ORIGINAL ARTICLE
 Topical silver-impregnated
 dressings and the importance
 of the dressing technology
 Keith Cutting, Richard White, Hans Hoekstra
 Cutting Keith, White Richard, Hoekstra Hans. Topical silver-impregnated dressings and the importance of the
 dressing technology. Int Wound J 2009; 6:396?402
 ABSTRACT
 A wide variety of silver-impregnated wound dressings has become available in recent years. This has given the
 practitioner choice but little evidence by which an appropriate dressing may be selected. In many instances, the
 ancillary function(s) of the dressing will become differentiating factors that influence choice. For example, the
 dressing capacity to manage exudate, maintain an optimum moist environment, reduce or avoid maceration,
 maintain an intimate contact with the wound bed, promote autolytic debridement, sequester bacteria and bind
 matrix metallo proteases (MMPs) are some of those functions that are of clinical significance and may dictate
 choice. In this article we present the evidence for these functions, thereby enabling practitioners to evaluate
 comparative dressing attributes, and so make an informed choice of which silver dressing best suits the needs of
 the wound under differing circumstances.
 Key words: silver impregnated dressings ? dressing technology ? dressing characteristics ?maceration ? intimate contact with wound
 bed ? autolytic debridement ? bacterial sequestration ? binding of MMPs
 INTRODUCTION
 The use of silver in medicine has an extensive
 history (1) but the incorporation of silver into
 Key Points
 ? the incorporation of silver into
 wound dressings is a contem-
 porary development that has
 initiated a revolution in the
 management of local wound
 infection
 ? modern silver dressings run
 the risk of being viewed by
 the uninformed as no more
 than a combination of two
 technologies?the dressing with
 added silver
 wound dressings is a contemporary develop-
 ment that has initiated a revolution in the man-
 agement of local wound infection. It is inter-
 esting to note that the use of topical antisep-
 tics came under severe criticism in 1980s and
 1990s (2) with the main target being those anti-
 septics that were identified as cytotoxic in vitro
 not only to micro-organisms but to the host?s
 own cells (3). However, history has taught us
 that caution should always be exercised when
 translating in vitro findings to the in vivo
 situation. More recently, clinical concerns asso-
 ciated with the use of silver dressings in wound
 care have been explored and discussed (4).
 Authors: K Cutting, MN, RN, Buckinghamshire New University,
 Buckinghamshire, UK; R White, M.I. Biol, C. Biol, PhD, University
 of Worcester, Worcestershire, England WR2 6AJ, UK; H Hoekstra,
 MD, Burns Research Institute, Beverwijk, the Netherlands
 Address for correspondence: K Cutting, Buckinghamshire
 New University, Buckinghamshire, UK
 E-mail: keith.cutting@bucks.ac.uk
 Modern silver dressings run the risk of being
 viewed by the uninformed as no more than a
 combination of two technologies ? the dressing
 with added silver. This sometimes leads to a
 misdirected emphasis being placed on issues
 such as bacterial time to kill and kill rate
 thereby implying that there is an enhancement
 of dressing performance in terms of clinical
 safety and antimicrobial efficacy. Such issues
 are of dubious clinical significance and run
 the risk of appearing no more than marketing
 exercises, intended to influence choice. This
 approach, in turn, ignores the intrinsic value
 of the carrier dressing suggesting that it is no
 more than a passive delivery vehicle for sil-
 ver and disregards the contribution that the
 dressing itself can make to a successful clinical
 outcome.
 One of the most significant statements
 focussing on silver dressings has been made
 recently by Mooney et al. (5). Their opinion
 can be summarised as follows:
 ? Silver broad spectrum antimicrobial
 efficacy is not in dispute.
 396 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc ? International Wound Journal ? Vol 6 No 5
Topical silver-impregnated dressings
 ? Choice of dressing rests on
 ? characteristics of the carrier
 dressing;
 ? delivery kinetics of silver to the
 wound;
 ? the needs of the wound at any
 given time.
 Viewing all silver dressings from the sole
 perspective that they are no more than
 dressings with added silver relegates the dressing
 component to that of a simple vehicle for the
 delivery of silver. It is, therefore, now necessary
 to look beyond the mere delivery of the topical
 agent and its antimicrobial impact and examine
 the contribution that the carrier dressing has to
 make to the progress of the wound. That is,
 what does the dressing do that impacts on the
 factors that inhibit healing?
 HOW THE DRESSING TECHNOLOGY
 CAN ASSIST IN MANAGING PAIN
 Pain is a known impediment to healing
 that produces physiological stress (6). The
 changing of a wound dressing is recognised as
 a time when pain is most likely to occur (7).
 Preventing wound trauma and pain were
 identified as the two main considerations at
 dressing change highlighted via a survey of
 nearly 4000 clinicians using a multiple choice
 questionnaire (7). It is therefore important to
 use tactics that avoid/minimise trauma to the
 wound/peri-wound skin and the occurrence
 of what Krasner (8) has called cyclic acute
 wound pain. Wound dressing technology has
 an important role to play if it can avoid those
 factors that are considered as contributing
 to pain at dressing change. The three most
 important factors identified by Moffatt et al. (7)
 are dried out dressings, products that adhere
 and adhesive dressings. There are limited
 clinical studies that focus on the relationship
 of wound pain and the dressing material.
 Pain occurring at dressing change, that is
 operational pain, has received increasing atten-
 tion in recent years. Two influential publica-
 tions have focussed on pain associated with
 dressing related procedures: the World Union
 of Wound Healing Societies? Principles of
 best practice (9) and European Wound Man-
 agement Association?s Position document (10).
 These publications propose broad strategies to
 assist in minimising pain at dressing change
 [reviewed by White and Harding (11)]. A third
 publication by Thomas (12) proposed that the
 term ?atraumatic dressing? could be used to Key Points
 ? viewing all silver dressings from
 the sole perspective that they
 are no more than dressings
 with added silver relegates the
 dressing component to that of
 a simple vehicle for the delivery
 of silver
 ? one of the most significant
 statements focussing on sil-
 ver dressings has been made
 recently by Mooney et al. Their
 opinion can be summarised as
 follows:
 ? Silver broad spectrum antimi-
 crobial efficacy is not in dis-
 pute.
 ? Choice of dressing rests on
 - characteristics of the car-
 rier dressing
 - delivery kinetics of silver
 to the wound;
 - the needs of the wound
 at any given time
 ? it is, therefore, necessary to
 look beyond the mere delivery
 of the topical agent and
 its antimicrobial impact and
 examine the contribution that
 the carrier dressing has to
 make to the progress of the
 wound
 ? the changing of a wound
 dressing is recognised as a time
 when pain is most likely to
 occur
 ? preventing wound trauma and
 pain were identified as the
 two main considerations at
 dressing change highlighted
 via a survey of nearly 4000
 clinicians using a multiple
 choice questionnaire
 ? wound dressing technology
 has an important role to play if
 it can avoid those factors that
 are considered as contributing
 to pain at dressing change
 ? there are limited clinical studies
 that focus on the relationship
 of wound pain and the dressing
 material
 describe those products that are proven to
 avoid causing trauma to the wound bed or
 peri-wound skin on removal, and included a
 review of the literature focussing on soft sil-
 icone dressings. Soft silicone dressings until
 very recently have not been available in topical
 antimicrobial form, nevertheless the atrau-
 matic dressing performance characteristic is
 important (13).
 In a randomised study comparing a silver
 polyethylene mesh dressing with 0.5% silver
 nitrate solution, Tredget et al. (14) found that
 on dressing removal, patients reported wound
 pain was lower with the silver polyethylene
 mesh than on removal of the silver nitrate
 solution. However, patients also reported that
 the pain was comparable during application
 and 2 hours following application of either
 dressing. Therefore, in the short term there
 appears to be little merit in using this dressing
 approach.
 In an open, prospective, randomised, con-
 trolled, multicentre study, a total of 131
 leg ulcer patients were recruited and ran-
 domised to hydrofibre or to alginate dressing
 groups (15). Ease of application was rated
 ?excellent? by 76% in the hydrofibre group
 compared with 55% in the alginate group
 (P = 0.03). More importantly, ease of removal
 was rated as excellent by 51% of the hydrofi-
 bre group compared with 24% of the alginate
 group (P = 0.006). No pain at dressing removal
 was experienced by 82% of the hydrofibre
 group compared with 62% in the alginate
 group (P < 0.001). Less adhesion (P < 0.001)
 and less residue (P < 0.001) were also reported
 in the hydrofibre group thus minimising
 trauma to the wound bed. Moffatt et al. (7)
 stated that products such as hydrofibres, algi-
 nates amongst others are least likely to cause
 pain. In the above study it can be seen that
 hydrofibre outperformed alginate according to
 the identified parameters.
 In a randomised acute/surgical wound
 study in 100 patients, hydrofibre performance
 was compared with that of alginate (16).
 Ninety-two per cent of patients randomised
 to the hydrofibre dressing were found to expe-
 rience less pain (mild or none) compared with
 those who received alginate dressings 80%.
 Similarly, those patients who were pain free
 at week one postoperatively were hydrofibre
 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc 397
Topical silver-impregnated dressings
 84% compared with alginate 58%. Although
 statistical significance was not shown, the
 researchers concluded that the hydrofibre
 dressing consistently performed better than
 the alginate.
 A multicentre prospective randomised con-
 trolled trial (RCT) (17) reported on the use of
 a carboxymethylcellulose dressing containing
 ionic silver (AgNaCMC) and 1% silver sul-
 phadiazine (SSD) cream impregnated gauze
 in the management of partial-thickness burns
 (n = 84). The authors reported less pain dur-
 ing dressing change and less burning/stinging
 during wear time (up to 21 days) with the
 AgNaCMC together with a decreased demand
 for procedural and narcotic analgesia.
 Fifty patients with partial-thickness burns
 were randomised into two equal groups who
 received either 1% SSD or a silver-coated,
 high-density polyethylene mesh dressing (Ag
 polyethylene mesh) (18). Treatments consisted
 of either dry gauze dressing with 1% SSD
 changed twice daily or dry gauze moistened
 with sterile water and application of an Ag
 polyethylene mesh with the gauze being
 moistened twice daily and the outer Ag
 polyethylene mesh changed every 3 days. The
 conclusions drawn by the authors of this study
 were that the Ag polyethylene mesh provided
 a less painful alternative to wound care than
 1% SSD because of longer wear time and ease
 of application/removal (average pain scores
 being 4 ? 0.6 for an Ag polyethylene mesh
 versus 5 ? 0.7 for 1% SSD).
 In an open label, multicentre, non compar-
 ative study on 18 patients with chronic leg
 ulcers where the primary aim was to assess
 safety of an AgNaCMC dressing, Vanscheidt
 et al. (19) found that a significant reduction in
 the pain scores recorded by the patients was
 achieved. It needs to be borne in mind that
 11 of the 18 subjects? wounds were infected at
 baseline. At each dressing change the patient
 was asked if the dressing had been comfort-
 able since the last visit. All 129 responses were
 either very comfortable (13.18%) or comfort-
 able (86.82%). For pain on dressing removal,
 no pain was recorded at 45.7% (59) of dressing
 changes with low levels of pain (score  2.5)
 being recorded on 33.3% (43) occasions.
 Jester et al. (20) recognises the fact that
 dressings differ in material characteristics
 and evaluated dressing performance and pain
 during dressing change of two silver dressings:
 a soft polyester with lipido-colloid coating
 impregnated with SSD (polyester LC SSD) and
 a non adhesive polyurethane foam dressing
 impregnated with silver (polyurethane foam
 Ag). This retrospective cohort study included
 two groups of 20 burns treated with polyester
 LC SSD and polyurethane foam Ag until the
 wounds healed or were grafted. There were
 67 dressing changes in the polyester LC SSD
 group and 70 in the polyurethane foam Ag
 group. Both dressings were found to perform
 well when considering pain at dressing
 change and ease at dressing application. The
 polyurethane foam Ag dressing was found to
 have a greater absorptive capacity than the
 polyester LC SSD dressing.
 In a prospective, randomised study, Glat
 et al. (21) assessed the clinical and microbiolog-
 ical characteristics of two silver-based topical
 agents in the management of paediatric partial-
 thickness burns. Twenty-four patients ranging
 in age from 2 months to 18 years with total
 body surface area (TBSA) burns ranging from
 1% up to 40% were enrolled and completed
 the study. Patients were randomised to either
 a silver-containing gel or to a SSD cream for up
 to 21 days or to the point of full reepithelialisa-
 tion of the wound. No statistically significant
 differences were found when assessing the rate
 of infection, time to reepithelialisation, or the
 number of dressings changes required during
 treatment. A reduction of pain and improved
 patient satisfaction with the use of the gel indi-
 cates an important role for it in the treatment
 of partial-thickness burns.
 THE VALUE OF CLOSE
 ASSOCIATION OF DRESSING
 WITH THE WOUND BED
 Snyder (22) has recorded that the presence of
 dead space may act as a nidus for infection and
 contribute to delayed healing. Robson et al.
 (1973) cited by Edberg (23) states that dead
 space lends itself to infection because it does
 not possess a defence mechanism.
 These statements clearly indicate that there
 is a need to avoid the creation of dead space
 (void within a viscus or between dressing and
 wound bed) as there is an apparent association
 of dead space with risk of infection.
 In order to circumvent this situation when
 applying a wound dressing, the clinician
 should ensure that the dressing has the
 capacity to maintain a close association with
 398 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Topical silver-impregnated dressings
 the wound bed. It is also reasonable to assume
 that in those dressings with an absorptive
 capacity, a close association of the dressing
 with the wound bed will help promote
 absorption of exudate and the delivery of
 silver to the wound bed in silver-containing
 dressings. Vanscheidt et al. (19) made an
 empirical observation in their study on 18
 patients with chronic leg ulcers that the gel
 matrix formed by the AgNaCMC dressing
 moulded itself over the wound surface and
 eliminated dead space. This observation was
 subsequently confirmed by Jones et al. (24)
 who investigated the conformability in vitro of
 two silver dressings to human wound tissue,
 dried dermal membrane and indented agar
 plates that had been seeded with MRSA or
 Pseudomonas aeruginosa. The results showed
 that there was excellent conformability of
 the AgNaCMC dressing to the dermal tissue
 (wound bed) but this was less evident with
 Ag polyethylene mesh dressing. Incidentally,
 the AgNaCMC dressing in this study was more
 effective at killing bacteria on the indented agar
 plates than the Ag polyethylene mesh dressing.
 The intimate association of a dressing with
 the irregular undulating topography of the
 wound bed would appear to offer advantages
 when considering the avoidance of the creation
 of dead space, absorption of exudate and
 bactericidal activity of ionic silver.
 FLUID-HANDLING PROPERTIES
 ABSORPTION/RETENTION,
 LATERAL WICKING,
 SEQUESTRATION
 Before the advent of products that incor-
 porated antimicrobials, dressings were used
 principally from the perspective of material
 performance in situ. Up until the 1960s, dress-
 ings comprised mainly of woven textiles with
 a primarily covering/protective function and
 were not regarded as agents capable of enhanc-
 ing healing. Following the work of Winter (25),
 dressing design took into account the contri-
 bution that the dressing material could make
 to the reparative process. However, traditional
 dressing materials such as gauze continue to
 be used despite recognition that it does not
 comply with optimal management require-
 ments (26). Modern wound dressings have
 been developed primarily to afford a moist
 wound environment while at the same time
 providing an absorptive capacity. If prob-
 lems associated with excess moisture at the Key Points
 ? the intimate association of
 a dressing with the irregular
 undulating topography of the
 wound bed would appear
 to offer advantages when
 considering the avoidance of
 the creation of dead space,
 absorption of exudate and
 bactericidal activity of ionic
 silver
 ? traditional dressing materials
 such as gauze continue to be
 used despite recognition that it
 does not comply with optimal
 management requirements
 ? modern wound dressings have
 been developed primarily to
 afford a moist wound envi-
 ronment while at the same
 time providing an absorptive
 capacity
 ? if problems associated with
 excess moisture at the dressing
 interface are not managed
 correctly, then optimal healing
 will be compromised
 ? in addition to the ancillary
 attributes listed above, it has
 been claimed that the capacity
 of a dressing to absorb and
 retain (i.e. sequester) bacte-
 ria is an important function,
 particularly in chronic wounds
 dressing interface are not managed correctly,
 then optimal healing will be compromised.
 Where absorption of exudate is required, the
 dressing should also be capable of retaining
 the fluid ensuring at the same time that the
 peri-wound skin is not subjected to macera-
 tion. Parsons et al. (27) in an in vitro study
 investigated the clinical performance of seven
 proprietary silver-containing dressings includ-
 ing fluid-handling properties and dressing
 pH. The findings show that the best fluid
 retention under compression was achieved
 by AgNaCMC and a silver-containing algi-
 nate dressing (Ag alginate) with the lowest
 level of lateral wicking occurring with the
 AgNaCMC dressing. This paper also states,
 ?This study suggests that dressing selection
 should be based on the overall properties of
 the dressing clinically relevant to the wound
 type and condition?.
 SEQUESTRATION
 In addition to the ancillary attributes listed
 above, it has been claimed that the capacity of
 a dressing to absorb and retain (i.e. sequester)
 bacteria is an important function, particularly
 in chronic wounds (28). In vitro and animal in
 vivo microbiological studies have illustrated
 the extent of this effect in hydrofibre and
 alginate dressings (29?32). Whilst the clinical
 significance of this feature is yet to be shown,
 it is likely to be of value in reducing bioburden
 in colonised wounds where antimicrobials
 are not indicated, that is routine use in
 chronic wounds. This would not contribute
 to selection for resistance as the function
 is purely physical. A similar function has
 been described for the binding of bacterial
 toxins (33). In this context, a silver dressing
 containing activated charcoal has been shown
 to adsorb endotoxins from Escherichia coli and
 P. aeruginosa in a standard assay. Although
 this too has yet to be shown clinically, it is
 an important mechanism for neutralising an
 important virulence determinant.
 The physical principle of hydrophobic
 interaction has been utilised to sequester
 bacteria through the addition of a hydrophobic
 coating containing a fatty acid derivative
 (dialkylcarbamoyl chloride) to the dressing
 fibres. Bacteria and other micro-organisms are
 ?bound? to the dressing when in contact with a
 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc 399
Topical silver-impregnated dressings
 moist environment. The micro-organisms are
 then removed when the dressing is changed.Key Points
 ? although inflammation is a
 necessary process, excessive
 or prolonged inflammation
 results in delayed healing and
 increased scarring
 ? solely considering antimicro-
 bial activity as a measure
 of dressing performance views
 product efficacy from a too nar-
 row perspective
 ? clinicians cannot afford to
 ignore the ancillary activity
 of the dressing if patients
 are to receive optimal and
 comprehensive care
 In a 116 patient multicentre study with a mean
 treatment period of 37 days, 81% of wounds
 showing signs of infection at the start of
 the treatment healed. Twenty-one per cent of
 patients? wounds healed with a further 72%
 showing improvement in wound healing (32).
 Hydrophobic interaction would appear to
 offer a ?natural? approach to wound healing.
 There are no chemically active agents and no
 known side effects or risk of bacterial/fungal
 resistance.
 CONTROLLED SUSTAINED RELEASE
 It is generally recognised that for any antimi-
 crobial to be effective, it is important that the
 target organisms be exposed to a cidal con-
 centration for sufficient time ? without tissue
 toxicity (33). This applies to silver-containing
 wound dressings, the characteristics of the
 ?ideal? silver-containing dressing having been
 published (34). The antibacterial activity of sil-
 ver emanates from the ionic form Ag+; this
 has been studied extensively in vitro and
 reviewed (35). Whilst there is still very little
 published information on silver in controlling
 wound bioburden, it is possible to state that
 sustained exposure (over 24 hours or more) to
 very low levels (parts per million) will be effec-
 tive against a wide range of bacterial species
 including those with known antibiotic resis-
 tance, for example MRSA and Vancomycin
 resistant enterococci (VRE) (12,24,35?37).
 It is pertinent to emphasise at this point the
 fact that publications reporting on aqueous
 silver concentrations do not differentiate
 between active ionic silver (Ag+) and inactive
 silver in solution (Ag0); they only measure
 total silver content (26). Parsons et al.?s (26)
 in vitro findings also clearly inform us that
 the antimicrobial activity of any dressing is
 not necessarily dependant on the amount of
 silver released as ?there appears to be no
 correlation between total silver in solution and
 antimicrobial efficacy?.
 This accentuates our earlier statement that
 the ancillary function of dressings containing
 silver should be taken into account and
 draws attention to the physical components
 of dressings and the role they have to play in
 promoting healing (38).
 Silver has been used prophylactically and
 silver-coated metallic dressings have been
 found in vitro to be effective against fungi,
 bacteria and multiresistant bacteria (39?41).
 Atiyeh et al. (42) confirm that this form of silver
 dressing may be useful in preventing infection
 and also indicate that silver-coated metallic
 dressings provide a high concentration of sil-
 ver (around 70 ppm) in the wound by releasing
 Ag+ and Ag0. What is not clear is the propor-
 tion of Ag+ and Ag0 present in the wound and
 the value of such a high concentration if silver
 is accepted as being bactericidal/bacteriostatic
 at oligodynamic concentrations. Although Ag0
 (metallic silver) may oxidise to Ag+ in con-
 tact with the atmosphere, there is no evidence
 that it is antimicrobial in action. However,
 Atiyeh et al. (42) do suggest that the disso-
 lution of silver may favour antimicrobial and
 anti-inflammatory activity.
 MODULATION OF INFLAMMATION
 Inflammation is an early and vital stage of
 the reparative process and is mediated by a
 number of cells (43). Although inflammation
 is a necessary process, excessive or prolonged
 inflammation results in delayed healing and
 increased scarring. In a study using a rat
 wound model, Hoekstra et al. (43) made a his-
 tological comparison of acute inflammatory
 responses in partial-thickness wounds when
 using a hydrofibre or tulle gauze dressing. The
 findings show that there was minimal inflam-
 mation in the hydrofibre dressed wounds
 when compared with the Tulle gauze dressed
 wounds. This difference was attributed to
 the formation of a thin fibrin polymerised
 layer between the hydrofibre dressing and
 the wound bed. This layer of fibrin clearly
 separated the Polymorphonucleocytes (PMNs)
 within the hydrofibre dressing from the
 macrophages that invaded the wound bed
 3?4 days after wounding. Fewer macrophages
 were evident in the wound bed and none were
 detected in the dressing. Macrophages sepa-
 rated from granulocytes act in the repair mode
 and are not activated for defence purposes.
 This phenomenon of reduction of inflamma-
 tion is termed ?quiet inflammation?. In the
 wounds dressed with Tulle gauze, material
 was found embedded in the wound bed
 which showed ?a disturbed pattern of epithe-
 lial outgrowth? and ?damage to the dermal
 matrix?.
 400 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc
Topical silver-impregnated dressings
 CONCLUSIONS
 It can be seen from the above discussion
 that solely considering antimicrobial activity
 as a measure of dressing performance views
 product efficacy from a too narrow perspective.
 Clinicians cannot afford to ignore the ancillary
 activity of the dressing if patients are to receive
 optimal and comprehensive care.
 REFERENCES
 1 White RJ. An historical overview of the use of silver
 in wound management. Br J Commun Nurs
 2001;6 Silver Suppl 1:3?8.
 2 Cutting KF. A dedicated follower of fashion? Topical
 medications and wounds. Br J Nurs 2001;10 Silver
 Suppl:9?16.
 3 Wilson JR, Mills JG, Prather ID, Dimitrijevich D. A
 toxicity index of skin and wound cleansers used
 on in vitro fibroblasts and keratinocytes. Adv Skin
 Wound Care 2005;18:373?8.
 4 Cutting KF, White RJ, Edmonds M. Silver ? address-
 ing concerns. Int Wound J 2007; 4:177?84.
 5 Mooney EK, Lippitt C, Friedman J. Safety and effi-
 cacy report ? silver dressings. Plast Reconstr Surg
 2006;117:666?9.
 6 Johnson M. Physiology of pain. In: White R, Hard-
 ing K, editors. Trauma and pain in wound care
 volume II, Chapter 1. Aberdeen: Wounds UK
 Publishing, 2008;1?40.
 7 Moffatt C, Franks PJ, Hollinworth H. Understand-
 ing wound pain and trauma: an international
 perspective. In: EWMA position document ? pain
 at wound dressing changes. London: MEP, 2002.
 8 Krasner D. The chronic wound pain experience:
 a conceptual model. Ostomy Wound Manag
 1995;41:20?7.
 9 World Union of Wound Healing Societies. Prin-
 ciples of best practice: minimising pain at
 wound dressing-related procedures. A consen-
 sus document. London: MEP Ltd, 2004;URL
 http://www.wuwhs.org. Accessed: 4 April 2009.
 10 European Wound Management Association. EWMA
 Position document ? pain at wound dressing
 changes. London: MEP Ltd, 2002;URL http://
 www.ewma.org. Accessed: 4 April 2009.
 11 White RJ, Harding K. Pain & trauma in wound
 management. Aberdeen: Wounds-UK publish-
 ing, 2004.
 12 Thomas S. MRSA and the use of silver dressings:
 overcoming bacterial resistance. URL www.
 worldwidewounds.com/2004/november/
 Thomas/Introducing-Silver-Dressings.html
 [accessed on 4 April 2009], 2004.
 13 White RJ. Evidence for atraumatic soft silicone
 dressing use. Wounds-UK 2005;1:104?109.
 14 Tredget EE, Shankowsky HA, Groeneveld A, Burrell
 R. A matched-pair, randomized study evaluating
 the efficacy and safety of acticoat silver-coated
 dressing for the treatment of burn wounds. J
 Burn Care Rehabil 1998;19:531?7.
 15 Harding KG, Price P, Robinson B, Thomas S,
 Hofman D. Cost and dressing evaluation of
 hydrofiber and alginate dressings in the manage-
 ment of community-based patients with chronic
 leg ulceration. Wounds 2001;13:229?36.
 16 Foster L, Moore P, Clark S. A comparison of hydrofi-
 bre and alginate dressings on open acute surgical
 wounds. J Wound Care 2000;9:442?5.
 17 Caruso DM, Foster KN, Blome-Eberwein SA,
 Twomey JA, Herndon DN, Luterman A, Silver-
 stein P, Antimarino JR, Bauer GJ. Randomized
 clinical study of Hydrofiber dressing with sil-
 ver or silver sulfadiazine in the management
 of partial-thickness burns. J Burn Care Res
 2006;27:298?309.
 18 Muangman P, Chuntrasakul C, Silthram S,
 Suvanchote S, Benjathanung R, Kittidacha S,
 Rueksomtawin S. Comparison of efficacy of 1%
 silver sulfadiazine and Acticoat? for treatment
 of partial-thickness burn wounds. J Med Assoc
 Thai 2006;89:953?7.
 19 Vanscheidt W, Lazareth I, Routkovsky-Norval C.
 Safety evaluation of a new ionic silver dressing
 in the management of chronic ulcers. Wounds
 2003;15:371?8.
 20 Jester I, Bo?hn I, Hannmann T, Waag K-L, Loff
 S. Comparison of two silver dressings for
 wound management in pediatric burns. Wounds
 2008;20:303?308.
 21 Glat PM, Kubat WD, Hsu JF, Copty T, Burkey BA,
 Davis W, Goodwin I. Randomized clinical study
 of SilvaSorb gel in comparison to Silvadene silver
 sulfadiazine cream in the management of partial-
 thickness burns. J Burn Care Res 2009;30:262?7.
 22 Snyder RJ. Managing dead space: an overview.
 Podiatry Manage 2005;24:171?4.
 23 Edberg SC. Methods of quantitative microbiological
 analyses that support the diagnosis, treatment,
 and prognosis of human infection. CRC Crit Rev
 Microbiol 1981;8:339?97.
 24 Jones S, Bowler PG, Walker M. Antimicrobial activ-
 ity of silver-containing dressings is influenced by
 dressing conformability with a wound surface.
 Wounds 2005;17:263?70.
 25 Winter G. Formation of the scab and rate of
 epithelialisation in the skin of the young domestic
 pig. Nature 1962;193:293?5.
 26 Ovington LG. Hanging wet-to-dry dressings out to
 dry. Adv Skin Wound Care 2002;15:84?6.
 27 Parsons D, Bowler PG, Myles V, Jones S. Silver
 antimicrobial dressings in wound management:
 a comparison of antibacterial, physical, and
 chemical characteristics. Wounds 2005;17:222?32.
 28 Wysocki AB. Evaluating and managing open skin
 wounds: colonization versus infection. AACN
 Clin Iss 2002;13:382?97.
 29 Bowler P, Jones SA, Davies BJ, Coyle E. Infection
 control properties of some wound dressings.
 J Wound Care 1999;3:499?502.
 30 Tachi, Hirabayashi S, Yonehara Y, Suzuki Y,
 Bowler P. Comparison of bacteria-retaining
 ability of absorbent wound dressings. Int Wound
 J 2004;1:177?81.
 31 Newman GR, Hobot JA, Walker M, Bowler PG.
 Visualisation of bacterial sequestration and
 bactericidal activity within hydrating hydrofibre
 dressings. Biomaterials 2005;27:1129?39.
 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc 401
Topical silver-impregnated dressings
 32 Newman GR, Walker M, Hobot JA, Bowler PG.
 Visualisation of bacterial sequestration and
 bactericidal activity within hydrating Hydro-
 fiber wound dressings. Biomaterials. 2006 Mar;
 27(7):1129?39.
 33 Muller G, Winkler Y, Kramer A. Antibacterial activ-
 ity and endotoxin-binding capacity of Actisorb
 Silver 220. J Hosp Infect 2003;53:211?4.
 34 Kammerlander G, Locher E, Suess-Burghart A, von
 Hallern B, Wipplinger P. An investigation of
 Cutimed? Sorbact? as an antimicrobial alter-
 native in wound management Wounds-UK
 2008;4:10?20.
 35 White RJ, Cooper RA. The use of topical antimicro-
 bials in wound bioburden control. In: White R,
 editor. The silver book, Chapter 6. Dinton: Quay
 Books, 2003;46?58.
 36 White RJ. An historical overview of the use of silver
 in wound management. In: White RJ, editor. The
 silver book. Dinton: Quay Books, 2003;65.
 37 White RJ, Cutting KF. Exploring the effects of
 silver in wound management ? what is optimal.
 Wounds 2006;18:307?314.
 38 White RJ, Cutting K, Kingsley A. Topical antimicro-
 bials in the control of wound bioburden. Ostomy
 Wound Manage 2006;52:26?58.
 39 Walker M, Hobot JA, Newman GR, Bowler PG.
 Scanning electron microscopic examination of
 bacterial immobilisation in a carboxymethyl
 cellulose (AQUACEL) and alginate dressings.
 Biomaterials 2003;24:883?90.
 40 Lansdown ABG. The role of silver. ETRS Bull
 2002;9:108?111.
 41 Wright JB, Lam K, Burrell RE. Wound management
 in an era of increasing bacterial antibiotic
 resistance: a role for topical silver treatment. Am
 J Infect Control 1998;26:572?7.
 42 Wright JB, Lam K, Hansen D, Burrell RE. Efficacy
 of topical silver against fungal burn wound
 pathogens. Am J Infect Control 1999;27:344?50.
 43 Yin HQ, Langford R, Burrell RE. Comparative eval-
 uation of the antimicrobial activity of Acticoat?
 antimicrobial barrier dressing. J Burn Care Reha-
 bil 1999;20:195?200.
 44 Atiyeh BS, Costagliola M, Hayek SN, Dibo SA.
 Effect of silver on burn wound infection control
 and healing: review of the literature. Burns
 2007;33:139?48.
 45 Hoekstra MJ, Hermans MH, Richters CD, Dutrieux
 RP. A histological comparison of acute inflamma-
 tory responses with a hydrofibre or tulle gauze
 dressing. J Wound Care 2002;11:113?7.
 402 ? 2009 The Authors. Journal Compilation ? 2009 Blackwell Publishing Ltd and Medicalhelplines.com Inc