case study - Hartmann - Paul Hartmann AG

Issue 3 Spring 2006 

woundforum 

Sharing European Wound Management Experiences 

INSIDE: 

Ewma 2006 

Case Study 1: Treatment of a necrotic wound 

Case Study 2: Large abdominal abscess after dislocated 

percutaneous feeding tube 

SPECIAL REPORT 

624 Patient Observation Study of New Low Cytotoxicity Silver Dressing 

130 years of high performance, cost effective solutions

Welcome 

to this ‘new look’ issue of Hartmann’s Wound Forum journal. 

The Wound Forum journal has appeared in many guises over 

the years as some of the images below show. 

CASE STUDY 

The author: 

Frans Meuleneire, AZ St. Elisabeth, Heelkunde 2E, 

Godveerdegemstraat 69, 9620 Zottegem, Belgium 

F. Meuleneire, St. Elisabeth, Zottegem, Belgium 

Treatment of a necrotic 

wound due to 

subcutaneous haematoma 

This latest issue aims to draw on the experience and expertise of 

Hartmann’s technical specialists together with our end users to 

share with you examples of wound management practice in 

different settings within the UK and 

across Europe. 

You may have also seen the start of 

our series of advertising campaigns 

which are currently appearing in 

eminent UK and European journals. 

These highlight the history of 

Hartmann in the development of 

the first antiseptic dressings in 1870 

with Sir Joseph Lister – a story 

covered on page 12. 

Today, Hartmann continues to strive to use its up-to-date 

manufacturing processes and technical expertise to bring the NHS 

dressings that are clinically effective but which aim to provide the best 

value for money – a factor that is difficult to ignore in today’s climate. 

The latest example of this is our new product launch of Atrauman 

Ag - a silver primary dressing that combines efficacy with cost 

effectiveness. Now available on Drug Tariff and via NHS Logistics, 

Atrauman Ag has been successfully proven. The outcomes of a 624 

patient study using Atrauman Ag can be found on pages 8 – 11 and 

14, together with further case study information. 

Hartmann’s dressings are proven in use in over a billion instances 

each year, across 80% of the world’s countries, resulting in an 

extensive bank of knowledge relating to good wound management 

practices. I look forward to sharing further experiences of our users 

with you in future issues of Wound Forum. 

Hayley Summersgill 

Marketing Manager, Wound Management Division (Great Britain) 

The following case study demonstrates how treatment with phased 

use of different wound dressings, each with differentiated principles 

of action, can selectively stimulate and promote wound healing. 

Introduction 

An 84-year-old female patient had hit her lower leg on a chair, resulting 

in the formation of a haematoma of the left lower leg. The skin became 

necrotic relatively quickly and after ten days a small amount of wound 

exudate seeped through the absorbent dressing. Although the dressing was 

changed daily, there was still no improvement one week later (Fig. 1). The 

patient was in constant pain. Clinical signs of infection were also present: 

There was oedema and the peri-wound area felt hyperthermic to the touch. 

Since no positive development was apparent, the patient was referred to 

the wound centre for consultation. Here the patient’s vascular status was 

evaluated and a search was undertaken for possible systemic factors affecting 

wound healing. Despite her advanced age, only slight arterial insufficiency 

was detected. The venous circulation was normal. The patient was not taking 

medication that interfere with wound healing and no other diseases were 

present which could have caused a deterioration in wound healing. 

Local wound treatment / course 

After taking the medical history and inspecting the wound conditions, 

the treatment plan was established. 

Since the presence of necrotic tissue with an incipient infection was 

identified as the most serious interfering factor, the first therapeutic 

intervention consisted in removing the necrotic material as rapidly as 

possible. The following principle should be remembered: the more 

rapidly the necrosis can be eliminated, the sooner the wound can 

enter the granulation phase. Furthermore, necrotic tissue is a nutrient 

substrate for aetiologic agents that can cause wound infection. 

In the first step, the wound was thoroughly cleansed by thorough and 

extensive debridement and thereby prepared for further treatment. Since 

single debridement rarely provides sufficient wound cleansing in wounds 

of this type, the subsequently applied wound dressing must provide for 

continuous cleansing. This means that the wound dressing must be able 

to progress the wound into the granulation phase within a short time both 

by stimulating autolytic debridement and by active osmotic debridement. 

This patient had a dry, necrotic, oval wound bed measuring approximately 

7x 4 cm. Since the wound was not very deep, we chose an oval TenderWet 

2 Hartmann Woundcare Forum

24 wound pad of the same size (Fig. 3). With its special principle of action, 

TenderWet 24 is particularly effective in rapidly cleansing wounds. 

The wound pad has an absorbent core made of a super-absorbent 

polymer which is saturated in an amount of Ringer’s solution 

appropriate to the size of the wound before being applied. The 

Ringer’s solution is then released into the wound, actively softening 

and debriding the necrotic material. At the same time, microbially 

contaminated wound exudate is absorbed into the pad, reliably 

removing micro-organisms, debris and toxins from the wound. 

cells. After one full week we removed PermaFoam and observed a remarkable 

improvement in the wound condition. Both the depth and the surface of the 

wound had decreased considerably (Fig. 7). 

Considering the extremely positive development of the wound, a new 

PermaFoam dressing was applied. 

This dressing was also not removed until after one whole week and we 

again noted that the wound surface area had decreased by half. Because 

of this positive development of the wound and the fact that PermaFoam 

was not completely saturated, we were now able to leave the dressing 

in place on the wound for ten days. On removing the dressing, we 

observed that epithelisation was almost complete (Fig. 8). 

Since the patient resides at a distance of 90 km from our wound centre, 

we did not issue her a new appointment for a further assessment of her 

wound. After one week she informed us by telephone that the wound 

had closed completely. 

Fig. 1: Necrotic wound due to 

subcutaneous haematoma, status 

at start of treatment. 

Fig. 3: Start of treatment with 

TenderWet 24 for further 

Fig. 2: Extensive debridement from 

initial cleansing. 

Fig. 4: Wound cleansing with 

TenderWet 24 produces good results. 

wound cleansing. 

The TenderWet wound dressing was changed daily. On removing the dressing, 

we observed that it was moderately adhering to the surface of the wound. 

When the dressing was carefully removed, the patient experienced no 

appreciable pain. Moreover, the adhesion had the effect of mechanically 

cleansing the wound, making wound irrigation hardly necessary (Fig. 4). 

Conclusion 

A wound treatment plan is always based on contemporary principles 

of wound healing. In 2000, Falanga described it as a comprehensive 

program of management in which we have to include all aspects of 

wound care. Wound bed preparation is performed initially to eliminate 

all the necrotic material from the wound. The moist wound healing 

environment described by G. Winter more than 40 years ago is of great 

importance especially for wound conditioning and should be taken 

into account as appropriate in every case. Furthermore, the bacterial 

equilibrium has to be re-established and maintained. Finally, we have to 

promote the process of epithelization as effectively as possible. 

By using the resources offered by modern wound dressings, we are 

now in a position to influence the individual phases of wound healing 

by stimulating and promoting the overall process and applying the 

principles of wound healing in an optimal manner. 

Ten days later the wound bed had almost reached skin level. It was free from 

necrotic tissue and only small amounts of wound exudate were present. 

Epithelization was clearly starting from the wound margins. The TenderWet 

wound pad had now become too large for the regenerating wound and was 

causing moderate maceration of the wound margins (Fig. 5). 

Because of this changed wound situation, we were obliged to select 

a wound dressing with a different principle of action. We decided in 

favour of the PermaFoam foam dressing (Fig. 6). Its therapeutic efficacy 

derives from its special pore structure: Large pores become increasingly 

smaller towards the top layer, generating a strong vertical wicking effect 

and resulting in rapid absorption of exudate. The good fluid binding of 

PermaFoam is also of great practical importance. 

This protects wound edges against maceration and the foam dressing can be 

left on the wound for several days even with heavy exudation (in the absence of 

complications). In the case described here, the wound showed only moderate 

exudate production, allowing us to leave the PermaFoam foam dressing on the 

wound for a whole week. The wound healing process continued undisturbed 

during this period: detritus, wound exudate with toxins and bacteria are actively 

absorbed by this dressing, which in turn promotes the migration of epithelial 

Fig. 5: Because of the altered 

wound situation, time to change 

the wound dressing. 

Fig. 7: State of the wound after 

one week’s undisturbed healing 

under PermaFoam. 

Fig. 6: Change to PermaFoam 

foam dressing, which remains on 

the wound for a week. 

Fig. 8: Wound healing almost 

complete after another 10 days’ 

PermaFoam treatment. 

Hartmann Woundcare Forum 3

CASE STUDY 

The Author: 

Friedhelm Lang, Head of Surgical Department, General Surgery Clinic Leonberg District Hospital, Rutesheimer Straße 50, D-71229 Leonberg 

F. Lang, Leonberg District Hospital 

Large abdominal abscess following dislocated 

percutaneous feeding tube 

PEG (percutaneous endoscopically controlled 

gastrostomy) is a patient sparing method 

of enteral nutrition with only a low rate of 

complications. If in rare cases the feeding 

tube becomes dislocated, immediate surgical 

intervention followed by adequate local wound 

treatment is indicated. 

PEG was developed in 1980 by Ponsky and 

Gauderer in the United States. In Germany, 

Fresenius introduced the tube in 1984 in a 

form modified by Keymling. The PEG is now 

the method of choice for long term enteral 

nutrition. For the patient it generally means an 

improvement in nutritional status and quality 

of life because enteral feeding resembles the 

physiological intake of food and the gastric 

and intestinal regions continue to be involved 

in digestion. Another benefit of the method 

is that swallowing and speaking are not 

compromised and the patient can move about 

freely with the tube if mobility is preserved. 

PEG is now regarded as a standard procedure with 

a low rate of complications. Complications can 

occur during placement (e.g. peritonitis) or during 

the indwelling period (e.g. incorrect administration 

of tube nutrition, ingrowth of the fixation plate 

into the stomach or abdominal wall, tube 

dislocation). Since PEG is an invasive therapeutic 

modality the permanent risk of infection should 

also be taken into account, which mandates 

a strictly aseptic procedure during care of the 

tube insertion site. In care of the tube insertion 

site however, products containing polyvidone 

should be avoided, since they can cause the tube 

material to swell and become brittle. Dressings 

with wound-friendly polyhexanide have proved 

more suitable. Attention is also explicitly drawn to 

the importance of secure retention of the external 

fixation plate with surgical adhesive tape to 

eliminate the risk of dislocation, for example when 

the patient changes position. 

Complication: dislocation 

Feeding tube dislocation which can occur in 

rare cases is a serious, often life-threatening 

complication. Disclocation of the internal 

fixation plate is usually the result of the tube 

being subjected to extreme tension. This 

tension forcibly tears the fixation plate out 

of the stomach wall, leaving behind a large 

perforation site. As a result, stomach contents 

can enter the abdominal cavity which can lead 

to peritonitis. 

The signs indicating that a feeding tube is not 

correctly in place are unequivocal: 

• The fluid diet can only be delivered through 

the tube with difficulty, if at all 

• Pain accompanies the administration 

of nutrition 

• Increasing pain in the upper abdomen, not 

necessarily around the stoma 

• Rigidly tense, tender abdominal wall 

• Elevated temperature to the point of fever 

Elderly or somnolent patients must be 

critically monitored, since these subjects often 

exhibit the symptoms at a late stage or in a 

masked form. 

If a feeding tube becomes dislocated, the 

patient requires immediate surgical treatment. 

The timing of the surgical intervention 

determines the patient’s prospects of survival. 

Case study 

The following case report describes the 

dislocation of a feeding tube in which the 

internal fixation plate came to be positioned 

subcutaneously. The patient was 86 years old 

and was referred to our surgical outpatient 

department by a care institution due to 

“feeding tube infection”. The referral report 

contained the diagnoses Alzheimer dementia, 

aortic aneurysm, coronary heart disease 

(CHD) and hypertension. The patient was fed 

with 1,500 ml tube nutrition and additionally 

750 ml liquid. The patient’s extremities were 

completely contracted. 

On admission to hospital, the patient was 

found to have a hard swelling in the area of 

the feeding tube and a soft abdomen. Exertion 

of pressure at the tube insertion site resulted 

in the discharge of a large amount of pus. 

The fistula was exposed to reveal a dislocated 

feeding tube with the fixation plate in the 

subcutaneous tissue. A pronounced fistula 

system was also observed. 

Gastrointestinal transit with gastrografin 

administered through a stomach tube revealed 

a normally contoured stomach, with the status 

post tube feeding still apparent. There was no 

fistulation after complete filling of the stomach. 

The abdominal survey film taken after one 

hour with the patient supine showed that the 

contrast agent had already passed through the 

small intestine. 

In the ensuing operation the patient was 

difficult to position because of her contractures. 

The feeding tube was cut off to a length of two 

centimetres above the skin. After disinfection 

of the skin and waterproof draping, the 

feeding tube was excised in a spindle shaped, 

transverse manner. This revealed the base plate 

of the tube in an immediate subcutaneous 

position. From there, we proceeded to an 

epifascial cavity measuring two handbreadths 

and containing necrotic material, extending as 

far as the anterior axillary line on both sides. 

On applying compression to the abdominal 

wall, no fluid was discharged from the already 

granulated fistula channel of the feeding tube 

and therefore laparotomy was not performed 

since the abdomen was preoperatively 

completely soft. A counter-incision was made 

on the left side. 


Fig. 1: X-ray: Fistula filled with 

contrast agent, the subcutaneously 

located fixation plate and the full 

extent of the abscess are clearly seen. 

Fig. 3: PermaFoam cavity is placed 

loosely in the abscess cavity. The soft 

foam material and the special porous 

structure allow uncomplicated 

tamponading with good adaptation 

to the wound surfaces. 

Fig. 2: First dressing change after 

feeding tube removal and abscess 

removal, wound cavity with residual 

necroses and heavily exuding. 

Fig. 4: Wound cavity completely 

padded out with PermaFoam 

cavity. 

Wound management 

Dressing change was carried out once daily. After removal of the 

dressing and wound inspection, the wound cavity debrided on 

removing the feeding tube was irrigated with copious amounts 

of polyhexanide solution. This served to remove residual necrotic 

debris and fibrin layers. In addition, the wound cavity was cleansed 

mechanically for the first three days by drawing through cotton 

compresses. On the fourth day, the wound cavity already showed good 

blood supply with only residual fibrin layers. Mechanical cleansing 

with cotton compresses was therefore now unnecessary, allowing the 

initiation of wound conditioning while preserving the undisturbed state 

of the wound and without cell stripping. 

PermaFoam cavity completes the range of the foam dressing PermaFoam, 

which is available in a variety of presentations. Because of its soft 

material and special porous structure, PermaFoam cavity can be adapted 

individually to the wound and easily tamponaded into the cavity. 

Following the initial wound cleansing activities, the wound cavity was 

padded out very carefully and lightly with the foam dressing PermaFoam 

cavity to promote the formation of granulation tissue in the wound 

cavity (Fig. 3/4). Because of its special pore structure which generates a 

strong vertical wicking action, PermaFoam has pronounced absorbent 

and retention properties. In practical use, this means that excess, 

aggressive wound exudate, pus and cell debris are rapidly absorbed 

into and retained in the foam structure. This also has the effect of 

preventing maceration and irritation of the wound edges. On absorbing 

exudate, the foam dressing changes only slightly in size and the material 

therefore does not exert pressure inside the wound cavity. 

Fig. 5: PermaFoam cavity before 

the dressing change after 48 hours. 

The soft foam reliably stores excess, 

aggressive wound exudate, the wound 

edges are free from macerations. 

Fig. 7: PermaFoam cavity 

saturated with wound exudate and 

cell debris. 

Fig. 6: The wound is clean and 

moist, with increasing formation of 

granulation tissue. 

Fig. 8: On the day of discharge, 

the wound has decreased enough 

in size to allow loose tamponading 

with Sorbalgon calcium alginate 

compresses for the further treatment. 

This allowed the extensive necrotic cavity to be irrigated from both sides 

postoperatively. Preoperative laboratory parameters with a leukocyte 

count of 18, 6000 and C-reactive protein of 22 clearly demonstrated the 

presence of an infection. Rectally measured body temperature was 38 

°C. The patient was given 2.2 g Augmantan t.d.s. for three days. 

Thanks to the high absorption and retention capacity of PermaFoam 

cavity, a dressing change was only necessary every second day. This 

was performed in a cell-sparing manner and without administering 

analgesics, since PermaFoam has atraumatic properties and does 

not dry out the wound. We observed no adhesion to the wound even 

with longer dressing change intervals. Overall, we observed good 

conditioning when using PermaFoam cavity, with increasing formation 

of granulation tissue (Fig. 6). 

The tamponading properties of PermaFoam cavity were also good. 

The material remains compact under tensile stress and does not 

tear. Cutting to size beforehand to match the size of the wound is 

unnecessary, since the special porous structure of the foam material 

allows it to be adapted to the correct size before being placed in the 

wound. As a result, PermaFoam cavity can be placed in any wound 

and abscess cavity. Like all PermaFoam wound dressings, PermaFoam 

cavity is indicated for moderately to heavily exuding wounds in the 

inflammatory or proliferative phase of healing. This facilitated our 

continuous wound therapy activities. 

In our example of a large abdominal wall abscess, the wound steadily 

decreased in size during treatment with PermaFoam cavity, so that 

on the day of discharge from hospital, treatment was changed to 

Sorbalgon calcium alginate compresses for the patient’s further 

management in the care facility (Fig. 8). 


Clinical efficacy of the polyurethane foam dressing 

PermaFoam in the treatment of chronic wounds - 

a prospective and multicentre observational study 

with 53 patients 

Treatment of patients with chronic wounds 

involves – besides treating the underlying 

disease – the stage-adapted use of hydroactive 

wound dressings, which maintain a moist wound 

condition (Choucair MM, Fivenson DP. Leg ulcer 

diagnosis and management. Dermatol Clin 2001; 

19: 659-678). A physiological moist environment 

encourages the migration of key cells, such as 

macrophages, keratinocytes, fibroblasts and 

endothelial cells and enhances granulation and 

reepithelialization (Mendez MV, Raffelto JD, 

Philipps T, Menzoian JO, Park HY. The proliferative 

capacity of neonatal skin fibroblast is reduced 

after exposure to venous ulcer wound fluid: a 

potential mechanism for senescence in venous 

ulcers. J Vasc Surg 1999; 30: 734-743). An 

appropriate wound dressing can remove excessive 

amounts of wound exudate while retaining a 

moist environment that supports the healing 

process (Reddy M, Kohr R, Quees D, Keast D, 

Sibbald RG: Practical treatment of wound pain 

and trauma: a patient-centred approach. An 

overview. Ostomy Wound Manage 2003; 49: 2- 

15; Schultz GS, Sibbald RG, Fallanga V, Ayello EA, 

Dowsett C, Harding K, Romanelli M, Stacey MC, 

Teot L, Vanscheidt W. Wound bed preparation: 

a systematic approach to wound management. 

Wound Rep Reg 2003; 11: 1-28). Polyurethane 

foam dressings such as PermaFoam have been 

introduced into clinical practice in order to 

promote a moist wound environment while, at 

the same time, being able to absorb excessive 

amounts of exudate and debris from the wound 

(Seaman S. Dressing selection in chronic wound 

management. J Am Podiatr Med Assoc 2002; 

92: 24-33). The fluid absorption and retention 

capacity of the foam dressing PermaFoam has 

been investigated in laboratory tests. Due to the 

high affinity of the foam material for exudate, 

PermaFoam binds it very efficiently. In comparison 

to competitor products, PermaFoam showed the 

highest residual absorption capacity. 

In a clinical study, conducted by Fernando 

Martinez Cuervo and his colleagues, the 

efficacy of PermaFoam in the treatment of 

chronic wounds of different aetiologies has 

been analysed (Cuervo FM, Gómez TS, Pérez 

FA, Soraiano JV, de con Ridondo J, García 

TL. Revista de Enfermería 2005; 28: 29-34). 

The investigators enrolled 53 patients in the 

prospective, randomised observational study, 

31 men (58%) and 22 women (42%) with a 

mean age of 76.1 years. Some of the patients 

suffered from comorbidities such as diabetes 

(13 patients), malnutrition (12) and lower limb 

arteriopathy (11). 37 patients took two or 

more drugs such as anxiolytics, neuroleptics, 

hypnotics, anticoagulants and antihypertensives. 

As Cuervo and colleagues report, the majority 

of the patients suffered from chronic, non/ 

delayed healing wounds: Most frequently 

PermaFoam was used for the treatment 

of pressure ulcers (26), venous ulcers (11), 

mixed lesions (10) and 9 wounds with other 

aetiologies (4 surgical, 3 burns, 1 neurotrophic 

and 1 traumatic). Overall, 56 wounds were 

treated. The mean wound duration was 270 

days (± 604 days), the median 85 days. 

The maximum duration of the trial was 8 weeks 

for each patient, unless complete healing of 

the wound or withdrawal. Re-assessments of 

Tab. 1: Perilesional skin of wounds enrolled in the 

study before and after treatment with PermaFoam 

at admittance end of study 

maceration 12 2 

erythematous 9 3 

lacerated 4 0 

Tab. 2: Opinion of professionals on the use of PermaFoam 

wound state were performed during the 1st, 

3rd, 5th and 7th weeks, and the final clinical 

examination was undertaken in the 8th week. 

According to the authors statement, 21 wounds 

(37.5%) completely healed in the course of the 

study, 6 patients withdrew (4 due to transfer and 

2 because of a fatal outcome unrelated to the 

treatment). The size of the wounds decreased 

from 26.44 cm 2 to 13.02 cm 2 (reduction 13.42 

cm 2 ; 95% CI: 7.39-19.45), at the end of the 

study. The mean relative reduction was 61.31% 

(95% CI: 50.66-71.97). The wound healing rate 

expressed as the percentage relative reduction of 

the wound over time is summarised in figure 1. 

The investigators further figured out that 

the numbers of exuding wounds decreased 

markedly. At the beginning of the study, 36 

wounds exhibited a moderate, 17 a heavy and 

3 a very heavy exudation. Of the wounds which 

had not healed after eight weeks, 9 showed a 

sparse, 15 moderate, 4 heavy and 1 very heavy 

exudation. At the same time less pathological 

findings in the perilesional skin has been 

diagnosed (table 1). The opinion of the treating 

physicians on the dressing and its performance 

during the study is given in table 2. 

As the investigators point out, PermaFoam 

demonstrated a very good performance profile 

in the course of the study. In an unselected 

panel of patients, mostly reflecting non-healing 

wounds encountered in daily practice, the 

wound size clearly decreased. The long mean 

very good good acceptable poor 

Ease of application 43.3% 53.3% 3.3% - 

Ease of removal 36.7% 36.7% 20% 6.7% 

Absorption capacity 50% 26.7% 23.3% 

Retention capacity 43.3% 30% 23.3% 3.3% 

Sparing of perilesional skin 56.7% 30% 13.3% - 

Pain due to dressing 53.6% 39.3% 7.1% - 

Flexibility/adaptability 60% 26.7% 13.3% - 

Opinion of dressing 23.3% 70% 3.6% - 

Acceptance of dressing by patient 50% 43.3% 6.7% - 


wound duration shows that physicians were 

confronted with long-term wounds, which have 

undergone multiple treatments and multiple 

medications. The positive assessment by the 

treating physicians revealed that PermaFoam 

was beneficial and the results indicated a 

significant reduction in the size of the wound 

over the study period, which was not affected 

either by the duration of the wounds or its 

aetiology. Most patients, who Cuervo and his 

colleagues enrolled in the study, suffered from 

chronic, non-healing wounds. The condition 

of the wound base (slough, exudation) and 

the surrounding skin at the time of inclusion 

into the study were correspondingly poor. 

PermaFoam was adapted to these conditions 

and enhanced the healing of the wounds. 

Furthermore the authors of the publication 

emphasise that maceration is usually the most 

common problem of the perilesional area 

(Cutting KF, White RJ. Maceration of skin and 

wound bed 1: its nature and causes. J Wound 

Care 2002; 11: 275-278), sometimes as a result 

of the use of moist wound dressings (Gago 

M, García RF, Gaztelu V, Romero J, Jiménez A. 

Problemas detectados en la piel perilesional al 

realizar cura húmeda con apósitos adhesivos 

hidrocoloides. Enf Cien 2000; 10: 36-41). 

Another common problem of the perilesional 

skin is erythema, which is usually caused due 

to the presence of exudate or the reaction 

between the skin and the adhesives in the 

dressings (Gago M, García F, Segovia T, Verdú 

J. Piel perilesional. En: Soldevilla JJ, Torra 

JE (Eds.). Atención integral de las heridas 

crónicas, 1a ed. Madrid: SPA 2004; Dykes PJ, 

Hill SA. Effects of adhesive dressings on the 

stratum corneum of the skin. J Wound Care 

2001; 10: 7-10). Appropriate monitoring of the 

exudate together with the characteristics of the 

adhesives has resulted in a smaller proportion 

of maceration and erythema of the perilesional 

skin. Maintaining adequate moisture conditions 

in the wound bed and sparing the perilesional 

skin is therefore one of the cardinal rules in 

the treatment of chronic wounds (Bergstrom 

N, Bennett MA; Carlson CE et al. Treatment of 

pressure ulcers: Clinical practise guideline, No 

15. Rockville, MD. AHCPR publication no 95- 

0652. December 1994). From the investigators 

point of view the study could demonstrate that 

PermaFoam promoted control of the exudate 

and care of the wound surrounding skin. 

Summarising the conclusion of the authors, 

PermaFoam occasioned the complete healing or 

improvement of the final size of all the lesions 

treated, regardless of aetiology, 

stage or duration. Treatment with 

the foam dressing enabled the 

physicians to control exudation, 

the retention time on the lesion 

prolonged and the number of 

changes of dressing reduced. 

By eliminating the exudate from 

the surrounding skin, it reduces 

changes in the perilesional area. 

The assessment of the patients 

and professionals was good or 

very good for practically all the 

aspects evaluated. 

PermaFoam is composed of three layers 

(Fig. 2). Wicking layer: The wound facing 

side is characterised by large-sized pores 

(1000 µm diameter) which rapidly absorb 

large quantities of exudate, cell residues 

and viscous exudates without the pores 

collapsing or clogging. Distribution layer: The 

second layer is composed of pores of smaller 

diameter (400-500 µm), which promotes good 

distribution and retention of the exudate 

Fig 1: 

Wound healing rate (relative percentage of wound healed) in 

the course of the study, n = 56 (p < 0.001) 

absorbed. Semipermeable top layer: The last layer is characterised by its pronounced elasticity 

and permeability to water vapour, endowing it with perfect adaptability and semipermeability. 

Fig. 3: Comparison of residual absorption capacity (retention) 

of five foam dressings under a 35 mmHg pressure. 

This difference in pore size 

is known as pore gradient. 

The high affinity of the 

foam material efficiently 

holds exudate and cell 

residues, preventing 

exposure of the wound 

to aggressive proteolytic 

enzymes and reducing 

the risk of maceration. 

In a laboratory test 

PermaFoam showed the 

highest residual absorption 

capacity under pressure compared with four competitor foam dressings (Fig. 3). For this reason 

PermaFoam is particularly efficient in combination with compression therapy. 

PermaFoam has been independently tested to 

provide higher fluid handling capacity than 

one of the current, UK market leading foam 

dressings*. Meaning reduced maceration and 

longer wear times with the subsequent cost 

savings and greater convenience for nurse 

and patient. 

Due to the vertical absorption mechanism 

and unique pore gradient, PermaFoam 

absorbs faster and is able to retain exudate 

at greater levels than other foam products 

even under compression. 

* SMTL 2006 

Fig. 2: Pore size decreasing from the bottom 

(wound-facing side) increases capillary 

strength, resulting in exudate absorbing into 

foam matrix and the back. 

Fig. 4: Vertical absorption and distribution 

by PermaFoam of a methylene blue solution. 


Treatment of infected and infection-prone wounds with Atrauman Ag - A new, low cytotoxicity silver dressing 

Clinical observation study in 624 patients confirms 

good efficacy and tolerability 

Summary 

More than 600 patients with predominantly 

chronic wounds – about two thirds of 

them infected – were treated with the 

silver-containing dressing Atrauman Ag 

in a multicentre clinical observation study 

conducted in an outpatient setting. Wound 

condition improved markedly during the 

wound treatment which lasted for a mean 

period of 23 days. 

While at the beginning of the study 9% of 

the wounds were completely and 24.7% 

extensively covered with a coat of necrotic 

debris, at the final examination these 

proportions had decreased to 2% and 0.8% 

respectively. At the same time, the proportion 

of wounds without coatings increased from 

27% to 77%. Wound exudation was also 

reduced by treatment with Atrauman Ag. 

The marked decrease in wound coatings and 

exudation was accompanied by an increase in 

granulation and epithelial tissue. 

The number of wounds with moderate, 

pronounced or complete epithelization 

increased from 4.5% to just below 45%. 

Further parameters which improved during 

Atrauman Ag treatment included wound pain, 

number of infected wounds and condition 

of the peri-wound area. The treatment was 

tolerated very well by the patients. Both the 

physicians and patients therefore rated the 

tolerability of wound treatment with Atrauman 

Ag as good or very good. 

Conclusion: Atrauman Ag is an effective 

wound dressing for the management of 

infected and infection-prone wounds and can 

be used not only in the exudation phase but 

also in multiple phases of wound healing. 

Acute wounds and chronic ulcers are 

frequently colonized by faecal, oral and dermal 

microorganisms. Since wound flora can become 

colonized not only with bacteria but also with 

pathogenic and antibiotic resistant species, 

depending on the patient’s immune status 

colonization can lead – especially in therapy 

refractory chronic ulcers – to wound infection. 

In daily clinical practice, methicillinresistant 

strains of Staphylococcus aureus (MRSA) present 

a logistic and therapeutic challenge. 

A wound infection prolongs the exudative 

healing phase, resulting in a delay in the overall 

wound healing process. This has far reaching 

consequences for the patient, who not only has 

to tolerate considerably more pain but also has to 

anticipate a prolonged treatment period of several 

months to years until the wound heals completely. 

Tab.1: Bacterial strains reliably killed by 

Atrauman Ag 

Staphylococcus aureus DSM 346 

Staphylococcus aureus (MRSA) ATCC 6538 

Staphylococcus epidermidis DSM 2134 

Klebsiella pneumoniae DSM 789 

Pseudomonas aeruginosa DSM 1117 

Escherichia coli DSM 1103 

Bacillus subtilis DSM 347 

The silver-containing dressing Atrauman Ag has 

proved successful both in the primary management 

of contaminated wounds and in the treatment 

of chronic ulcers with an elevated infectious risk. 

When applied to the wound, Atrauman Ag releases 

silver ions into its environment and acts against 

a broad spectrum of different bacteria (Tab.1), 

including microorganisms such as methicillinresistant 

strains of Staphylococcus aureus, which 

can cause major therapeutic problems in wound 

infections. Since only as many silver ions are 

released as are necessary to exert an efficient 

antimicrobial effect, Atrauman Ag – especially 

when compared to other silver-containing wound 

dressings – has only limited toxic effects on the 

cells in the wound area. 

Atrauman Ag has already demonstrated its 

clinical efficacy and tolerability in an observation 

study in 86 patients. These results have now been 

confirmed in a larger, prospective multicentre 

clinical observation study involving more than 

600 patients with acute and chronic wounds of 

differing aetiology. 

Structure and mode of action of 

Atrauman Ag 

The support material of Atrauman Ag is made 

from a water repellent polyamide textile 

coated with metallic silver firmly bound to the 

support material. This in turn is impregnated 

with a hydrophilic ointment consisting mainly 

of triglycerides. When Atrauman Ag is applied 

to the wound, the wound dressing releases 

silver ions from its metallic surface on contact 

with exudate. Most of these ions remain in the 

immediate environment of the wound dressing 

– only very few ions enter the wound itself 

– and adhere to the surface of the bacteria and 

reliably kill them. The wound exudate together 

with the killed bacteria and the endotoxins 

formed in the process are absorbed into the 

secondary wound dressing. 

624 patients treated with Atrauman Ag 

The prospective, multicentre clinical observation 

study was performed in the ambulatory setting 

by 211 physicians – general practitioners, 

dermatologists, surgeons and internal specialists 

– and 11 community nursing services, who 

treated 624 patients with Atrauman Ag and 

documented the course of wound healing over 

altogether 2352 visits. 

A standardized questionnaire was used to record 

the patients’ age, gender, general state of health 

and co-existing diseases, the age and size of the 

wound, previous treatments and concomitant 

medications. Wound status was evaluated at 

the initial examination and over the course of 

the three dressing changes on the basis of the 

following parameters: 

– smeary, purulent coat 

– exudation 

– wound pain 

– granulation tissue 

– epithelial tissue 

The size of the wound and the state of the 

peri-wound area were also documented at the 

beginning and end of the study. 

At the end of the observation study, physicians and 

nursing staff evaluated the efficacy and tolerability 

and the application characteristics of the silvercontaining 

impregnated tulle dressing. The patients 

were also questioned about their treatment with 

Atrauman Ag at the end of the study. 


Aetiology of wounds 

Tab. 2: Age of the wounds, listed according to indication 

Indication 

arithmetic 

mean 

median 

standard 

deviation 

Venous leg ulcer (n = 261) 1.6 years 4 months 4.0 years 

Arterial leg ulcer (n = 27) 1.2 years 6 months 1.5 years 

Mixed leg ulcer (n = 75) 3.0 years 1 year 7.4 years 

Diabetic foot (n = 57) 1.6 years 3 months 1.5 years 

Burn (n = 35) 13 days 2 days 1.6 months 

Pressure sore (n = 60) 6 months 2 months 1.1 years 

Other (n = 136) 11.3 months 1.5 months 5.2 years 

Almost two thirds of the wounds 

Concomitant therapies with Atrauman Ag 

Tab. 3: Microbial spectrum of infected wounds identified by swab test (multiple responses possible) 

Fig.1 Aetiology of wounds. The majority of the patients 

were suffering from chronic wounds. 

The data recorded on case report forms were 

analyzed using descriptive statistical methods 

and the mean values, standard deviations and 

medians were calculated. Because of missing 

data, not all the parameters elicited could be 

included in the analysis. The individual results 

were therefore calculated using different baseline 

values. The number of results included in the 

analysis is shown for each of the parameters. 

43% of the patients had chronic venous ulcers 

The patients – 61.4% were male, 38.6% female – 

had a mean age of 70 (±16) years. The physicians 

reported that just under 14% were in very good 

and 27.4% in a compromised general condition 

due to co-existing diseases. Just below 60% were 

in an age appropriate physical condition. 

The physicians and nursing staff treated patients 

with chronic and acute wounds of differing 

aetiology (Fig.1). At 43.3% (270 patients), venous 

leg ulcers were the wounds by far the most 

commonly treated with Atrauman Ag. This was 

followed by mixed ulcers (12.5%; 78 patients), 

pressure sores (9.8%; 61 patients), diabetic foot 

syndrome (9.1%; 57 patients), burns (5.6%; 35 

patients), arterial ulcers (4.5%; 28 patients) and 

other wounds (22.3%; 139 patients). 

Genus 

Number of 

selections 

Staphylococcus 60 

Pseudomonas 25 

Streptococcus 17 

E. coli 11 

Oxacillin-resistant Staphylococcus aureus (ORSA) 11 

Methicillin-resistant Staphylococcus aureus (MRSA) 9 

Proteus 9 

Enterococcus 7 

Acinetobacter 3 

Klebsiella 3 

Serratia liguefaciens 2 

Serratia marcescens 2 

Alcaligenes xylosoxidans 1 

Citrobacter 1 

Corynebacterium 1 

Gram-negative microorganisms 1 

Gram-positive chain cocci 1 

Haemophilus 1 

Moraxella 1 

Pyocyaneus 1 

Mixed infection 2 

No information on microbial spectrum 10 

The mean age of the wounds was 1.36 years 

(± 4.5 years). The longest mean age was 3 years 

for mixed leg ulcer and diabetic foot syndromes 

and venous leg ulcer at 1.6 years (Tab. 2). 

Wound dressings previously used 

for treatment 

The treating physicians documented for 463 

patients which wound dressings had been used 

prior to study enrolment. Most of the patients had 

been treated with impregnated tulle dressings 

(98 patients), foam dressings (68 patients), 

hydrocolloids (66 patients), silver- containing 

wound dressings (60 patients) and wound 

dressings with antibiotics (59). 

were infected 

The investigators diagnosed clinical symptoms 

of infection in more than 60% of the wounds 

(364 of 600). 

For every third infection the diagnosis was 

confirmed by taking swab samples from the 

wound. The most frequently detected aetiologic 

agents were staphylococci (in 60 patients), 

pseudomonads (25 patients) and streptococci 

(17 patients) (Tab. 3). 

Of the 364 infected wounds, 110 were treated 

with systemic antibiotics (ciprofloxacin, amoxicillin, 

fusidic acid, clindamycin, doxycyclin etc.). 

Two thirds of the patients (365 cases) received 

pharmacological treatments concurrently 

with Atrauman Ag; just under one-third 

(205 patients) received analgesics, 16.5% 

(103 patients) antibiotics, 6% (39 patients) 

anticoagulants and 10% (62 patients) other 

products such as diuretics, antidiabetics etc. 

The treating physicians also prescribed 

compression therapy for the 270 patients with 

venous ulcer and for another 46 patients with 

a different indication. Further supplementary 

measures - depending on the diagnosed 

indication - included pressure relief of the 

wound, elevation of the legs, special nutritional 

therapies, physiotherapy etc. (continued...) 


Secondary wound coverage 

Atrauman Ag, like all other primary dressings, 

is used in combination with a secondary, 

absorbent wound dressing. The physicians and 

nursing staff used a variety of products for the 

dressing, but predominantly traditional wound 

dressings such as wound dressing pads or 

gauze swabs (in 411 patients) were used for 

fixation of Atrauman Ag or wound coverage. 

Products such as foam dressings, hydrogels, 

TenderWet or calcium alginates were used, in 

some cases in combinations. 

Number of wounds covered completely 

or substantially with necrotic debris coats 

decreased from 35% to 3% 

The patients were treated for a mean 23 days 

with Atrauman Ag, with three dressing changes 

per patient. Documentation of the course of 

wound healing showed that the condition of the 

wounds improved considerably with Atrauman 

Ag (Fig. 2). While at the beginning of the study 

9% of the wounds were covered completely 

and 24.7% substantially with a smeary coat, 

this incidence had decreased to only 2% and 

0.8% respectively at the final examination. 

At the same time, the proportion of wounds 

without coat increased from 27% to above 

77%. The degree of wound exudate formation 

also improved. The number of heavily and very 

heavily exudating wounds decreased from 39% 

to below 6% during the course of the study. 

The marked decrease in necrotic debris coatings 

and exudation was accompanied by an increase 

in granulation and epithelial tissue. The 

proportion of wounds in which no granulation 

tissue formed on the wound bed, or in which 

only one quarter of the wound bed was covered 

decreased from just below 90% to 37% by the 

end of the observation study. During the same 

period, the number of wounds with moderate, 

marked or complete epithelization increased 

from 4.5% to just below 45%. 

Wound pain and infections 

The patients also derived direct benefits from 

the wound healing promoting influence of 

the treatment. The proportion of patients with 

severe or very severe wound pain decreased 

from just below 40% to 6.5%. At the end 

of the study 53.5% of the patients reported 

having no pain. Before the start of Atrauman 

Ag treatment this was the case for 17%. The 

marked improvement in wound status and 

wound pain was accompanied by a decrease in 

the number of infected wounds. At the end of 

the study, 80% of the wounds were free from 

clinical signs of infection. 


Less oedema or dermal changes in the 

peri-wound area 

Not only the wound itself, but also the condition 

of the peri-wound area improved during the 

course of the study (Fig. 3). For example, the 

proportion of wounds with inconspicuous 

wound margins increased from 8.3% to 46.7%, 

and oedema decreased from 34.5% to 10%. 

At the initial examination, macerations were 

diagnosed in every fourth patient, and at the 

end of the study in only 4.3%. 

The average wound size decreased from 4.9 

(±3.8) cm in length and 3.3 (±2.6) cm in width 

to 3.5 (±3.6) cm und 2.4 (±2.6) cm, respectively. 

Physicians and patients rated the 

tolerability of Atrauman Ag as very good 

Both the treating physicians and the patients 

were very satisfied with the treatment 

outcome and the application characteristics of 

Atrauman Ag. Both emphasized the very good 

tolerability of the wound therapy, which was 

rated by over 90% as good or very good (Tab. 

4/5). Conformability to the wound bed, ease 

of removal and application characteristics 

were rated by more than 90% of users as 

very good or good. Furthermore, more than 

90% were of the opinion that the state of 

the wound had improved or even markedly 

improved compared to the initial examination 

(Fig. 4). Only 2.5% stated that the relevant 

wound parameters had deteriorated with 

Atrauman Ag treatment. 17.2% considered 

their expectations of the treatment had been 

exceeded and just under 60% regarded them 

as fulfilled (Fig. 5). 

Discussion 

Heavy microbial contamination of the wound 

can greatly influence the wound healing process. 

Besides an infection confined to the wound 

area, a growing bacterial burden resulting 

from a local wound infection can give rise to a 

systemic infection which may lead to sepsis (6). 

The development of silver-containing wound 

dressings has significantly improved the 

management of critically colonized and 

infected wounds (7). Especially for patients 

for whom systemic antibiotic therapy is not 

indicated but for whom topical antimicrobial 

therapy is beneficial, silver-containing wound 

dressings have a firmly established place. 

They also offer the possibility of providing 

additional topical therapy as a supplement to 

systemic antibiotic therapy. 

Compared to antibiotics, silver-containing 

wound dressings offer the advantage of having 

only a very slight tendency to induce bacterial 

resistance, even over long periods of use (8). 

The silver ions responsible for the bactericidal 

action, however, are also toxic for the cells in 

the wound area (9). Silver-containing wound 

dressings should therefore only release as 

many silver ions into their environment as are 

necessary to produce an effective bactericidal 

action. The silver-containing dressing Atrauman 

Ag was developed in accordance with this 

concept. Clinical studies and laboratory tests 

have already demonstrated the beneficial profile 

of action of low toxicity and potent antimicrobial 

action (Ziegler et al, Skin Pharmacology and 

Physiology), which showed keratinocyte survival 

to be 90% for Atrauman Ag compared with 

Acticoat’s 2%. These results have now been 

confirmed in the present large-scale, prospective 

multicentre clinical observation study conducted 

in the outpatient setting. 

Most of the patients were suffering from 

therapy refractory ulcerations – 60% of 

the wounds had no granulation tissue on 

study enrolment, almost 80% had formed 

no epithelial tissue – of the type frequently 

encountered in daily clinical practice. 

(continued on page 14 - back page) 


A history of ideas 

“Dear sir, I send you, according to your request, 

samples of the different materials which I use for 

antiseptic treatment…” 

This letter was written on 27 April 1874 by Sir Joseph 

Lister, recognised in history as the founder of antiseptic, 

to Paul Hartmann Senior in Heidenheim, Germany, the 

owner of a cotton spinning mill and bleaching works, 

which his father Ludwig von Hartmann had taken over 

in 1818. 

Fascinated by the advances 

in the fields of bacteriology 

and hygiene and also 

influenced by his son 

Arthur, who was a doctor, 

Paul Hartmann senior had 

attempted the industrial 

production of new kinds 

of wound dressings. The 

Hartmann company began 

production of impregnated 

absorbent cotton wool as early in 1870 

and thereby brought about a revolution in 

wound treatment. In 1874 the production 

programme was expanded through the socalled 

“Lister carbol gauze”. Both products 

were rightly regarded as significant advances 

in a medical as well as a humanitarian 

respect. 

New 

Atrauman ® Ag silver 

primary contact dressing 

Effective control of infection without the 

risk of bacterial resistance or cytotoxicity 

• Kills micro-organisms quickly to avoid risk 

of resistance 

• Proven low cytoxicity 

• Acts for up to 7 days to counter any recurring contaminants 

• Enables user to choose the most appropriate secondary dressing 

• Does not discolour the wound edges enabling better 

wound assessment 

• High conformability for difficult to dress areas 

PAUL HARTMANN LTD, 

Heywood 0L10 2TT, 

www.hartmann.co.uk

Do you want to investigate the value for money 

of your current dressing provider? 

If so and you would like to consider the added benefits that 

Hartmann’s proven range of modern wound dressings can bring, 

please use the fax back form below to request further data. 

Organisation / Trust 

Address 

Please send me via: Email 

Post 

Postcode 

Further product information 

Telephone 

Further clinical data 

Concerning 

PermaFoam Hydroactive 

foam dressings 

Atrauman Ag silver 

primary contact dressing 

All Hartmann dressings 

Email 

Professional Addresses Only 

Please fax this page to: 

01706 363 201 

Please arrange for a representative to contact me 

Name 

Hartmann continues to support EWMA 

at Prague 2006 

For those considering attendance at EWMA’s 

annual conference in Prague 18-20th May 

2006, Hartmann welcomes you to join our two 

English language workshops run by 

Dr Sabina Svestkova, University Hospital 

Brno, Czech Republic and Dr Jean-Francois, 

Department of Anatomy, University of Paris. 

Their workshops are both related to venous 

insufficiency and are respectively entitled 

“The most efficient therapy of venous leg 

ulcers - Hydroactive dressings and short stretch 

compression” and “Anatomy of the venous 

system and compression”. Details of time and 

locations can be found in your delegates’ 

programme. Hartmann are also exhibiting in 

the main hall focusing on a range of newly 

launched hydroactive dressings. You are very 

welcome to join our staff to hear the latest 

Hartmann product developments. 


PAUL HARTMANN LTD 

Heywood Distribution Park 

Pilsworth Road 

Heywood 

Lancashire 

0L10 2TT 

Tel: 01706 363200 

Fax: 01706 363201 

Web: www.hartmann.co.uk 

E-mail: helpline@uk.hartmann.info 

(continued from page 11: Clinical observation study in 624 patients confirms good efficacy and tolerability) 

Tab. 4: Assessment of Atrauman Ag use by treating physicians 

very good 

% 

Tab. 5: Assessment of wound treatment with Atrauman Ag by patients 

very good 

% 

Furthermore, a large proportion of the wounds 

were infected and extensively covered by 

smeary purulent coats. Just under two thirds 

were producing large amounts of wound 

exudate. Treatment with Atrauman Ag markedly 

improved the condition of the wounds. During 

the course of the three dressing changes, the 

investigators diagnosed many fewer wound 

coats and much less exudate, while at the 

same time the proportion of granulation 

and epithelial tissue increased. The number 

of infected wounds also decreased. In the 

view of the treating physicians, 90% of the 

patients had experienced a marked or even 

very marked improvement in the condition of 

their chronic wound compared to the initial 

examination. Atrauman Ag, like all other 

impregnated tulle dressings, is combined 

with a secondary absorbent wound dressing. 

Both laboratory tests and clinical practice use 

have demonstrated the effective bactericidal 

and wound healing promoting properties in 

combination with numerous hydroactive and 

traditional wound dressings. The user can 

therefore select a suitable secondary dressing 

good 

% 

good 

% 

satisfactory 

% 

satisfactory 

% 

adequate 

% 

Conformability to wound bed (n = 613) 49.3 44.7 5.7 0.3 0 

Ease of removal (n = 612) 60.8 35.9 2.6 0.5 0.2 

Tolerability (n = 609) 56.5 38.3 2.3 0.8 2.1 

Application characteristics (n = 612) 51.5 45.6 2.6 0.3 

Overall impression (n = 609) 42.0 52.5 3.8 1.5 0.2 

adequate 

% 

Tolerability (n = 601) 60.9 32.8 3.3 0.3 2.7 

In-use comfort (n = 601) 54.9 39.1 4.3 0.8 0.8 

Overall impression (n = 599) 52.1 40.9 4.8 0.3 1.8 

poor 

% 

poor 

% 

depending on the state of the wound. It is also 

possible to continue using the previous wound 

dressing if supplementary treatment with 

Atrauman Ag is temporarily indicated. 

References 

1. Gillitzer R. Modernes Wundmanagement. 

Hautarzt 2002; 53: 130–147 

2. Hess CT, Kirsner RS. Orchestrating wound 

healing: Assessing and preparing the wound 

bed. Advances in Skin and Wound Care 2003; 

16: 246–259 

3. Mulligan S, Denman S, Bennett RG, 

Greenough WB, Lindsay J, Zelesnick LB. 

Methicillin-resistant Staphylococcus aureus 

colonization in a long-term care facility. Journal 

of the American Geriatrics Society 1992; 40: 

213–217. 

4. Bowler PG, Armstrong DG. Wound 

microbiology and associated approaches to 

wound management. Clinical Microbiology 

Reviews 2001; 14: 244–269 

Conclusion 

Atrauman Ag is an effective wound dressing 

for the management of infected and infectionprone, 

treatment refractory ulcers and can be 

used not only in the exudation phase but also in 

multiple phases of wound healing. Since only as 

many silver ions as are necessary to effectively 

kill bacteria are released into the dressing 

environment, Atrauman Ag offers an excellent 

benefit-risk ratio. Its cytotoxicity is low, its 

tolerability has proved to be very good, and the 

risk of resistance development is very low. 

5. Nishijima S, Kurokawa I, Nakaya H: 

Susceptibility change to antibiotics of 

Staphylococcus aureus strains isolated from skin 

infections between July 1994 and November 

2000. Journal of Infection and Chemotherapy 

2002; 8: 187–189 

6. Scheithauer M, Riechelmann H. Die 

gestörte kutane Wundheilung. Laryngo-Rhino- 

Otologie 2003; 82: 36–39 

7. Lansdown AB. A review of the use of silver 

in wound care: facts and fallacies. British 

Journal of Nursing 2004; 13: S6–19 

8. Percival SL, Bowler PG, Russel D. Bacterial 

resistance to silver in wound care. Journal of 

Hospital Infection 2005; 60: 1–7 

9. Hollinger MA. Toxicological aspects 

of topical silver pharmaceuticals. Critical 

Reviews in Toxicology 1996; 26: 255–260 

(Original published in German in: Aktuelle 

Dermatologie 2005; 31: 561– 565) 

Holger Kapp 

Department Clinical Studies 

PAUL HARTMANN AG 

D-89504 Heidenheim, Germany

case study - Hartmann - Paul Hartmann AG

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