Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. 2007; 117:(5)1219-1222

Assal JP, Mehnert H, Tritschler HJ On your feet! Workshop on the diabetic foot. J Diabetes Complications. 2002; 16:(2)183-194

Rathur HM, Boulton AJ. The diabetic foot. Clin Dermatol. 2007; 25:(1)109-120

Prompers L, Huijberts M, Schaper N Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008; 51:(10)1826-1834

Protective and damaging aspects of healing: a review. 2006. (accessed 23 November 2020)

McLennan S, Yue DK, Twigg SM. Molecular aspects of wound healing in diabetes. Primary Intention. 2006; 14:(1)8-13

Blume PA, Walters J, Payne W Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial. Diabetes Care. 2008; 31:(4)631-636

Sharman D. Moist wound healing: a review of evidence, application and outcome. The Diabetic Foot. 2003; 6:(3)112-120

Lansdown AB. Silver. I: Its antibacterial properties and mechanism of action. J Wound Care. 2002; 11:(4)125-130

Silver antimicrobial dressings in wound management: a comparison of antibacterial, physical, and chemical characteristics. 2005. (accessed 23 November 2020)

Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing hydrofiber dressing. Wound Repair Regen. 2004; 12:(3)288-294

Demling RH. The role of silver in wound healing. Part 1: effects of silver on wound management. Wounds. 2001; 13:(1)4-15

Percival SL, Bowler PG, Russell D. Bacterial resistance to silver in wound care. J Hosp Infect. 2005; 60:(1)1-7

Oyibo SO, Jude EB, Tarawneh I A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001; 24:84-88

Numhom S, Ariyaprayoon P, Srimuninnimit V. Clinical evaluation of new blue nano-silver biocellulose ribbon dressing in cavity wounds. J Med Assoc Thai. 2017; 100:(11)212-219

Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996; 35:528-531

Chang AC, Dearman B, Greenwood JE. A comparison of wound area measurement techniques: Visitrak versus photography. Eplasty. 2011; 11

Registered Nurses' Association of Ontario (RNAO). Nursing best practice guideline: Reducing foot complications for people with diabetes. 2020. (accessed 24 November 2020)

Diabetes UK. Putting feet first: National minimum skills framework. Joint initiative from the Diabetes UK, Foot in diabetes UK, NHS Diabetes, the Association of British Clinical Diabetologists, the Primary Care Diabetes Society, the Society of Chiropodists and Podiatrists. 2011. (accessed 27 November 2020)

Foot care for people with diabetes: the economic case for change. 2012. (accessed 27 November 2020)

National Institute for Health and Clinical Excellence. Diabetic foot problems: prevention and management [NG19]. 2015. (accessed 27 November 2020)

Muller IS, de Grauw WJ, van Gerwen WH Foot ulceration and lower limb amputation in type 2 diabetic patients in Dutch primary health care. Diabetes Care. 2002; 25:(3)570-574

Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005; 366:(9498)1719-1724

Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Fam Physician. 2002; 66:(9)1655-1662

International Diabetes Federation Clinical Guidelines Taskforce. Global guideline for type 2 diabetes. 2012. (accessed 27 November 2020)

Wound bed preparation: TIME in practice. 2005. (accessed 27 November 2020)

Atkin L, Bucko Z, Conde Montero E Implementing TIMERS: the race against hard-to-heal wounds. J wound Care. 2019; 28:S1-S49

Treating hard-to-heal ulcers: biocellulose with nanosilver compared with silver sulfadiazine

02 September 2022
Volume 6 · Issue 3



Controlling infection and promoting healing should be the aims of hard-to-heal diabetic ulcer treatment, along with improving a patient's general condition and their blood sugar control. Many hard-to-heal diabetic ulcers present with cavities, tracks or a combination of these. There is a new biocellulose (with a nanosilver dressing) which has the ability to contour around and conform to the irregular surface of a wound bed. The purpose of this study was to evaluate its efficacy compared with a silver sulfadiazine cream, for hard-to-heal diabetic ulcer treatment.


In this randomised control trial, patients with hard-to-heal diabetic ulcers were divided into two equal-sized groups: treatment with the biocellulose with blue nanosilver (experimental group), and treatment with silver sulfadiazine cream group (control group). Cotton gauze was used as the secondary dressing for both groups. Demographic data, wound size, wound classification, wound photography and bacterial cultures were recorded at the beginning of the study. Wounds were debrided as necessary. Dressings were changed twice daily in the control group, and every three days in the experimental group.


A total of 20 patients took part in the study (10 patients in each group). The highest mean wound healing rates were 91.4% in the experimental group and 83.9% in the control group. No wound infections or adverse effects from the dressings were detected in either group.


In this study, biocellulose with blue nanosilver adapted well to the wound bed. Wound reduction was greater in the experimental group than the control group. Biocellulose with blue nanosilver could therefore be a good choice for hard-to-heal diabetic ulcer treatment, due to its good healing rates and minimal care requirements.

Adiabetic wound is a major complication of diabetes, and a major component of the diabetic foot. It occurs in 15% of all patients with diabetes and precedes 84% of all lower leg amputations.1

A US study in 1999 estimated the average outpatient cost of treating one diabetic foot ulcer (DFU) episode as $28,000 over a two-year period.2,3 In Europe, the authors estimated that costs associated with treatment of DFUs might be as high as 10 billion euros per year.4

Major increases in mortality among patients with diabetes, observed over the past 20 years, are thought to be due to the development of macro- and microvascular complications, including failure of the wound healing process.5 Wound healing refers to the portion of tissue that is destroyed in any open or closed injury to the skin. Being a natural phenomenon, wound healing is usually taken care of by the body's innate mechanism of action, which works reliably most of the time. A key feature of wound healing is stepwise repair of lost extracellular matrix (ECM) that forms the largest component of the dermal skin layer.5 Therefore, controlled and accurate rebuilding becomes essential, so as to avoid under- or overhealing that may lead to various abnormalities.5 However, in some patients, certain disorders or physiological insults disturb the wound healing process. Diabetes is one such metabolic disorder that impedes the normal steps of the wound healing process. Many histopathological studies show a prolonged inflammatory phase in diabetic wounds, which causes delays in the formation of mature granulation tissue, and a parallel reduction in wound tensile strength.6

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