This month's issue includes three important review articles related to alternative/local wound care, support surface evaluation testing, and skin failure. The "alternative" medicine review was originally submitted by three colleagues from Nanavati College of Pharmacy in India. The editorial team connected the investigators with Dr Laura Bolton, a collaboration that resulted in an excellent scoping review summarizing 50 years of literature.

Natural and synthetic agents have been used to optimize local wound care for centuries. The authors reviewed 281 abstracts outlining 274 studies with 28,315 participants. Agents with more than 10 randomized controlled trials supporting their outcomes included honey, alginate gels or fiber dressings, polyurethane gel or adhesive dressings (often foams), aloe vera gel, and dextran powder. Many of the studies used skin graft donor sites and had gauze dressings as the comparator. Often, other ingredients in the studies (eg, silver combined with alginate dressings) made the contribution of each component unclear. Some studies were derived from preclinical data and the chronic wounds studied included diverse etiologies.

Although some of these agents have entered clinical practice, the gauze comparator may not be as effective as hydrocolloids in skin graft donor site studies or other commonly used dressing categories. That said, larger studies and safety data are needed for everyday clinical practice. That is, the review helps to answer patient questions on alternate solutions to modern wound dressings, but there are safety concerns, such as the presence of other ingredients and the formats in which patients may try these agents.

For example, the review included some data on henna, which can occasionally act as an allergen and may be processed through open skin by the immune system more readily than when used as a hair dye. The authors also express concern about oral ingestion of some of these agents and natural substances where safety data are not available. This review should not promote the application of these agents by wound care professionals outside of approved uses but could facilitate the design of (pre)clinical investigations to generate appropriate safety data.

The second review in this month's issue features new testing procedures for support surface selection that can facilitate the prevention and management of PIs. Physiotherapist Kristen Thurman and colleagues reviewed the support surface evaluation science outlined in the 2019 Clinical Practice Guideline. This document defines a support surface as a specialized device for pressure redistribution designed for management of tissue loads, microclimate, and other therapeutic functions. Pressure redistribution consists of a combination of immersion (ability of the body to sink into a surface) and envelopment (how the surface conforms to the body). Too much of a good property is not necessarily better; excessive immersion can lead to bottoming out, combined with tight envelopment causing limitations to movement.

Microclimate is influenced by increased moisture (urine, feces, perspiration, and wound drainage), along with increased temperature. Clinically, suspect shear if a PI has asymmetric undermining around the edges of the wound. The more resistance to friction (rubbing of two surfaces), the greater the susceptibility to shear where the bony skeleton moves in an opposite direction to the surface skin. The authors state that confidential data from performance tests are often available from manufacturers to help clinicians and organizations make informed decisions about support surfaces. Decision makers need to match the needs of their patients to the performance characteristics of a support surface, and performance should then be linked back to quality improvement data and clinical outcomes. We applaud this important article that has standardized and provided a way to interpret key testing procedures for support surfaces across a group of collaborating suppliers.

The third article is a 30-year skin failure literature scoping review by an Australian group. From 663 publications, they summarized 180 records and distilled them into two narrative themes. The first was the etiology of skin failure. The leading cause cited was dermatologic conditions. The second theme was the confusing interchangeable terms and definitions of skin failure. Of the 27 reported definitions, 56% included a failure of the skin to maintain its functions. The authors acknowledge the gaps in the literature and challenge clinicians and researchers to develop a globally agreed-upon definition of skin failure.

These summaries can facilitate practice by stimulating new inquiry. The next step is for expert panels to review the scientific evidence and reach consensus to facilitate informed patient care decisions.

R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN