Dressings for Acute and Chronic Wounds

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REVIEW

Dressings for Acute and Chronic Wounds

A Systematic Review

Guillaume Chaby, MD; Patricia Senet, MD; Michel Vaneau, PharmD; Philippe Martel, MD;Jean-Claude Guillaume, MD; Sylvie Meaume, MD; Luc Teot, MD, PhD; Clelia Debure, MD;

Anne Dompmartin, MD; Helne Bachelet, PharmD; Herve Carsin, MD; Veronique Matz, PharmD;Jean Louis Richard, MD; Jean Michel Rochet, MD; Nathalie Sales-Aussias, PharmD;Anne Zagnoli, MD; Catherine Denis, MD; Bernard Guillot, MD; Olivier Chosidow, MD, PhD

Objective: To critically review the literature on the ef-ficacy of modern dressings in healing chronic and acutewounds by secondary intention.

Data Sources: Search of 3 databases (MEDLINE,EMBASE, and the Cochrane Controlled Clinical TrialsRegister) from January 1990 to June 2006, completed bymanual research, for articles in English and in French.

Study Selection: The end points for selecting studieswere the rate of complete healing, time to complete heal-ing, rate of change in wound area, and general perfor-mance criteria (eg, pain, ease of use, avoidance of woundtrauma on dressing removal, ability to absorb and con-tain exudates). Studies were selected by a single re-viewer. Overall, 99 studies met the selection criteria (89randomized controlled trials [RCTs], 3 meta-analyses [1of which came from 1 of theselected systematic reviews],7 systematic reviews, and 1 cost-effectiveness study).

Data Extraction: The RCTs, meta-analyses, and cost-effectiveness studies were critically appraised by 2 re-viewers to assess the clinical evidence level according to

a modification of Sacketts 1989 criteria. Ninety-three ar-ticles were finally graded.

Data Synthesis: We found no level A studies, 14 levelB studies (11 RCTs and 3 meta-analyses), and 79 level Cstudies. Hydrocolloid dressings proved superior to sa-line gauze or paraffin gauze dressings for the completehealing of chronic wounds, andalginates were better thanother modern dressings for debriding necrotic wounds.Hydrofiber and foam dressings, when compared withother traditional dressings or a silver-coated dressing, re-spectively, reduced time to healing of acute wounds.

Conclusions: Our systematic review provided only weaklevelsof evidence on the clinical efficacy of modern dress-ings compared with saline or paraffin gauze in terms ofhealing, with the exception of hydrocolloids. There wasno evidence that any of the modern dressings was betterthan another, or better than saline or paraffin gauze, interms of general performance criteria. More wound careresearch providing level A evidence is needed.

Arch Dermatol. 2007;143(10):1297-1304

WOUNDS ARE A MAJOR

cause of morbidityand impaired qual-ityoflifeandtakeupsubstantial health

careresources indeveloped countries.1 Eachyear in theUnited States,over 1.25 million

people experience burns, and 6.5 million

have chronic skin ulcers caused by pres-sure, venous stasis, or diabetes mellitus.2

Since the 1960s, it has been acceptedthat wound healing is optimal when thewound is kept in a moist environmentrather than air dried.3,4 Occlusive or semi-

occlusive dressings that promote reepi-thelialization andwound closurehave beendeveloped for chronic and acute woundsto reduce pain and healing time, absorbblood and tissue fluids, and to be pain-lesson application and removal.5 The mainocclusive or semi-occlusive dressings are

hydrocolloid dressings (HCDs), algi-nates, hydrogels,foam dressings (FDs), hy-drofiber dressings (HFDs), and paraffingauze and nonadherent dressings. Re-cent products that are reported to induceangiogenesis or reduce infection are hy-aluronic acid (HA) cream or dressings anddressings supplemented with activatedcharcoal or silver.

Current clinical practice guidelines onthe treatment of pressure ulcers, leg ul-

See also page 1291

Author Affiliations are listed atthe end of this article.

(REPRINTED) ARCH DERMATOL/VOL 143 (NO. 10), OCT 2007 WWW.ARCHDERMATOL.COM1297

2007 American Medical Association. All rights reserved.on November 14, 2010www.archdermatol.comDownloaded from
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cers, and diabetic foot lesions and available systematicreviews on the treatment of arterial leg ulcers or surgicalwounds have not established a care strategy foreach typeof wound.6-12 The choice of ideal dressing remains con-troversial. We assessedthe level of published clinical evi-dence in support of the efficacy of modern dressings for

the care of chronic and acute wounds in terms of com-plete healing or aspects such as pain, ease of use, avoid-ance of woundtrauma on dressing removal,abilityto ab-sorb and contain exudates, and prevention of infection.

METHODS

DATA SOURCES AND SELECTION CRITERIA

Threebibliographic databases were searched fromJanuary 1990to June 2006: MEDLINE, EMBASE, and the Cochrane Con-trolled Clinical TrialsRegister. Thesearch wasrestricted to pub-lications in English and in French. Keywords and selection cri-teria are given in Table 1. From the list of retrieved titles and

abstracts, 1 reviewer (G.C.) selected the studies that usedtheseselection criteria to compare dressings. Case reports and caseseries wereexcluded.The reviewer checked studyrelevanceanddesign using the full versions of the articles. Additional refer-ences were retrieved by manual searches.

Wounds were considered to be chronic if time to healingwas delayed as a result of impaired tissue repair due to pooroxygenation, malnutrition, or infection.13 Chronic wounds in-clude legulcers, pressure sores, anddiabeticfoot ulcers. Acutewounds, however, tend to undergo an orderly and timely re-pair process that results in sustained restoration of anatomicand functional integrity.14 They include skin graft donor sites,

partial-thickness burns, and posttraumatic and surgical woundsthat heal by secondary intention. Studies on deep partial- andfull-thickness burns were excluded.

CRITICAL APPRAISALOF SELECTED STUDIES

Selected studies were distributed among 19 reviewers who wereasked to grade trials using a checklist of items for methodologi-cal quality based on a modified version of Sacketts criteria forclinical evidence.15,16 Each trial was graded by 2 reviewers (G.C.and 1 other reviewer). The 2 modifications to Sacketts crite-ria15,16 were as follows: (1) meta-analyses that included level Crandomized controlled trials (RCTs) were downgraded fromlevel A to level B, and (2) RCTs were as graded level C if theyhad 1 or more of the following methodological shortcomings:evaluation of primary outcome was not blind, randomizationmethod was performed incorrectly when it was described, pri-mary and secondary objectives were not clearly defined, objec-tiveor subjective measuresof dressing performancewerenot de-scribed, and patient groups were not comparable at baseline.17

The criteria we used for clinical evidence are given in Table 2.

RESULTS

Overall,2330 studieswereretrievedby electronic (n= 2305)andmanual (n= 25) searching(Figure).Ofthese,141 wereconsidered relevant on the basis of title and/or abstract.However, only 99 full-text articles met our selection cri-teria (89 RCTs, 3 meta-analyses [1 of the meta-analysescame from 1 of the selected systematic reviews], 7 sys-tematic reviews, and 1 cost-effectiveness study). The ref-

Table 1. Keywords and Selection Criteria

Key Words

Selection CriteriaMEDLINE EMBASE

Randomized controlled trials, or meta-analysis, or review,or review-literature, or guidelines, or consensus, orconsensus-development-conferences or congresses orrecommendation(s) in combination with bandages,including hydrocolloid dressings, hydrocellular or

polyurethane foams, alginate dressings, hydrogels,hydrofiber dressings, dextranomer, paraffin dressing,nonadherent dressings, dressings containinghyaluronic acid, silver-coated dressing or activatedcharcoal dressing, protease-modulating matrix(Promogran a) in combination with wound healing orvacuum or vacuum-assisted closure or negativepressure wound therapy, or topical negative pressureor leg ulcer or therapy, drug therapy, nursing, surgeryor decubitus ulcer or therapy, drug therapy, nursingand surgery or chronic disease or therapy, drugtherapy, nursing and surgery or surgical-wound-dehiscence or therapy, drug therapy, nursing andsurgery or surgical wound infection or therapy, drugtherapy, nursing and surgery or skin transplantation ortherapy, drug therapy, nursing and surgery or skindiseases vesiculobullous or therapy, drug therapy,

nursing, and surgery or nursing or surgery or burns orskin graft or donor site or skin ulcer or pressure ordiabetic with ulcer or trauma(tism)and wound(ing) ordrug therapy or therapy or nursing

Review or systematic review or meta-analysisor practice guideline or consensus orconference-paper or recommendation(s)or randomized-controlled-trial i ncombination with bandages-and-

dressings, or wound-dressing or colloid orhydrogel or calcium-alginate orpolyurethane or charcoal or silver orhyaluronic-acid in combination withleg-ulcer or decubitus or skin-ulcer ordonor-site or bullous-skin-disease ortrauma(tism) with wound(ing) or pressureor diabetic with ulcer or surgery or drugtherapy or nursing or therapy

Complete healing measured by anobjective method: rate of completehealing or time to complete healing orrate of change in wound area and/orvolume; pain or ease of use or

avoidance of wound trauma ondressing removal or ability to absorband contain exudates or prevention ofinfection or cost

a Johnson & Johnson, Issy-les-Moulineaux, France.




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erences, number of studies by type of dressing, and theirlevel of evidence are given in Tables 3, 4, and 5.18-108

There were no largeRCTs with definitive conclusions (levelA trials) for any type of dressing. No level B trials werefound for either hydrogels or activated charcoal.

CHRONIC WOUND CARE

Treatment with HCD resulted in a statistically signifi-cant improvement in the complete healing rate of leg ul-cers and pressure sores according to 3 meta-analyses18-20

comparing HCD withparaffin gauze and wet-to-dry gauzedressings (odds ratio, 2.57 [95% confidence interval, 1.58-4.18]18; odds ratio, 2.45 [95% confidence interval, 1.18-5.12], P =.0219; number needed to treat, 7 [95% confi-

denceinterval, 4-16]20

). However, there wasno differencebetween the healing rates of HCDs and FDs whether forpressure sores or leg ulcers.18,20 An RCT101 comparing Pro-mogran (Johnson & Johnson, Issy-les-Moulineaux,France) with a nonadherent dressing reported no differ-ence in the complete healing rate of leg ulcers. In brief,for the complete healing of chronic wounds, HCD seemsto be more effective than paraffin gauze and wet-to-drygauze dressings, and there is no difference between FDand HCD in terms of optimizing complete healing rate.

Alginates considerably reduced chronic wound area infull-thickness pressureulcers when usedsequentially withHCD (alginates for the first 4 weeks and HCD for the next4 weeks compared with HCD alone) and when compared

with dextranomer.41,80 Pain on removal of a dressing, al-though never evaluated as a primary outcome, was lowerfor a nonadherent dressing than for HCD in a study of legulcers.53 Macerationandodor were also less marked.53 Scoreson pain when changing a dressing were lower with an al-ginate than paraffin dressing in diabetic foot lesions.73

ACUTE WOUND CARE

There was no difference in the efficacy of FD, a paraffingauze dressing, polyethane film, or polyurethane film on

Table 2. Criteria for Assessing Clinical Evidencea

Level Criteria

A Large, randomized, double-blind, controlled studies with lowfalse-positive () and low false-negative () errors; MAsof RCTs

B RCTs including a small number of patients, therebyincreasing the likelihood of high false-positive and/orfalse-negative errors; MAs that i nclude low-evidence RCTs(level C)a

C Trials that lack 1 or more of the following criteria: evaluationof primary outcome blind, randomization methodperformed correctly when described, primary andsecondary objectives clearly defined, objective orsubjective measures of dressing performance described,and patient groups comparable at baselineb; case reports;case series

Abbreviations: MAs, meta-analyses; RCTs, randomized controlled trials.a According to the criteria of Bouvenot and Vray.17b According to modifications to Sacketts criteria.15,16

2305 References camefrom electronicsearch (MEDLINE,EMBASE, CochraneControlled ClinicalTrials Register)

141 Potentially relevantarticles (accordingto title on abstract)

93 Graded articles

99 Selected articles25 Potentially relevantarticles came frommanual search

1 Cost-effectiveness

study

7 Systematic reviews,

consensus, andguidelines

89 RCTs

3 MAs

78 RCTs1 Cost-effectiveness

study

14 Evidence level Bstudies

11 RCTs3 MAs

79 Evidence level Cstudies

0 Evidence level Astudies

Figure. Flowchart describing the selection of studies for analysis. MA

indicates meta-analysis; RCTs, randomized controlled trials. The asteriskindicates that 1 of the MAs came from a selected systematic review. Thedagger indicates that 6 of the 7 systematic reviews, consensus, andguidelines did not have any RCTs or MAs and were not critically appraised. 15

Table 3. Selected Studies by Type of Dressing a

Type of Dressing RCTs

Clinical EvidenceLevel

B C

Hydrocolloids18-54 343MAs

241,53 32

318-20

Hydrocellular or polyurethane

foam18,20,30-37,55-68222

MAs

257,65 20

218,19

Alginate38-40,59,60,69-84 21 441,73,78,80 17

Hydrogels52,85-92 9 0 9

Hydrofiber77,78,93-95 5 378,94,95 2

Dextranomer80,91,93,96,97 5 180 4

Paraffin gauze21,23,27,29,57,69,71,73,74,92 10 257,73 8

Nonadherent53,82,98-101 6 253,101 4

Hyaluronic acidimpregnated97,102,103 3 1102 2

Silver-coated 65,67,83,84,104,105 6 165 5

Activated charcoal66 1 0 1

Protease-modulating matrix(Promogran b)101,106,107

21 CES 1101 1

1

Abbreviations: CES, cost-effectiveness study; MAs, meta-analyses;

RCTs, randomized controlled trials.a Data are given as number of selected studies (we found no level A

studies); n= 99.b Johnson & Johnson, Issy-les-Moulineaux, France.




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between SCD and FD was found in the incidence of posi-tive bacterial cultures.65

COMMENT

According to our systematic review, the methodologicalquality of most studies of wound dressings is poor (levelC). There is little evidence to indicate which dressings arethe most effective in chronic and acute local wound carein terms of complete healing, comfort, and prevention of

infection. Most studies had several of the following limi-tations: (1) the number of patients was not based on asamplesize calculation performed beforehand;(2)the ran-domization method was not described; (3) assessment ofoutcomes was not blinded to treatment or was not com-pletely objective; (4) an intention-to-treat analysiswas notalwaysused; (5)assessment of objective or subjectivemea-sures of dressing performance was not always clearly de-scribed; (6) the study population was heterogeneous, par-ticularly in studies of leg ulcers; (7) whether adjuvanttreatments, such as pressure-relieving surfaces for pres-sure sores or off-loading devices for neuropathic diabeticfoot ulcers, were used in each treatment group was notspecified; and (8) a small sample size was combined with

multiple outcome measures.There is,however, good (levelB)evidenceto suggest that, for chronicwounds, HCD dress-ings arebetter than salinegauze or paraffin gauze for com-plete healing and that alginates, used either singly or insequential treatment, are better than other modern dress-ings in reducing wound area, perhaps because they causedebridement of necrotic tissue. There was no differencebetween HCDs and FDs in terms of an optimizing com-plete healing rate, but this does not mean that the prod-uctsare equivalentbecauseno noninferioritytrial hasbeenperformed. Only 1 level B study73 found a statistically sig-

nificant difference for pain reduction in chronic wounds.However, pain was a secondary outcome measure in thisstudy, and the result was statistically significant(P =.047).

In the case of acute wounds, the studies (level B) pro-vided little useful information. Only 1 study reported anotable difference in healing rate between modern dress-ings (an HFD) and paraffin gauze or wet-to-dry gauzedressings (modern dressings included alginate, FD, andHCD).95 An HA or SCD, when compared with a glycerine-impregnated dressing or an FD, respectively, delayedhealing.

No scientific evidence was found for the use of spe-cific dressings in the following cases: hemorrhagicwounds, malodorous wounds, fragile skin, and preven-tion and treatment of infection. Nor was the evidence suf-ficient to show a benefit of modern dressings on pain orother performance factors in the dressing of acute orchronic wounds when compared with saline or paraffingauze dressings (eg, ease of use, avoidance of woundtrauma on dressing removal, ability to absorb and con-tain exudates). In fact, dressing selection by physiciansis more about matching criteria such as absence of pain,ease of use, avoidance of wound trauma on dressing re-moval, and ability to absorb and contain exudates rather

than healing properties. Future trials should use vali-dated and standardized tools to measure pain, quality oflife, andcomfort of use. They shouldassess healing usingclinically relevant objectives, especially the rate of com-plete healing and time to heal rather than reduction inwound area. Other performance factors should be evalu-ated independently of any potential effect on healing. In-termediate goals in wound management strategy (ie, pri-mary endpoints such as complete wounddebridement forhydrogel dressings and lowering of systemicinfection andprescription of antibiotics for SCDs) might be worth test-

Table 5. Level B Clinical Evidence for Acute Wounds a

SourceType of

DressingType ofWound

Patients(Wounds),

No.Primary End Point

and OutcomeP

ValueArea Reduction and/or Other

Secondary Outcomesb

Persson andSalemark57

FD vs PGD vsPF vs PUF

SGDS 80 (80) Complete healing at 14 d, .30 PUF more comfortable (14 d aftersurgery), P=.01

Innes et al65 FD vs SD SGDS 17 (34) Mean (SD) t ime to complete healing(90% reepithelialized),9.1 (1.6) d vs 14.5 (6.7) d

.004 NA

Barnea et al95 HFD vs PGD SGDS 23 (46) Mean t ime to complete healing,7-10 d vs 10-14 d

.02 Pain during dressing change: lowerfor HFD, P .001Ease of use greater for HF,P=.003

Cohn et al94 HFD vs WDG SW 50 (50) Mean (SD) rate of healing (10.3[2.0] d vs 9.1 [1.6] d)

.08 Ability to absorb and containexudates, Pnot calculated

Bettinger102 HA vs GD SGDS 11 (22) Mean (SD) time to completehealing, 10.3 (2) d vs 9.1 (1.6) d

.05 NA

Foster et al78 HFD vs Alg SW 100 (100) Pain on dressing change, ease ofuse

NA NA

Abbreviations: Alg, alginate; FD, foam dressing; GD, glycerine-impregnated dressing; HA, hyaluronic acidimpregnated dressing; HFD, hydrofiber dressing;NA, not available; PF, polyethane film; PUF, polyurethane film; PGD, paraffin gauze dressing; SGDS, skin graft donor site; SW, surgical wound;WDG, wet-to-dry gauze.

a All of these studies were randomized controlled trials (RCTs). Level B studies were defined as (1) RCTs including few patients but with primary outcomesevaluated blindly, randomization method performed correctly, primary and secondary objectives clearly defined, and patient groups comparable at baseline or (2)

meta-analyses including level C RCTs.b Pain, ease of use, avoidance of wound trauma on dressing removal, and ability to absorb and contain exudates.




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ing. Other end points could be evaluated in specific situ-ations (eg, when there is a need to control bleedingin hem-orrhagic wounds or avoid trauma in cases of fragile skin).

In conclusion, available systematic reviews of the valueof different types of dressing in the management of acuteand chronic wounds provide only weak levels of evi-dence on clinical efficacy.10-12,18 The review by Palfrey-manetal12 identified 42 RCTs that evaluateddressings forthetreatmentof venous legulcers but found that no dress-

ing was better than any other in terms of number of ul-cers healed.12 In our review, thestudies with the best levelof evidence underline the potential interest of some mod-ern dressings (ie, use of HCDs and FDs) in optimizing thecomplete healing rate of chronic wounds, of alginates forthe debridement of necrotic tissue from chronic wounds,and of HFDs for hastening the healing of acute wounds.However, ourreviewalso stresses theneed formore woundcare research providing level A evidence. Health care pro-fessionals require more detailed recommendations on theuse of dressings. A discussion of our review by an expertpanel would be useful in achieving professional agree-ment on the recommended use of dressings.

Accepted for Publication: June 14, 2007.Author Affiliations: Department of Dermatology, Cen-tre Hospitalier Universitaire dAmiens, Amiens, France(Dr Chaby); Department of Geriatrics, Assistance Pub-liqueHopitaux de Paris, Hopital Charles Foix, Ivry-sur-Seine,France (DrsSenet andMeaume); DermatologyCon-sultations, Assistance PubliqueHopitauxde Paris,HopitalRothschild, Paris, France (Dr Senet); Haute Autorite deSante, Saint Denis, France (Drs Vaneau, Martel, andDenis);Department of Dermatology,CentreHospital Gen-eral de Colmar, Colmar, France (Dr Guillaume); Depart-ment of Orthopedic Surgery and Burn and Plastic Sur-gery Center, Hopital Lapeyronie, Montpellier, France(Dr Teot); Department of Vascular Rehabilitation, As-

sistance PubliqueHopitaux de Paris, Hopital Brous-sais, Paris (Dr Debure); Department of Dermatology, Cen-tre Hospitalier Universitaire de Caen, Caen, France(Dr Dompmartin); Department of Pharmacology, Cen-tre Hospitalier Regional Universitaire Lille, Lille, France(Dr Bachelet); Department of Burns, HopitaldInstructiondes Armees Percy, Clamart, France (Dr Carsin); Depart-ment of Pharmacology, Centre Hospitalier Bar le Duc,Bar le Duc, France (Dr Matz); Department of Nutri-tional Diseases andDiabetology, Centre Medical, Le Graudu Roi, Centre Hospitalier Universitaire Nmes, France(Dr Richard); Department of Physical and RehabilitationMedicine, Centre de Reeducation de Coubert, Coubert,France (Dr Rochet); Department of Pharmacology, Assis-

tance Publique-Hopitaux de Marseille, Marseille, France(Dr Sales-Aussias); Department of Dermatology, Hopi-taux dInstruction des Armees Clermont Tonnerre, Brest,France (Dr Zagnoli); Department of Dermatology, Cen-tre Hospitalier Universitaire de Montpellier, Montpellier(Dr Guillot); and Universite Pierre-et-Marie-CurieParisVI, and Department of Dermatology and Allergy, Assis-tance PubliqueHopitaux de Paris, Hopital Tenon, Paris(Dr Chosidow).Correspondence: Olivier Chosidow, MD, PhD, Depart-ment of Dermatology and Allergy, Hopital Tenon, 4 rue

de la Chine, 75970 Paris, CEDEX 20, France ([email protected]).Author Contributions: Study concept and design: Chaby,Senet, Vaneau, Meaume, Teot, Dompmartin, Denis, andChosidow.Acquisitionof data: Chaby, Martel, Guillaume,Meaume, Debure, Dompmartin, Guillot, and Chosidow.Analysis and interpretation of data: Chaby, Senet, Martel,Guillaume, Meaume, Teot, Dompmartin, Bachelet, Car-sin, Matz, Richard, Rochet, Sales-Aussias, Zagnoli, Guil-

lot, and Chosidow. Drafting of the manuscript: Chaby,Senet, Vaneau, and Guillaume. Critical revision of themanuscript for important intellectual content: Senet, Va-neau, Mar tel, Guillaume, Meaume, Te ot, Debure,Dompmartin, Bachelet, Carsin, Matz, Richard, Rochet,Sales-Aussias, Zagnoli, Denis, Guillot, and Chosidow. Sta-tistical analysis: Chaby. Obtained funding: Chaby and Va-neau.Administrative, technical, and material support: Va-neau, Martel, and Sales-Aussias. Study supervision: Chaby,Senet, Vaneau, Guillaume, Debure,Dompmartin, Richard,Rochet, Denis, Guillot, and Chosidow.Financial Disclosure. Dr Meaume participates in edu-cational programs on Profore multilayer bandaging manu-factured by Smith & Nephew and is a co-organizer for

an international study on the epidemiology of pain andwounds for Molnlycke Products. Dr Teot is involved inthe following collaborations and partnerships: scientificcollaboration of wound dressings with Braun (random-ized trial on calgitrol vs alginate in infected wounds) andKinetic Concepts Inc (KCI) (and the French Ministry ofHealth) on a medical-economic study of the effects ofvacuum-assisted closure (KCI); editorial collaborationwith Molnlycke Products (pain and dressing changes foracute wounds), KCI (on technical considerations ofvacuum-assisted closure [World Union of Wound Heal-ing Societies statement]), and Coloplast (on pain man-agement of wounds); and educational partnerships withSmith & Nephew, Johnson & Johnson, and Urgo. Drs

Senet and Chosidow are presently involved in buildinga protocol using Dermagen to treat diabetic foot ulcers;Dermagen is manufactured by Genevrier, a French com-pany that also sells HA-associated dressings.

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