Volume 33 Number 4

Introduction

During the healing process, re-epithelialisation occurs from the edges to the center of the wound, since the edges are rich in keratinocytes, which proliferate and differentiate, promoting healing in a process called epiboly.^1-2 Healing can stagnate due to a deregulation of this phase, as the edges wrap around themselves, forming what is known as an epibole.³ The incidence of epibole is associated with difficult-to-heal, refractory wounds and is common to any etiology.⁴ In this sense, a continuous approach to wound hygiene has been recommended to promote the healing of difficult-to-heal wounds. Hard-to-heal wounds are defined as wounds that present exudate, slough and increase in size within 3 days, not responding to care based on scientific evidence.The approach consists of four stages: cleaning the wound and perilesional skin, debridement (whenever necessary), reconstruction of the wound edges and application of dressings.⁵

In the wound edge reconstruction stage, it is recommended that the edges be debrided until bleeding occurs on light touch, removing, among other things, the curled tissue, in other words, the epibole.⁵ In the case of the presence of an epibole on the edges, the wounds remain stationary in the inflammatory phase or in the proliferation phase, regardless of whether or not there is appropriate management of the tissues in the bed.^6-7 Removing the epibole will promote the advancement of healthy tissue, due to the exposure of healthy tissue.⁵ Some authors, despite the scarcity of information, associate edge curling as a process resulting from low humidity in the lesion, lack of healthy granulation tissue for the epithelial cells to move through, presence of necrosis or cavities, with epibole being a complication responsible for delayed wound healing.⁴

One of the most widely used methods for assessing wounds is the “TIMERS” strategy. In this mnemonic, the letter “E” refers to “epithelial edge” and characterises epithelial margins and the need for their evaluation during the wound treatment process, in order to identify the presence of any condition that makes healing impossible, such as epibole it self.⁸

However, little research is currently available on rolled edges, resulting in high financial costs for unsuccessful treatments. Therapeutic approaches for epiboles have been based on the assumptions and practical choices of individual professionals. It is therefore extremely important to know the evidence on this issue. The aim of this study is to map the interventions for treating epiboles on wound edges.

Methods

Since the data included in this review were in the public domain, this study was not submitted to the Research Ethics Committee (REC). There were no time or language limitations when conducting the searches. Researchers searched the databases between May 2022 and May 2024, following the steps recommended by the Joanna Briggs Institute (JBI):

• identification of the guiding question;
• identification of relevant studies;
• selection and inclusion of studies for the review;
• data mapping; and
• collection, compilation and description of the results.

According to the JBI Manual, scoping reviews are conducted with the aim of mapping or providing an overview of emerging evidence and can be used when there are few studies available on the topic. A scoping review cannot be used to make recommendations for clinical practice, but it is possible to identify gaps in knowledge, clarify concepts and identify available evidence.⁹

In order to identify scoping reviews or research protocols similar to this study, the databases Database of Abstracts of Reviews of Effects (DARE); The Cochrane Library; International Prospective Register of Ongoing Systematic Reviews (PROSPERO); and Open Science Framework (OSF) were checked. The search results showed that there were no studies with similar objectives to this review. 

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews¹⁰ checklist was used for the review. In addition, the study was registered in the Open Science Framework (OSF) with DOI:10.17605/OSF.IO/6JH4X.

The research question was developed based on the mnemonic PCC (Population, Concept, Context). Population: wounds with epibole on edges; Concept: interventions for the treatment of epibole; Context: all types of wounds and healthcare settings. Thus, the following guiding question was formulated: What are the interventions for the treatment of epibole on wound edges?

To search the databases, descriptors were listed based on the mnemonic PCC. (P) Wounds with epiboly on edges, indexed in the Medical Subject Headings (MeSH) and Health Sciences Descriptors (DeCS). In addition, keywords resulting from the search in studies available in the National Library of Medicine (PubMed) and Cumulative Index of Nursing and Allied Health (CINAHL) databases were included, as suggested in the JBI manual. The following were obtained: “epiboly”, “epibole”, “wound and injury”, “wound healing”, “wound edges” and “rolled wound edges”.

They were then linked using the Boolean operators AND and OR. Based on the descriptors and keywords listed, search strategies adapted to each data source were defined, with a view to delimiting and refining the search, which are shown in Table 1. The literature search strategy was defined by the researchers, who have experience in conducting literature reviews. The type of wound was not delimited in the search because in the previous research to define the descriptors carried out in PubMed and CINAHL, it was analysed that this strategy would restrict the results, which were scarce. Different cross-references were tested in each database and those that resulted in the greatest number of studies in the search were chosen.

 

Table 1. Search strategy in data sources.

 

The search was carried out through the Journal Portal of the Coordination for the Improvement of Higher Education Personnel (CAPES), using remote access to the content of the Federated Academic Community (CAFe), made available by the Federal University of Rio Grande do Norte (UFRN) in the following data sources: MEDLINE/National Library of Medicine (MEDLINE/PubMed), Science direct, Latin American and Caribbean Literature in Health Sciences (LILACS), Scientific Electronic Library Online (SciELO), SCOPUS and Web of Science (WOS). The gray literature search included: Brazilian Digital Library of Theses and Dissertations (BDTD), Theses Canada, Europe E-Theses Portal (DART), South African National (ETD Portal) and Google Scholar.

We included studies available in full online that described at least one wound edge epibole treatment intervention, published in scientific articles, as well as gray literature, such as dissertations, theses and guidelines. 

Included were scientific articles published online in their entirety, with no time or language restrictions, with a population of any age group, which answered the proposed research question. Materials that did not address a treatment for epibole in lesions or that addressed treatments in animals were excluded, and duplicate studies were considered only once. 

The search for articles was carried out by two researchers, independently and simultaneously, to carry out an initial screening based on reading the titles, abstracts and subsequent evaluation of the complete files in relation to the inclusion criteria. Before, there was a pilot screening between reviewers, to ensure that both understood the concept of epibole. There was no stakeholder participation and there was no patient and public involvement.

The data from the electronic search was stored and described in tables containing information on the databases and general results. This data was exported in Excel, Refman/RIS or Text format. The inclusion and exclusion of records was carried out by two independent reviewers (R1 and R2) who blindly read the title and abstract using the Rayyan QCRI platform and tool.

The selection of papers from the databases that did not offer the possibility of export to Rayyan was initially carried out by independently reading the titles and abstracts and then reading them in full to select the relevant ones to make up the final sample. A reverse search was also carried out on the articles’ references.

The selected studies were retrieved in full, analysed and entered into a form previously prepared by the researchers in a Microsoft Excel spreadsheet to identify and organise the data, including: source, type of document, authors, year, title, objective, journal, country of origin, target population and main results. The data was then analysed and presented in table format. The PAGER structure (Patterns, Advances, Gaps and Evidences for practice, Research recommendations) was used to analyse the selected studies and present a consistent approach.¹¹

Results

As detailed in the flow in Figure 1, the initial search identified a total of 2753 studies in the data sources, 558 of which were in MEDLINE/PubMed, 314 in SCOPUS, 865 in WOS, 2 in LILACS, 24 in sciELO, 3 in BDTD, 26 in DART, 796 in the South African National ETD Portal, 165 in Google Scholar. No results were found in the other data sources. After excluding duplicate articles and applying the inclusion and exclusion criteria, 12 articles were selected to be read in full and nine studies were chosen to make up the sample for this review.

 

Figure 1. Flow diagram for the scoping review process adapted from the PRISMA statement.

 

The studies were published between 2002 and 2023, most of them in 2023 (44.4%) and seven of them were carried out in the United States of America (USA) and two in Brazil. There was a predominance of publications in English and two in Portuguese.

The studies were characterised according to: authors/year, study design, number of participants, type of wound, intervention for epiboly and results found. The interventions were mapped by detailing the treatment used and the results found (Table 2). 

 

Table 2. Characterisation of the studies and mapping of interventions cited in each study.

Among the interventions mentioned: 33.3% used polymeric membrane dressings with a specific application technique (n=3); 11.1% used cutting debridement with the “edge trecnching” technique (n=1); 11.1% used cutting debridement with the “soap scrap” technique (n=1); 11.1% used the topical use of hyperbaric oxygen and electrical stimulation with high-voltage pulsed current (n=1); 11.1% used silver nitrate (n=1); 11.1% conventional sharp debridement (n=1); and 11.1% a combination of coverings (n=1).

All studies found were case studies, indicating gaps in robust scientific evidence on this topic.

Strategies were used to resolve epibolus in different types of wounds: Venous ulcers (four cases); stage IV pressure injuries (three cases); mixed ulcers (three cases, with one case post amputation); difficult-to-heal wounds without specification of etiology (two cases); and foot ulcer of a person with diabetes, surgical dehiscence, abscess, traumatic wound, arterial ulcer and wound of infectious origin (one case for each type of wound).

An analysis with a consistent approach to all of the studies was conducted using the PAGER framework. It highlights the need for more studies with larger samples and more robust methods (Table 3).

 

Table 3. PAGER structure obtained from the analysis of the selected papers.

 

Figure 2 shows an overview of the interventions found. The combination of restructuring cream, gelling fiber with polyvinyl alcohol, bacterial cellulose membrane and textile mesh impregnated with a healing matrix and silver¹⁷ was not shown in the figure, as the study did not detail the specific intervention for the wound epibole, but only mentioned the coverage used and that the wound healed (Figure 2).

 

Figure 2. Interventions found for treating epibole on wound edges.

 

Discussion

Attention to wound edges has been increasingly highlighted in important international documents and consensuses, such as TIMERS,⁸ the National Pressure Injury Advisory Panel guideline,¹⁹ among others. However, little is known about the recommendations for use in cases of border epibole, a condition that prolongs healing time.

Among the interventions found in this review, debridement with sharp instruments was present in three studies, with different techniques and associations. Debridement is intended to make the wound acute again, restarting the healing cascade, the release of growth factors by platelets and the migration of keratinocytes from the edges to the base of the wound.^3,13

The Brazilian study¹⁸ that mentioned scarification did not detail how it was carried out, with which instruments, angulation, etc. It also didn’t present the results after the procedure, demonstrating that the study lacked important information. In some parts of northeastern Brazil, it has become widespread among the scientific community to make small inclined grooves in the edge with an epibowl, but no study was found on this technique.

Two studies in the sample mention the recommendation to perform this debridement on the epibole at a 45º angle to the wound base, but this is not always possible, especially when the wounds are deep. For this reason, one of them¹³ recommends what it called “edge trenching” debridement, where the edge and base of the wound are resected halfway between them with a curette, creating a new wound that connects the edge to the base, creating a favorable transition angle for the two parts to fuse.¹³

The other study³ used the Soap Scrap Technique, where in addition to debridement with sharp instruments, negative pressure therapy (125 to 175mmHg) and/or compressive bandages and immobilisation of the wound site are associated, with results in two to three sessions. The authors explain that using Fick’s law of diffusion, compression between the debrided areas (margin between edge and base) promotes the diffusion of molecules which allows the tissues to join together. Immobilisation, on the other hand, is performed so that there is no shear and the tissues move en bloc. In the lower limbs, immobilisation was done with Cam Walker (boots) and in other places with clamps.³ It is necessary to understand how each of the procedures that make up the Soap Scrap Technique contributes to resolving the epibole. 

Another way to debride the epibole was to use a chemical cauterising agent, silver nitrate. The use of silver nitrate sticks is well known in wound treatment and is widely used to cauterise hypergranulation, granulomas and unwanted tissue.¹⁴

The use of chemical cauterisers causes aggression to the tissue, which also leads to a return to the inflammatory phase. In this way, generating trauma, whether by sharp debridement or caustic product, favors the return of correct healing of the edges.¹⁴

In Brazil, in the state of the Federal District, there is a technical opinion from the council that regulates the nursing profession which allows the use of trichloroacetic acid (10 to 70%) by nurses to resolve epibole on wound edges.²⁰ This acid causes coagulation of epidermal and dermal proteins and collagen necrosis. Re-epithelialisation begins from surviving islets of keratinocytes and skin appendages. The clinical effects of the acid are due to the resulting increase in the dermal volume of collagen, glycosaminoglycans and elastin. It is autoneutralising, so it is not absorbed systemically, even if high concentrations are used.²¹

The use of retinoic acid (concentration around 10%) for epibole is also widespread in the Brazilian scientific community, but no studies have been found on this product.

Although they have been shown to have a potentially positive effect on epiboles, both sharp debridement and chemical cauterisation can cause bleeding, discomfort and pain to the patient. Therefore, they need to be used with caution by experienced professionals and with the patient’s agreement. 

The use of topical hyperbaric oxygen and high voltage pulsed electrical stimulation provided reversal of the curled edges and complete healing.¹² The mechanism of action of topical hyperbaric oxygen is still not completely known. It is known from thermographic studies that it causes a decrease in temperature at the wound site, suggesting that thermoregulation and microcirculation initiate healing.²² With regard to electrical stimulation, as well as reducing pain and increasing adherence to treatment, it is believed to act by activating macrophages, proliferating and migrating endothelial cells, fibroblasts and keratinocytes. There is a consensus that monophasic and pulsed currents are more effective for healing.²³

In the study we found,¹² the patient received many lengthy treatment sessions, which may not be positive for adherence. In addition, other protocols need to be tested in order to better understand the effects of these therapies together on the epibole.

In general, the cases presented in the sample were patients with wounds that had been treated for a long time and had changed topical therapy several times, showing no response to the treatment methods previously adopted by the professionals.

Topical therapy using a polymeric membrane showed therapeutic relevance. However, it was applied using a specific technique in which gauze was attached to the membrane, promoting firm contact between the covering and the edges of the wound. The authors hypothesise that the irritation of pressure against the edges increases local permeability and that the hydrophilic components of the polymer membrane produce an osmotic gradient that draws fluids from the rolled edges, creating a medium for the growth of capillaries.¹⁶

However, it remains to be seen whether this filling of the entire empty space, with the pressure and firm contact of other coverings with the edges of the wound, especially absorbent ones, would also be enough to break the epibole, since epiboly seems to be associated with reduced humidity, the presence of a cavity and altered granulation tissue in the lesion. When compared to other treatments, this method was defended for avoiding pain and bleeding.

Regarding the use of the combination of restructuring cream, gelling fiber with polyvinyl alcohol, bacterial cellulose membrane and textile mesh impregnated with healing matrix and silver, more information is needed to understand the role of this treatment in the destruction of the epibole. The paper is a poster presented at an event, with very brief information, which does not allow for further conclusions¹⁷.

This study highlights the importance of making the edges of wounds with epiboly acute again, either with sharp debridement or with chemicals, as a way to restart the healing cascade. Management of exudate and dead space with firm dressings or with compression over the wound with negative pressure therapy also appears to help in the resolution of epibolus. The role of complementary therapies such as topical hyperbaric oxygen and electrical stimulation and negative pressure therapy needs to be further elucidated.

This study found only case studies. The grey literature published on wound care association websites around the world was not consulted and this is a limitation of this study.

As this study is a scoping review, it is not intended to make recommendations for clinical practice. This review only intended to map what has been published about the treatment of epibole, showing that this is a topic that needs to be explored in more depth by the scientific community.

However, gaps were found. It is not possible to know the cost-benefit and risks associated with each technique cited or to know the results that would be found when the interventions are used in other types of wounds or in different populations, such as neonates, children and the elderly.

Future research can expand the population studied in each intervention, investigate the application of these techniques in different types of wounds, analyse the cost-benefit of each of these interventions in relation to healing time and analyse the risks associated with each of the techniques.

Conclusions

Through the results of this scoping review, it was possible to map the strategies adopted for the treatment of epibole on wound edges. It was found that the main forms of treatment described, with their respective application protocols, were: topical hyperbaric oxygen associated with high-voltage pulsed electrical stimulation, polymeric membrane dressing applied in firm contact with the wound edges, the use of silver nitrate, sharp instrumental debridement with scarification, edge trenching and the Soap Scrap Technique.

Although they present cases of success, they are not sufficient results for generalisations, since they are all case studies, a fragile method for suggesting evidence for clinical practice. More studies are needed with robust methods and greater strength of evidence for clinical practice.

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

An ethics statement is not applicable.

Funding

The authors received no funding for this study.

Author contributions

Mariana Freire Fernandes contributed the critical review of the work. Thainna Sabrina da Silva contributed with the conception, design and acquisition of data of the work. Iasmin Freitas Bessa participated with the acquisition, analysis of data of the work. Rafael Moreira do Nascimento, Macyra Celly de Sousa Antunes and Isabelle Katherinne Fernandes Costa reviewed critically the intellectual content and interpretation of data. Rhayssa de Oliveira e Araújo contributed with the conception, analysis and interpretation of data and final approval of the version to be published.

Author(s)

Mariana Freire Fernandes¹, Thainna Sabrina da Silva¹, Iasmin Freitas Bessa¹,
Rafael Moreira do Nascimento¹, Macyra Celly de Sousa Antunes², Isabelle Katherinne Fernandes Costa³, Rhayssa de Oliveira e Araújo³*
¹Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
²Brazilian Hospital Services Company, Onofre Lopes Unisiversity Hospital, Natal, Rio Grande do Norte, Brazil
³Department of Nursing at the Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil

*Corresponding author email rhayssa.araujo@ufrn.br

References

1. Shi Z, Zhu M, Zhang M, Ye X. Wound repair using discarded skin tissue from the rolled edge of pressure injury: a feasibility study of five cases. Wounds. 2022; 34(12):283–287. doi: 10.25270/wnds/21091
2. Holt JR, Zeng WZ, Evans EL, et al. Spatiotemporal dynamics of PIEZO1 localization controls keratinocyte migration during wound healing. Elife. 2021;27(10):e65415. doi: 10.7554/eLife.65415
3. Melnychuk I, Juriga J. “Soap scrap” technique: a tissue-preserving approach to treating wounds with undermining or pockets. Adv Skin Wound Care. 2023;36(9):495–501. doi:10.1097/01.ASW.0000931584.75689.df
4. Bare KS, Drain J. Resolving epibole with polymeric membrane dressings in home care. J Wound Ostomy Continence Nurs. 2017; 44(1): 89–92. doi: 10.1097/WON.0000000000000296
5. Murphy C, Atkin L, Swanson T, et al. International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care. 2020; 29(Suppl 3b):S1–28. doi: 10.12968/jowc.2019.28.12.818
6. Martinengo L, Olsson M, Bajpai R, et al. Prevalence of chronic wounds in the general population: systematic review and meta-analysis of observational studies. Ann Epidemiol. 2019; 29:8–15. doi: 10.1016/j.annepidem.2018.10.005
7. Mehl AA, Schneider Jr B, Schneider FK, et al. Measurement of wound area for early analysis of the scar predictive factor. Rev Latino-Am Enfermagem. 2020;28:e3299. doi: 10.1590/1518-8345.3708.3299
8. Atkin L, Bućko Z, Montero EC, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019;28(Sup3a):S1–S50. doi: 10.12968/jowc.2019.28.Sup3a.S1
9. Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020. doi: 10.46658/JBIMES-20-12
10. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews BMJ. 2021;372:n71 doi: 10.1136/bmj.n71
11. Bradbury-Jones C, Aveyard H, Herber OR, et al. Scoping reviews: the PAGER framework for improving the quality of reporting. Int J Social Res Methodol. 2021;25(4):457–470. doi: 10.1080/13645579.2021.1899596
12. Edsberg LE, Brogan MS, Jaynes CD, et al. Topical hyperbaric oxygen and electrical stimulation: exploring potential synergy. Ostomy Wound Manage. 2002;48(11):42–50. PMID: 12426451
13. Melnychuk I. Edge trenching: a case study of a novel debridement technique. J Wound Care. 2023;32(5):S22–S24. doi: 10.12968/jowc.2023.32.Sup5.S22
14. Hawkins-Bradley B, Walden M. Treatment of a nonhealing wound with hypergranulation tissue and rolled edges. J Wound Ostomy Continence Nurs. 2002;29(6):320–324. doi:10.1067/mjw.2002.129929
15. Benskin, L. Solving the closed wound edge problem in venous ulcers using polymeric membrane dressings. J Wound Ostomy Continence Nurs. 2008;35(3):S30–S31. doi:10.1097/01.WON.0000319331.91583.75
16. Benskin L. Deep ulceration treated with polymeric membrane dressings until complete wound closure. J Wound Ostomy Continence Nurs. 2006;33(3):S22–S22.
17. Ilário S, Wilke MG. EP404 Injury management in a diabetic patient using advanced technologies. J Wound Manag. 2023;24(2):304. doi:10.35279/jowm2023.24.02.02
18. Martins JMM. A atuação do enfermeiro no manejo do paciente portador de feridas em pé diabético — estudo de caso  [monograph]. Guaíra: Curso de Enfermagem, Universidade Paranaense; 2023.
19. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline. The International Guideline. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA: 2019.
20. Conselho regional de enfermagem - DF (COREN/DF). Parecer técnico COREN/DF 10/2021. Utilização do ácido tricloroacético (ATA) pelo enfermeiro em lesões que apresentam epíbole em sua borda. 2021. Available from: https://www.coren-df.gov.br/site/parecer-tecnico-coren-df-no-10-2021/
21. Uliano EJM, Avila DFV, Lucchese IC, et al. Tecido de granulação hipertrófico: série de casos tratados com ácido tricloroacético a 75%. Revista Brasileira de Cirurgia Plástica. 2018; 33(Sup1):59–61. doi: 10.5935/2177-1235.2018RBCP0046
22. Kasprzyk-Kucewicz T, Cholewka A, Englisz-Jurgielewicz B, et al. Thermal effects of topical hyperbaric oxygen therapy in hard-to-heal wounds-a pilot study. Int J Environ Res Public Health. 2021; 18(13):6737. doi:10.3390/ijerph18136737
23. Milne J, Swift A, Smith J, et al. Electrical stimulation for pain reduction in hard-to-heal wound healing. J Wound Care. 2021;30(7):568–580. doi:10.12968/jowc.2021.30.7.568