Clinical ProblemHypergranulation tissue (HT) is granulation tissue that grows higher than the periwound skin level. HT can prevent epithelial cell migration and therefore inhibit wound healing.

The recognized causes of hypergranulation tissue include:

• unresolvedinflammation,asoccurswithchronicinfection

• highexudatelevelsandfluidasaresultofedema

• externalfriction

• foreignbodyirritant

• tooocclusiveofanenvironment

ManagementoftheunderlyingcauseiskeytoresolutionofHT.Previously,HTwasmanagedwithan antimicrobial barrier dressing. The approach was unsatisfactory because the dressing adhered tothewound,causing:a)traumaandpain;b)increasedproliferationofHT;c)woundtissuediscoloration,makingassessmentsdifficult;and,d)longer,morecomplicatedandexpensivewound clinic visits due the need to provide pre-dressing removal pain management and time required for adhered dressing removal.

4HTcasesarepresented;seechartfordetails.

Probable contributing causes of HT in these cases included:

• excesswoundmoistureassociatedwithedema

• woundinfection,amajorcauseofchronicwoundinflammation

• excessivewoundmoisture contributedby tissue edemacombinedwith ahydrogel andasecondary dressing used to enhance autolytic debridement

• acceleratedtissuegrowthpossiblyduetohighlyvasculartissue

All of the cases received previous unsuccessful treatments with advanced dressings or topical wound care products.

RationaleMultifunctional silver polymeric membrane dressings (SPMDs)* were chosen to manage the HT of all case studies. The dressings contain key components necessary for ideal wound healing. SPMDs are able to absorb 10 times their weight because the dressings contain a superabsorbent starch copolymer. The semipermeable film backing on the dressing allows for the appropriate moisturevaportransmissionrate(MVTR)whichbalancesthecorrectamountofgas(oxygenandcarbondioxide)exchangebetweenthewoundbedwiththeoutsideenvironment.SPMDscontain the same benefits as the polymeric membrane dressings plus the antimicrobial benefits of smallelementalsilvertohelpprotectthewoundsfrommicrobialcontamination.Inflammationistheresultoftissueinjuryeitherbytraumaorinresponsetoinfection,delayingwoundhealing.Polymericmembranedressings(PMDs)havebeenshowntoquiettheinflammatoryresponsebyreducingthespreadofmacrophagesandneutrophilstoareasofsecondaryinjurywithoutinterferingwithlocalinflammation,necessaryforhealing.Thedressingscontainanontoxicnonirritating cleanser that continually cleanses the wound. Glycerin keeps the wound bed moist while ensuring the dressing will not stick to the wound. SPMDs encourage autolysis by loosening the bonds between the slough and wound bed.

Clinical Treatment Approach Before and After SPMDMultifunctional SPMDs were utilized in two ways in managing HT: 1) HT was first destroyed with silver nitrate/cautery and then SPMD applied; 2) SPMD was begun without priorHT destruction. SPMDs were chosen for their antimicrobial benefits and their ability to prophylactically maintain low bio-burden. After HT was resolved SPMD or PMD was continued to closure.

The protocol at this facility is to cleanse wounds prior to dressing application to assist in the removal of debris and apply a barrier cream to the periwound skin as needed. The wounds for case1,2and4weresharpdebridedandpremedicatedasneededwithatopicalanaestheticduring the course of management.

C A S e S e R i e S

Hypergranulation Tissue: A Challenging Problem With an easy SolutionDeniseSmithRNWCC,ShariHouleRNCWS,LeslieSearlsDO,HyperbaricMedicalDirector,McLarenGreaterLansingWoundCare&HyperbaricCenter2727SPennsylvaniaAve,LansingMI48910

Bibliography1. Burd A, Kwok CH, Hung SC, Chan HS, Gu H, Lam WK, Huang L. A comparative study of the cytotoxicity

of silver-based dressings in monolayer cell, tissue explant, and animal models. Wound Repair and Regeneration.2007; 15:94-104.

2. Borkowski S. G tube care: Managing hygranulation tissue. Nursing. 2005; 35(8): 24.3. *Davies L, White R.J. Defining a holistic pain-relieving approach to wound care via a drug free polymeric

membrane dressing. Journal of Wound Care. 2011; 20(5): 250-256.4. Harris A, Rolstad BS. Hypergranulation tissue: A nontraumatic method of management. Ostomy/Wound

Management. 1994; 40(5): 20-30.5. Hawkins-Bradley B, Walden M. Treatment of a nonhealing wound with hypergranulation tissue and rolled

edges. J WOCN. 2002; 29:320-4.6. Johnson S. Overcoming the problem of overgranulation in wound care. Wound Care. 2009; June: S6-S12.7. Phillips P. Postoperative endonasal dressing with polymeric membrane material. Presented at the American

Rhinologic Society, September 2003. Orlando, Florida.8. Vuolo J. Hypergranulation; exploring possible management options. British Journal of Nursing. 2010; 19(6): S4-S8.

Patient Outcomes

UseofSPMDseliminatedHTforall4patients,leadingtowoundclosure.

They found that SPMDs:

• maintainedoptimumwoundmoisture

• didnotadheretothewoundbed,sotherewasnotraumaorpainduringdressingchanges,whichin-turnreducedtheinflammatorycyclethat is a driving force of hypergranulation tissue formation

• reducedstimulationoftheHTformationprocess,accompaniedbyfaster wound healing and fewer clinic visits

• resultedinvisitsthatwereatleast10minutesshorterbecausenotime was required for removal of dressings adhered to the wound bed or administration of additional pain medication prior to dressing removal

• didnotdiscolorthewoundtissue,allowingforimprovedevaluationof the wound

Afterthissuccessfulinformalevaluation,amoreformalevaluationwasperformed.

Becauseofthesignificantoutcomes,thiscliniccontinuestouseSPMDfor HT as well as the standard polymeric membrane dressing (PMD) for their wound care needs.

Conclusions

NotonlydidSPMDprovideexcellentclinicaloutcomes,buttheclinicians and patients found the dressings’ use easy and convenient. SPMDs are now the standard of care at this facility for managing HT.

Objectives

1. Recognize that SPMDs are able to provide the appropriate absorbency conditions to maintain optimal healing while preventing adherence and enhance autolytic debridement.

2.DiscusshowSPMDshelptoinhibitandmanagewoundinfections.

3. Review the benefits of SPMDs which have been shown to inhibit the nociceptor response activity that is triggered during tissue trauma or aninfection,therebyhelpingtoreducewoundpain,andinflammationthroughout the wound management process.

Initial admission to the wound center

prior to sharp debridement of necrotic

tissue.

CASE 2

WOUND CARE &HYPERBARIC CENTER

Case Age Gender Wound description and relevant co-

morbidities

Pain Score (0-10 scale)

Previous Treatments HT treatments Treatment outcomes with SPMD

1 64 M • Left Pre-tibial• Result of trauma• Infected with cellulitis

• Co-morbidities Venous hypertension

10 • Sharp debridement

• 5 Gentamycin drops to wound; discontinued with necrotic tissue eliminated

• To be evaluated for a bilayered skin substitute

• Enzymatic debrider daily & non adherent dressing, gauze pad secured with stretch gauze, 21 days (discontinued due to excessive edema and wound deterioration)

• 3x/wk. dressing changes with PMDs, regular or thick depending on exudate, 14 days

• gauze pad secured with stretch gauze and tubular bandage

• Hydrogel and every other day/wk. dressing changes

• Lidocaine gel for dressing changes (discontinued at day 49 days with PMDs because dressing changes no longer painful)

• Autolytic debridement of eschar with hydrogel after which time HT developed (duration-14 days)

* hydrogel covered with regular or extra thick polymeric membrane dressings covering depending on exudate level—wound became too moist at this point and hypergranulation became problematic

• wound “split” into 2 wounds as granulation bridge formed;

• HT developed in the distal wound

• Silver nitrate cautery applied

• SPMD applied, secured with gauze padding, stretch bandage and elastic tubular bandage

• Dressings changed daily

• Silver nitrate cautery applied

• SPMD applied, secured with gauze padding, stretch bandage and elastic tubular bandage

• Dressings changed daily

• Discontinuation of the hydrogel eliminated HT in 14 days; wound continuously, appropriately moist

• PMD, without silver used when HT resolved

• Wound closed in 14 days after HT resolution.

• Bilayered skin substitute no longer needed

• Pain reduced to 4, from 10 and then eliminated

Wound closure in 98 days from initial treatment with no further development of HT

2 85 M • Infected necrotic forehead wound as result of fall during stroke

• Necrotic tissue, slough and fibrin sharp debrided

• HT identified at wound edge

• Heavy bleeding controlled with silver nitrate cautery and pressure

• After debridement: calcium alginate applied covered with silicone silver foam dressing, secured with tape

• Changed 3x/wk. for 14 days while in nursing home

• Discontinued because alginate adhered to wound bed and needed to be debrided from wound bed at dressing change

• SPMD applied to forehead and secured with cloth tape

• Changed 3x/wk.

• HT eliminated in 14 days; progressing to closure

3 88 M • Non-healing post-surgical left groin incision site after endograft repair of abdominal aortic aneurysm that became infected

• NPWT to near closure

• Switched to silicone-coated foam dressings for 14 days

• HT formed superficially after wound closure

• Silver nitrate cautery applied

• SPMD secured with cloth tape; changed at nursing home 3x/wk.

• HT eliminated in 7 days

Wound closure in 7 days

4 52 F • Left pre-tibial venous ulcer

• Poor compliance with compression or elevation

• Uncontrolled edema and draining ulcers

Co-morbidities • Mentally challenged and cared for by mother

• Silver sulfadiazine covered by non-adherent dressing and gauze pad with non-elastic, adjustable compression garment

• SPMDs primary management

• HT formed at wound edges due to inadequate compression and dressing left in place for too long

• SPMD applied; secured with 2 layer adhesive wrap

• Changed 1x/wk

• HT eliminated in 23 days

• Wound closed in 58 days

CASE 4

14 days after the use of a calcium alginate dressing, the dressing adhered to the wound bed. To remove the dressing, it was necessary to debride the area and the calcium alginate dressing was discontinued. HT had been revealed with the debridement of necrotic tissue. HT developed on the wound at the mid left side of the wound at approx. 8-10 0’clock. Note: The red is raised exposed tissue. The wound measures: 7cm x 5.2cm x 0.2cm. Area- 36.4 cm². SPMD are initiated.

14 days after the application of SPMD dressings. HT eliminated and the wound is granulating.

Wound Measurement:7.0cm x 3.8cm x 0.1cmArea 26.6 cm²

Area of exposed bone-2.8cm x 2.4cm

Photo – 42 days later.

Wound is progressing towards closure.

HT developed from excessive moisture due to edema.

Wound Measurements:3cm x 2.2cm x 0.1cm Area- 6.6cm²

There is moderate amount of serosanguineous drainage with no odor. Wound bed with red granulation tissue.

SMPD was applied and secured with a 2-layer elastic wrap for compression.

23 days later the HT is eliminated.

Photo taken 37 days from start of SPMD.

Wound closure 58 days after HT resolved.

*PolyMem®, PolyMem Silver® and PolyMem MAX® wound dressings are made by Ferris Mfg. Corp., 5133 Northeast Parkway, Fort Worth, TX 76106 USA, 1-800.POLYMEM (765.9636) • www.polymem.com • This case study was unsponsored. Ferris Mfg. Corp. contributed to this poster presentation.