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To cite this article: N. Mao & S.J. Russell (2004): Nonwoven Wound Dressings, Textile Progress,
36:4, 1-57
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NONWOVEN WOUND DRESSINGS
N. Mao and S.J. Russell
and the method of wound closure. Wounds are also classified in terms of how they heal, and
by the type of bacterial contamination [2]. In clinical practice, wounds are usually divided
into two types: acute and chronic. The terms ‘acute wound’, ‘chronic wound assessment’,
‘wound extent’, ‘wound burden’, and ‘wound severity’ and the guidelines for assessment of
wounds and the evaluation of healing have been reviewed by Lazarus et al. [1].
Examples of different wound categories include [3]:
(i) donor sites, grazes and abrasions;
(ii) incisions and puncture wounds;
(iii) deep wounds, where there is extensive loss of sub-epidermal tissue;
(iv) burns, caused by scalding, electricity, fire, chemicals, or irradiation; and
(v) pressure sores.
Wound healing is defined as a complex dynamic process that results in the restoration
of anatomic continuity and function [1] and it usually involves an orderly sequence of
biological events [4]. Wound healing may be referred to as first or second intention [5].
Wound dressings are a medical means of cleaning, covering and protecting wounds in order
to facilitate healing. Wound healing and the dressings employed rely on different approaches
including conventional wet-to-dry [5], modern moist wound healing [3] and bioengineered
skin replacement therapy [6], topical negative pressure therapy [7–9], heat therapy [10, 11],
oxygen therapy [12–14], enzyme therapy [15], maggot therapy [16, 17], and other therapies
[18]. In this review, we focus on dressings for moist wound healing.
Winter [21] and Hinman and Maibach [25] proposed an explanation for the benefits of
moist wound healing using occlusive or semi-permeable occlusive dressings by suggesting
that epidermal migration is physically facilitated in moist conditions and in the absence of a
crust. Rovee [26] stressed that greater epidermal cell movement, rather than mitosis, is
responsible for the increased rate of epithelialisation of occluded wounds. Numerous
investigators have since confirmed the usefulness of various types of occlusive dressings in
human non-experimental acute wounds. Barnett et al. [27] concluded that split-thickness
skin-graft donor sites covered with polyurethane film dressings (specifically, OpSite or
Tegaderm) healed nearly twice as fast as those covered with a highly permeable fine-mesh
gauze dressing. Similarly, a positive experience with a poly(ethylene oxide) hydrogel dressing
(Vigilon) was reported by Mandy [28], in his studies of wounds made during the process of
hair transplantation and demarcation.
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There are other possible explanations for the effectiveness of moist wound healing and the
function of occlusive dressings. One that has been suggested is the role of occlusion in
maintaining a normal voltage gradient lateral to the wound. Human skin has measurable
transcutaneous potential differences that are decreased by wounding, and there is evidence
that the maintenance of such electrical fields may be important to epidermal cell migration
[54]. It has been shown [55] that in vitro electrical stimulation leads to an increased
expression of receptors for growth factors by human dermal fibroblasts and subsequently to
a greater synthesis of collagen after the addition of the growth factor. Some researchers [40]
have suggested that a higher receptor number for growth factors available in wound fluid
might be a favourable effect of occlusion.
Eaglstein et al. [56], after examining the effect of delayed application and early removal
of a polyurethane dressing (Tegaderm) on epithelialisation, indicated that, from initial
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wounding to six hours later, the application of the dressing increases the rate of epitheliali-
sation. Moreover, after the first twenty-four hours, keeping the dressing on the wound was
not necessary to enhance epithelialisation.
2. WOUND DRESSINGS
Wound dressings are used to clean, cover and protect wounds in order to facilitate healing,
and nonwoven fabrics are increasingly important in this area.
resulting in trauma when the dressing is removed. Such passive products include [62]:
conventional gauze (yarn-based products composed of viscose rayon, cotton or
polyester);
paraffin tulle dressings, medicated and non-medicated;
non-paraffin, non-tulle, woven products, medicated and non-medicated;
non-adherent dressings; and
combinations of the above.
Bioactive and interactive wound dressings, which include antimicrobial materials, algi-
nates, hydrocolloids, materials containing collagen or other extracellular matrix components
(in particular hyaluronic acid), and skin-replacement materials, have been summarised by
Stewart [63]. Besides maintaining a moist wound environment, these dressings will also either
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interact with cells or matrix proteins in the wound bed or sustain the release of antimicrobial
agents (e.g. Iodosorb, Actisorb Silver 220, Acticoat 7) to promote wound healing.
Wounds have different characteristics, and these dictate specific design features in the
dressing. According to the interaction of fluid with the dressing in moist wound healing,
dressings may be divided into two main groups:
(i) absorbent, physically porous dressings, which allow free passage of exudate from the
surface, and
(ii) non-absorbent, liquid-impermeable, occlusive dressings, where the wound exudate is
retained at the wound bed.
Composite or laminated dressing structures are not included in these two categories.
(iii) Hydrocolloid dressings [69]: Hydrocolloids [70] are hydrophilic polymers, of vegetable,
animal, microbial or synthetic origin, that generally contain many hydroxyl groups
and may be polyelectrolytes. Most important among their properties are viscosity
(including thickening and gelling) and water binding.
Hydrocolloid dressings [71] are multi-component structures and are sterile, self-
adhesive, waterproof and semi-permeable. The wound-contact layer is made from an
adhesive matrix containing a homogenous dispersion of a hydrophilic substance such
as carmellose sodium, gelatin, hydroxyethylcellulose, calcium alginate, chitosan or
pectin. The hydrocolloid matrix is applied in a uniform manner in a carrier which
may consist of a semi-permeable film or a polymeric foam layer or a combination of
both. The hydrophilic components of the dressing are opaque, gas-impermeable, and
absorbent and can take up wound exudate to form a gel. When applied to wounds,
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the accumulation of wound fluid causes a gradual separation of the dressing from the
wound. Hydrocolloids can be used on lightly to moderately exuding wounds such as
leg ulcers, pressure wounds, burns, donor sites, etc. [72]. Sometimes hydrocolloids do
not completely retain liquids, resulting in leakage of odorous exudate and wound
dressing gel [40].
(iv) Hydroactive dressings [73]: Hydroactive and hydrocolloid dressings are similar.
Hydrocolloid dressings form a gel whereas hydroactive dressings trap the fluid within
the matrix structure and swell when combined with wound exudates. Hydroactive
dressings mainly absorb the water from wound fluid and leave growth factors and
proteins in the wound [74]; they are usually non-adherent, waterproof and claimed to
be bacteria-proof. Hydroactive dressings are suitable for wounds with a moderate to
high level of exudate, such as minor burns, grazes and lacerations, pressure wounds
and leg ulcers.
(v) Hydrogel dressings [71]: Hydrogels are three-dimensional polymer chain networks
that swell, but do not dissolve, in water. They are commonly made of poly(ethylene
oxide) membranes or other polymers, and contain up to 95% water.
Hydrogel dressings, in general, are said to have a soothing effect on tissues and can
significantly reduce pain. They are able to donate moisture to dehydrated tissue and
absorb some moisture from an exuding wound. Hydrogels are available in two
forms, amorphous hydrogels and sheet hydrogels. Amorphous hydrogels are soft
formless gels that become less viscous as they absorb fluid. They are particularly
useful for rehydrating sloughy or necrotic tissue and enhancing autolytic debride-
ment. Sheet hydrogels are available as sheets of gel that swell when fluid is absorbed
but maintain their integrity. Sheet hydrogel dressings are non-particulate, non-toxic
and non-adherent, and are useful in the treatment and prevention of pressure
wounds because they can withstand significant friction and shear. As the absorbency
of hydrogels is limited, they are best used on low-exuding or dehydrated wounds
such as minor burns, grazes/lacerations, donor sites and pressure sores [71].
Each of the basic dressing materials mentioned above has a particular combination of
properties and none are suitable for universal use.
2.1.2 Limitations of Occlusive Dressings and Their Combination with
Absorbent Dressings
While occlusive dressings are useful in maintaining a moist wound-healing environment,
they have well-documented limitations. Because film and hydrocolloid dressings are
6 Textile Progress
aggressive adhesives, they can result in stripping of the skin around the wound margins upon
removal [75, 76]. Foams can stick to the wound bed if wound exudation is low or has
decreased while the dressing is in situ [77]. Hydrogels rely on secondary coverings for
maintaining them on the wound surface [78]. If the secondary covering is highly absorptive,
it may deplete the moisture in the hydrogel and dehydrate the wound bed. If an adhesive film
is applied over a hydrogel, the excess moisture accumulated around the wound margins can
cause maceration and wound deterioration.
When fluid accumulates below the surface, or leakage channels break the seal to the
external environment, bacterial proliferation is facilitated. Therefore, the accumulation of
large amounts of exudate from the wound is a problem associated with occlusive wound
dressings.
The problem of excess wound fluid accumulation may be dealt with in two ways. Firstly,
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the fluid may be absorbed, but this can lead to increased adherence of the dressing, infection
and impaired healing. Secondly, water from the wound fluid may be allowed to evaporate.
Alper et al. [79] advocated aspirating the fluid from under the dressing, thereby avoiding
premature dressing removal. Semi-permeable polyurethane membrane films (e.g. OpSite,
Tegaderm and Pharma-Plast [80]) and foam (e.g. Lyofoam [81]) were introduced to be
permeable to water vapour and oxygen but impermeable to liquids. Removal of adherent
occlusive dressings risks stripping of the newly epithelialised surface [82]. However,
dehydration leading to increased adherence and impaired healing may result, and controlled
evaporation and the maintenance of a layer of fluid at the wound surface are not easy to
achieve. To overcome the build-up of exudate under conventional plastics film dressings on
heavily exuding wounds, nonwoven composite dressings have been developed in which the
exudate is transported, through a perforated film, into an absorbent nonwoven layer [5].
These apertured films are designed to be low-adherent owing to their surface morphologies.
Gel-forming or highly absorbent fibres can be incorporated into semi-occlusive nonwoven
dressings to overcome the problems associated with films. Such speciality fibres include
alginates, carboxymethylated cellulose, chitin and chitosan. On contact with exudate, the
wound-contact layer containing such fibres forms a gel, providing a moist wound-healing
environment and low adherence. In the case of calcium alginate fibre dressings, calcium ions
in the fibre exchange with sodium ions in the wound to form a sodium alginate gel above
the woundbed. Where such nonwoven contact layers are applied, vapour-permeable films
are commonly used to secure the secondary dressing. However, the weight of absorbed
exudate in the nonwoven dressing can pull the film away from the skin surface, loosening
the sealed edges.
Commercial dressings are frequently layered structures comprising different occlusive
materials and nonwoven absorbent pads. Such dressings usually comprise a hydrating layer,
which may contain antibiotic ointments or petroleum jelly, a non-adherent contact layer, an
absorbent, a cushioning nonwoven layer, and a securing layer made of tape or a wrap [83].
Interactive wound dressings or skin replacement products are also composite materials
with controlled porosity and defined biodegradability to control moisture loss and liquid
retention [84].
Over the centuries, traditional wound dressings such as gauze gradually evolved into
more sophisticated structures, although their mode of operation and effect on wound healing
essentially remained unchanged. The dressings were non-occlusive and tended to dry out,
leading to adhesion of the dressing to the wound bed. Even if drying-out is incomplete,
capillary loops, associated with granulation tissue, can grow into the dressing structure [88],
resulting in dressing adherence. Such adherence creates wound trauma on removal of the
dressing, leading to bleeding and pain. Before the 1960s, gauze was widely used as an
absorbent dressing and was impregnated with paraffin wax to decrease adhesion to the
wound bed (tulle-gras). This type of low-adherent dressing was used to treat burns and
similar wounds [180].
Before the 1960s, one of the major functions of a wound dressing was to act as a barrier
between the wound and the outside environment to protect the site from gross microbial
contamination and to help prevent cross infection [40]. This ‘plug and conceal’ approach to
wound healing was also widespread where exuding wounds would be dried out by the
application of an absorbent dressing.
dressings to be produced [93]. The early occlusive film dressings provided some pain relief by
preventing dehydration of the wound surface and bathing the exposed nerve endings in
physiological wound secretions; however, the aggressive adhesiveness of these products was
reported to cause skin tears on removal [94]. The accumulation of excessive wound exudate
was also noted because of the low absorbency.
New approaches were therefore introduced to minimise wound trauma upon removal of
the dressing [95] and the accumulation of excessive fluid. Absorbent wound dressings were
developed including hydrocolloids [96], foams [97, 98], hydrogels [99, 100] and alginates
[101, 102]. The inherent water-vapour permeability of these dressings helped to prevent
maceration and decreased the possibility of infection by preventing the accumulation of
sweat and secretions [103] while providing a moist wound-healing environment. Composite
wound dressings comprising an absorbent pad and water-vapour-permeable materials to
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control the moisture content of the wound bed were also developed.
Hydrophobic silicone sheets and coatings that do not dry out when applied on top of a
wound-contact layer and maintain the non-adherence of the contact layer were designed
[104, 105] to deal with the problem of skin tears on removal of the dressing. Such dressings
were indicated for the treatment of burns [106], the resolution of hypertrophic scars [107]
and helping to minimise pain during removal [108]. These soft silicone dressings maintain
contact with the wound bed without friction and shear, thereby reducing the pain and the
tearing force during removal [109].
Recently, new hydrocolloids, foams and wound dressings containing highly absorbent
gelling fibres (e.g. hydrofibres) [110, 111] assembled into nonwoven fabrics have been
introduced and have improved fluid-handling properties. Such materials minimise adhesion
to the wound bed, increase the overall absorption capacity and permit painless dressing
removal [112, 113].
Because of the flexibility of web formation processes [119], a large variety of speciality
fibres can be converted into nonwoven fabric and are increasingly found in tissue-engi-
neering matrices, including PET [120], PLA [121] and PGA [122, 123], PPDO/PLLA-b-PEG
[119], alginate [124], chitin and chitosan [125], fungal cellulose, carboxymethyl cellulose
fibres [126], hyaluronic acid derivative [127] and collagen [128].
Owing to the comparative performance benefits and the inherent versatility of manu-
facturing technology, nonwoven fabrics are increasingly incorporated into wound-care
products [129–131], where previously woven gauze would be selected. The functional attri-
butes and economic advantages of nonwoven wound dressings have been recognised by
both medical professionals and consumers [132–135]. In 1995, it was proposed that
standards for nonwoven fabrics intended for other medical and surgical uses should also be
considered for inclusion [132, 136] in The United States Pharmacopeia [137], in addition to
absorbent gauze.
A further area of development concerns electrospun nonwoven dressings [138], which
hold significant potential for producing nonwoven fabrics direct from solvated biomaterials.
With a fibre-diameter distribution from 3 nanometres to 3 micrometres, such dressings
provide interesting opportunities for protecting wounds from particulate contamination and
controlling permeability.
2.3.1.1 Control of Moisture Content In a dry skin wound it is possible for the dermis to
impede the movement of epidermal cells and prolong wound healing. In a moist wound bed,
wound healing is faster [19, 25, 40, 41, 141]. Leg ulcers and donor sites frequently produce
large volumes of exudate, and some burns have been shown to produce up to 5200 g m 2 day 1
[142] because of damage to the epidermis, which leads to dehydration of the tissue.
10 Textile Progress
healing.
Control of the water-vapour transmission rate is one approach for influencing the
moisture content of the wound surface. Many researchers have studied the effect of water-
vapour transmission in wound healing [151, 152]. Lamke et al. [153] found that after thermal
injury the evaporative water loss from the wound surface can be twenty times greater than
that from normal skin. Queen et al. [154] tested in vitro the permeability characteristics of a
series of commercially available dressings by using a modified international standard
technique [155, 156] to assess the water-vapour transmittivity and predict the build-up of
wound exudate under film or the strike-through under foam.
2.3.1.2 Pressure of Oxygen (PO2) and Gaseous Permeability In healing of wounds, the
effect of oxygen tension has been intensively studied and is controversial. A useful summary
is presented by Whitney [157]. Oxygen is thought to be involved in the following five
components of the healing process: hemostasis and inflammation, fibroblast proliferation,
angiogenesis, collagen synthesis and re-epithelialisation [158, 159].
One group of scientists suggests that high oxygen pressure promotes wound healing and
that application of oxygen can play a role in the prevention and control of wound infection
[160–162]. Silver [160] demonstrated that moist wound healing beneath permeable dressings
takes place more quickly in the presence of oxygen than under hypoxic conditions.
Horikoshi et al. [163] reported that epidermal cell growth in vitro is inhibited at oxygen
pressures that exceed that of ambient air [164].
It has been reported [165] that a hypoxic condition may rapidly be reached under
occlusive coverings and that this condition may encourage angiogenesis, negatively affecting
collagen synthesis and epithelialisation. In addition to minimising anaerobic flora by
discouraging germination, hypoxic conditions are known to reduce the concentration of
other pathogens as well [166].
Based on the belief that a sufficient oxygen level is needed to provide optimal healing,
oxygen-generating dressings [167, 168] and a combination of layered dressings having an
external low oxygen-permeability layer and an abutting internal oxygen-permeable layer
have been proposed [169]. A hyperbaric bandage [170] and a disposable hyperbaric
treatment bag with improved closure have been produced [171].
However, it is also claimed that reduced oxygen pressure promotes in vitro growth
of fibroblasts and production of angiogenesis factors from tissue macrophages
[172–174]. Because angiogenesis (the formation and growth of new blood vessels) is funda-
mental to the healing process and fibroblasts are associated with the production of new
Nonwoven Wound Dressings 11
tissue, Varghese et al. [175] suggested that a low rather than a high pressure of oxygen could
enhance the healing process.
It seems that there is little dispute about the effect of increased oxygen tension on the
improved healing of ulcers. It is believed that the increased oxygen tension in the wound
most likely results directly from increased diffusion into the wound surface from the exterior
oxygen supply [14].
Standard methods [176] are available to assess oxygen and carbon dioxide transmission,
and, by adopting a gas-to-liquid technique [177–179], the carbon dioxide transmission rate
in hydrogel dressings can be assessed. The British Pharmacopoeia also defines the testing
method for permeability and the water vapour transmission rate [61].
2.3.1.3 pH Effects In the blood, the release of oxygen from oxyhaemoglobin takes place
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most rapidly in an acid environment. During exercise, carbon dioxide and lactic acid build
up in the muscles, and the pH decreases, resulting in the maximum release of oxygen to meet
the needs of the body’s tissues. Conversely, an alkaline environment will tend to stablilise
oxyhaemoglobin and thus reduce the available oxygen [180]. Experimental results [175] have
indicated that wound fluid is more acidic under an impermeable hydrocolloid dressing (pH
6.1) than under an oxygen-permeable polyurethane dressing (pH 7.1), and bacterial growth
is retarded at an acidic pH similar to that found under hydrocolloid dressings.
2.3.1.4 Infection Control Skin wounds tend to acquire pathogenic bacteria, due to the
increased water activity in serous exudates. The presence of dead tissue in burns and
particles shed from a dressing in the wound may lead to a wound infection [181].
One of the functions of a wound dressing is either to prevent or to remove bacteria from
wound sites to optimise re-epithelialisation rates, to reduce the incidence of wound sepsis and
to prevent cross-contamination [182]. Electrospun nonwoven wound dressings [138] have
been developed in recent years, which, owing to the small-diameter fibres ranging from several
nanometres to several micrometres, are thought to be useful in protecting wounds from
contamination. Another important function of a dressing is to remove debridement to
control wound infection [183]. Modern wound dressings such as hydrocolloids and other
occlusive dressings are found to be effective in reducing wound infections [184].
Dressings also provide vehicles for the delivery of phenol [185], chlorhexidine [186], silver
[187, 188], iodine [189, 190], zinc [191] and other antiseptics [192] to combat wound sepsis.
However, it has been argued that antiseptics have little influence on either the bacterial
content in wound sites or wound sepsis rates [193]. It is also claimed they are to some extent
toxic to skin [194].
2.3.1.5 Low Adherence Pain and tissue trauma are related to dressing changes [195]. Low
adherence to the wound bed is important for alleviating pain during such changes [196].
Non-absorbent, non-porous metal foil [197] and films have been used as non-adherent
wound dressings [198]. Nonwoven dressings containing hydrophobic fibres, such as
polypropylene [199] or EPTFE [200], with a controlled microscopic porosity, are claimed
to be non-adherent. Certain fibre finishes also help to minimise adherence in absorbent
wound dressings [201], and superabsorbent gelling materials, including hydrocolloids [202],
alginate [203], hydrofibre [204] and banana leaf dressings [205] are reported to be completely
non-adherent. The classification and management of skin tears using a soft silicone-coated
net dressing [206] that is non-adherent [207] have also been reported.
12 Textile Progress
2.3.1.6 Effect of Growth Factors With rapid progress in the purification and cloning of
numerous growth factors, and the expanding understanding of the matrix proteins that
promote epidermal migration and growth [208], there is improved understanding of the
pathophysiology of diseases and of wound healing. Wound dressings incorporating growth
factors have therefore been developed [209].
Falanga [40] proposed the ‘growth dressing’ that combines occlusion with the timed or
pulsed delivery of specific growth factors designed to help a specific clinical problem. He
proposed the use of occlusion with an angiogenic growth factor to stimulate granulation
tissue, and then subsequently the use of an occlusive dressing that would deliver various
growth factors to speed up epithelialisation.
The application of growth factors in a gauze or beneath a watertight film or film chamber
has also been proposed [24]. Vehicles include the use of cream such as silver sulphadiazine
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that releases growth factor (GF) slowly for at least twelve hours when applied to wounds
[24]. Pluronic acid is a liquid at room temperature that becomes a gel at body temperature,
and is of interest together with collagen gels that dissolve over time and release growth
factors. Other approaches include the inclusion of growth factors in normal wound dressings
or in a polymer matrix to allow the production of active wound dressings [209] and
intelligent dressings incorporating therapeutic agents [210]. The intelligent dressing was
produced by a versatile branched pore-forming technique (VBPT) in which highly absorbent
areas take up wound exudate and these are interlaced with low-absorbing sites that release
therapeutic agents. The architecture and pore structure of nonwoven fabrics can be thought
to be similar in some respects to collagenous tissue, and nonwovens have been evaluated as
tissue-engineering matrices in recent years [211–213].
2.3.2 Requirements of an Optimum Wound Dressing
The function and properties of a nonwoven wound dressing are critically dependent on the
component fibre properties and the geometrical fabric construction. Both are available for
engineering purposes.
At present there is no universal wound-dressing design that is suitable to meet the
requirements of all clinical applications and, not surprisingly, the features of an ‘optimum’
wound dressing vary with the particular wound type. However, there are certain general
performance requirements if the healing rate is to be clinically acceptable and these have
been established over many years.
The functions of a wound dressing were first summarised by the surgeon Abraham Rees in
1819 [214]. Thereafter, various researchers have sought to summarise the basic requirements.
The desirable properties of wound-dressing materials were defined by Winter [21], Turner
[3, 215, 216] and other workers [23, 217, 218]. Turner [215] identified the performance
characteristics of an ideal wound dressing as ‘those factors which will produce a micro-
environment associated with the wound that will allow healing to proceed at the maximum
possible rate commensurate with the age and physiological condition of the patient’. In
1995, Whitby [23] proposed a more systemic list of requirements based on the biology of
wound healing as follows:
to maintain high humidity in the wound (epithelialisation proceeds more rapidly in a
moist environment);
to permit gaseous exchange; to maintain PO2 and pH at appropriate levels;
to maintain wound temperature close to body core temperature, allowing mitosis and
phagocytosis to proceed at optimal levels;
Nonwoven Wound Dressings 13
to aid removal of dead tissue and bacterial, chemical and physical contaminants (excess
wound exudate containing cellular debris increases the risk of bacterial infection, and
the presence of foreign material prolongs the inflammatory phase);
to be impermeable to bacteria; and
to be non-adherent, non-allergenic and free from contaminants (adherent dressings that
damage new epithelium when they are changed, and toxic and particulate contaminants
in the dressing that may prolong the inflammatory phase).
Walker [219] proposed that the requirements of a composite dressing should be:
to maintain high humidity at the wound/dressing surface;
to remove excess exudates;
to allow gaseous exchange;
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[231]. Plastics wound dressings usually consist of two layers: an absorbent pad impregnated
with antiseptics and a plastics adhesive tape consisting of a film (impermeable, permeable or
waterproof and vapour-permeable, as required).
Perforated-film absorbent dressings usually consist of three layers [239]: the wound-facing
or contact layer, an absorbent middle layer and a backing layer. The three different types of
perforated-film absorbent dressing are summarised as follows. In Type I, the wound-facing
layer is a perforated film made of poly(ethylene terephthalate), the absorbent layer is a
porous nonwoven fabric made of bleached cotton fibre, viscose rayon fibres or a blend of
the two fibres with polyacrylonitrile. The backing layer is an apertured nonwoven cellulose
fabric. In Type II, the wound-facing layer is the same as in Type I, the absorbent middle
layer is a bleached cotton nonwoven fabric, and the backing layer is identical to the
wound-facing layer. In Type III, the outer layer (wound-facing layer and backing layer) is a
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sleeve consisting of perforated film made of poly(ethyl methyl acrylate). The sleeve forms
the wound-facing layer on the side without the join and the backing layer on the side
with the join. The absorbent middle layer is made of bleached cotton or viscose, or a
blend of both, sandwiched between two layers of an apertured nonwoven cellulose fabric.
This structure is very similar to the five-layer wound dressing that has been described
by Walker [219].
An example of a commercial perforated-film absorbent dressing is EXU-DRY (Smith &
Nephew) [232]. EXU-DRY is designed to cover the wound with reduced friction, save
nursing time and lower total dressing costs. It is claimed to protect the wound, support
healing, reduce friction and shearing and wick away drainage, and to be non-adherent,
non-occlusive, highly absorbent, and lint-free. The structure consists of:
an outer layer consisting of high-density-polyethylene film,
an inner layer of a highly absorbent viscose/cellulose blend nonwoven,
an anti-shear layer composed of high-density-polyethylene film, and
a wound-contact layer composed of high-density-polyethylene film.
Many current wound dressings containing nonwoven fabrics are laminate structures
containing up to four elements:
(i) non-adherent or ‘gelling’ wound-contact layer;
(ii) wicking/transmission layer (cushions, protects and insulates);
(iii) diffusion layer; and
(iv) backing layer (bacterial barrier and moisture-vapour/gas-permeable film).
It is clear that nonwoven materials, as defined by various workers [180, 219], must be
combined with other fabric structures to perform as an ‘ideal’ wound dressing. Moist
wound healing can be obtained by maintaining high humidity at the wound surface using
moisture-vapour-permeable film backing layers [65, 229–231] or a gelling wound-contact
layer (perforated film, foam, calcium and sodium alginate fibres, hydrocolloids, hydrogels
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and hydrofibres [223]). Excessive exudate may be removed from the wound surface by an
absorptive nonwoven material and may be enhanced by the use of a wicking or diffusion
layer, which may be a nonwoven fabric [231] or paper. Maintaining the temperature of
the wound surface and mechanical protection of the wound from external agencies can be
achieved by selection of appropriate absorptive nonwoven fabrics and backing materials.
The removal of dressings without trauma requires low-adherent materials and struc-
tures [180]. Wounds covered with gel-forming polymers can be gently irrigated to clear
any residues on removal. Dressings made from biodegradable materials can reduce
the trauma upon removal significantly because the frequency of dressing changes is
decreased.
Although moist wound healing requires the wound dressing to have the capability to
retain the wound surface at a high humidity level, the absorption of excess fluid in the form
of exudate is also fundamental. Many researchers have examined the clinical problems
associated with copious or excessive wound exudate [234–237], and the maceration of the
intact skin surrounding a chronic wound is a common clinical problem [238]. The removal of
exudate avoids tissue sloughing, and exotoxins or cell debris, which may retard growth or
extend the inflammatory phase, are also removed along with the excess exudates [3]. The
balance of humidity and liquid absorption is critical and, because of this, excessive wicking
must be avoided to prevent drying of the wound surface. This may be adjusted by
controlling the absorbency, the moisture vapour transmission rate of the dressing
components and the hydrophobicity of the different layers.
Traditional absorbent dressings based on gauze and similar textile materials are designed
to dry out the wound surface but, despite this, they remain the most commonly used wound-
dressing material. Basic gauzes are effective in removing blood and exudate from the wound
but they all, to a lesser or greater extent, adhere to the wound surface and may cause
considerable pain on removal.
2.3.3.2 Low Adherence The need for absorbency is very important but it must be
achieved while maintaining low adherence. An early attempt to produce a non-adherent
dressing involved impregnating gauze with paraffin cream, poly(ethylene glycol) or aluminium
stearate, but this was not entirely successful. Low adherence for nonwoven absorbent
dressings may be achieved [239] by various means, including:
preventing dehydration of the exudate;
reducing absorption of fluids into the interior of the dressing; and
treating the dressing surface to render it non-adherent.
16 Textile Progress
permeable films [65, 229–231]. The oxygen pressure and gaseous exchange through the
dressing, which are believed to influence wound healing, are also affected by the choice of
backing layer [65, 66, 69, 229–231].
2.3.3.4 Composite Wound Dressings for Better Wound Healing To avoid the problems
associated with traditional dry absorbent dressings and the disadvantages of occlusive
dressings, laminated dressings have been designed. In The British Pharmacopoeia, for
example, four kinds of composite plastics wound dressing are defined:
(i) impermeable plastics wound dressings [228];
(ii) permeable plastics wound dressings [229];
(iii) vapour-permeable waterproof plastics wound dressings [230]; and
(iv) perforated-film absorbent dressings [231].
All of the above consist of at least two layers: an absorbent pad, which is usually a
nonwoven impregnated with antiseptics, and a plastics adhesive tape, which is made from a
film that is impermeable, permeable, waterproof, or vapour-permeable.
One example is a composite dressing comprising an apertured wound-contact layer that
allows exudate to pass freely into the absorbent layer but separates the absorbent layer from
the wound surface [240]. A composite absorbent dressing comprising polyurethane foam has
also been developed using a standard wound model [93].
Other examples are composed of an absorbent nonwoven fabric covered with a perforated
film. The film reduces the amount of absorbed exudate, leaving moist gel at the wound surface.
Therefore, adherence to the wound causing trauma on removal is minimised. However, it
is known that columns of dried exudate, which form in the film pores, can effectively connect
the wound surface to the dressing. Consequently, tissue damage is caused when the dressing
is removed [241]. There is increasing interest in exploiting a variety of new natural bio-
compatible materials in wound dressings because of the disadvantages of traditional yarn-
based gauze and the desire to design an ‘optimum’ wound-dressing structure.
must not alter the configuration of stability of any cellular or soluble materials in
blood, must not induce any adverse inflammatory or foreign body reaction, and
must not be carcinogenic.
3.1.1.1 Cotton Cotton is a natural absorbent cellulosic fibre, which has long been used in
gauze and surgical swabs. Traditionally, for wound dressings or healthcare products, cotton
must be scoured and bleached to remove chemical impurities and wax. Scouring and bleaching
increase the absorbent capacity, optical whiteness and chemical purity. A typical cotton
scouring and bleaching process is shown in Fig. 1.
Cotton is readily converted into drylaid webs and batts that can be needlepunched,
hydroentangled, chemical-bonded, thermal-bonded or stitch-bonded. Cotton fibre specifi-
cations for drylaid hygiene products are given in Table 1 [243]. Additional requirements for
purified cotton fibre are shown in Table 2 [243].
Because cotton is biodegradable, it is still applied in composite wound dressings as an
absorbent. Examples include US P 6 155 083 [244], 6 653 520 [245], and 6 599 523 [246].
Table 1
Bleached Cotton Properties for Nonwoven Roll Goods*
Micronaire: greater than or ¼ 4.9
Length: greater than or ¼ 0.95 inch
Uniformity: greater than or ¼ 81.0%
Strength: greater than or ¼ 23.0 gf/tex
Non-lint content 0.8% maximum (MDTA-3)
Fibre-to-fibre cohesion, 1700 gf maximum (ICI Fibres Cohesion Test)
Fibre openness Equal to 100 cm3/g minimum (ITT Test Method)
*
From ref. [243].
Table 2
US Pharmacopeia Requirements for Purified Cotton*
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Test Specifications
Absorbency sinking time 10 s max.
Water retention from sinking test 24 times orig. wt.
Ash residue 0.2% max.
Water extract 0.35% max.
Ether extract 0.70% max.
*
From ref. [243].
However, it is seldom used in 100% form because of the related problems of linting
and sticking to the wound. Carboxymethyl cellulose and other cellulose derivatives are
increasingly common to reduce the adhesion of the contact layer to the wound.
3.1.1.3 Keratin Fibres Keratin fibres, including human hair, wool and silk, are naturally-
occurring polyamides. The disulphide bonds in human hair [257] can be partially oxidised to
sulphonic acid residues, which are then reacted with a cation, to make a hydratable form
of keratin that is suitable as an absorbent wound dressing. Few examples of wool and silk
wound-contact layers have been reported, although wound dressings composed of
regenerated silk fibres are known [258]. Removal of the wool cuticle increases hydrophilicity
and a wound dressing composed of wool fibres with cuticular modification has been
proposed [259]. It has been suggested that hydrophilic wool fibres can form a suitable liquid-
permeable layer in absorbent wound dressings [260]. The chemistry of wool provides a basis
for its conversion into keratin membranes, films, foams, powders, hydrogels and fibrous
structures for potential uses in skin substitutes or implant matrices. Because of its high
cysteine content (c. 12–17% by weight), wool keratin has been proposed as an activated
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protein for use in wound dressings [261]. It has been suggested that the activated protein
could be attached to the skin by the formation of disulphide bonds in order to moisturise
and provide a vehicle to carry other agents into the dehydrated skin.
wound care are alginates, chitin, chitosan, collagen, fungal cellulose, carboxymethylated
cellulose (CMC), polylactic acid (PLA), polyglycolic acid (PGA), fibronectin, hylaronic acid
and fibres made from other biodegradable polymeric materials. These fibres tend to have
comparatively poor tensile properties and are therefore difficult to form into fabrics other
than by nonwoven processes.
3.1.2.1 Chitin and Chitosan Fibres Chitin is estimated to be the second most abundant
polysaccharide in nature, with a synthesis of around one billion tons a year by marine
organisms [266]. It exists in the cell walls of fungi and the hard shell of insects and
crustaceans; the waste from shrimp, lobster and crab seafood industries contains 10–15%
chitin.
Chitin is a polysaccharide comprising poly(N-acetyl-D-glycoamine) of relatively high
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molecular weight. Since chitin contains one aminoacetyl group per recurring unit, it can be
absorbed in the tissue after undergoing enzymatic decomposition in vivo; the biocompat-
ibility of chitin is especially important for wound dressings as well as other medical products.
However, in the natural state chitin exists only as short fibrous material, e.g. from the
carapace or tendons of crustaceans. Therefore, efforts have been made to form chitin into
longer fibres. The development of chitin fibres is described in various sources [267–270]. In
the early development [271], chitin films and fibres were formed by preparing a solution in
aqueous acids, and then spinning or casting, followed by coagulation with a non-solvent.
After the filaments were dried under tension, their tensile strength was quite low. Drawn
filaments extruded from lithium thiocyanate have also been reported in an effort to develop
molecular orientation [272], but an X-ray pattern of a chitin sheet reprecipitated from
lithium thiocyanate solution and supported on a glass plate showed only the broad diffuse
nodes of a strained, non-crystalline material.
Early US patents [273–275] describe the preparation of chitin xanthate for regenerating
chitin (or chitin-cellulose) films and fibres. These patents mention the stretching of filaments
in the gel state to improve physical properties, but not the drawing of solid chitin, required
for orientation. A xanthate process used to spin chitin fibres [276], which is analogous
to the spinning of cellulose to form rayon, was also described; the resultant 50:50
chitin:cellulose fibre was reported to be of 12.3 denier and have a tenacity of 1.08 gf/denier
(dry) and 0.13 gf/denier (wet).
A chitin derivative, dibutyryl chitin, was spun into fibres by a research group at the
University of Leeds. Dibutyryl chitin was prepared by treatment of krill chitin with butyric
anhydride in the presence of perchloric acid as a catalyst in a reaction carried out at
25–30 8C. Polymer samples with molecular weights high enough to form fibres were obtained
and dibutyryl chitin fibres were made by a simple method of dry spinning a 20–22% solution
in acetone. Chitin fibres with good tensile properties produced in this way by alkaline
hydrolysis of dibutyryl chitin fibres without destroying the fibre structure were claimed.
Bechitin is a commercial chitin-based nonwoven dressing, which has found clinical
acceptance. Although relatively few commercial dressings based on chitin or chitosan fibres
have become available, there has been considerable development of chitin nonwoven
dressings [277].
The British Textile Technology Group (BTTG) described a procedure for making fibrous
dressings based on chitin or chitosan fibres produced from fungi rather than from shrimp.
Because this method uses a non-animal source as the raw material, the resulting micro-
fungal fibres are different from normal extruded chitin fibres. They have highly branched,
Nonwoven Wound Dressings 21
Table 3
Properties of Chitin Fibres
Tensile Strength (kgf/mm2) Reference
Fibre Natural chitin 58 Clark and Smith [272]
Regenerated chitin 35 Kunike [271]
Regenerated chitin 63 Austin et al. [268]
Silk 35.6 Clark and Smith [272]
Viscose rayon 25 Kunike [271]
Wool 14.5 Clark and Smith [272]
Film Regenerated chitin (6.3*103 1bf/in2) Joffe and Hepburn [283]
Regenerated chitin 9.49 (dry), 1.75 (wet) Thor and Henderson [284]
Regenerated celullose 9.10 (dry)
irregular structures, which can form a three-dimensional matrix. Unfortunately, the fibres
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tend to be brittle when allowed to dry and a plasticiser has to be used. The fibres are
converted into a nonwoven dressing fabric by wet-laying [278]. A wet-laid nonwoven fabric
has been produced composed of chitin fibres of 30-mm length and 150-mm diameter [279]. In
a Japanese patent [280], chitin fibres of 1–5 den and 1-gf/den fibre strength were combined
with a chitin dope to act as a binder to form a nonwoven fabric. The nonwoven fabric
described in another source [281] was composed of 3-den (and ,10-den maximum) chitin
fibres without a binder. Nonwoven wound dressings containing very fine chitin fibres are
described elsewhere [282]. The dressing was composed of chitin fibres having a linear density
of less than 1 den and a strength of not less than 2 gf/den. A summary of the properties of
chitin fibres from various studies is given in Table 3. Values for other fibres are given for the
purpose of comparison.
Chitin fibres are claimed to have high tensile strength, flexibility and good absorption
properties [267]. Other attractive properties of chitin and chitosan include biocompatibility,
bio-absorbability and high absorbency. Prudden et al. [285] claimed that chitin containing
n-acetyl glucosamine is useful in accelerating wound-healing.
3.1.2.2 Alginate Fibres Alginate polymers [286] and the fibres produced from them are
derived from brown seaweed (Phaeophyceae, mainly Laminaria), and those used for wound
dressings are preferably from Laminaria hyperborea or any other suitable source. Alginates
are linear unbranched polymers containing b-(1!4)-linked D-mannuronic acid (M) and
a-(1!4)-linked L-guluronic acid (G) residues. The ratio of guluronate/mannuronate
residues in alginate determines the solubility of alginate in water. It is recommended that
the ratio ranges from 1.5:1 to 2.5:1, preferably from 1.75:1 to 2.4:1, and may be about 2:1 or
2.3:1 [287]. Alginate-containing mannuronic and guluronic acid units in a mannuronic
acid:guluronic acid ratio in the range from about 55:45 to about 75:25 were proposed in a
US patent [288].
Alginate is favoured in dressings because it is bioresorbable and does not shed large
quantities of hydrocolloid material into the wound. Alginate also has good absorbency and
this is one reason why it is extensively used in the management of heavily exuding wounds
such as ulcers. Through a process of ion exchange, alginate dressings can donate calcium
ions to the wound, positively affecting haemostatic properties [289]. Normally, calcium
alginate is a solid but, in contact with wound fluid (or alkaline solutions), the ionic exchange
leads to a sodium alginate gel, which is usually soluble. In addition, calcium ions released
during the process of ionic exchange stimulate platelet aggregation and coagulation and thus
play a role in haemostasis. The conversion of alginate into a hydrogel when in contact with
22 Textile Progress
wound exudates promotes low adherence to the wound bed and a moist healing
environment, both of which are desirable. It is widely used to control haemorrhage, to fill
‘dead space’ after the removal of organs or massive tissue, to act as tissue-isolating films, and
externally as burn, ulcer and wound-dressing covers. Alginates are suitable for use in
moderate to highly exudating wounds and are useful for the treatment of acute traumatic
wounds that are bleeding heavily.
Alginate is formed into fibres using established production techniques such as wet-
spinning. Commercial alginate fibres used in nonwovens consist of calcium and sodium salts
of alginic acid. Alginate fibres for medical purposes are made from alginic acid with different
cations, e.g. sodium, calcium, zinc, silver, ammonium, magnesium, hydrogen ions [290] and
mixtures of them [291–296]. The preferred first cation is calcium, which is believed to have a
haemostatic effect on wounds. Zinc is also believed to be effective in the control of bacteria
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and disease. The use of alginate for the deliveries of antimicrobials, notably silver ions, has
been reported [297]. Sodium, potassium, lithium, ammonium, and magnesium alginates are
readily soluble. Alginate can also be incorporated with one or more pharmaceuticals such as
local anaesthetics or novocain, as well as antibacterial or antifungal agents, for use in
dressings. Many patents have been published on the extrusion of alginate solutions into
an aqueous solution containing calcium ions to form yarns of calcium alginate filaments
[298–302].
Films and filaments of alginic acid can be produced by preparing an aqueous solution of
alkali-metal alginate (using ammonia and alkali hydroxides or carbonates as solvents) whose
concentration does not exceed 10% expressed as alginic acid [298]. The solution is still acid,
neutral or only weakly alkaline and is transformed into a solid film by drying for 15
minutes or formed into a solid filament by spinning the acid solution flow into an aqueous
solution containing calcium ions. The proportion of ammonium alginate is not more than
85% of the total alkali present in the alkali-metal/ammonium alginate solution. Sterilisation
can be effected by heating the solution to 100 8C, or by incorporating a germicide with the
solution, for example, one part in ten thousand of copper ions.
Calcium alginate filaments can also be prepared by extruding a 5–10% aqueous solution
of sodium alginate into an aqueous solution containing 5–35 g/L of calcium chloride (or an
equivalent amount of any other calcium salt) [303]. It is also claimed that the ribbon-like
cross-section can greatly reduce brittleness of the alginate fibres [303].
Besides the ratio of guluronate/mannuronate residues in alginate, the ratio of sodium
cations to calcium (silver, zinc, magnesium, ammonium, etc.) cations also has significant
influence on the water absorbency and fibre mechanical properties.
Many wound dressings composed of mixed sodium and calcium alginate fibres have been
described [304]. The cation ratios in a mixed-salt alginate dressing are intended to achieve a
highly effective combination of properties. Bonniksen [291] proposed that the cation ratios
in alginate should be in such a proportion that the composition so formed can swell to any
desired degree in watery fluids to produce a gel-like slab but cannot disperse. Calcium
alginate fibres have been converted to a 50:50 Ca:Na mixed-salt fibre (on an equivalent
basis) to increase the solubility and to promote haemostasis [292, 295]. However, the 50:50
Ca:Na mixed-salt fibre was difficult to handle in contact with liquid wound exudates, and an
alternative ratio of sodium cations to calcium cations in the range from 30:70 to 15:85 was
recommended [305].
In addition to fibres, a method [306] of impregnating nonwoven absorbent pads with 5%
(by weight) of calcium alginate or a mixture of calcium and sodium alginate to form a
Nonwoven Wound Dressings 23
dressing with mixed cations has been reported. Alginate nonwoven dressings usually consist
of compression-bonded or needlepunched carded webs that are parallel-lapped or cross-
lapped before bonding. Perhaps surprisingly, hydroentangled alginate dressings have also
been commercially produced. Deionised water is required to prevent the gelling of fibres
during the process [307]. The production of spunlaid alginate filaments has also been
demonstrated, based on wet-spinning.
Alginate dressings are sometimes produced in combination with hydrocolloids or
activated charcoal for the control of malodourous wounds. A water-swellable but insoluble
wound-dressing material is described in US P 6 022 556, which comprises 5%–50%
of an alginate ester, or propylene glycol alginate. Insolubility is achieved by the addi-
tion of polyvalent cations such as calcium ions, or by covalent cross-linking of the PGA, or
by adding from 10 to 35% by weight of water-swellable polysaccharide such as gelatin, or by
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agent has also been described [322]. As the porosifying agent degrades in situ, an implant
with an inter-connecting network is formed. The resultant mechanically-stable implant
allows tissue and fluid influx into the collagen matrix.
A wound dressing made of genetically-engineered human collagen that could allow faster
and improved healing of injuries has been developed by researchers in Israel [323]. The
dressing incorporates an inner layer of genetically-engineered, human recombinant collagen.
This material becomes a soluble, readily enzymatically degradable molecule in the wound
tissue. The molecular fragments that are formed have been shown to play an important role
in the healing process. An outer layer, also of biological origin, is provided in the wound
dressing to provide initial protection prior to release of the delicate collagen layer.
3.1.2.4 Aliphatic Polyester Fibres Poly(lactic acid) (PLA) and poly(glycolic acid) (PGA)
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3.1.2.6 Other Special Materials Fibres composed of other speciality materials are also
used in dressings including branan ferulate, which is a polysaccharide or carbohydrate
polymer extracted from corn bran [340, 341]. Other fibres that are used in wound dressings,
but not necessarily as the wound-contact layer, are carbon fibre, poly(hyaluronic acid) (HA)
[342], hyaluronan derivatives [343] and starch-based materials. A nonwoven absorbent
fabric composed of biodegradable polyhydroxyalkanoate (PHA) copolymers is claimed to
be suitable for use in wound dressings [344] and a nonwoven fabric containing microfungal
26 Textile Progress
hyphae fibres has been revealed [345]. The nonwoven comprises a wet-laid web of micro-
fungal hyphae fibres treated with a plasticiser before the hyphae are allowed to dry, to
prevent embrittlement. Various applications for the fabrics are envisaged, including wound
dressings and metallic-ion-capture substrates.
Other developments include a dressing consisting of a cellulose diacetate and poly-
vinylpyrrolidone fibre blend in a weight ratio of 4:1 to 10:1 [346] and a lyophilised foam
sponge product formed from hydrocolloids (e.g. gelatin, pectin, and sodium carboxy-
methylcellulose) with a density of 0.01–0.10 g/cm3 [347]. The dressing is prepared by forming
an aqueous colloidal dispersion of hydrocolloids, aerating or foaming, freezing, and lyo-
philising. Other natural and synthetic fibres, including banana-leaf fibres [348] and carbo-
hydrate polymer fibres, [349] have also been documented for use in wound dressings.
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gel-forming fibres are needlepunched to both sides of a reinforcing scrim [360]. Composites
containing a carded web and polyurethane foam, which acts as the absorbent, and an inner
skin-facing layer in a compression bandage system are produced in this way [361].
Hydroentangled (spunlaced) fabrics are favoured because they are low linting, comformable,
clean and soft. They also have a pore structure that can be adjusted during fabric production
and different layers can be mechanically laminated during the process to produce absorbent
composites. Most fibres are compatible with hydroentanglement; even some hydroentangled
alginate dressings are manufactured. The structural patterning and aperturing capabilities of
hydroentanglement have long been exploited in the production of dressings. Many are
superficially gauze-like in appearance, having apertures of different shapes, dimensions and
spatial arrangements. Hydroentangled fabrics with parallel ribs interconnected by loose fibre
bundles extending between adjacent ribs are claimed to produce dressings with particularly
good absorbency [362]. Chemically-bonded fabrics are found in certain composite dressings,
for example, as barriers to liquid-borne bacteria [363]. One type of body-fluid-absorbent pad
is composed of wood pulp bonded with thermoplastic fibres such as the polyolefins [364].
Polyethylene, polypropylene and polyester spunbonded and meltblown fabrics provide low-
adherent permeable wound-contact layers that possess good mechanical properties [371,
365, 366]. Nonwovens combined with hydrophobic silicone finishes are also intended as non-
adherent layers [104, 105, 106] and assist in the reduction of skin tears [367].
structural parameters and dimensions, including fibre diameter and fabric density. Polyester,
viscose, polypropylene, polyethylene and their blends [374] are widely used to form
nonwoven components in dressing composites. A multilayer dressing [375] in which each
layer consists of fibres with progressively decreasing linear density is reported to have a high
drying rate and an improved rate of in-plane body fluid penetration. A nonwoven dressing
structure that allows interchange of the position of the low and high density layers to aid
wound healing has also been developed [376].
The applications of nonwoven fabrics, used either as a monolayer or as a component in
composite wound dressings cited in the patent literature, may be classified as follows:
(i) active agent carriers;
(ii) liquid absorption, transfer and barriers;
(iii) high conformability components;
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The absorptive capacity and the liquid transfer of a compacted nonwoven fabric are
reported to be greater than that of a hydroentangled fabric of the same weight and fibre
composition [392].
In composite wound dressings, absorbent nonwoven structures are frequently combined
with thin films, which are impermeable to liquid water and bacteria but permeable to water
vapour. This provides protection for a patient from sources of infection external to the skin,
helps to retain body fluids at the wound site and allows the skin to breathe normally [393].
For example, a composite dressing has been designed having a layer of low density absor-
bent fabric covered by an upper layer of high density fabric. The wicking rate of the cover is
higher than that of the low density layer. These two layers are placed between a permeable,
non-adherent, bacteria barrier and a lower perforated sheet [225]. Another example of such
a composite structure consists of a laminated nonwoven absorbent fabric with a film to
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produce an absorbent, non-adherent dressing [394]. The nonwoven absorbs the body fluid
while the support film is transparent or translucent permitting visual inspection of the pad.
Four composite wound-dressing structures containing absorbent pads have been defined
in the BP [395]: impermeable plastics wound dressing (waterproof plastics wound dressing);
permeable plastics wound dressing; vapour-permeable waterproof plastics wound dressing;
and perforated-film absorbent dressing. These composite wound dressings usually consist of
three layers: a film or a pad protector layer in contact with the wound surface, an absorbent
pad, and a back layer, which is usually waterproof and permeable to gas/water vapour.
The nonwoven absorbent cores in the three types of perforated-film absorbent dressing
defined in the BP differ in their suitability for use with wounds generating high and low
amounts of exudate. In Type 1, the absorbent middle layer is a nonwoven material
consisting of bleached cotton or viscose together with polyacrylonitrile fibres. The wound-
facing layer is a film of PET perforated in a regular pattern, and the backing layer is an
apertured nonwoven cellulosic material. For Type 2, the absorbent middle layer is a
nonwoven material consisting of bleached cotton, and the wound-facing layer is similar to
that of Type 1. The backing layer is identical to the wound-facing layer. For Type 3, the
absorbent middle layer is a nonwoven consisting of bleached cotton or viscose fibres or a
mixture of both sandwiched between two layers of an apertured cellulosic nonwoven. The
outer layer is a sleeve consisting of a film of PET, perforated in a regular pattern.
Nonwovens containing superabsorbents make a highly effective absorbent core in wound
dressings. Superabsorbent powders, granules and fibres are available. The fibre sources
include polyacrylate-based Oasis superabsorbent fibre (Oasis SAF) [395A] and multi-
component superabsorbent fibres from BASF [395B]. Both hydrophilic fibres [396] and
hydrophobic fibres [397] may be incorporated with appropriate superabsorbent materials.
The nonwoven structure itself can be a composite. For example, an absorbent construct
composed of a polypropylene nonwoven fabric sandwiched between two layers of cellulose
tissue [398] has been described.
Combining both hydrophobic and hydrophilic fibres in a composite hydroentangled
dressing has been considered. Such layered dressings can exhibit good liquid absorbency
as well as provide a barrier against bacteria. The hydrophobic nonwoven layer acts as the
wound-contact layer and exudate passes through the water-permeable hydrophobic layer
to be absorbed by the hydrophilic core layer [399]. An extensible and water-impervious
microfibre laminate has been designed to increase hydrostatic head at higher extension [400].
In this laminate, a creped hydrophobic microfibre structure is sandwiched between and
bonded to two reinforcing layers of nonwoven fabric. The purpose of the creped microfibre
30 Textile Progress
inner layer is to minimise liquid absorption in the laminate and to prevent liquid strike-
through, even after considerable fabric extension.
4.1.3 High Conformability Components
Good conformance with the wound site is required in a dressing. Recovery from extension
or deformations imposed on the dressing during application or in situ is also desirable. Many
biocompatible polymer films have excellent barrier properties and elasticity or stretch-
recovery but are fragile, easily curl and can readily catch on rough objects, resulting in
damage. Most nonwovens do not have good elasticity but many have high extensibility and
good absorbency. Therefore, nonwoven fabrics used in dressings have been incorporated
with elastomeric films [401], elastic meltblown aromatic polyether urethane nonwoven
membranes [402–404], and elastomeric moulded copolymers [405] to improve dressing
comfort and fit. A further option is microcreping of the fabric. The recent introduction of
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elastomeric spunbonded fabrics [405A, 405B] provides additional opportunity for the design
of conformable wound dressings.
When dressings are applied over a relatively large wound at bending sites of the body,
such as the elbows and knees, nonwovens having high extensibility may be useful support
components in an adhesive bandage [406]. A corrugated nonwoven fabric having contiguous
anti-nodes of adjacent waves has good stretch for medical and surgical compresses [407].
Absorbent nonwovens also form part of dressings that are applied as part of a
temperature pack to promote wound healing. Such dressings are composed of an elongated
pack, which is applied to the body for the purpose of increasing or decreasing the
temperature of the patient [408].
4.1.4 Mechanical Reinforcement and Moisture Control in the Back Layer
A sponge wound dressing can be reinforced by a point-bonded nonwoven [409] and a
meltblown nonwoven web [410], rather than a conventional spunbonded fabric.
Attempts to improve the cross-directional extension of dressings have also been made
[411]. The fabric is elongated in the cross direction and then necked to increase the extension
in this direction. The resultant nonwoven is highly extensible and is suitable for use in
wound dressings, bandages, and personal care articles as well as wipes and tissues.
In commercial dressings containing absorbent components, the backing and secondary
retaining layers are important. The backing layer of a dressing can be adhesive or non-
adhesive. Adhesive is used to keep the wound pad in place on the backing layer and to the
wound area. The adhesive should be impermeable to liquid water but permeable to moisture
vapour. Adhesive materials for alginate wound dressings are recommended to have a
moisture vapour permeability of at least 300 g m 2 day 1 at 40 8C/80% r.h. [412].
Besides absorbent dressing cores, nonwovens having high extension may form the back
layer of adhesive bandages and dressings to control the conformity [413], and water vapour
transport [414] of the dressing.
Table 4
Examples of Nonwoven Components in Wound Dressings from the British Drug Tariff
Name Type Structure Function of Nonwoven Manufacturer
Algisite M Primary Dressing– A primary needled nonwoven made from calcium Absorbent, conformable Smith & Nephew
Calcium alginate alginate fibres, rich in mannuronic acid. Healthcare Ltd
Kaltostat Dressing–Hydrofibre An absorbent mechanical-bonded fabric composed Highly absorbent, ConvaTec Ltd
of staple fibres of sodium and calcium salts of alginic gel forming
acid in the ratio of 80:20.
Tegagen Dressing–Calcium Hydroentangled, calcium alginate nonwoven dressing. Good wet integrity 3M Health
alginate Care Ltd
Aquacel; Dressing–Hydrofibre A soft, hydrophilic nonwoven ribbon or flat dressing Superabsorbent, ConvaTec Ltd
Aquacel composed of hydrocolloid fibres (sodium gel forming
ribbon carboxymethylcellulose).
9
Acticoat 7 Primary dressing– Two layers of silver-coated polyethylene mesh and >
> Absorbent core (hydro- Smith & Nephew
[418] Silver-coated >
an inner core (two layers of an apertured nonwoven>
> philic and hydrophobic), Healthcare Ltd
>
>
low-adherent made from rayon and polyester plus a layer of >
= support layer to [419]
silver-coated PU). silver-coated layers.
>
Acticoat Two layers of silver-coated polyethylene mesh and >
>
>
>
an inner core (one layer of an apertured nonwoven >
>
>
made from rayon and polyester). ;
Mepilex Island dressing– An absorbent, self-adhesive island dressing Absorbent core Mölnlycke
Nonwoven Wound Dressings
(Continued)
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Table 4 (Continued)
32
Mepiform Dressing–Self- A viscose nonwoven fabric coated with silicone Carrier of silicone, water Mölnlycke
adhesive soft silicone and bonded to a semipermeable polyurethane vapour permeable Healthcare Ltd
scar treatment membrane.
Micropore Tape–Permeable, A conformable, non-extensible viscose nonwoven Permeable to water and 3M Health
nonwoven with fabric coated with a layer of an acrylic adhesive. water vapour, Care Ltd
synthetic adhesive radio-transparent.
Hypafix Tape–Apertured, An apertured, nonwoven polyester fabric coated The apertured structure Smith & Nephew
nonwoven, with a layer of acrylic adhesive, and protected on imparts a lateral extensibility, Healthcare Ltd
synthetic adhesive the roll by a release paper backing. conformability and
permeability to the product.
Mefix Tape–Apertured, An apertured, nonwoven polyester fabric coated Mölnlycke
nonwoven, with a layer of an acrylic adhesive, and protected Healthcare Ltd
synthetic adhesive by a release paper backing.
Melolin Dressing–Perforated A perforated film of poly(ethylene terephthalate), Absorbent, permeable, Smith & Nephew
film absorbent BP bonded to an absorbent layer consisting of a backing layer Healthcare Ltd
(Type 1) blend of cotton and polyacrylonitrile fibres, backed
with a layer of an apertured nonwoven cellulose
fabric.
Mepore Island dressing– A self-adhesive absorbent dressing that has an absorbent Permeable and flexible. The Mölnlycke
Textile Progress
Nonwoven fabric wound pad located centrally on a piece of apertured, polyester backing layer and Healthcare Ltd
adhesive nonwoven polyester fabric coated with a layer of an acrylic viscose absorbent layer are
adhesive. The wound pad is a viscose nonwoven coated with also the acrylic adhesive and
a polyolefin layer to give a smooth surface and render it polyolefin carriers respectively.
low-adherent.
Proguide Multilayer bandage– Comprises a kit containing three components: a Nonwoven layer is to protect bony Smith & Nephew
compression system primary dressing composed of PU foam composite, prominences from excess pressure, Healthcare Ltd
a roll of absorbent padding and an elastic, woven but it also serves as a secondary
compression bandage. The padding layer is absorbent layer in the treatment of
formed from a polyester and viscose fibre blend. heavily exuding ulcers.
Actisorb Dressing with Consists of activated carbon impregnated with Support layer to silver-coated Johnson & Johnson
Silver 220 activated charcoal metallic silver. The carbonised fabric is sealed in layers; facilitate handling Medical Ltd
cloth and silver a sleeve of a nylon spunbonded fabric to facilitate particle and fibre loss.
handling and reduce particle and fibre loss.
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and cells were pioneered in Boston, USA, in 1955 and during the early 1960s [423]. This
sophisticated biological approach in wound healing with the use of artificial skin substitutes
began in the burns area in the 1970s [424]. The transplantation of extrarenal solid organs
was still largely experimental until the late 1970s although the mechanisms of cell growth
had been studied [425, 426]. In 1981, the first artificial skins by O’Connor et al. [427] and by
Burke et al. [428] in treating burn injuries were reported. Russell [429] reviewed the concept
of selective cell transplantation, and conceptually this offered a potential methodology for
the restoration of tissue function. Inspired by the previous work, Vacanti [430] applied the
principles of selective cell transplantation using three-dimensional synthetic biodegradable
polymer matrices to create visceral organs in vitro.
From the 1990s, it was established that cell migration, replication and differentiation,
and the synthesis of extracellular matrix (ECM) are common to wound healing, embryonic
development and tumour growth. As a result of developments in cellular and molecular
biology, the mechanisms of normal wound healing and ways in which this can be
manipulated are being further elucidated [24].
In recent decades, matrices made from new synthetic materials and material-processing
techniques have been used in forming blood vessels and intestine [123, 431, 432], liver,
ligament, tendon, bone, specific shapes of cartilage for the ear [433], finger [434] and heart-
valves [435]. Although the development of entirely man-made organs (in vitro) and tissues
(e.g. kidneys, skin, liver) for transplantation over the last forty years has been remarkable,
these substitutes do not function as well as natural organs or tissues [436].
Some general strategies are utilised in the creation of new tissue including [421]:
(i) the replacement of only those isolated cells or cell substitutes needed to restore
functions;
(ii) the production and delivery of tissue-inducing substances such as growth factors and
signal molecules;
(iii) the placing of cells on or within a matrix fashioned from synthetic polymers (e.g.
textile materials) or natural substances such as collagen; the matrix may be an open
or a closed system.
Open cell-matrix systems are designed to be implanted in the body to become completely
integrated with the host tissue, allowing free transport of molecules and cells between the
host tissue and implanted cells. A closed matrix system may be transplanted in the body
or used as an extracorporeal device [421, 437]. In a closed matrix system, cells are isolated
Nonwoven Wound Dressings 35
from the body by a membrane that permits nutrient and gas exchange while acting as a
barrier for large entities such as antibodies and white cells [438].
acid [213], peptides [441] and growth factors [442–444] have been in development. The
advancements in biomaterials and tissue-engineered skin equivalents [445, 446], both cell-
free matrices (acellular matrices) and cell-containing matrices [447], have led to several
products [448], such as Dermagraft [449] and Apligraf [450], Alloderm [451], Oasis [452] and
Integra [84], available commercially.
A summary and comparison of the clinical applications of these artificial skin substitutes
can be found in the literature [63, 453], and the details of the history of cultured epithelial
autografts can be found elsewhere [454, 455]. An overview of the current advances and
challenges in the field of biological skin substitutes has been given by Jones et al. [456].
induce in-growth of desirable cell types from surrounding tissue. The optimal matrix
microstructure is to some extent determined by the tissue to be transplanted. Generally,
matrix structures should be open with high porosity to allow cells to penetrate into the
scaffold and to give a high cell-seeding density. It is also important that nutrients can reach
the cells and there should be a large surface area to volume ratio for cell–polymer
interactions [490]. Agrawal and Ray suggested that a porosity of at least 90% is ideal for
specific scaffold–cell interactions, nutrient and waste diffusion, and sufficient space for
extracellular matrix (ECM) regeneration within the scaffold [465].
A tissue-engineered scaffold should be mechanically stable [466], regulating cell activities
[467] and capable of functioning biologically in the implant site [468]. Mechanical stability is
dependent primarily on the selection of the biomaterial of the ECM, the ECM architectural
design, and the cell–material interactions. Biologic functioning is regulated by biologic
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signals from growth factors and the surrounding cells and also determined by the ECM [469].
The matrix should be easy to reproduce in a variety of shapes and structures and retain its
shape when implanted.
polymers can be readily adjusted through variation of their molecular structures in order
to meet the functional requirements of the application without the use of either fillers
or additives.
A variety of synthetic polymers, both degradable and non-degradable, have been utilised
to fabricate tissue-engineered matrices [485, 486]. Langer [487] used biodegradable tubular
structures with cultured smooth muscle cells obtained from bladder wall biopsies. In 1994,
Mooney et al. [488] attempted to engineer urologic structures, which involved implanting
collagen sponge tubes as ureteral replacements in animals. The formation of an epithelial
cell-lined tubular tissue was intended, but salt deposits on the collagen matrix were observed
when the structure was exposed to urine.
Because permanent polymers carry the risk of infection, calcification, and unfavourable
connective-tissue response, the use of biodegradable synthetic polymers which break down
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continuity dictate the interaction of porous materials and transplanted cells with the host
tissue.
The process of cell transplantation results in the formation of a capillary network in the
developing tissue [498]. Fibrovascular tissue will invade a device if the pores are larger
than 10 mm, and the rate of invasion will increase with the pore size and total porosity of
a device [498–500]. Some of the engineered tissue may be required to meet the metabolic
requirements of the tissue and integrate it with the surrounding host. In urologic
applications it may also be desirable to have a nonporous luminal surface to prevent
leakage of urine from the tissue [501].
The matrices may act as a physical barrier to the immune system of the host or act as a
frame for tissue regeneration, depending on the design of the scaffold. Immunoprotective
devices utilise a semipermeable membrane to limit interactions between cells in the device
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and the host. The small pores in these devices (d , 10 nm) allow low molecular weight
proteins and molecules to be transported between the implant and the host tissue, but they
prevent large proteins (e.g. immunoglobulins) and the host cells (e.g. lymphocytes) of the
immune system from entering the device and mediating rejection of the transplanted cells.
In contrast, open structures with large pore sizes (d . 10 mm) are typically utilised if the
new tissue is expected to integrate with the host tissue [502].
Pore size also controls how effectively the cells of various sizes can penetrate into the
three-dimensional network and how effectively nutrients can be delivered to the cells once
they have been seeded [490]. If the pore size is too small, cells will be unable to initially
penetrate the scaffold and subsequently migrate to other regions of the scaffold to produce
uniform cell seeding throughout. If the pore size is too large, cells will be unable to bridge the
pore during cell proliferation, thus inhibiting effective neo-tissue generation.
It has been observed that fabric architecture including fibre alignments (i.e. fibre orienta-
tion) in fibrous scaffolds can positively influence the orientation of collagen fibre. When
random and parallel-oriented scaffolds were seeded with cells, collagen-fibre orientation
was increased in the parallel direction in the early stages of static in vivo culturing [503, 504].
The morphology of the matrices can guide the structure of an engineered tissue, includ-
ing the size, shape, and vascularisation of the tissue [490]. Open, porous, three-dimensional
structures using degradable polymers have been designed to maximise diffusion parameters
and to permit vascular in-growth into the implanted structures [505, 506].
bond the PGA fibres [512]. The specific shape and size of the implants was maintained as the
polymer degraded, and the newly-formed cartilaginous tissue demonstrated resilence,
returning to its original configuration after bending. The cartilaginous structure of the
human outer ear is extremely complex and offers a significant challenge in reconstructive
surgery. In 1992, a soft nonwoven polymer mesh with 14-mm-diameter fibres (PLA, PGA
and PLGA) was formed into the shape of a human ear by using a silicone prosthetic ear as a
mould, and then the cell was seeded onto the ear-shaped structures and implanted on the
back of an athymic mouse [513]. Plastic and orthopaedic surgeons are often faced with
repair and reconstruction of tendon defects. In 1995, Cao et al. [514] seeded tenocytes onto
a strip of nonwoven PGA mesh and PGA fibres arranged in parallel with a knot at one end.
They found that the rate of the parallel arrangement of the tissue structures was enhanced
when longitudinal polymer fibres were used.
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Class I — Non-critical items requiring only general regulation to prevent, for example,
adulteration and misbranding. Usually the manufacturer can provide reasonable
assurance of safety and effectiveness. Examples of fabric products in Class I include
surgical sponges, dressings and examination gowns.
Class II — The nature of the device requires more than just general control. The device
should comply with established performance standards. Examples of fabric products in
Class II are surgical gowns, drapes and sterilisation wraps.
Class III — These products are intended for supporting or sustaining human life and/or
making products that do not have enough historical data to assure safe and effective
performance or present a potential for unreasonable risk of illness or injury. Pre-market
approval is required. Examples of fabric products in Class III include arterial grafts.
6.1 Some Important Wound Dressing Standards (BP, ASTM and BS)
Many standards for dressings have been introduced by the American Society for Testing and
Materials (ASTM), The British Pharmacopoeia (BP), and British Standards Institution (BSI)
in recent years. BP [522] defined a series of test methods for surgical dressings including fibre
identification, yarn linear density, threads per stated length (unstretched, fully stretched),
weight per unit area (non-adhesive dressings, adhesive dressings, weight of adhesive mass),
minimum breaking load, elasticity, extensibility, adhesiveness, water-vapour permeability
(tapes, foam dressings), waterproofness, absorbency (sinking time, water-holding capacity),
water-soluble substances, ether-soluble substances, colour fastness, content of antiseptics,
content of zinc oxide in the adhesive mass, X-ray opacity, sulphated ash of surgical
dressings, and water-retention capacity. Other standards relevant to wound dressings
include sterility tests [523], microbial contamination tests [524], efficacy of antimicrobial
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water-vapour transmission [556] in textile fabrics given by the ASTM are also valuable for
evaluating wound-dressing fabrics.
Standard test methods for nonwoven fabrics given by the ISO include: definition of
nonwovens [557], vocabulary of web formation and bonding in nonwovens [558],
determination of mass per unit area [559], determination of thickness [560], determination
of tensile strength and elongation [561], determination of tear resistance [562], absorption
[563], determination of bending length [564], determination of liquid strike-through time
(simulated urine) [565], and determination of drape coefficient [566].
Forty-four standard test methods have been established in the name of ERT (EDANA
Recommended Tests) by EDANA (European Disposables and Nonwovens Association)
[567]. Among them, thirty-one test methods are intended for nonwovens and twelve methods
for superabsorbent materials. The ERT testing methods not endorsed in the IST and ISO
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6.3 Some Major Standards for General Medical Devices Related to Wound
Dressings (ASTM, ISO and BS)
Some ASTM standard test methods for medical devices that are relevant to dressings relate
to general practice for medical devices [592, 593], analysis of medical materials [594–598],
methods for medical packages [599–601], methods for implant and tissue materials [602,
603], fluid penetration [604], and sterilisation and disinfection [605, 606].
The ISO standard test methods for devices relating to medical textiles and wound dressings
include: sterilisation [607–613], quality systems [614–616], clinical-investigation methods
[617] and risk management [618], and biological evaluation of medical devices [619–634].
Standard methods for determining human reaction to skin contact with hot surfaces [635],
medical bandages [636] and sterilisation are also given in the British Standards [637–639].
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