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8.4 Clinical Applications of Alginate Wound Dressings 153
clinical trial. Epithelialization occurred after 10 days in the alginate group and 11
in the gauze group (not signicant). Earlier reharvesting of the donor site was pos-
sible in the alginate group than in the control group, and removal of the alginate
dressing caused signicantly less trauma and pain than the gauze.
Steenfos and Agren [71] comparedaber-freealginate dressing (Comfeel SeaSorb)
with paran gauze on donorsites in 17 patients. Bothdressings were applied to parts
of each wound and covered with gauze and a crêpe bandage. The alginate absorbed
40% more blood during the rst 10 minutes post-wounding than the gauze. Exami-
nation of punch biopsies from 10 wounds on day6 showed that 9 of the areas treated
with the alginate had fully epithelialized compared with 7 treated with gauze. This
dierence did not reach statisticalsignicance. The authors concluded thatalthough
the alginate showed increased initial blood absorption and quicker hemostasis, it
had no clear benecial eect on epithelialization. They suggested that this might
have been due to the small sample size and to their failure to occlude the alginate
over the critical rst two postoperative days.
Calcium alginate was compared with Scarlet Red ointment dressing by Bet-
tinger et al. [7] in 12 paired wounds in 7 patients undergoing skin grafting. No
signicant dierences in healing time were recorded, with both groups taking
11.8 days. However, the dressing procedures used may have extended the healing
time of the alginate. The same two dressings were compared in a second study
by Lawrence and Balke [43] in which 46 patients had split-thickness skin grafts
harvested from the upper inner thigh. Kaltostat and Scarlet Red were each applied
to half of the wound and covered with gauze, cotton wool, and a crêpe bandage.
The dressings were changed after 10 days when healing was assessed. The oint-
ment was signicantly better than the alginate, with 84% and 72% having healed
respectively.
The relative merits of Kaltostat and a porcine xenograft (E-Z Derm) were exam-
ined in a controlled, prospective study of split-thickness skin graft donor sites on
20 patients [84]. Time to complete healing, quality of regenerated skin, and patient
comfort were assessed. Time to healing was 8.1 days with the alginate and 11.3 with
the xenograft. The quality of the healed skin under the alginate was superior to
that under the xenograft in 95% of patients. No hypertrophic scarring was noted in
patients treated with alginate, compared to 25% of xenograft sites.
Kelly et al. [39] used the gel-forming properties of alginates to protect exposed
tissue, using them as a temporary recipient bed dressing prior to the delayed appli-
cation of split skin grafts.
Deep burns of the hand represent a common serious surgical problem with
major occupational and economic implications. Alginate dressings help to control
hemorrhage during excision and grafting and prevent desiccation of important
deep structures such as extensor tendons or joints that may be exposed during
surgery [41].
A novel use of an alginate in the management of extensive burns on a
seven-year-old boy was described by Varma et al. [85]. In the absence of su-
cient donor site material to cover the area with a conventional graft, small skin
grafts (edges of meshed grafts and shredded skin) were cut into small pieces, formed
154 8 Clinical Applications of Alginate Wound Dressings
into a suspension, and poured evenly over a sheet of Kaltostat, which was applied
to the wound. Epithelial islands were visible after 10 days and complete coverage
was achieved by day 28.
The problem of donor-sitepainwas addressed by Butler etal. [13] in astudyinvolv-
ing 45 patients undergoing split-thickness skin grafting. After harvesting the graft,
each patient was randomized to dry Kaltostat, Kaltostat moistened with 20 ml of
saline, or Kaltostat moistened with 20 ml of bupivacaine 0.5%.The dressing was cov-
ered with an outer wound pad and secured with an adhesive dressing. A blinded
medical observer assessed postoperative pain at 24, 48, and 72hours using a lin-
ear analog scale. The dressing was removed on day 10 and healing was assessed,
when ease of removal and the presence of infection were also recorded. There was
a dramatic statistical dierence in pain scores between patients who received the
bupivacaine-soaked dressing and the other two groups at 24 and 48 hours. However,
by 72 hours all patients reported only lowlevels of discomfort. No dierencesin ease
of removal were recorded.
Porter [55] compared alginate dressings with hydrocolloid dressings in the heal-
ing of split skin graft donor sites. Sixty-ve patients were randomized to treatment
and the rates of epithelialization, patient discomfort, and convenience of clinical use
were compared. The alginate dressing was applied to the raw donor areas and held
in place by layers of dry gauze, plaster wool, and a crêpe bandage. The hydrocolloid
was applied after hemostasis was achieved, and covered by plaster wool and a crêpe
bandage. At therst dressing change, 87% of the donor areas dressed withthe hydro-
colloid, and 86% of those dressed with the alginate were more than 90% healed. The
mean time from operation to complete healing was 10 days for areas dressed with
the hydrocolloid and 15.5 days for those dressed with alginate. This dierence was
statistically signicant. It is considered that the poor performance of the alginate
dressing was due to dressing technique.
8.4.5 Applications of Alginate Wound Dressings as a Hemostatic Agent
for Bleeding Wounds
There is a long history of alginate bers being used as a hemostatic agent. In 1951,
Blaine performed a comparative evaluation of absorbable hemostatic agents that
included alginates [8]. Although calcium alginate bers took up to 12 weeks to be
fully absorbed, sodium calcium alginates were generally absorbed within 10 days. In
experiments where there was minimal trauma involving small implants, uneventful
absorption took place within a few days. No evidence of adverse local histological
changes were detected, although the rate of absorption varied with the location and
vascularity of the surrounding tissue. A further study showed that in the presence
of antiseptic agents such as cetylpyridinium bromide, the absorption process was
generally incomplete, and some histological changes were noted including encap-
sulation and giant cell production [52].
In a more recent study, Segal et al. [62] showed that alginate materials activated
coagulation more than non-alginate materials. The extent of coagulation activa-
tion was aected dierently by the alginate M or G group composition. It was
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8.4 Clinical Applications of Alginate Wound Dressings 155
demonstrated that alginates containing zinc ions had the greatest potentiating
eect on prothrombotic coagulation and platelet activation.
As a hemostatic agent, the lack of adverse tissue reactions to alginates was
described by Jaros and Dewey [37], following long-term administration of sodium
alginate as an adjuvant for repository hyposensitization agents. The material was
well tolerated with less of a reaction rate than expected using regular allergenic
extracts.
Blair et al. [9] compared the hemostatic eect of four dierent materials in liver
lacerations in the rabbit. The products examined were oxidized cellulose (Surgicel),
porcine collagen (Medistat), calcium alginate (Kaltostat), and surgical gauze. Cal-
cium alginate stopped bleeding in less than three minutes compared with a mean
of 5.7 ± 0.75 minutes for porcine collagen, 12.5 ± 0.9minutes for oxidized cellulose,
and >15 minutes with gauze. Oxidized cellulose and calcium alginate reabsorbed
within three months, leaving a brous scar, but a vigorous foreign body reaction
was observed with porcine collagen. In a further group of animal samples, all three
hemostatic agents were left in situ on the liver and small bowel mesentery for three
months. The porcine collagen caused fatal intestinal obstruction in ve animals.
Sirimanna [64] investigated the use of calciumalginate ber forpacking nasal cav-
ity following surgical trimming of the inferior turbinates. Thirty-two nostrils were
packed with Kaltostat for 36–48 hours to achieve hemostasis. There was no bleeding
while the packs were in place or after removal. These results were compared retro-
spectively with two other treatments, i.e. trousered paran gauze and glove nger
packs, both of which had been associated with bleeding in over 50% of cases either
while in situ or after removal.
In a second study, the three types of packing were compared prospectively [65].
All three were similarly eective in preventing bleeding while in situ, but the algi-
nate caused signicantly less bleeding on removal. Reduced bleeding was recorded
with all three packs if left for 48hours. It was suggested that the observed reduction
in bleeding might lead to a decrease in postoperativeinfections. In a follow-up study
on the same group of patients over a three-week period [66], packing for 48 hours
resulted in signicantly more complications for all three materials than when packs
were removed at 24 hours. It appeared that more infection, crusting, and airway
problems were associated with use of the alginate than the other two treatments if
the packs were left in place for 48 hours. However, patient numbers were too small
to test this statistically.
The exchange of calcium ions with sodium ions in the blood is commonly known
as the main reason for hemostasis ecacy of alginate wound dressings and it is
reasonable to suppose that products made from alginates containing a higher pro-
portion of mannuronic acid residues, which give up their calcium ions more readily
than those high in guluronic acid, could be more eective hemostats. Evidence for
the hemostatic activity of one high mannuronic alginate dressing, Sorbsan, was
produced in a study in which the dressing was applied to experimental, full- and
partial-thickness wound models for up to 14 days to assess its eects on healing.
Histological evaluation showed the dressing to be an eective hemostat, generally
well-tolerated by body tissues. Good epidermal healing was seen on all wounds,
156 8 Clinical Applications of Alginate Wound Dressings
although cellular reactions could be provoked in full-thickness wounds without
occlusion if there was an insucient volume of exudate to completely wet the
alginate bers [3].
8.4.6 Applications of Alginate Wound Dressings in Surgical Wounds
Gupta et al. [35] studied the use of alginate ber (Sorbsan) for packing cavities fol-
lowing surgery in 29 patients. Compared with proavine-soaked gauze, the alginate
dressing caused less pain and reduced the need for analgesia. Alginate dressing
also appeared to reduce bacterial counts within the wound. The authors concluded
that the advantages oered by the alginate dressing outweighed the increased
cost.
In another study [23], 16 patients were randomized to receive calcium alginate
dressing and 18 to saline-soaked gauze for packing abscess cavities following inci-
sion and drainage. At therst dressing change, thepatient marked on a linear analog
scale the pain experienced, while the nurse noted the ease of removal. Patients eval-
uated the alginate dressing as signicantly less painful, and nurses found it easier to
remove than the gauze.
Similar advantages for the use of a calcium alginate dressing (Sorbsan) over con-
ventional paran gauze/cotton packs were reported following a prospective ran-
domized study following hemorrhoidectomy [23]. Fifty patients were prospectively
randomized to receive paran gauze/cotton gauze roll or alginate roll as a postop-
erative pack. Pain was assessed at six hours postoperatively, on removal of rectal
packing and at rst bowel action. Hemorrhage was monitored at six hours and on
removal of pack. Patients who received the alginate dressing reported reduced pain
at the time of removal/spontaneous discharge of rectal packing and rst postopera-
tive bowel action. No signicantdierence in postoperative hemorrhage, or hospital
stay was reported.
Cannavo et al. [15] compared the performance of three dierent dressings in the
management of 36 dehisced surgical abdominal wounds. These were a standard
alginate dressing, a gauze moistened with sodium hypochlorite (0.05%), and a com-
bined dressing pad, with the latter consisting of an absorbent pad to which is added
a semi-permeable lm dressing. No statistically signicant dierences in healing
rates between the three treatment groups were detected but there was a trend for
the combined dressing pad protocol to produce a greater reduction in wound area.
Maximum pain was signicantly greater and satisfaction signicantly lower among
patients who received the sodium hypochlorite treatment. The associated treatment
costs were also substantially higher for thisgroup of patients. The authors concluded
that the use of sodium hypochlorite-soaked dressings for surgical wounds should be
abandoned.
Patients with gaping abdominal wounds following cesarean section and radical
vulvectomy [58] were also managed successfully with alginate dressings. A patient
with a 10-year history of heroin abuse and multiple ulcerations to his upper
arm had his wounds dressed with a calcium alginate rope and covered with a
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8.4 Clinical Applications of Alginate Wound Dressings 157
Figure 8.3 An illustration of fat liquefaction of incision wound.
four-layer bandage. Dressings were changed weekly and during treatment the
patient remained heroin free. Complete healing was achieved in 42days [20].
Fat liquefaction of incision wounds such as the one shown in Figure 8.3 com-
monly occurs after surgical operation,especiallyamong overweight people. The high
absorption capacity and gel-forming properties of alginate wound dressings are par-
ticularly suited for this type of wound. Gu et al. [34] compared the applications of
alginate dressing and vaseline gauze on 31 cases of fat liquefaction incision after
abdominal surgery. Results showed that after four weeks, the overall result of the
alginate dressing group is clearly better than the control group of vaseline gauze.
With alginate wound dressing, there was no adherencebetween dressing and wound
bed, and the release of calcium ions improved blood clotting. On the other hand, the
use of vaseline gauze caused pain and wound bleeding. As shown in Tables 8.1 and
8.2, the clinicalecacy of alginatewound dressing is advantageousto the traditional
vaseline gauze.
Table 8.3 compares the clinical ecacy of the two test groups, showing that algi-
nate dressings are far better than vaseline gauze in the treatment of incision wounds
with fat liquefaction.
Table 8.1 A comparison of pain experienced during the treatment of fat liquefaction
incision wound.
Group Number of cases No pain Slight painful Painful Heavily painful
Alginate dressing 31 5 19 7 0
Vaseline gauze 30 0 6 19 5
158 8 Clinical Applications of Alginate Wound Dressings
Table 8.2 A comparison of the frequency of dressing change during the treatment
of fat liquefaction incision wound.
Group
Number of dressing changes
(first week)
Number of dressing changes
(after one week)
Alginate dressing Every three days Every four days
Vaseline gauze Daily Every two days
Table 8.3 A comparison of clinical efficacy during the treatment of fat
liquefaction incision wound.
Cases showing different levels of clinical efficacy
Group Overall cases Healed Recovered Improved No effect
Alginate dressing 31 29 2 0 0
Vaseline gauze 30 9 6 8 7
8.4.7 Applications of Alginate Wound Dressings in Nose Surgery
Xie et al. [87] compared the ecacy of four commonly used nasal packing materi-
als, i.e. vaseline gauze strips, rapid rhino nasal pac with gel knit, calcium alginate
dressings, and expansive sponge. Table 8.4 shows a comparison of the degree of
bleeding following removal of nasal packing materials. For the traditional vaseline
gauze, not only 35 of the 40 patients under treatment felt pain on dressing removal,
38 of them continued to bleed upon dressing change. Calcium alginate dressing
showed one of the best performances, with none of the 23 patientsshowing bleeding
after removal of the dressing, and bleeding completely stopped among 22 of the 23
patients under treatment.
Liu and Zheng [44] used calcium alginate wound dressing to ll in one side
and aureomycin gauze in another side during nasal surgery, and compared nasal
Table 8.4 A comparison of the degree of bleeding following removal of
nasal packing materials.
Degree of bleeding
Nasal packing materials No Little Yes Overall cases
Vaseline gauze strips 2 24 14 40
Rapid rhino nasal pac with gel knit 32 3 0 35
Expansive sponge 19 13 6 38
Calcium alginate dressing 22 1 0 23
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8.4 Clinical Applications of Alginate Wound Dressings 159
Table 8.5 A comparison of nasal mucosal edema and submucosal inflammatory cell
infiltration.
Degree of nasal
mucosa edema
Degree of inflammatory
cell infiltration
Group Cases Light Medium Heavy Light Medium Heavy
Calcium alginate dressing 53 19 28 6 16 30 7
Aureomycingauze 53 1029 14 1526 12
mucosal edema and submucosal inammatory cell inltration. Results showed that
during removal of the dressing, the level of pain was much lower with the alginate
dressing. As shown in Table 8.5, the overall ecacy is much better for the alginate
dressing than aureomycin gauze.
8.4.8 Applications of Alginate Wound Dressings in Anal Fistula Surgery
Wei et al. [86] compared alginate wound dressing and traditional gauze dressing on
mixed hemorrhoid, anal stula and prolapsed hemorrhoid wounds after surgery.
One hundred and sixty cases were split into two groups with 90 cases treated with
alginate dressing and the other 70 treated with iodoform gauze. Tables 8.6–8.8 com-
pared the pain during application and removalof the dressing, bleeding, and patient
comfort during treatment. Results showed that the overall clinical ecacy of algi-
nate dressing is much better than the conventional iodoform gauze.
In anal stula surgery, the lling of surgical wounds with alginate wound
dressing can relieve pain and improve the process of application and removal
of the cavity-lling process. While conventional method of lling the surgical
Table 8.6 A comparison of pain during treatment.
Group
To tal n u mbe r
of cases No pain Slight pain
Medium level
of pain
Highly
painful
Alginate dressing 90 41 31 15 3
Iodoform gauze 70 6 12 46 6
Table 8.7 A comparison of bleeding during treatment.
Group
Total number
of cases
No bleeding
(%)
Slightly bleeding
(%)
Bleeding
(%)
Alginate dressing 90 81.1 16.7 2.2
Iodoform gauze 70 24.3 58.6 17.1
160 8 Clinical Applications of Alginate Wound Dressings
Table 8.8 A comparison of patient comfort during treatment.
Group
To tal n u mbe r
of cases
Bulge feeling
(%)
Odor
(%)
Uroschesis
(%)
Tamponade tolerance
≤12 h (%)
Alginate dressing 90 18.9 10.0 7.86.7
Iodoform gauze 70 87.1 85.7 25.768.6
wound with iodoform gauze can have antimicrobial and other clinical ecacy, its
low absorbency and poor adherence properties can cause pain and discomfort to
patients undergoing such operations.
8.4.9 Applications of Alginate Wound Dressings in Cavity Wounds
Berry et al. [5] compared Kaltostat with a polyurethane foam dressing (Allevyn)
in the management of patients with non-infected cavity wounds. Both dressings
were found to be easy to use, eective, and acceptable to patients and clinicians. A
controlled trial set out to compare calcium alginate dressing with more traditional
saline-soaked gauze for packing abscess cavities, following incision and drainage.
Patients were randomized to receive either calcium alginate dressing (16 patients)
or gauze dressing (18 patients). At the rst dressing change, the patient marked on
a linear analog scale the pain experienced, while the nurse noted similarly the ease
of removal of the dressing. Calcium alginate dressing was signicantly less painful
to remove after operation, and also easier to remove than gauze dressings. If abscess
cavities are packed after incision and drainage, calcium alginate dressing appears to
be an improvement on conventional dressings [23].
8.4.10 Applications of Alginate-Based Composite Wound Dressings
Composite dressings containing alginate have been developed in a variety of forms
that include simple adhesive island dressings (Kaltoclude) to absorbent pads with
an alginate wound contact layer (Sorbsan Plus). An alginate-faced dressing contain-
ing activated charcoal for use in the management of malodorous wounds has also
been developed and the results of a laboratory-based evaluation to compare the per-
formance of this dressing with other charcoal dressings has been described in the
literature [81].
8.5 Main Properties of Alginate Wound Dressings
Calcium alginate bers are chemically the salt between calcium ion and alginic acid
and upon contact with wound exudate, the calcium ions in the ber exchange with
sodium ions in the exudate, resulting in the formation of sodium alginate which is
watersoluble and can absorbalarge amount of waterintotheber structure, causing
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8.5 Main Properties of Alginate Wound Dressings 161
Figure 8.4 Cotton gauze wet in normal saline.
the swelling of the berand the in situ formationof a brous hydrogel on the wound
surface. This unique gelling property gives alginate wound dressing a number of
clinical benets in wound management that outperforms traditional wound man-
agement materials such as cotton gauzes.
As shown in Figure 8.4,when wet in normal saline, the absorption of cotton gauze
takes place in the capillary spaces between the yarns. Although absorption capacity
can be substantial, the liquid held by the cotton bers can easily spread along the
textile structure, often from the exuding wound to surrounding areas, causing mac-
eration to healthy skin around the wound. On the other hand, alginate bers swell
greatly when in contact with wound exudate, and subsequently, the lateral spread-
ing of wound exudate is blocked because of the closure of the spaces between bers,
resulting in the “gel blocking” property of alginate wound dressings as can be seen
in Figure 8.2.
After many years of clinical applications, alginate wound dressings have been
proven to have a number of wound-healing properties, some of which are summa-
rized below.
8.5.1 Wound-Healing Promotion
Berven et al.[6] showed that as a marine bioactivesubstance, alginate haschemotac-
tic properties and can acceleratethe wound healing process by attracting wound site
cells that are involved in the wound repair process. Attwood [2] compared alginate
dressing and conventional gauze dressing ondonorsite wounds. Results showed that
among the 130 wounds, the time needed for complete healing reduced from 10 days
for traditional gauze to 7 days for alginate wound dressings.
In another study, Sayag et al. [60] showed that under the same condition, 74%
of the patients had their wound area reduced by 40% when treated with alginate
162 8 Clinical Applications of Alginate Wound Dressings
dressing, while only 42% of the patienthad this outcomewhen using tradition gauze.
The application of alginate wound dressing can reduce the healing time by eight
weeks.
Doyle et al. [26] studied the eect of alginate wound dressing on broblast cells,
endothelial cells, and keratinocytes. Results showed that alginate bers can promote
the growth of broblast cells, while inhibit the growth of endothelial cells and ker-
atinocytes. Overall, the application of alginate wound dressings can promote the
wound-healing process.
8.5.2 The Hemostatic Properties of Alginate Wound Dressing
Alginate wound dressings possess excellent hemostatic properties due to a number
of factors such as the rapid swelling of the bers upon contact with blood and the
release of calcium ions through ion-exchange. Groves and Lawrence [33] found that
within ve minutes of contact with bleeding wounds, the alginate wound dressings
had aected bloodclotting. Segal et al.[62] assessed thehemostatic properties of sev-
eral types of alginate wound dressings with dierent chemical structures and found
that the hemostatic properties of alginate wound dressings were due to two mecha-
nisms, i.e. blood coagulation and platelet activation, which is promoted through the
action of calcium ions released from the dressing. It was found that zinc alginate
wound dressings had better hemostatic properties than calcium alginate, mainly
because the zinc ions are better at blood coagulation and platelet activation.
Davies et al. [21] compared the hemostatic eect of alginate wound dressing and a
traditional gauze and found that onaverage,theblood loss during surgery withgauze
is 139.4± 9.6 ml, while it was 98.8 ± 9.9ml with alginate dressing. After the surgical
operation, the blood loss was 158.4 ± 17.3ml with gauze and it was 96.6 ± 11.7 ml
with alginate dressing,showing the excellenthemostatic property of alginate wound
dressing over conventional wound management products.
8.5.3 Pain Relief Properties of Alginate Wound Dressing
Butler et al. [14] studied the ecacy of alginate wound dressings on skin donor sites.
They found that when the alginate dressing is soaked in hypochlorite solution and
applied to wound, there was an obvious relief of pain. A prospective double-blind
controlled trial examined the dierences in postoperative split skin graft donor site
pain between sites dressed with three dierently treated types of dressing, i.e. a
dry calcium alginate dressing, a saline-moistened calcium alginate dressing, and a
bupivacaine hydrochloride (0.5%) moistened calcium alginate dressing. There was
a signicant reductionin postoperative pain inthe calcium alginate andbupivacaine
group (group 3) at 24 and 48 hours when compared to the other two groups. There
was no dierence in ease of removal of dressings or the quality of wound healing
on day 10 between the three groups. This study suggested a signicant reduction
in postoperative pain in bupivacaine-soaked calcium alginate, without reducing the
benecial eects of the calcium alginate on donor site healing. Bettinger et al. [7]
found similar pain relief eect when applying alginate wound dressings on burn
wounds.
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