Types of Chronic Wounds: Indications for Enzymatic Débridement

  • R. D. Sinclair
  • T. J. Ryan


The role of proteolytic enzymes in wound healing can no longer be seen as mere wound débridement Rather it should be considered as a single, but important player in the wound healing orchestra. Proteolytic enzymes are a family of proteins that serve to degrade necrotic débris derived from cell breakdown. They are produced endogenously often as precursor proteins whose activation is precisely regulated. These activated enzymes serve many functions in normal as well as pathological situations. In particular they are involved in the regulation of cell maturation and multiplication; collagen synthesis and turnover; celt deformation, migration and reepithelialisation; the development and removal of the perivascular fibrin cuffs found in venous insufficiency and leg ulceration, as well as the removal of dead tissues following inflammation. As a limited number of enzymes perform all these functions, it is difficult to predict the effects of applying synthetic proteolytic enzymes to a wound. Many such enzymes are currently commercially available and being promoted as alternatives to surgical wound débridement. It is important for their use to be considered in the context of their interaction with endogenous proteases, their physiological role in tissue, their ability to reach a desired target and the stage of wound healing at the time they are applied. Empirical observations and conventional wisdom however, support the view that sloughy wounds need to be débrided.


Wound Healing Proteolytic Enzyme Lytic Enzyme Venous Insufficiency Venous Ulcer 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Elliot IMZ (1964) A short history of surgical dressings Pharmaceutical Press. LondonGoogle Scholar
  2. 2.
    Teh BT (1979) Why do Skin Grafts Fail? Plastic and Reconstructive Surg 63:323–332CrossRefGoogle Scholar
  3. 3.
    Stone LL (1980) Bacterial débridement of the burn eschar: The in vivo activity of selected organisms. J Surg Res 29:83–92PubMedCrossRefGoogle Scholar
  4. 4.
    Ryan TJ (1983) The management of leg ulcers. Oxford Medical Publishers. OxfordGoogle Scholar
  5. 5.
    Cherry GW, Cherry CA, Jones RL, et al (1988) Clinical experience with DuoDERM in venous ulcers and clot resolution in experimental full thickness wounds. In: Cederholm-Williams SA, Ryan TJ, Lydon MJ (eds) Fibrinolysis and angiogenesis in wound healing. Excerpta Medica, Princeton, pp 19–23Google Scholar
  6. 6.
    Carpenter BG, Hill SS (1993) Varidase ® — the science behind the medicament. (Unpublished)Google Scholar
  7. 7.
    Ahle NW, Hamlet MP (1987) Enzymatic frostbite eschar débridement by bromelain. Ann Emerg Med 16: 1063–1065PubMedCrossRefGoogle Scholar
  8. 8.
    Westerhof W (1990) Prospective randomized study comparing the dé-briding effect of Krill enzymes and a non-enzymatic treatment in venous leg ulcers. Dermatologica 181: 293–297PubMedCrossRefGoogle Scholar
  9. 9.
    Tolstykh PI (1990) Characteristics of wound process after high energy laser débridement and enzyme treatment. Khirurgiia Mosk 6: 12–16PubMedGoogle Scholar
  10. 10.
    Ryan TJ (1969) The epidermis and its blood supply in venous disorders of the legs. Trans St John’s Hospital Dermatol Soc 59: 51Google Scholar
  11. 11.
    Bollinger A, Speiser D, Haselbach P, Jager K (1988) Microangiopathy of mild and severe chronic venous incompetence studied by fluorescence videomicroscopy. Schweiz Med WochenschGoogle Scholar
  12. 12.
    Thomas PRS, Nash GB, Dormandy JA (1988) White cell accumulation in dependant legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin. Br Med J 296: 1693–1695CrossRefGoogle Scholar
  13. 13.
    Coleridge Smith, Thomas P, Scurr JH, Dormandy JA (1988) Causes of venous ulceration: a new hypothesis. Br Med J 296: 1726–1727CrossRefGoogle Scholar
  14. 14.
    Browse NL, Gray L, Jarrett PEM, et al (1977) Blood and vein wall fibrinolytic activity in health and vascular disease. Br Med J 274: 478–481CrossRefGoogle Scholar
  15. 15.
    Herrick SE, Sloan P, McGurk M, et al (1992) Sequential changes in histologic pattern and extracellular matrix deposition during the healing of chronic venous ulcers. Am J Path 141: 1085–1095PubMedGoogle Scholar
  16. 16.
    Falanga V and Eaglestein WH (1993) The “trap” hypothesis of venous ulcération. Lancet 341: 1006–1008PubMedCrossRefGoogle Scholar
  17. 17.
    Salzman EW, McManama GP, Shapiro et al. (1987) Effect of optimization of haemodynamics on fibrinolytic activity and antithrombotic efficacy of external calf compression. Ann Surg 206:636–641PubMedCrossRefGoogle Scholar
  18. 18.
    Mulder G, Jones R, Cederholm-Williams S, Cherry G, Ryan T (1992) Fibrin cuff lysis in chronic venous ulcers treated with a hydrocolloid dressing. International J Dermatol 32:1–8Google Scholar
  19. 19.
    Burnand KG, Clemenson G, Morland M, et al (1980) Venous lipodermatosclerosis: treatment by fibrinolytic enhancement and elastic stockings. Br Med J 1980 280: 7–11CrossRefGoogle Scholar
  20. 20.
    Petersen MJ, Woodley DT, Strickling GP, et al (1988) Constitutive production of procollagenase and tissue inhibitor of metalloprotienase by human keratinocytes in culture. J Invest Dermatol 92: 156–159CrossRefGoogle Scholar
  21. 21.
    Krane SM (1982) Collagenases and collagen degradation. J Invest Dermatol 79:83s–86sPubMedCrossRefGoogle Scholar
  22. 22.
    Parish C (1986) Cutaneous elastin degradation in ageing and inflammation. Cosmetic Dermatology 1: 97–112Google Scholar
  23. 23.
    Mortimer PS, Cherry GW, Jones RL, et al (1983) The importance of elastic fibres in skin lymphatics. Br J Dermatol 108:561–566PubMedCrossRefGoogle Scholar
  24. 24.
    Ryan TJ (1989) Biochemical consequences of mechanical forces generated by distention and distortion. J Am Acad Dermatol 21: 115–130PubMedCrossRefGoogle Scholar
  25. 25.
    Ryan TJ (1985) The Dowling Oration: morphosis, occult forces and ectoplasm — the role of glues and proteolysis in skin disease. Clin Exp Dermatol 10: 507–522CrossRefGoogle Scholar
  26. 26.
    Curtis ASG, Seehar GM (1978) The control of cell division by tension or diffusion. Nature 274:52–53PubMedCrossRefGoogle Scholar
  27. 27.
    Burger MM (1970) Proteolytic enzymes initiating cell division and escape from contact inhibition of growth. Nature 227: 170–171PubMedCrossRefGoogle Scholar
  28. 28.
    Nishioka K, Ryan TJ (1972) The influence of the epidermis and other tissues on blood vessel growth in the hamster cheek pouch. J Invest Dermatol 58: 33–45PubMedCrossRefGoogle Scholar
  29. 29.
    Gabbiani G, Hirshel BJ, Ryan GB, et al (1972) Granulation Tissue as a contractile organ. A study of structure and function. J Exp Med 135: 719–734PubMedCrossRefGoogle Scholar
  30. 30.
    Nishioka K, Ryan TJ (1971) Initiators and proactivators of fibrinolysis in human epidermis. Br J Dermatol 85: 561–565PubMedCrossRefGoogle Scholar
  31. 31.
    Singer II (1982) Association of fibronectin and vinculin with focal contacts and stress fibres in stationary hamster fibroblasts. J Cell Biol 92: 398–408PubMedCrossRefGoogle Scholar
  32. 32.
    Hebert CA, Baker JB (1988) Linkage of Extracellular plasminogen activator to the fibroblast cytoskeleton colocalization of cell surface urokinase with vinculin. J Cell Biol 106: 1241–1247PubMedCrossRefGoogle Scholar
  33. 33.
    Morioka S, Lazarus GS, Jensen PJ (1987) Migrating keratinocytes express urokinase type plasminogen activator. J Invest Dermatol 88: 418–423PubMedCrossRefGoogle Scholar
  34. 34.
    Lazarus GS, Schectler N, Jensen P, et al (1991) Proteinase metabolism in the human skin: The role of plasminogen activator and mast cell proteinases in cutaneous biology. In: Goldsmith LA. Physiology, Biochemistry, and Molecular Biology of the Skin. Second Edition. Oxford University Press, p 462-479Google Scholar
  35. 35.
    Arnold F and West D (1991) Angiogenesis in wound healing. Pharmacol Ther 52: 407–422PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 1994

Authors and Affiliations

  • R. D. Sinclair
    • 1
  • T. J. Ryan
    • 1
  1. 1.Department of DermatologyThe Churchill HospitalOxfordEngland

Personalised recommendations