Which wound dressing is appropriate for different wound characteristics (clean low‑exudate superficial, moderately exudating partial‑thickness, dry or necrotic, infected, malodorous, deep or complex, heavily exudating) taking into account patient factors such as diabetes, peripheral vascular disease, and allergies?

Wound Dressing Selection by Wound Characteristics

Select dressings primarily based on exudate control and moisture balance, using the least expensive option that maintains a moist wound environment—not based on wound healing claims or specialized products. 1, 2

General Principles Across All Wound Types

The fundamental approach is moisture-retentive dressing matched to exudate level, with cost as the deciding factor when options are equivalent. 1

• Basic wound contact dressings perform equally well as expensive specialized products for most wounds 3
• Dressing selection should never overshadow critical interventions like debridement, offloading, and vascular assessment 3
• The TIME principle guides all wound management: Tissue debridement, Infection control, Moisture balance, and wound Edges 4

Specific Dressing Recommendations by Wound Characteristics

Clean, Low-Exudate Superficial Wounds

• Use hydrogels or films to maintain moisture in minimally draining wounds 1, 2
• Films provide occlusive or semi-occlusive coverage for dry wounds 1
• Hydrogels facilitate autolysis while keeping the wound bed moist 1, 2

Moderately Exudating Partial-Thickness Wounds

• Use hydrocolloid dressings that absorb exudate while maintaining appropriate moisture 1, 2
• These dressings facilitate autolysis and handle moderate drainage effectively 1
• For diabetic patients specifically, basic non-adherent dressings work equally well at lower cost 3

Dry or Necrotic Wounds

• Use continuously moistened saline gauze or hydrogels to facilitate autolysis 1
• Hydrogels are preferred for promoting autolytic debridement of necrotic tissue 1, 2
• Sharp debridement remains the primary intervention; dressings are adjunctive 1, 3

Heavily Exudating Wounds

• Use foam dressings as first-line for high-volume exudate 1, 2
• Critical exception for diabetic patients: Do NOT use alginate dressings despite their absorption capacity 1, 3
• The IWGDF provides strong recommendations against alginates for diabetic foot ulcers based on nine RCTs showing no benefit 1, 3

Infected Wounds

• Do NOT use antimicrobial dressings (silver, iodine, honey) to enhance healing 1
• This is a strong recommendation with moderate certainty evidence from the 2024 IWGDF guidelines 1
• Focus on systemic antibiotics, surgical debridement, and source control instead 1
• Avoid occlusive dressings during active infection 2
• Use simple moisture-retentive dressings after infection control is achieved 1

Malodorous Wounds

• Address the underlying cause (infection, necrosis) rather than masking odor with specialized dressings 5, 6
• Foul odor has high specificity (100%) for wound infection and warrants microbiological assessment 6
• Sharp debridement of necrotic tissue is the primary intervention 1, 3
• Do NOT use honey or herbal remedies despite traditional use for odor control 1

Deep or Complex Wounds

• Consider negative pressure wound therapy (NPWT) after revascularization when primary closure is not feasible 1
• NPWT is particularly useful post-amputation or after extensive debridement 1
• Standard moisture-retentive dressings remain appropriate for most deep wounds 1
• Ensure adequate vascular perfusion before selecting any advanced therapy 4

Patient-Specific Considerations

Diabetes

• Avoid collagen and alginate dressings entirely—strong recommendation from 2024 IWGDF guidelines 1, 3
• Use basic moisture-retentive dressings as standard of care 1, 3
• For non-infected neuro-ischemic ulcers failing standard care after 2 weeks, consider sucrose-octasulfate impregnated dressing 1
• Offloading and sharp debridement are more critical than dressing choice 3
• Do NOT use antimicrobial dressings routinely 1

Peripheral Vascular Disease

• Obtain ankle-brachial index, toe pressures, and transcutaneous oxygen measurements before selecting dressings 3, 4
• If toe pressure <30 mmHg or TcPO2 <25 mmHg, urgent vascular referral supersedes dressing selection 3
• After revascularization, standard moisture-retentive dressings are appropriate 1
• Consider hyperbaric oxygen therapy for ischemic wounds failing standard care where resources exist 1

Allergies

• Use plain saline-moistened gauze or simple non-adherent dressings to avoid allergen exposure 1
• Avoid adhesive products if contact dermatitis is present 2
• Films and hydrocolloids contain adhesives that may trigger reactions 1

Common Pitfalls to Avoid

• Do not select dressings based on marketing claims about enhanced healing—no specialized dressing has proven superior to basic moisture-retentive options 1, 3
• Do not use expensive products routinely—they waste resources without improving outcomes 1, 3
• Do not delay sharp debridement while waiting for autolytic debridement from dressings 1, 3
• Do not use enzymatic, biosurgical, or ultrasonic debridement over standard sharp debridement 1
• Do not apply advanced dressings to ischemic wounds without vascular assessment 3, 4

Algorithm for Dressing Selection

1. Assess vascular status first (pulses, ABI, toe pressures) 3, 4
2. Perform sharp debridement of necrotic tissue and callus 1, 3
3. Control infection with systemic antibiotics and surgical management if present 1
4. Match dressing to exudate level:
   • Minimal/dry → hydrogel or film 1, 2
   • Moderate → hydrocolloid 1, 2
   • Heavy → foam (NOT alginate if diabetic) 1, 2
5. Select the least expensive option that meets moisture requirements 1, 2
6. Reassess at 2 weeks—if no improvement with proper debridement and offloading, consider adjunctive therapies only then 1, 3