This episode critically examines the use of foam, combine, crepe and skin closure strips in wound management, addressing their potential misapplications and the resultant complications that may arise from such practices. Our discussion encompasses the phenomenon of “foam fights” among clinicians, reflecting the confusion stemming from the myriad of products available, which often appear deceptively similar yet serve varying purposes.

Timestamps

00:00 Introduction

00:51 WTFoam and the C word

01:47 Foam fights and confusion

04:24 Financial and clinical governance confusion

06:59 Are foams a panacea?

11:36 Foam fantasy

12:05 C words

15:34 Crepe alternatives

16:38 Combine maybe but then there’s that green dressing?

18:40 What ifs, clinical governance and risk reporting.

22:24 Enter and exit stage left – skin closure strips

25:35 Challenges and enablers of reporting harm

28:57 Summary Don’ts and Dos

Resources mentioned:

• Edwards–Jones V, Idensohn T, Westgate S et al (2025) Dialkylcarbamoyl Chloridecoated wound dressings: An evidence review and position document. Wounds International. https://woundsinternational.com/wp-content/uploads/2025/09/ESS25_PD_DACC_WINT-web-v2.pdf
• Nokaneng E et al. Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International 2025. (p26). Available to download from www. woundsinternational.com https://woundsinternational.com/consensus-documents/best-practice-recommendations-for-the-prevention-and-management-of-skin-tears-in-aged-skin-2nd-edition/

Endnotes

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The views expressed in this podcast are our own and is intended specifically for healthcare professionals. Always follow your organisation's policies and procedures or refer to your healthcare provider for individual wound advice.

Welcome to the Tour Kidney podcast from Advancing Wound Care, an online education platform for clinicians.

You're with Monica and Donna, two advanced practice nurses with decades of experience in hard to heal wounds burrowing into prickly conversations.

Welcome back to the next episode of the 2Echidnae podcast from Monica and Donna from Advancing Wound Care.

Now, the topic that we're going to cover and hello today.

Hello.

Hello.

Yes, I should let you say hello.

Well, I'm a bit.

I'm chomping at the bit here because I'm a bit excited about what we're going to talk about.

And Monica's laughing over in the background.

We have thought very carefully about.

Because we don't, you know, want to talk a lot about products so much, but we do, you know, wound care, wound management is what we do, and we use products for sure.

So we have titled this episode what the Foam.

This is definitely a WTF acronym in there.

And the C word, which is going to stand for two categories of products that we use, and they are combines and crepes.

And we want to cover off on foams as well.

When they're used potentially inappropriately or when we have kind of those, aha, exclamation mark moments, things that we see some of the harms that are caused when they might be inappropriate, they're necessarily bad products.

But the same with the combines and the crepes, when those things are certainly overused and used in very inappropriate and harmful circumstances.

And also the foam fights, you know, this foam's better than that foam, which is better than that.

Now, did you just come up with the two Fs, the foam fights?

Because that is actually a thing.

I know, I know, the foam fights.

People lose their crap over the foams.

No, this one's better.

No, no, I like the orange one.

No, I like the blue one, not the beige one.

Yeah, that's huge.

And also, we wanted to talk about, I think when we were mentioning that a lot of the foams are packaged very similarly.

Yeah.

And a lot of the names.

There's so many variants now with the same names.

That can be a risk as well.

Yeah.

I mean, I remember when the first foams came out and it was very exciting because we really had hydrocolloids predominantly then that we had access to.

Yes.

And then the first foam came out and then another foam came out and suddenly the whole commercial world of wound management companies thought, ah, this F thing's a great thing.

Let's put out a foam.

So every human being and their dog, cat and mouse.

Yes, Put out a foam.

And that caused immense confusion amongst clinicians.

And then as you were saying, some company, a lot of companies brand.

Have the same brand colors and brand their product all the same way.

And sometimes, you know, there are some.

There's a company that has a ph.

Home that's also impregnated with ibuprofen or not impregnated.

Sounds good, isn't it?

It's definitely on the F theme.

And yes, it, it has ibuprofen in it.

That's the best way I could I can say.

And maybe it is, I don't know.

Okay, let's just write that down onto follow up list.

Because one thing we do do is we have these questions and then we just impregnated.

Oh, geez.

Okay, go straight face.

Straight face.

So, yeah, so it has ibuprofen in it and the packaging there, two foams, they look identical.

They come in the same box and yet the only thing separating them is the, the name of the company and the foam on one box and the name of the company and the foam and just three letters that signify what that product that foam is impregnated with.

Yeah, it's a joke, but whatever.

So.

And that causes confusion.

Yeah, so there's foam confusion.

What about financial confusion?

Because.

Oh, I've just thought another if.

Yes, because I have had a lot of people.

I'm not saying in relation to that particular impregnated product.

It's going to be the theme now, so we'll have to rename this whole episode.

But, you know, they've ended up with a box of a particular product because it's got a very similar name and they haven't known which one to order.

And often times I have found too that the clinical staff in there, they might not be responsible for the ordering and someone else has done the ordering.

Maybe not even a clinician.

Could be a case manager or a facility manager or the accounts person, all of the above.

And they've ended up with the wrong one and they're using it and they don't even know they're using it.

But really that has happened.

I found two different lots of.

And no.

3 Actually, no.

4 Actually, they go, it's growing four different lots of ergo, products being used on the same wound a couple of weeks ago.

And yes, the packets are different colors, but the staff actually thought they're all the same product.

So what did you do in that situation?

Oh, I completely simplified.

And it actually was not.

The wound was not even appropriate for continuing to use those products.

So there was a bigger issues going on with what I had available at the time.

I was able to actually say, these aren't appropriate to use any longer.

We actually change.

It had so much confusion around it that I chose to just get away.

They were nearly finished using the products anyway before they ordered more.

I'm very considerate of the finances and getting back the F word.

They had run their course anyway.

Been using them for a long time.

There was no harm.

So it wasn't about picking out that.

And they were very grateful for the clarification.

And we just communicated to everyone that we're now not using that product.

We're going to something else that had a clinical, more appropriate clinical rationale for what the wound, how the wound was presenting.

So I just did away with them all and we went to something completely different because it re.

There's a lot of.

There was a lot of different people who were attending the dressing in the whole picture.

So there was a lot of other circumstances going on.

And I think that's why there was a bit of confusion too, because there were people from different services.

Someone was attending Monday, someone else is attending Wednesday, someone else is attending Friday.

That is fraught with potential for confusion at the best of times.

Yeah.

But even as you're talking, you know, and going back to the theme on flames and, you know, I was just looking up.

Yeah.

There are five fraternities, you know, people who like it, you know, we're discussing certain foams and then you've got the issue where foams are considered a panacea, you know, a cure all for any wound, I think.

And that's the biggest problem.

Yes.

It becomes.

Don't know what to do.

Will put a foam on.

And so.

And I think what's complicated is the.

The issue of prophylactic dressings and pressure injury.

And I think they're becoming less and less favourable because the bottom line is you still have to offload that bony Prominen feet if you're going to put on a prophylactic foam dressing.

Absolutely.

And also then you've got the silicone foams and people putting silicone foams on lymphoria.

And then you get foams slipping off and not doing.

Performing the function that you need them to perform.

We actually need super absorbent polymer dressings rather than foam dressings.

And the foam dressings cause more harm and more contact dermatitis, particularly on those very, you know, wet lymph rear legs.

Yeah.

So foams have become a bit of a band of my Life because I don't tend to use foam dressings as much.

I still have to, there's no question, but definitely less so than I used to.

Still have a place in skin tears?

Very much so, yes, but, but again you don't just put a foam on every single skin tear.

It might be, it might.

I can see how other people will rationalize and say, well if you, if the person doesn't know what they're doing and they found a wound, it might be a safe thing to use initially.

I've heard that argument and yes, I can see that.

But I think we've gone too far the other way.

Like I said, I've just become that panacea.

It's actually very hard to find a non silicon foam in a lot of places.

And herein lies the issue.

Yeah, that's right.

So people just become very familiar with it and I will often look at them as like a lot of other dressings and we're dealing with a lot of biofilm, a lot of extra date that's quite damaging to the surface of the wound and the peri wound.

We need to get that fluid up and away.

But a lot of these products, and they're great products, absolutely are designed to keep the fluid near the wound and moist wound healing, of course, but there's too much fluid and they're quite easily overwhelmed because I think historically too they were all.

Before we had a lot of the more advanced super absorbent dressings.

You know, foams were always marketed as holding moderate to large amounts of fluid.

Not at all the large amounts of fluid that we routinely deal with.

And we know so much more about biofilms now and what happens under them.

So yeah, it's, they, they, I would say the same.

They've become the bane of my life too in a lot of places.

Again, I think there's nuances around what I describe as highly exudative is completely different to how someone else might describe highly exudating.

And different farms do perform differently.

But I don't want to go to the extreme and, and start saying they've got no clinical application.

In many instances they've got clinical applications.

But sometimes it's.

As you were saying, that's the first thing that people consider, especially in a, again, a person with a skin tear who's bleeding a lot, don't bother, put a, put a foam on, put a calcium to stop the bleeding, apply pressure, but they'll put a foam on.

By that stage you've got the epidermis that's separated from the dermis.

But between that there's blood and people put foam on top of that.

But then you know what they'll come along and do?

This is a bit of a WTF moment for me.

A lot.

They won't recognise that that foam wasn't designed to be used that way.

It's got silicone on it, but if it's not holding the amount of exudate, they'll put another layer on the top of it to absorb it.

So they'll put the super absorber on the top even if it's got a semi occlusive backing layer on it.

So it causes harm.

Foams cause har of harm.

A lot more maceration and we get very wet.

We just seem so wedded to these.

Yeah.

Products.

Foam fantasy.

Foam fantasy, yes.

But I.

And again, it's not so much the problem of the foam, it's the problem with the human being using the foam and not using it in its.

In its correct application.

Yeah.

You know, so.

Yeah, so that's.

Oh, look, I'm sure as we talk, I think we'll come across more foam foibles.

But what about the C word or the C words?

Do you want to introduce that?

Because it was something you said today that really got us thinking about it.

Yes.

I had a referral which had said they were struggling with extra date management and instead of putting their super absorbent dressing on, had gone for something more absorbent, being the combine, and secured it with crepe.

Combine and crepes for dramatic effect.

Yes.

We say it all the time.

Yeah.

And it really made us want to include it in this episode.

Because we do.

I do find that a lot of people are.

Well, we're struggling.

We'll grab the combine because it's highly absorbent.

It's just highly cheap.

Again, not demonizing the product, but when we're.

Well, you won't demonize the product.

I'll demonize.

Okay, you can demonstrate.

I don't think it has any clinical application in.

In 20, 26 and beyond ever.

Burn.

So burn the combine.

Yeah, Burn the combine with the crepe.

No, you can.

No, I'm going to be.

Guys, is.

People think if the combine's cheap, but it's actually expensive because it causes harm.

And then we get a reflection fur all.

It is just cotton wool in and outer layer.

Yeah.

That the fluid just wicks through.

But you know what?

I remember when combines were first.

Well, I remember we started using combines and then we got.

I won't mention the company because I don't know whether they still manufacture it, but it was supposed to be really super duper combine, but it wasn't.

Yeah.

Which one I'm talking about?

Oh no, no, it's.

I think I've blocked it out.

Yeah.

I think it's vague.

And then crepe.

I see so much harm with crepe.

I see.

But crepe is.

Yes, crepe may be cheap to apply, but if it doesn't retain the dressing and therefore the wound doesn't heal because even the wounds the dressing slips and slight.

You know, you're often using a non adhesive dressing and that's why using crepe.

And if then just it just this comedy of error that occurs and all because the crepe is cheap.

We have a lot of problems with people using a very thin amount of crepe bandage if it is appropriate for a crepe.

Well, I mean, yes, there's different weights of crepe bandage, but I'm talking about trying to put a 5 centimeter or even I've seen a 2 centimeter crepe tried to be wound up a leg.

I'm not kidding.

Oh no.

Yeah.

Yep.

You know, when we're coming along and writing plans like put the bandage or you know, from toe to knee, but they'll try to.

They'll use a 5 centimeter bandage and try to cover the whole.

It just doesn't.

Doesn't work or ring barking a limb crepe around and around and around and around.

And clearly you've got lots of limb you can use it up on.

But I think the, even the art of basic bandaging, I don't see it done.

And I do get very concerned even when we're trying to teach people to put on more complex bandage systems, but they can't even put on a crepe.

Like just those.

Yeah.

You know, but is that.

Is there a twilight period now between not using crepe and using more of the tubular retention bandages?

Tubular blend.

Again, we were often repeating ourselves.

We're rinsing, repeating not to apply it too short, not to mix it up with the compressive tubulars.

Yes, yes.

And that happens a lot again.

Well, here I'm saying a lot.

Well, I see it a lot.

Yeah, we see it a lot too.

Yeah.

And then that becomes more expensive.

Like we've gone from crate to using tubular compression.

Straight tubular compression.

The wrong size being used.

Oh yes.

Oh yeah.

Okay.

All right.

Yeah.

And so the only time that accommodation.

Mine's maybe good when you're putting a Splint.

Someone's had an IV and they're putting a splint on.

But even now they've got padded splints.

So I'm just trying to find a good place for that C word to go.

But I think it's got to go up into the clouds.

It's pretty limited.

What about in skin creases, Skin folds?

Now I have seen that done, but I've seen that done very poorly as well.

I think for me it might be a little bit of a padding layer for someone where a super absorbent dressing might not be needed.

But the minute there's too much moisture and it gets really wet, that's the time for me to say, no, no, combine is not useful.

But then you'd use your super absorbent smell and also saw back dressings because we can talk about sore back because it's a unique product.

Yeah, yeah.

Putting sore backed in between those folds.

Probably still more suitable.

Definitely more suitable.

I often can't get it into places.

Okay.

Yeah, yep.

And why not?

It's a health economics discussion.

Yeah, yeah, yeah, yeah, yeah, yeah, yeah, yep.

Oh, yeah.

That would always be my product of choice.

Always.

And more vigilant cleaning.

But you know, I just know there are some people who will just use a little bit of combine.

It will be okay.

So I'm always going to struggle with it.

I guess.

I have, in my practice, I have found there are a lot of products I will say I don't like either.

But, you know, then again I will come across someone using it quite well and their clinical outcomes are okay.

I'm talking about the general population wise.

Yeah.

Most people, it won't be used well, but there will always be some people who are okay with it.

So I just struggle with benefit.

Isn't it really?

Yeah.

And I think the risks are greater than the benefits of one or two people using it.

Well, I'm thinking more about systemic change.

Yeah.

I'm completely playing devil's advocate.

Yeah.

But it's good because we, if we don't have cost effective alternatives.

So I'm not saying keep it, keep the combine or keep the crepe, but we don't have ready access to the alternative.

So maybe we ban it and then people have to get them in.

I don't know.

Yeah.

What would happen if.

Yeah, that's a good thought, isn't it?

What would happen if they just magically.

If they magically disappeared?

What if managers didn't.

Procurement officers didn't know that a product like that existed?

What if People started.

Now this is.

I'm completely ridiculous here, but what if we started putting riskmans and reports in for when harm is done?

Yeah, we don't do the either.

Yeah, yeah.

Why do we tolerate.

We're aiming for the utopian solution.

We should see going back to what the foam and the C words crepe and combine.

I think governance structures that support procurement, making clinical decisions that are often.

Well, of course they're purely financial is probably one of the most riskiest positions that organizations put themselves in.

And so you are actually spot on.

Start putting in clinical risk forms, whatever you have in your organization, highlighting that to managers because very quickly you develop a case series and a trend.

When you think about it, you actually have raised a really good point.

I don't think I've ever.

I think it is.

It's tricky.

I am often conflicted when I see some harms being done and how I go about documenting that in clinical notes as someone in private practice.

Okay.

Not everyone's going to be in private practice, of course, but we have a culture in my organisation that we do try to call a spade a spade.

Where we can objectively and sensitively because most managers wear.

We go.

They actually want to know what the problems are.

And that's why we enjoy the places that we do go because we can say this is what's causing harm.

And they're very invested in wanting to improve practice and actually work out the real barriers, not just what dressing to put on or what the product solution is so where we can help that quality process the better.

So yeah, maybe that.

That's something that you tackle from a risk in a risk framework.

I mean we've gone from what the foam to now clinical risk.

It is hard.

Like it's all good and well for me to say put in a risk, you know, whatever.

Yeah.

Whatever process you use, software you use.

But it's easier said than done because if, for example, I'm just thinking I come in and someone's wound has, you know, I saw it two days ago, someone had put a foam on a highly exudating wound.

The foam wasn't managing the exudate.

Now you've got a bigger wound because it's the.

The wounded has just started to perish and I submit a risk.

I'm trying to be very generic with the terms I use.

Yes.

But I raise that clinical risk.

But it's really hard.

Well, to start to be hurt and offended and thinking.

Taking it personally.

Yeah.

When really, you know, could be related to the person prescribed the Wrong product.

But as you were alluding to before, that's often all that they have.

And so then they bear the burden of decisions making made well above them taking the burden of blame for something that was way out of their control.

Absolutely.

The blame culture is really significant and we're very cautious of that.

It's about practice improvement.

I've just thought of something we really needed to have added to this episode and I really love what you're saying about those decisions being higher, but I think it's hard for staff to appreciate that we have the benefit of understanding those governance systems and procurement process and health economic decisions.

A lot of clinicians at the bedside and on the floor don't.

But let's add skin closure stress trips to this conversation because as you were describing that higher level decision making, it remind.

It reminded me of on a number of occasions where I've been providing, asked to provide education in a variety of residential and general practice settings.

And as part of the skin tear talk, you know, it's about the role of skin there being no role for skin closure strips and the evidence.

And I've generally, I would say 80% of the time had a really good.

Oh yes, we have not used those here for years.

But I've learned because of the 20% of times where I have had knives nearly thrown at me if people could throw a knife with the way they look at me.

And I've had to backpedal really, really quickly and take the education a whole nother direction to not further offend them so they can get some value out of what I'm saying, because they are so wedded to those products and it.

They're in place historically not because of their own fault, but they do take it on as like you're criticizing what we're doing here.

I have no hesitation in banning skin closure strips.

Like what about over a flexion point, over a joint, over a finger.

I've no hesitation in banning skin closure strips in the realm of skin tears.

I think where there are lacerations and other traumatic.

Different types of traumatic wounds, possibly.

But then here's my clinical argument would be, well, if you have a good quality silicon foam and we're coming back to the foams again, aren't there other ways to stabilize a joint?

Well, I haven't yelled skin, skin over joint.

Yes, I, I'm just playing devil's advocate because that's.

Yes, because that's often the argument I get.

Well, but we don't.

We need the skin closure strips to hold the strip down.

No, the dressing's doing that really well.

And it also forces people to over to compensate.

When you've got a Category 2 skin tear where you've got some skin loss, people try and convert it to a Category 1 by yanking that little skin across, stretching the skin across the deficit when the skin really can't stretch and then you lose the whole.

All the skin.

Yeah.

Yep.

I've got a file of, well, I'm sure, as I'm sure you and a lot of our colleagues do, of photos of grossly, and I mean grossly malapplied skin clocher's chips that have caused harm.

But when do we, when do we put it in our risk forms for those.

That's not on the tip of everyone's tongue.

I know, but that's really hard because.

Oh.

So I think culturally it's very, very difficult and really requires a conversation with a manager that you trust and that a manager who has your back and that can get very political and icky.

So a lot of what we're talking about is even relating then to the crepes and combines is going to be in the same domain as that, isn't it?

I suppose then if you get together as a team as much as you can in these very busy times, but agree that you will be putting in clinical incident forms and determining from the outset that it's not about the person who applied the product because that's all that they've got access to, but the.

Your most former.

A little pact to submit these clinical incident forms to put pressure on the manager to elevate and escalate the risk and then do something about it.

Yep.

And that also being well supported by your clinical governance documentation, being well in place and well communicated and agreed on first by clinically suitable, you know, authors who write those policies and procedures.

So there's an expectation that's already set and you have that to fall back on.

Not all organizations have that though.

No.

But for foundational things like skin injuries, a lot of them do, but the bigger ones do.

A lot of them will have access.

To shared policies and then I suppose to prove that the product, not the person who put it on.

If a clinician has a formulary that they can choose, choose from and they prescribe the wrong product and if there's harm caused, well, the responsibility is more likely on that person.

But if you don't have, you've got a minimal formulary that you can use of dressing products that you can choose and all you have is a combine to put on a highly exudating wound and then that wound gets worse.

Well, I don't think anyone would begrudge you for putting in a clinical incident form or that's.

That gets very difficult because then I suppose if you've got to start explaining yourself, you may be asked, well, why didn't you escalate the issue with your manager?

It's tricky.

Yep, it's tricky.

And.

And we don't.

We're not saying we have the answers.

We've certainly gone down a road in this episode, in this conversation that, you know, started off as like, certainly serious for us, but there are really significant ramifications and implications.

And these are the.

They are seemingly simple products but have significant implications to the staff who use them and on wounded people and people at risk of wounds as well.

So.

All right, in terms of summary of this episode, don't use.

Combine Steri strips.

Don't use.

It depends if you maybe have a skin tear over a knee or a finger maybe.

But really, again, you've got other alternatives.

Crepe.

If you've got any hard to heal wound, it really doesn't have an application.

Particularly if you've got a wound on the lower leg that you should be compressing.

Don't use crepe.

Absolutely.

If you've got a particularly poorly perfused wound, don't use crepe.

You're more likely to cause harm.

Foams.

Foams have many, many, many great applications, but they never, never, never stop pressure injury.

And if you're in a situation where you have significant extra date maceration leakage through in one to two days, it's likely not the product that should be being used.

Correct.

And if you're changing a foam daily.

Wrong product.

Wrong product.

Yep, wrong product.

But foams, and particularly silicone foams, they've really revolutionized wound management because they are.

They're much less painful to remove and they do have a function.

Some foams actually fill, you know, minor deficits or, you know, fill in the cavities.

Slightly deep wounds.

Yes, yeah, yeah, they do.

So they perform different functions, but essentially they're not very.

They're not highly absorbent and we've got alternatives to those products now.

Super absorbent polymer dressings.

So, yes, that's WTF the C's.

And then.

Then you snuck in a little S word there.

Yeah.

Anyway, fantastic mod, great simulating episode.

I'm sure we'll reflect on this where this conversation's taken us.

So thank you very much for your expertise.

Oh, sharing.

Yeah.

And likewise.

Yeah.

Always enjoyable.

Absolutely.

Well, stay tuned.

Follow along.

We hope you're enjoying our new style to Echidnae Advancing Wound Care podcast.

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As we're planning educational resources for clinicians, check the show Notes.

We'll probably put some links in below for you as well.

Make your navigation easier and we'll catch you in the next episode.

Thanks, Monica.

Thanks Donna.

Bye Bye.

At Advancing Wound Care, we're proud to stand alongside clinicians who lead with heart, curiosity and a deep commitment to doing right by the people in their care.

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Cover you, but what you do, do what I do.