PracticeUpdate: Dermatology - Winter 2018

EDITOR’S PICKS 16

Silver Absorption and Toxicity Associated With Silver Wound Dressings in Chronic Wounds Journal of the European Academy of Dermatology and Venereology Take-home message

• This prospective study investigated the systemic absorption of silver in 37 individ- uals with chronic inflammatory wounds treated with silver-containing dressings. Among these individuals, 19 had elevated silver levels in their serum 28 days after beginning treatment with silver-containing dressings. There was a strong correlation between wound surface area and silver levels, with increased serum silver levels associated with larger wounds. On multivariate analysis, anemia was associated with higher silver levels in the serum after 28 days (OR, 5.33), and a higher serum albumin level was associated with decreased silver levels in the serum (OR, 0.84). Overall, there were no differences in hemoglobin level, white blood cell count, hepatic or renal function, albumin levels, or the clinical characteristics of the ulcers in individuals with and without increased silver levels after 28 days of treatment. • The long-term use of silver-containing dressings should be limited to prevent clinically significant silver absorption, particularly in elderly individuals who are more likely to have anemia and low albumin levels. Jeffrey F. Scott MD

COMMENT By Robert S. Kirsner MD, PhD C hronic wounds represent a significant healthcare burden. Over 6 million Americans suffer from chronic wounds, many of which are slow-healing, either in part related to or complicated by bacterial infection or colonization. To address this, we often use antimicrobial dressings; most commonly, silver- impregnated dressings. FDA-approved to reduce the bacterial burden within the dressings, they also slowly deliver silver to the wound, presumably reducing bacterial burden there as well. The desire to have prolonged delivery of silver is not new, as silver sulfadiazine cream was developed in the 1960s for burn patients just for that reason (in contrast to short-acting silver nitrate solution). Silver dressings are thought to be safe, but cases of argyria have been reported. The report by Brouillard et al, demonstrating significant increases in systemic silver in half of patients treated with silver dressings, particularly patients with larger wounds and those who were By Ashish C. Bhatia MD, FAAD T his is an interesting study looking at a specific silver-based dressing used in chronic wounds in the hands of home health nurses in France. Like many dermatologists, in our practice, we deal with both acute and chronic wounds. In either case, I rarely use silver-based dressings outside of occasional use of Silvadene in burns or infected wounds. Personally, I’ve switched to HOCl (hypochlorous acid)-based wound care to help with infections and biofilm because it is not toxic and is easy to use for cleaning the wounds. I do still use silver-containing dressings on wounds occasionally, but only for a short period of time (1 month). For wounds taking longer to heal, I stick with HOCl and petrolatum. The other interesting points in this article

anemic or malnourished, suggests that systemic absorption is real. The consequence is not clear, but these findings reinforce the clinical recommendations that silver dressings be used only short term (<4 weeks) for wounds that are critically colonized as determined clinically; for example, highly exudative wounds, foul-smelling wounds, those with friable or bleeding granulation, or those wounds that are clinically infected in combination with systemic antibiotics. In contrast to short-term use, prolonged use has not been shown to be beneficial.

Dr. Kirsner is Chairman and Harvey Blank Professor in Dermatology in the Department of Dermatology and Cutaneous Surgery at the University of Miami Miller School of Medicine, Chief of Dermatology at the University of Miami Hospital and Clinics and Jackson Memorial Hospital, and he directs the University of Miami Hospital Wound Center in Miami, Florida.

relate to the patients’ albumin and anemia status. Although the relationship cannot be taken as causal, it is important to keep in mind that patients whose nutritional status is poor may be at increased risk for high silver blood levels.

Dr. Bhatia is Assistant Professor of Clinical Dermatology at Feinberg School of Medicine, Northwestern University, Medical Director of Dermatologic Research at DuPage Medical Group, and Co-Director of Dermatologic, Laser and Cosmetic Surgery at The Dermatology Institute– Naperville, DuPage Medical Group in Naperville, Illinois..

PRACTICEUPDATE DERMATOLOGY