon S, et al. Effectiveness evaluation of a specific topic treatment for pressure sores prevention in high risk patients using transcutaneous oxymetry. 11th Conference of the European Wound Management Association; 2001 May 17‐19; Dublin, Ireland. 2001:75.
Casali 1997 {published data only}
    1. Casali B, Bonati PA, DelGin G, Ascari C. The use of a blood platelet lysate in the treatment of pressure sores. Experimental observations. European Wound Management Association Conference; 1997 April 27‐29; Milan, Italy. 1997.
Chang 1998 {published data only}
    1. Chang KW, Alsagoff S, Ong KT, Sim PH. Pressure ulcers: randomised controlled trial comparing hydrocolloid and saline gauze dressings. Medical Journal of Malaysia 1998;53(4):428‐31. - PubMed
Chen 2004 {published data only}
    1. Chen Q. Effect of egg albumen combined with infrared ray irradiation to treat patients with bedsore induced by fecal incontinence. Chinese Nursing Research 2004;18(9A):1550‐1.
Cheneworth 1994 {published data only}
    1. Cheneworth CC, Hagglund KH, Valmassoi B, Brannon C. Portrait of practice: healing heel ulcers. Advances in Wound Care 1994;7(2):44‐8. - PubMed
Chirwa 2010 {published data only}
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Chuangsuwanich 2011a {published data only}
    1. Chuangsuwanich A, Chortrakarnkij P, Karnwanpum J. Cost‐effectiveness analysis in comparing alginate silver dressing with silver zinc sulfadiazine cream in treatment of pressure ulcers. EWMA Journal 2011;11(2 Suppl):211. - PMC - PubMed
Chuangsuwanich 2011b {published data only}
    1. Chuangsuwanich A, Charnsanti O, Lohsiriwat V, Kangwanpoom C, Thong‐In N. The efficacy of silver mesh dressing compared with silver sulfadiazine cream for the treatment of pressure ulcers. Chotmaihet Thangphaet (Journal of the Medical Association of Thailand) 2011;94(5):559‐65. - PubMed
Chuangsuwanich 2013 {published data only}
    1. Chuangsuwanich A, Chortrakarnkij P, Kangwanpoom J. Cost‐effectiveness analysis in comparing alginate silver dressing with silver zinc sulfadiazine cream in the treatment of pressure ulcers. Archives of Plastic Surgery 2013;40(5):589‐96. - PMC - PubMed
Colin 1996a {published data only}
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Colin 1996b {published data only}
    1. Colin D, Kurring PA, Quinlan D, Yvon C. The clinical investigation of an amorphous hydrogel compared with a dextranomer paste dressing in the management of sloughy pressure sores. Fifth European Conference on Advances in Wound Management; 1995 November 21‐24; Harrogate, UK. 1996:155‐9.
Colonna 2004 {published data only}
    1. Colonna MR, Amadeo G, Giofre C, Strano A, Stagno D'Alcontres F. Are nanocristalline silver dressings effective in reducing both secretions and bacterial colonization in necrotic infected wounds?. Second World Union of Wound Healing Societies Meeting; 2004 July 8‐13; Paris, France. 2004:91.
Cooper 2008 {published data only}
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Coutts 2000 {published data only}
    1. Coutts P, Sibbald RG, Inman K, Maltby‐Stephens N. The use of an adhesive hydrocellular foam compared to a hydrocolloid dressing for the treatment of Stage II and III pressure ulcers. 13th Annual Symposium on Advanced Wound Care and 10th Annual Medical Research Forum on Wound Repair; 2000 April 1‐4; Dallas, (TX). 2000:D7.
D'Aniello 1998 {published data only}
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Dat 2014 {published data only}
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Day 1995 {published data only}
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Dealey 1997 {published data only}
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Dealey 1998 {published data only}
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Dealey 2008 {published data only}
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De Laat 2005 {published data only}
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De Laat 2011 {published data only}
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Dierick 2004a {published data only}
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Dierick 2004b {published data only}
    1. Dierick AM, Looverbosh D, Heyman H, Looverbosh D. An open, randomised, explorative, phase II, investigation comparing enamel matrix derivative proteins (EMD) and control in patients with pressure ulcer stage II. Wound Repair and Regeneration 2004;12(2):A26.
Dobrzanski 1990 {published data only}
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Durović 2008 {published data only}
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Dwivedi 2016 {published data only}
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Ellis 2002 {published data only}
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Ellis 2003 {published data only}
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El Zayat 1989 {published data only}
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Engdahl 1980 {published data only}
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Esch 1989 {published data only}
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Farsaei 2014 {published data only}
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Fear 1992 {published data only}
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Feldman 2005 {published data only}
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Felzani 2011 {published data only}
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Flanagan 1995 {published data only}
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Ford 2002 {published data only}
    1. Ford CN, Reinhard ER, Yeh D, Syrek D, Las Morenas A, Bergman SB, et al. Interim analysis of a prospective, randomized trial of vacuum‐assisted closure versus the healthpoint system in the management of pressure ulcers. Annals of Plastic Surgery 2002;49(1):55‐61. - PubMed
Fowler 1983 {published data only}
    1. Fowler EM. Clinical trial report: new, once‐daily pressure sore dressing speeds healing. Registered Nurse 1983;46(4):56‐7. - PubMed
Franek 2011 {published data only}
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Franek 2012 {published data only}
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Franken 1999 {published data only}
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Fulco 2015 {published data only}
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Fønnebø 2008 {published data only}
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García González 2002 {published data only}
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Garrett 1969 {published data only}
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Gerding 1992 {published data only}
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Gilligan 2014 {published data only}
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Goldmeier 1997 {published data only}
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Gostishchev 1983 {published data only}
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Guthrie 1989 {published data only}
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Hamilton Hislop 1962 {published data only}
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    1. Harada S, Ohara K, Takemura T, Niimura M, Nishikawa T, Kukita A. Clinical evaluation of M‐1011G (lysozyme hydrochloride ointment‐gauze) in patients with decubitus ulcer: a multi‐centered comparative study with lysozyme hydrochloride ointment. Rinsho Iyaku (Journal of Clinical Therapeutics and Medicine) 1996;12(2):321‐39.
Harding 1996 {published data only}
    1. Harding KG, Bale S, Stock J, Shutler S, Squires D, Wilson I, et al. A multi‐center comparison of a hydrocellular adhesive dressing and a hydrocolloid dressing in the management of stage II and III pressure ulcers. Ninth Annual Symposium on Advanced Wound Care and 6th Annual Medical Research Forum on Wound Repair; 1996 April 20‐24; Atlanta (GA). 1996:114.
Harding 2000 {published data only}
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Heuckeroth 2013 {published data only}
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Hofman 1994 {published data only}
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Horch 2005 {published data only}
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Hsu 2000 {published data only}
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Ishibashi 1996 {published data only}
    1. Ishibashi Y, Soeda S, Oura T, Nishikawa T, Niimura M, Nakajima H, et al. Clinical effects of KCB‐1, a solution of recombinant human basic fibroblast growth factor, on skin ulcers: A phase III study comparing with sugar and povidone iodine ointment. Rinsho Iyaku (Journal of Clinical Therapeutics and Medicine) 1996;12(10):2159‐87.
Janssen 1989 {published data only}
    1. Janssen PA, Janssen H, Cauwenbergh G, Doncker P, Beule K, Lewi P, et al. Use of topical ketanserin in the treatment of skin ulcers: a double‐blind study. Journal of the American Academy of Dermatology 1989;21(1):85‐90. - PubMed
Jercinovic 1994 {published data only}
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Kerihuel 2010 {published data only}
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Kloth 2000b {published data only}
    1. Kloth LC, Berman JE, Dumit‐Minkel S, Sutton CH, Papanek PE, Wurzel J. Effects of a normothermic dressing on pressure ulcer healing. Advances in Skin and Wound Care 2000;13(2):69‐74. - PubMed
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Kohr 2000 {published data only}
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Kordestani 2008 {published data only}
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Lee 2014 {published data only}
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Lum 1996 {published data only}
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Shannon 1988 {published data only}
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References to ongoing studies

ChiCTR‐TRC‐13003959 {published data only}
    1. ChiCTR‐TRC‐13003959. Moxibustion for the promotion of wound healing of pressure ulcers: randomized controlled pilot study. www.chictr.org.cn/showprojen.aspx?proj=5608 (first received 7 December 2013).
ISRCTN57842461 {published data only}
    1. ISRCTN57842461. To compare the polyurethane foam dressing (hydrocellular) and the hydrocolloid dressing in patients with pressure ulcers (stage II) in primary care. www.isrctn.com/ISRCTN57842461 (first received 19 June 2012).

Additional references

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