DIABETIC MICROVASCULAR COMPLICATIONS
Silver Dressings for
Diabetic Foot Ulcers
Silver dressings are an important adjunct to good wound care
to improve the wound environment and to facilitate healing.
BY EDWARD B. JUDE, MD, MRCP
I
nfection is a major impediment to healing of diabetic
foot ulcers. Before wounds become infected, most are
colonized. When the wound burden increases to >105
organisms, it is said to be critically colonized and clini-
cal infection can then occur.1 In more virulent organisms,
however, this critical wound burden is not always crucial.
Optimal management of the wound bacterial load is
important in achieving healing of diabetic foot ulcers. Most
often, antibiotics are necessary to treat infection and
reduce the bacterial load on the wound. Dressings also play
an important role in managing diabetic foot ulcers. Using
antimicrobials can reduce the number of organisms in the
wound and therefore not only treat the infection but also
prevent colonized wounds from becoming critically colo-
nized.
TOPICAL ANTIMICROBIAL AGENTS
Various topical antimicrobials, antiseptics, and antibi-
otics have been used in treating diabetic foot ulcer infec-
tion.2 Topical antibiotics such as neomycin, bacitracin,
polymyxin B, gentamycin, fusidic acid, mupirocin, and topi-
cal antiseptics including hexachlorophene, povidone
iodine, and chlorhexidine have been tried in various set-
tings. Although these have their advantages, topical antibi-
otics have not been very popular. Iodine is probably one of
the most common topical antiseptics used in infected foot
ulcers. Although antiseptics and antibiotics are widely used,
there is insufficient evidence for their use in diabetic foot
ulcers.2
SILVER A S AN ANTIMICROBIAL
Silver has been shown to have bactericidal properties
and has been used in wounds as an antimicrobial for more
than a century. It acts by impairing the bacterial electron
transport system and some of its DNA function. It kills the
microbes on contact through multiple mechanisms of
action, such as inhibiting cellular respiration, denaturing
nucleic acids, and altering cellular membrane permeability.
18 I REVIEW OF ENDOCRINOLOGY I JULY/AUGUST 2007
For this to happen, silver has to be bioavailable and should
be in the ionic form. In the past, silver nitrate (0.5% or 3,176
mg/L) and silver sulfadiazine (1%) were the primary sources
of silver. In the last few years, a number of silver-containing
dressings have been developed. Silver ions (ionic silver,
nanocrystalline silver) have been incorporated in hydro-
fiber, foam, hydrocolloid, and alginate dressings,3 and have
been used to treat acute and chronic wounds.4
FEW STUDIE S AVAIL ABLE
Very few studies have been published regarding the use of
silver-containing dressings in the treatment of diabetic foot
ulcers. In a small study of 27 patients, the healing of diabetic
foot ulcers using Contreet foam, silver-releasing foam dress-
ing, (Coloplast; Humlebaek, Denmark) was investigated. In
this open-label study of the 18 patients who completed it,
four healed (22.2%) in the 4-week treatment period with
reduced infection in the ulcer and with good exudate man-
agement.5 There was a 56% reduction in ulcer area during
follow-up. A progressive decrease in incidence and severity of
maceration from the first week of treatment with the overall
incidence declining from 52.8% to 30% was observed.
In the first randomized controlled trial of silver dressings in
diabetic foot ulcers, 134 patients with neuropathic foot
ulcers were randomly assigned to either Aquacel Ag (AQAg;
ConvaTec, Chester, UK) or Algosteril calcium alginate (CA)
(Smith & Nephew, Hull, UK) dressings and secondary foam
dressings.6 Patients were treated for 8 weeks or until healing,
whichever occurred first. The mean time to healing was 53
days in the AQAg-treated ulcers and 58 days for the CA-
treated ulcers (P=.34). Ulcers treated with AQAg, however,
showed greater depth reduction than CA-treated ulcers
(P=.04). Greater improvement in the ulcer was seen in the
AQAg group. Patients were also stratified according to those
requiring antibiotic treatment (ie, clinically infected ulcers),
and patients treated with AQAg primary dressing showed
improved healing and more overall ulcer improvement with
less deterioration in the ulcer (P=.02).
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SILVER DRE SSINGS IN CLINIC AL PR ACTICE Reviewofendo.com
All silver dressings have, in addition to the bactericidal
silver properties, the important function of the dressing
itself. The selection of a dressing will depend on the condi-
tion of the ulcer. Most diabetic foot ulcers produce copi- Reviewofendo.com
ous amount of exudate. The primary dressing therefore
should be either foam-based or hydrofiber, both of which
will absorb the exudate. One advantage with the hydro-
fiber dressing is its ability to hold wound exudate and Reviewofendo.com
microorganisms within its fibers where bacteria are then
killed by the ionic silver.7-9
Diabetic foot ulcers generally have multiple organisms
isolated from within the wound and methicillin-resistant Reviewofendo.com
Staphylococcus aureus (MRSA) is an important infecting
organism that can delay wound healing. Silver has bacteri-
cidal action against a number of microorganisms.10,11
The efficacy has been demonstrated in laboratory studies Reviewofendo.com
against S. aureus, MRSA, vancomycin-resistant enterococci,
and a number of gram-negative and anaerobic organisms.12
Therefore, it seems logical to use silver-based dressings in
wounds that are clinically infected or at risk of infection. Reviewofendo.com
It could be hypothesized from the study described6
that systemic antibiotics and topical silver act in synergy
with each other. The added advantage of a hydrofiber
dressing in exudating wounds has been proven. Hence, to Reviewofendo.com
improve outcomes in infected diabetic foot ulcers and
ulcers that are colonized, one should consider silver dress-
ings as an important adjunct to good wound care to
improve its environment and to facilitate healing. ■ Reviewofendo.com
Edward B. Jude, MD, MRCP, is a Consultant Physician and
Honorary Senior Lecturer at Tameside General Hospital,
Ashton-under-Lyne, UK. He is also a member of the Institute Reviewofendo.com
of Health Sciences Diabetes and Obesity Research Network.
He may be reached at Edward.Jude@tgh.nhs.uk.
1. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of bacteria. Surg
Clin N Am. 1997;77:637-650.
2. Mason J, O’Keeffe C, Hutchinson A, et al. A systematic review of foot ulcer in patients with Type 2 dia-
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betes mellitus. II: treatment. Diabet Med. 1999;16:889-909.
3. Bergin SM, Wraight P. Silver-based wound dressings and topical agents for treating diabetic foot
ulcers. Cochrane Database Syst Rev. 2006;1(CD005082).2.
4. White RJ, Cutting K, Kingsley A. Topical antimicrobials in the control of wound bioburden. Ostomy
Wound Manage. 2006;52:26-58.
5. Rayman G, Rayman A, Baker NR, et al. Sustained silver-releasing dressing in the treatment of diabetic
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foot ulcers. Br J Nurs. 2005;14:109-114.
6. Jude EB, Apelqvist J, Spraul M, Martini J and the Silver Dressing Study Group. Prospective random-

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ized controlled study of hydrofiber dressing containing ionic silver or calcium alginate dressings in non-
ischaemic diabetic foot ulcers. Diabet Med. 2007;24:280-288.
7. Newman GR, Walker M, Hobot JA, Bowler PG. Visualisation of bacterial sequestration and bacterici-
dal activity within hydrating hydrofiber wound dressings. Biomaterials. 2006;27:1129-1139.
8. Bowler PG, Jones SA, Davies BJ, Coyne E. Infection control properties of some wound dressings. J
Wound Care. 1999;8:499-502.
9. Piagessi A, Vaccetti F, Rizzo L, et al. Sodium carboxy-methyl-cellulose dressings in the management
of deep ulcerations of diabetic foot. Diabet Med. 2001;18:320-324.
10. Jude EB, Unsworth PF. Optimal Treatment of Infected Diabetic Foot Ulcers. Drugs Aging.
2004;21:833-850.
11. Tentolouris N, Jude E B, Smirnof I, et al. Methicillin-resistant Staphylococcus aureus: Increasing
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problem in a diabetic foot clinic. Diabet Med. 1999;16:767-771.
12. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-con-
taining hydrofiber dressing. Wound Rep Reg. 2004;12:288-294.
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