Correspondence  Clinical Letter

Clinical Letter

`` Normal saline (0.9 %)

Tissue management
Table 1  The acronym “M.O.I.S.T.” describes a modern concept for the topical treatment of chronic wounds. Exemplary treatment options are shown for the various

`` Preserved solutions
M.O.I.S.T. – a concept for the topical treatment

`` Ringer’s solution
Wound cleansing:
of chronic wounds

`` Mechanical
Debridement:

`` Biosurgical

`` Enzymatic
`` Autolytic

`` Surgical
DOI: 10.1111/ddg.13215

T
Dear Editors,

`` ­Inflammatory mediators
Wounds that have not healed after a period of eight weeks
are referred to as ‘chronic wounds’ [1]. Irrespective of this

`` Hyaluronic acid

`` Growth factors
time-based definition, wounds are classified as chronic from

Modification of:
the outset, if they require treatment for a persistent under-

Support
lying cause. This includes, for example, diabetic foot ulcers,

`` MMPs
wounds associated with peripheral artery disease (PAD),

`` pH
venous leg ulcers, or pressure ulcers. The success of any tre-

S
atment of chronic wounds hinges on the diagnostic workup
[2] and the causal treatment of the underlying, pathophy-

`` DACC-coated wound dressings

`` Silver-coated wound dressings

siologically relevant diseases [3], including relevant psycho-

(bacteria-binding properties)
social factors [4]. At the same time, most patients should
``Antiseptics (polyhexanide,
receive moist wound therapy based on the various phases of
wound healing [5]. Meta-analyses have shown that the use
Infection control

of such modern wound treatment promotes healing in chro- `` Medicinal honey

nic wounds [6]. Given the broad therapeutic armamentarium
octenidine)

available today, many physicians struggle to keep track.

In recent years, various acronyms have been introduced

Abbr.: MMPs, matrix metalloproteinases; DACC, dialkyl carbamoyl chloride.

that were meant to add structure to the topical treatment of
chronic wounds. First published in 2003, the T.I.M.E. con-
cept has gained the widest acceptance internationally. Over
I

the past ten plus years, however, many new aspects and
therapeutic options have emerged. On behalf of “Wund-
`` Normobaric oxygenation

D.A.CH.”, the umbrella organization of the various wound

`` Hyperbaric oxygenation

care societies in German-speaking countries, an interdiscip-

`` Hemoglobin spray

linary and interprofessional expert panel therefore set out to

Oxygen balance

refine the tried-and-true T.I.M.E. concept for the classificati-

on of topical chronic wound treatment in order to allow for
the inclusion of novel therapeutic options.
The factors of the T.I.M.E. concept designated by “T”,
“I”, and “M” still apply and remain important. They were the-
O

refore included, albeit slightly modified, in the new M.O.I.S.T.

concept (Table 1). The letter “E” of the T.I.M.E. concept origi-
nally stood for epidermis [7] and subsequently for edge (wound
Moisture balance

margins) [8], and comprised very different concepts aimed at

`` Superabsorbers

wound bed preparation and promotion of re-epithelialization

Moist wounds:
`` Wound gels

`` Hydrofibers

such as debridement, skin grafts, and biological wound thera-

Dry wounds:

`` Alginates

pies [8]. In the M.O.I.S.T. concept, “E” has now been replaced
categories.

`` Foams

by the letters “O” for oxygen balance and “S” for support as
this allows for the inclusion of new treatment options for targe-
M

ted therapy in a much more differentiated fashion.

© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017 1
 Correspondence  Clinical Letter
M – moisture balance
For several decades, moist wound therapy has been the gold
standard in the treatment of chronic wounds [4]. In this cont-
ext, it is essential to achieve an equilibrium between too little
and too much moisture in wounds. Accordingly, dry wounds
require the addition of moisture, for example, through hy-
drogels. Usually, however, there is an excess of moisture, thus
requiring the use of wound products such as superabsorbers.
O – oxygen balance
With respect to the pathophysiology of chronic wounds,
hypoxia plays a key role in nearly all types of wounds [9].
As regards topical treatment, this means that – especially if
measures such as revascularization and compression therapy
have been insufficient – there are therapeutic options avai-
lable to restore oxygen balance. Here, adjuvant treatments
include wound dressings or sprays as well as normobaric or
hyperbaric oxygen therapy [10, 11].
I – infection control
Infection control describes all antimicrobial strategies. Usual-
ly, systemic antibiotic treatment is only indicated for genui-
ne infections [12]. In order to prevent infections, eradicate
multiresistant pathogens (MRPs), or treat local infections,
antiseptics such as polyhexanide and octenidine or wound
dressings with antimicrobial effects, containing silver, honey,
or dialkyl carbamoyl chloride (DACC), are commonly used
in the topical treatment of chronic wounds [4].
S – support
In case of recalcitrant wounds despite apparently adequate
treatment, specific wound therapies may be used that actively
affect the impaired wound healing process. The promotion of
wound healing is achieved, for example, through a decrease
in metalloproteinases (MMPs) [13], lowering the pH [14], or
the application of growth factors [13]. While first tools to
measure the various aspects have been developed, they are
currently not used on a regular basis in daily clinical practice
[15].
T – tissue management
Tissue management describes all measures aimed at wound
bed preparation, and primarily includes the various methods
of debridement and wound cleansing, for example, with pre-
served solutions such as hypochlorous acid [16]. Subsequent
wound preparation may also comprise drug-free wound
dressings or physical measures such as negative pressure,
2 © 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017
electricity, or ultrasound [4]. Adjuvant use of these therapies
has beneficial effects on debridement, wound cleansing, gra-
nulation as well as re-epithelialization.
Summary
Developed by an interdisciplinary and interprofessional ex-
pert panel, the M.O.I.S.T. concept for the first time intro-
duces a new acronym that includes the ideas of the tried-
and-true T.I.M.E. concept, and refines them by adding
novel aspects. Thus, the M.O.I.S.T. concept is meant to hen-
ceforth assist physicians in systematically planning topical
treatment of chronic wounds using the most recent scientific
advances.
Conflict of interest
The authors declare the following conflicts of interest: J. Dis-
semond: Acelity, B. Braun, BSN, Coloplast, Convatec, Draco,
Engelhardt, Flen Pharma, Paul Hartmann, Juzo, Lohmann
& Rauscher, Medoderm, Mölnlycke, Neubourg Skin Care,
SastoMed, Serag-Wiessner, Urgo; V. Gerber: Mölnlycke,
SastoMed, Lohmann & Rauscher; P. Kurz: BSN Medical,
Coloplast, Focusmed-Beyer, Paul Hartmann, Heaco, Hein-
tel, Sorbion, Repuls, SastoMed, Publicare; S. Läuchli: Abb-
vie, Mimedex, SastoMed, Flen Pharma, Roche, Urgo, BSN,
Galderma, Meda, Wound check, Ebi-Pharm, Scholl, Bristol-
Myers-Squibb; S. Probst: Mölnlycke, BSN, APR, Aurealis,
Curea, Cinogy; K. Protz: Mölnlycke, BSN, Coloplast, Loh-
mann & Rauscher, Convatec, Medoderm, SastoMed, Urgo,
Hartmann, Acelity; J. Traber: Epifix, Organogenesis, Urgo;
S. Uttenweiler: Mölnlycke Healthcare, IVF Hartmann, gd
Medical, Serag-Wiesner, Agentur Scherrer, BSN, SastoMed;
R. Strohal: Pfizer, Schülke & Mayer, Lohmann & Rauscher,
Meda, Menarini, Stockhausen, Smith & Nephew, SastoMed,
Novartis, Flen Pharma, APR, Urgo, Chemomedica, Pantec,
3M, Enjo Commercials. B. Assenheimer and K. Kröger
declare no conflict of interest.
Joachim Dissemond1, Bernd Assenheimer2,
Peter Engels3, Veronika Gerber4, Knut Kröger5,
Peter Kurz6, Severin Läuchli7, Sebastian
Probst8, Kerstin Protz9, Jürg Traber 10,
Siegfried Uttenweiler 11, Robert Strohal12
(1) Department of Dermatology, Venereology, and
Allergology, University Hospital Essen, Hufelandstraße 55,
D-45147, Essen, Germany
(2) School of Nursing, University Medical Center Tübingen,
Geissweg 3, D-72076, Tübingen, Germany
(3) Engels Consults, Gartenstr. 25, D-51429, Bergisch
Gladbach, Germany
Correspondence  Clinical Letter

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© 2017 Deutsche Dermatologische Gesellschaft (DDG). Published by John Wiley & Sons Ltd. | JDDG | 1610-0379/2017 3