Thanks to the latest topical creams, dressings, and treatments, today’s clinicians can offer virtually pain-free wound care to patients.

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cknowledgement that pain is a major issue for patients suffering from many different wound types is increasing among healthcare professionals. Ineffective wound pain management results in delayed healing, lack of compliance, and prolonged care. Greater attention should be paid to wound product evaluations and surveys where characteristics, such as pain, maceration, trauma, and comfort, are observed.¹ From a sensory dimension, information about how the wound “hurts” and what it feels like is uncovered. Following the initial tissue damage, the inflammatory response sensitizes the pain receptors in the skin. This helps the individual locate the extent and site of the wound so that it can be protected. When evaluating nonverbal and/or cognitively impaired individuals, start by performing a physical exam for evidence of purulent discharge, bone involvement, tenderness, erythema, or induration. Many cognitively impaired patients can respond to a simple pain scale like the Wong-Baker FACES Pain Scale.²
       In the acute wound, the pain subsides with healing. In chronic wounds, however, the impact of the prolonged inflammatory response can cause the patient to have an increased sensitivity in the wound (primary hyperalgesia) and surrounding skin (secondary hyperalgesia). If further painful or noxious stimuli are added to the equation as the result of repeated manipulation, such as during dressing changes, this acts as a “wind-up” mechanism, locking the patient into a cycle where any sensory stimulus will register as pain (this is known as allodynia).¹
       Since wounds consistently involve damage to nerves, some patients may experience altered sensations as a result of the changes in how the nerves respond (ie, neuropathic pain). Even the lightest sensation, such as a change in temperature or air blowing on the wound, can produce an exaggerated response from the central nervous system, causing the individual excruciating pain (allodynia). Wound healing complications, such as maceration, infection, and ischemia, may further contribute to the pain response.

Table 1

The European Wound Management Association (EWMA) published a position statement¹ on pain during wound dressing change; Table 1 lists the key findings of this report.
       Wound pain can serve as an indicator of inadequate wound management, an untreated underlying cause, and/or an infection. Such pain frequently happens during dressing change or debridement; as a result of exudate pressure; around wound edges; in the infected wound; with the application of antiseptics; and during certain wound cleansing procedures.¹ Be sure to consider not only pain-free wound dressings but also advanced dressings to decrease the frequency of dressing changes.
       Professionals often define and understand a patient’s wound pain based on clinical assumptions. For example, it is frequently accepted that arterial ulcers are more painful than venous ulcers and that small ulcers are less painful than large ulcers. The relationship, however, between the intensity of pain a patient experiences and the type or size of the injury is highly variable and not an accurate predictor of pain.¹ Between 60–80% of patients with chronic wounds experience some degree of pain, and 50% of patients with pressure ulcers have pain, particularly those with stage 3 and 4 pressure ulcers.³ The degree of pain has also been correlated to the stage of the pressure ulcer, thus contradicting the common wisdom that stage 4 pressure ulcers are painless.⁴
       Szor and Bourguignon⁴ have reported that 87.5% of patients reported pain at dressing change, and 84.4% of patients with wounds reported pain at rest. Of those patients reporting pain during dressing changes, 18% described their pain as “horrible” or “excruciating.” Forty-two percent of patients reported their pain as continuous, occurring both at rest and at dressing change. Only 6% of patients had been prescribed analgesics to address their pain.

Wound Pain Essentials

       Assume that every wound is painful and every patient who has a wound is in pain. Patients frequently experience pain during dressing changes (eg, from dried dressings, strong adhesives, debridement, and the pressure of exudate), around wound edges, and in infected or inflamed wounds. Wound pain can serve as an important indicator of inadequate wound management, untreated underlying cause, and/or infection.
       Moist wound healing has been demonstrated to result in faster healing, less scarring, and less pain. The pain reduction is attributed to the bathing of nerve endings in fluid, preventing dehydration of the nerve receptors.⁵
       The following pain relief strategies are intuitive but sometimes forgotten:
• Handle all wounds gently; flush, do not rub, when cleaning.
• Avoid unnecessary stimuli to the wound, such as drafts from an open window, fan, or vent, and prodding or poking.
• Protect wound edges with barrier co-polymer, cream, or a hydrocolloid wafer cut to fit around the wound.
• Allow patients to change their own dressings if possible.
• Allow patients to call “time out” verbally or by some nonverbal cue like raising their hands.
• Encourage slow, rhythmic breathing and other relaxation techniques.
• Let patients know that there are “no points for bravery” and that blood flow can actually be decreased during episodes of pain.
• Medicate prior to dressing change and debridement. Topical EMLA (eutectic mixture of local anesthesia) cream is a useful anesthetic that is safe and easy to use. It should be applied approximately 1–2 hours before the procedure, depending on the area to be treated and the extent of treatment.
• Use dressings least likely to adhere and cause pain, such as hydrogels, hydrofibers, alginates, silicones, cellulose, and polyacrylates. Dressings that can dry out, like gauze, can cause tremendous pain, especially when removed.
• Avoid using gauze. It is a key factor in the development of painful wounds.¹ Alternatives like the polyacrylate dressings provide moist wound healing and fast, efficient debriding without pain.
• Choose high-tech dressings that are appropriate for a particular wound and can remain in place for longer periods of time to reduce the need for frequent dressing changes.
• Select dressings with absorbency that matches exudate levels.
       Edema, swelling, and inflammation can cause or contribute to the pain experience. Infection and inflammation alone can be painful. Superficial infection may cause local pain or discomfort due to the release of mediators by the bacteria and the host. The exudate of chronic wounds has abnormally high concentrations of proteases, particularly matrix metalloproteinases (MMPs).⁶ These increased proteases shift the wound healing balance into a continuing chronic-inflammatory phase. The use of compression bandages, hosiery, and binders can offer relief. Also, look to newer dressings, such as activated polyacrylates, which diminish edema at the wound site. Below are several methods to consider:
• The use of compression bandages, hose, and binders to decrease swelling and edema, thereby decreasing pain unless contraindicated by congestive heart failure or peripheral vascular disease
• Newer dressings like polyacrylates to help further diminish edema at the wound site and the periwound area
• For known chronic venous insufficiency (CVI) with an ankle brachial pressure index (ABI) > 0.8, apply appropriate compression stockings or 4-layer compression dressings and make sure that your residents elevate their lower extremities; this in turn decreases edema, which can alleviate discomfort.

Dressing and Treatment Strategies

       Dressing removal is considered to be the time of most pain.¹ Dried dressing and adherent products are most likely to cause pain and trauma at dressing changes. Products designed to be nontraumatic should be used to prevent tissue trauma. Gauze is most likely to cause pain and should be avoided. Clinicians should avoid wet-to-dry regimens.
       One of the most important things to consider in selecting a dressing to diminish pain in the wound is that the chosen dressing must minimize the degree of sensory stimulus to the sensitized wound area. Any dressing that sticks to the wound bed, such as gauze, or dries within the wound bed and is then pulled away sends more sensory information to receptors in the skin than a dressing that is easily rinsed away or slides off the inflamed tissue. Dressings like sheet and amorphous hydrogels, hydrofibers, alginates, soft silicones, cellulose dressings, ?smart? (ie, nonadherent) foams, and polyacrylates provide beneficial wound healing environments and also offer a virtually pain-free dressing removal while curtailing the pain experience during wearing time.
       Do not neglect pain management during wound cleansing, either. Appropriate noncytotoxic wound cleansers used at body temperature (~100°F) at 4–15 psi are best to keep discomfort at bay.⁹ Avoid cytotoxic solutions, such as povidone iodine or hydrogen peroxide, when cleaning the wound, as these can cause discomfort and can be lethal to fibroblasts and keratinocytes.
       When removing a dressing, make every possible effort to avoid unnecessary manipulation of the wound and prevent further damage to the delicate granulation and healing tissue within the wound bed and periwound skin. If the dressing has become dry, make sure to moisten it with an isotonic solution before removing. Choose dressings that allow less frequent and therefore less painful dressing changes. Also, consider contact layers that stay in place when the dressings are changed, thus staving off potential wound bed pain.
       Silver dressings, especially ionic silver hydrogels, could be ideal pain-free dressings. The dressings provide a broad-spectrum antimicrobial action with no known resistance and maintain moisture balance with pain-free application and removal. They also provide for autolytic, thus pain-free, debridement and display anti-inflammatory actions while eliminating any offensive odors.¹⁰
       Another area of concern with regard to the wound care patient and pain is how the dressing is attached. Evaluate the dressing tapes that you and your facility use. Are they gentle on thin, aging epidermis, holding tight with a low-sensitivity adhesive, yet allowing easy removal? Do you and your staff regularly use a co-polymer skin preparation with the application of all adhesives and tapes, providing strength and thus decreasing the chance of a skin tear (which can produce even more pain)? Check your protocols and be sure that this important step is not skipped. Do not forget about the “tapeless” ways of securing a dressing: Montgomery straps, Kling gauze, elastic netting, or “grip” elastic support bandages not only provide support to the dressing but further protect the patient from the injury and pain of removal and reapplication of tape.

Pain-Free Tactics

       What other pain-relieving measures can we integrate into our advanced wound caring practice? Dallum et al.¹¹ showed that pain was significantly lower in patients using support surfaces for pressure reduction. Support surfaces take pressure off of the body’s frame and soft tissue, promote a healthy microclimate, and conform to body contours.
       For gentle skin care, use a 4-pronged approach: clean, moisturize, protect, and nourish the skin of every patient, every time. Consider going soap-free. Newer products without harsh surfactant-type cleansers use phospholipids to clean, leaving the skin healthier and more comfortable. Look for ingredients like methylsulfonylmethane (MSM), which slows the conduction of pain fibers and helps to reduce inflammation.¹²
       When utilizing negative pressure wound therapy (NPWT) or Vacuum Assisted Closure (V.A.C.^® Therapy^TM, KCI, San Antonio, Tex), if the patient experiences pain, consider premedicating 30–60 minutes prior to removal of the dressing. Pain can be dramatically reduced by instilling normal saline onto the dressing and/or by a physician or nurse practitioner’s order for lidocaine solution to be injected 30–60 minutes prior to removal of dressings. Line the wound bed with an amorphous hydrogel or powder with ionic silver—it not only helps relieve pain on initiation and removal but can also cut offensive odor and number of days on NPWT—or a nonadherent gauze.¹³ Also, be sure to apply a skin prep or sealant to the periwound skin prior to applying the occlusive drape. Other strategies include keeping exposed tissue moist with normal, saline-soaked gauze or impregnated hydrogel gauze during long dressing changes and NPWT changes. Ensure that adequate personnel participate in the dressing change to minimize the time. More than 1 clinician is usually necessary to change these complex dressings.

Standards and Evidence

       Pain specialists estimate that at least 90% of patients with pain should experience satisfactory pain relief.² Yet at least 50% of patients needlessly suffer moderate to severe pain despite 2 decades of efforts to educate healthcare professionals.² Clinical practice guidelines for pain management have been available since the mid 1980s from organizations like the American Pain Society and the Agency for Healthcare Research and Quality (AHRQ).¹⁴ The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently released revised pain management standards.¹⁴ Among the requirements: pain must be assessed and reassessed regularly; routine and as-needed analgesics must be administered; and discharge planning and teaching must include continuing care based on the patient’s needs at the time of discharge, including pain management. Additionally, it requires that patients:
• Have the right to appropriate assessment of their pain
• Will be treated for pain or referred for treatment
• Will be taught the importance of effective pain management
•  Will be taught that pain management is a part of treatment
• Will be involved in making the care decisions.
       The AHRQ recommends that pressure ulcers be routinely assessed by healthcare workers who should not assume the absence of pain in patients who cannot express or manifest it.¹⁵ Assess all patients for pain related to the pressure ulcer or control the source of pain (eg, cover wounds, adjust support surfaces, reposition the patient). Provide analgesia as needed and appropriate. Prevent or manage pain associated with debridement as needed.
       Dallum et al.¹¹ reported that only 2% of patients with pressure ulcers who reported pain or discomfort received pharmacologic treatments. Krasner¹⁶ found that 42% of patients reported pain as continuous, occurring both at rest and at dressing changes. Only 6% of these patients were prescribed analgesics.
       The American Geriatric Society (AGS) Panel on Persistent Pain in Older Persons¹⁷ found that up to 80% of nursing home residents with pressure ulcers have significant pain that is undertreated.

Fast Forward

       What does the future hold? The lidocaine 5% patch (Lidoderm^® Patch, Endo Pharmaceuticals, Chadds Ford, Pa) was recently approved by the US Food and Drug Administration (FDA) for local anesthesia of neuropathic pain. Experimental use of lidocaine-infused amorphous hydrogels, compounded for sustained release into painful wounds, is underway. A commercial product available by prescription is Regenecare^® Wound Gel with 2% Lidocaine (MPM Medical, Inc., Irving, Tex). Bioengineered cellulose (XCell^® Cellulose Wound Dressings, Medline Industries, Inc., Mundelein, Ill), already shown to be a pain-free dressing choice, is currently being studied for its ability to deliver analgesics directly into the wound bed in a time-released fashion.¹⁸ Additionally, exploration of the effects of topical opioids, such as morphine-infused hydrogels, on treatment of painful wounds continues. Two topical products offering lidocaine-infused cream and lotion formulations for painful intact skin and periwound applications are LidaMantle^® Lotion (Lidocaine HCI 3%) and LidaMantle^® Cream (Lidocaine HCI 3%) from Doak Dermatologics, Fairfield, NJ.
       Providing tailored pain relief to our patients with wounds is common sense. It is a primary function to relieve pain and suffering. It is basic to the human spirit and enjoyment and quality of life. Remember that individual pain responses vary and treatment may require a variety of approaches including sensory, affective, cognitive, and socio-cultural dimensions.
       The bottom line is to be aware of nonverbal cues that your patient is experiencing wound pain. Pain is whatever the patient indicates it to be. Expect that your patient suffering with a wound is automatically suffering from pain, unless she or he tells you differently. To assess how your facility addresses pain, ask yourself the following questions. Do your protocols include the pain management components of wound care? Do you have a pain specialist on your wound care team? Are you using appropriate wound management techniques and dressings to help alleviate pain? Are you offering your patients a pain-free wound care experience? Make sure these goals extend to your wound care practices, and you will be performing 21st century care with a gentle hand. Today’s clinician can now offer virtually pain-free wound care with state-of-the-art topical therapies, advanced dressings, and treatments.