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A survey of approach to wound healing by secondary intention among British Society for Dermatological Surgery members

SIR, Secondary intention healing is a simple and swift approach to wound healing that, when used appropriately, results in a satisfactory cosmetic and cost-effective outcome. There are, however, no guidelines on how best to manage wounds healing by secondary intention postoperatively. A study comparing hydrocolloid occlusive dressings and conventional wound management (twice daily wound cleansing and topical application of bacitracin ointment and an adhesive dressing) found that wounds treated with occlusive dressings healed quicker and were less painful. However, this study looked only at shave biopsy and 3-mm punch biopsy sites. A recent Cochrane review of dressings and topical agents for general surgical wound healing by secondary intention was unable to make any firm conclusions as only small, poor-quality trials exist. We decided to investigate what choices individual dermatologists with an interest in surgery make regarding dressings and topical agents for wounds allowed to heal by secondary intention. British Society for Dermatological Surgery (BSDS) members were sent a single-page questionnaire via e-mail and were invited to participate in this study in September 2005. Two months later, a reminder was e-mailed to members. One hundred and eighty-two BSDS members with an e-mail address were invited to participate. Fifty-one (28%) replied. Twenty-nine of 51 (57%) had one dedicated surgical session per week with the remainder having two to four surgical sessions per week. Five (10%) carried out an average of fewer than five operations per week, while 22 (43%) undertook five to 10 per week and 24 (47%) performed > 10 per week. Secondary intention wound healing was used by 42 (82%) BSDS members on fewer than three wounds per week, by eight (16%) members on three to six wounds per week, and by a single member (2%) on more than six wounds per week. The choices made with regard to dressing type and topical agents for wounds healing by secondary intention are illustrated in Fig. 1a,b. The majority (n 1⁄4 40; 78%) said their patients had fewer than three follow-up visits at the dermatology department for wound care. Thirty-six (71%) members arranged for follow-up wound care at the patient’s general practitioner and most (71%) gave their patients a postoperative wound care information sheet. The questionnaire was kept brief to encourage uptake among BSDS members. A response rate of less than a third was therefore disappointing as published data on response rates to physician surveys suggest that response rates are routinely 40–50%. The brevity of the questionnaire we used limited the breadth of information obtained by this survey and issues such as the influence of patient comorbidities or wound site and size on selection of wounds for secondary intention healing were necessarily overlooked. None the less, we can make some conclusions from the responses received. We surveyed a group of dermatologists with a special interest in surgery. Their specialist interest is confirmed by their workload recorded – almost half of those surveyed performed > 10 operations per week. Wounds were left to heal by secondary intention by the respondents in a minority of cases. Perhaps this is a facet of the population of dermatologists surveyed – those with a greater interest and experience in surgical techniques may prefer to close wounds with grafts, flaps etc. rather than allow healing by secondary intention. There was no consensus on either dressing type or topical agent used for wound care, although alginate-based dressings and topica Polyfax (polymyxin B+ bacitracin) ointment (PLIVA, Petersfield, U.K.) and Bactroban (mupirocin) cream (GlaxoSmithKline, Uxbridge, 0 2 4 6 8 10 12 14 16 18 20