The effects of Arnebia euchroma ointment on second-degree burn wounds: a randomized clinical trial

Short-term effect of dressing with Dermaheal ointment in the treatment of diabetic foot ulcer: A double-blinded randomized controlled clinical trial

Background and Aims

Diabetic foot ulcers, a major cause of amputations in diabetics, could benefit from natural products as adjuncts to standard care, given the costs and adverse effects of typical therapies. This study aims to evaluate the short-term effects of dressing with Dermaheal ointment in the treatment of DFUs through a double-blinded randomized controlled clinical trial.

Methods

This double-blinded, placebo-controlled trial included 50 patients with Wagner's ulcer grade I or II, randomly assigned to Dermaheal and placebo groups (received standard treatment and placebo ointment). The ulcer site was dressed daily for four consecutive weeks with either Dermaheal or placebo ointment. Ulcer healing score (using DFU healing checklist), ulcer size with transparent ruler and largest dimension of ulcer, and pain severity using numerical pain rating score (were recorded at five-time points, including baseline, and on weeks 1, 2, 3, and 4). Also, ulcer healing status was investigated at the trial ended in November 2021.

Results

Both groups showed significant improvement in ulcer healing over 4 weeks (p time < 0.001), with more remarkable progress in the Dermaheal group (p group = 0.03). At the trial end, complete ulcer healing was also significantly higher in the Dermaheal group compared to the placebo group (56% vs. 12%, p = 0.002). Both groups exhibited a decrease in ulcer size (p time < 0.001). Considering the baseline ulcer size as a covariate, substantial changes in mean ulcer size were noted in the initial (p = 0.01), second (p = 0.001), third (p = 0.002), and fourth (p = 0.002) weeks of the intervention, showing a preference for the Dermaheal group. However, no significant between-group difference was observed in pain severity levels.

Conclusion

Dressing with Dermaheal as a topical treatment shows promise in improving healing and reducing the size of diabetic foot ulcers. Further research is needed to confirm these findings' long-term efficacy.

High-resolution neuraminidase inhibition profiling of Arnebia euchroma (Royle) I.M. Johnst. based on HR-MS and target isolation: An example study of anti-infectious constituents in traditional Chinese medicine

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese Medicines (TCMs) are an important source to discover new anti-infectious drugs. Neuraminidases (NAs) not only play a key role on human health, but also are promising targets for anti-infectious drugs. Arnebia euchroma which is a widely used traditional Chinese medicine with the effect of cooling blood and detoxifying showed potential inhibitory activities on both bacterial NA and virus NA, suggesting that the material basis of A. euchroma deserves in-depth study.

AIM OF THE STUDY

To investigate the anti-infectious constituents of A. euchroma based on NA inhibition.

MATERIAL AND METHODS

A HPLC-DAD system incorporated an auto-sampler was used for micro-fractionation. A nanoliter liquid handler and a high sensitive multimode plate reader system were used for high throughput NA inhibition screening. Thus a high-resolution NA inhibition profiling platform was constructed. The structures of potential active components in A. euchroma obtained by the high-resolution bioassay profiling were identified by DAD and MS in parallel. Then, a target and rapid isolation of NAIs from A. euchroma was achieved under the guidance of the spectrum-effect relationship obtained above. Finally, the isolated compounds were elucidated by extensive spectroscopic methods and their bioactivities were validated by in vitro assay and molecular docking.

RESULTS

16 potential active ingredients in A. euchroma were isolated and identified, including a new mero-monoterpenoid. The in vitro bioassay results revealed that 12 out of the 16 isolated compounds showed potent inhibitory activities on bacterial NA (IC50s = 1-6 μM) and five of them exhibited potent anti-microbial activities on methicillin-resistant Staphylococccus aureus (MRSA) with MICs in the range of 0.5-4 μg/mL. Furthermore, some isolated compounds showed equal or even better inhibitory activities on oseltamivir resistant viral NA than oseltamivir sensitive NA. The mechanism study in silicon revealed that these natural compounds possessed absolutely different binding modes on the bacterial and viral NAs.

CONCLUSIONS

Our study gave a clear spectrum-effect relationship of A. euchroma, providing a scientific evidence for future study of the multi-components synergistic effect of TCMs.

Euchronin A-F isolated from the Arnebia euchroma (Royle) Johnst. and their anti-proliferative activities in vitro

Six new naphthoquinones, euchronin A-F (1-6) and nine known naphthoquinones (7-15), were isolated from the roots of Arnebia euchroma (Royle) Johnst. The structures of the new compounds were confirmed by extensive spectroscopic analyses, including UV, IR, HR-ESI-MS, 1D and 2D NMR. In the present study, we estimated the anti-proliferative activities of these compounds with HaCaT cells. The results indicated that compounds 2 and 4 showed strong anti-proliferative activities at 25 μM, with relative viability at 38.83% and 68.44%, respectively.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Ethnopharmacological Study of Medicinal Plants Used in the Treatment of Skin Burns in the Arab World

Traditional healers are often practiced in rural areas owing to cultural beliefs and are known to provide various forms of healthcare and home remedies. Patients in the Mediterranean region rely on traditional medicine to cure a variety of health concerns, like skin burns. This study was conducted to identify the various practices used by traditional healers for treating skin burns. The survey was conducted in 18 Arab countries, including Syria, Iraq, Jordan, Saudi Arabia, Egypt, United Arab Emirates, Algeria, Bahrain, Palestine, Kuwait, Oman, Qatar, Lebanon, Yemen, Tunisia, Oman, Morocco, and Sudan. Between September 2020 and July 2021, an online questionnaire was administered to 7530 participants from 12 Asian and 5 African countries. The survey was designed to gather information from common medicinal plant users and herbalists on their practices as specialists in using various herbal and medicinal plant products for diagnosis and treatment. Among the participants, 2260 had a scientific background in plant application, and the study included one phytotherapeutic professional. The crude-extraction technique was favored, by Arabic folk, for plant preparation over the maceration and decoction method. Olive oil was the most commonly used product among participants as an anti-inflammation and for scar reduction. Aloe vera, olive oil, sesame, Ceretonia siliqua, lavender, potato, cucumber, shea butter, and wheat flour are used as crude drugs to reduce pain because of their analgesic and cooling effects. The present study is the first database of medicinal plants with burn-healing properties conducted in Arab countries. These plants can be employed in the search for new bioactive substances through pharmacochemical investigations, as well as in the development of new formulations containing a combination of these plants.

PLA-HPG based coating enhanced anti-biofilm and wound healing of Shikonin in MRSA-infected burn wound

Burn wounds are susceptible to bacterial infections, including Methicillin-resistant Staphylococcus aureus (MRSA), which typically form biofilms and exhibit drug resistance. They also have specific feature of abundant exudate, necessitating frequent drug administration. Shikonin (SKN) has been reported to reverse MRSA drug resistance and possesses anti-biofilm and wound healing properties, however, it suffers from drawbacks of low solubility and instability. In this study, we developed PLA-HPG based bioadhesive nanoparticles SKN/BNP, which demonstrated a drug loading capacity of about 3.6%, and exhibited sustained-release behavior of SKN. The aldehyde groups present on the surface of BNP improved the local adhesion of SKN/BNP both in vitro and in vivo, thereby reducing the frequency of drug dosing in exudate-rich burn wounds. BNP alone enhanced proliferation and migration of the fibroblast, while SKN/BNP promoted fibroblast proliferation and migration as well as angiogenesis. Due to its bioadhesive property, BNP directly interacted with biofilm and enhanced the efficacy of SKN against MRSA biofilm in vitro. In a mouse model of MRSA-infected burn wounds, SKN/BNP demonstrated improved anti-biofilm and wound healing efficiency. Overall, our findings suggest that SKN/BNP holds great promise as a novel and effective treatment option for clinical applications in MRSA-infected burn wounds.

The Potential of Medicinal Plants and Natural Products in the Treatment of Burns and Sunburn-A Review

Treating burns remains a challenge for modern medicine, especially in developing countries that cannot afford expensive, advanced therapies. This review article summarises clinical and animal model studies of botanical preparations and their mixtures in treating burn wounds and sunburn. Articles available in electronic databases such as PubMed, Scopus, Web of Science, Science Direct and Google Scholar, published in English in 2010-2022, were considered. In the described clinical trials, it was shown that some herbal preparations have better effectiveness in treating burn wounds, including shortening the healing time and reducing inflammation, than the conventional treatment used hitherto. These herbal preparations contained extracts from Albizia julibrissin, Alkanna tinctoria, Aloe vera, Arnebia euchroma, Betula pendula and Betula pubescens, Centella asiatica, Hippophaë rhamnoides, Juglans regia, Lawsonia inermis, and mixtures of Matricaria chamomilla and Rosa canina. Research on animal models shows that many extracts may potentially benefit the treatment of burn wounds and sunburn. Due to the diverse mechanism of action, antibacterial activity, the safety of use and cost-effectiveness, herbal preparations can compete with conventional treatment. The growing interest in alternative medicine and herbal medicine encourages further research. Not only single preparations but also their mixtures should be taken into account because the research conducted so far often suggests a synergistic effect of the ingredients.

Comparing Dermolina-Henna Cream with Mometasone Cream in Improving Radiodermatitis Among Patients with Breast Cancer: A Randomized Active-Control Double-Blind Clinical Trial

Objectives: Radiotherapy is one of the treatments used for different types of cancer. Acute radiodermatitis is one of its most common complications. Despite the high prevalence of radiodermatitis, few studies investigated how to prevent or treat this complication. Hence, a standard treatment has not been introduced so far. We sought to evaluate the efficacy of Dermolina-Henna cream, a new polyherbal formulation, compared to Mometasone cream for alleviating acute radiodermatitis among breast cancer patients. Design: Randomized active-control double-blind clinical trial. Setting/Location: The oncology clinic of Shohaday-e Tajrish Hospital (Tehran, Iran). Subjects: Women older than 18 years with breast cancer undergoing radiotherapy. Interventions: Patients were instructed to apply a thin layer of Dermolina-Henna or Mometasone cream once daily on their lesions at least 3 h after radiotherapy for 4 weeks, and if grade I or II radiodermatitis developed, also afterward. Patients were visited weekly until end of study at after 4 weeks. Radiation Therapy Oncology Group standard questionnaires were evaluated and recorded every week as the primary outcome. Outcome measures: Primary outcome was defined as evaluating the efficacy of Dermolina-Henna cream to change the radiodermatitis grade, while the level of patients' satisfaction and the rate of adverse events recorded by patients were secondary outcomes. Results: The trends on decrease in number of lesions, erythema, radiodermatitis grade, burning sensation, pain, and itchiness were statistically significant for each treatment, separately (p < 0.001), except for radiodermatitis grade in Mometasone group (p = 0.4). Dermolina-Henna was significantly better than Mometasone in alleviating burning sensation (p < 0.001) and itchiness (p = 0.041). Approximately 3.7% of patients showed adverse events and 3.7% declared dissatisfaction in both groups. Conclusions: In summary, we showed that Dermolina-Henna cream and Mometasone cream were significantly effective in decreasing severity of radiodermatitis symptoms among patients with breast cancer. Dermolina-Henna cream was significantly superior to Mometasone cream in alleviating burning and itchiness. Clinical Trial Registration Number: IRCT20200115046144N1.

Eight new arnebinol B-based meroterpenoids with planar chirality in the constrained 6/10/5 tricyclic skeleton from Arnebia euchroma and their cytotoxicities

Eight new arnebinol B-based meroterpenoids ((-)-1, 2, 3, (-)-5, and 7-10) with a constrained 6/10/5 tricyclic backbone were isolated from the roots of Arnebia euchroma. The planar and steric structures of these new compounds were unambiguously elucidated by extensive spectroscopic analyses, X-ray diffraction crystallography, and ECD calculations. The predominant relative orientation between H-7 and the Z double bond with a methyl substituent in the rigid 10-membered carbocycle, along with the planar chirality of the Z double bond was analyzed and discussed for the first time. The illustration of the planar chirality derived from the Z double bond should be paid great importance during the structure elucidation on these homologous meroterpenoids. All the isolated meroterpenoids were screened for their cytotoxicities against the HCT-8, PANC-1, HGC-27, HepG2, and PC9 cell lines, and compounds (+)-5 and (-)-5 exhibited the most potent cytotoxicity.

Hybrid PCL/chitosan-PEO nanofibrous scaffolds incorporated with A. euchroma extract for skin tissue engineering application

Skin tissue engineering is an advanced method to repair and regenerate skin injuries. Recent research is focused on the development of scaffolds that are safe, bioactive, and cytocompatible. In this work, a new hybrid nanofibrous scaffold composed of polycaprolactone/chitosan-polyethylene oxide (PCL/Cs-PEO) incorporated with Arnebia euchroma (A. euchroma) extract were synthesized by the two-nozzle electrospinning method. Then the synthesized scaffold was characterized for morphology, sustainability, chemical structure and properties. Moreover, to verify their potential in the burn wound healing process, biodegradation rate, contact angle, swelling properties, water vapor permeability, mechanical properties, antibacterial activity and drug release profile were measured. Furthermore, cytotoxicity and biocompatibility tests were performed on human dermal fibroblasts cell line via XTT and LDH assay. It is shown that the scaffold improved and increased proliferation during in-vitro studies. Thus, results confirm the efficacy and potential of the hybrid nanofibrous scaffold for skin tissue engineering.

Healing Effects of Human Amniotic Membrane and Burned Wool on the Second-degree Burn in Rats

Background:

This study aimed to compare sheep burnt wool and human amniotic membrane (AM) on second-degree burn wound healing in rats.

Materials and Methods:

Seventy-two adult male rats of Sprague Dawley underwent general anesthesia, and a deep second-degree burn was created on their skin by a hot iron plate. Afterward, human AM, silver sulfadiazine ointment (SSD), and sheep burned wool were used on wound area for burn treatment. On days 7, 14, and 21 of the experiment, the rats were sacrificed, and histopathological assessments were done.

Results:

Human AM, in comparison with other groups, significantly (P<0.05) showed better improvement in all pathologic variables. Burned wool showed significant improvement compared to the control group on day 7 in the angiogenesis, on day 14 in granulation tissue formation and epithelial formation, and on day 21 in new epithelial formation (P<0.05). Burned wool compared with SSD ointment in granulation tissue formation improved significantly (P<0.05) on days 7 and 14. Also, SSD ointment in comparison with the control group significantly improved (P<0.05) granulation tissue formation and macrophage on day 7.

Conclusion:

Human AM has a significant effect on the treatment of second-degree burn. Burned wool has a better effect on wound healing than SSD ointment and negative control group without treatment in terms of granulation tissue and epithelium formation.

Phytochemical constituents, distributions and traditional usages of Arnebia euchroma: A review

ETHNOPHARMACOLOGICAL RELEVANCE

The present study has indicated phytochemical composition, distribution and ethno-medicinal uses of Arnebia euchroma (Royle) I.M. Johnst, which is commonly known as "Ratanjot" in the Indian subcontinent. It has widely been used in the traditional systems of the Unani, Ayurvedic and Chinese medicines recipes due to its anti-fungal and anti-microbial properties. Instead, the gap of earlier studies is well defined that will be helpful for researchers to carry out more analysis and increase medicinal importance of this plant.

AIM OF STUDY

The main aim of this review study is to demonstrate the phytochemical composition and traditional ethno-medicinal uses of A. euchroma all over the world. Earlier studies related to this plant have been discussed in the present study and on that basis, future perspective of A. euchroma is also proposed.

MATERIALS AND METHODS

The information of A. euchroma has been gathered from various electronic database, reference books and available literature.

RESULTS

The study has indicated that Arnebia euchroma owing to anti-microbial and anti-inflammatory properties is used in the traditional medicines and pharmaceutical industries for the treatment of hair problems, remitting, chronic diseases, burnt limbs, cough and cold, etc., and besides as a vegetable colorant and dyeing of cloths. The important phytochemical constituents viz., shikonin, acetyl-shikonin, iso-butyryl-shikonin, β,β-di-methylacryl-shikonin, isovaleryl-shikonin, β-hydroxy-isovaleryl-shikonin, deoxy-shikonin, isobutyl-shikonin, arnebinone, arnebin-7, stigmasterol, etc., isolated from the roots of Arnebia euchroma are used for curing various harmful diseases.

CONCLUSIONS

The earlier studies have confirmed that Arnebia euchroma is having wound healing, anti-microbial and anti-bacterial properties and thus used for the treatment of several diseases. Although, a little works is done on the experimental study regarding anti-HIV, anti-cancer diseases, etc., so there is a requirement of more exploration via analytical studies on phytochemical compounds to treat such diseases. Moreover, the information of its clinical and pharmacokinetics uses is also limited. Therefore, further research is needed to understand bioavailability and pharmacokinetics of this species. In-situ and ex-situ conservations for the management of this endangered species are also lacking in the Himalayan perspective. Such studies will emphasize to explore the possibilities for its conservation and development of agro-technological protocol.

Efficacy of Lobelia alsinoides Lam ethanolic extract on a third-degree burn: An experimental study on rats

This is the first study to evaluate the topical application of Lobelia alsinoides Lam (LT) ethanolic extract on burns in rats. A deep third-degree burn wound was inflicted in adult male Wistar rats and the burns were dressed daily with a topical ointment formulation (Patent filed) comprising of Lobelia alsinoides Lam (5% and 10% w/w). The wound had noteworthy contraction and quicker eschar removal in 10% w/w LT-treated groups followed by 5% w/w treated groups on comparing with the commonly prescribed ointment (Silverex^TM containing 1% w/w Silver sulfadiazine). Histopathological analysis showed that ointment containing 10% w/w LT ethanolic extract significantly increased fibroblast growth, which plays a major role in anatomic integrity, collagen synthesis, and accelerated the rate of the healing process. This study shows that the ethanolic extract of Lobelia alsinoides Lam, a previously pharmacologically unreported traditional medicinal plant, possesses wound contraction and eschar removal properties on burn wounds.

WUWHS 2020 Global Healing Changing Lives, Abu Dhabi, UAE March 8-12

The abstract book contains the abstracts of keynote lectures, global gelebration, focus sessions, symposia, regional view, workshops, sponsored symposia, oral presentations, posters and the index.

Chemisorption and sustained release of cefotaxime between a layered double hydroxide and polyvinyl alcohol nanofibers for enhanced efficacy against second degree burn wound infection

Zn–Al layered double hydroxides (LDHs) were synthesized by a chemical method, while polyvinyl alcohol (PVA) nanofibers were fabricated by an electrospinning approach; we also synthesized Zn–Al LDH/cefotaxime (cefotax), Zn–Al LDH@PVA, and Zn–Al LDH/cefotax@PVA (LCP). Characterizations were performed by X-ray diffraction, Fourier transform infrared spectroscopy, field emission scanning electron microscopy, high-resolution transmission electron microscopy, energy dispersive X-ray spectroscopy, Brunauer–Emmett–Teller analysis, thermogravimetric-differential thermal analysis techniques, dynamic light scattering, X ray-florescence, and carbon, hydrogen, and nitrogen (CHN) analyses. The adsorption isotherm of cefotax and its entrapment percentage, release, and kinetics were also investigated. The results confirmed the elemental constituents of the mentioned formulas, which exhibited different degrees of crystallinity and different morphologies. Besides, these formulas were tested in vitro as antimicrobial agents and applied in vivo against second-degree wound burns induced in rats' skin. The adsorption of cefotax occurred chemically, and the experimental data were fitted with different isotherm models, where the Freundlich and Toth models gave the best fits. The entrapment percentage in LDH/cefotax was 77.41% and in LDH/cefotax@PVA, it was 67.83%. The sustained release of cefotax from LDH and LCP was attainable; the release percentages were 89.31% and 81.55% in up to 12 h, respectively. The release kinetics of cefotax from LDH fitted well with first-order kinetics, while that for LCP was parabolic. The formulas showed uneven antimicrobial effects against Gram-positive and Gram-negative bacteria; the best effect was exhibited by Zn–Al LDH/cefotax@PVA due to its sustained release. Finally, investigating the possibility of using these formulas in the clinical setting should be considered.

This study succeeded to formulate, characterize, and investigate cefotax release and kinetics, and to compare cetofax with other known antibacterial agents.

Tissue healing efficacy in burn patients treated with 1% silver sulfadiazine versus other treatments: a systematic review and meta-analysis of randomized controlled trials

This study aims to evaluate tissue healing efficacy in burn patients treated with 1% silver sulfadiazine versus other treatments. This is a systematic literature review and meta-analysis of randomized clinical trials performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) and PICO strategy, registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42017081057. The review found 71 studies in MEDLINE/Pubmed, 1 in Clinical Trials, 19 in the Cochrane Library, and 4 in LILACS in five manual searches. Of these, 81 studies were pre-selected. After independent analysis by two reviewers, only 11 studies met the inclusion criteria for the review. All studies (n = 11) using alternative treatments to silver sulfadiazine were shown to be superior in the mean time for complete wound healing, with statistically significant differences between experimental and control groups (p <0.00001); mean difference (- 4.26), 95% CI [- 5.96, - 2.56].

Advances in Regenerative Medicine and Tissue Engineering: Innovation and Transformation of Medicine

Humans and animals lose tissues and organs due to congenital defects, trauma, and diseases. The human body has a low regenerative potential as opposed to the urodele amphibians commonly referred to as salamanders. Globally, millions of people would benefit immensely if tissues and organs can be replaced on demand. Traditionally, transplantation of intact tissues and organs has been the bedrock to replace damaged and diseased parts of the body. The sole reliance on transplantation has created a waiting list of people requiring donated tissues and organs, and generally, supply cannot meet the demand. The total cost to society in terms of caring for patients with failing organs and debilitating diseases is enormous. Scientists and clinicians, motivated by the need to develop safe and reliable sources of tissues and organs, have been improving therapies and technologies that can regenerate tissues and in some cases create new tissues altogether. Tissue engineering and/or regenerative medicine are fields of life science employing both engineering and biological principles to create new tissues and organs and to promote the regeneration of damaged or diseased tissues and organs. Major advances and innovations are being made in the fields of tissue engineering and regenerative medicine and have a huge impact on three-dimensional bioprinting (3D bioprinting) of tissues and organs. 3D bioprinting holds great promise for artificial tissue and organ bioprinting, thereby revolutionizing the field of regenerative medicine. This review discusses how recent advances in the field of regenerative medicine and tissue engineering can improve 3D bioprinting and vice versa. Several challenges must be overcome in the application of 3D bioprinting before this disruptive technology is widely used to create organotypic constructs for regenerative medicine.

Comparative study of Silver Sulfadiazine with other materials for healing and infection prevention in burns: A systematic review and meta-analysis

The aim of this systematic review with meta-analysis was to compare the effect of Silver Sulfadiazine (SSD) with other new dressings, with or without silver, on healing and infection prevention in burns. The electronic search was carried out in the electronic databases of Pubmed, ScienceDirect, Lilacs and BVS. The articles included were randomized clinical trials about burn treatment with SSD, which evaluated the healing and infection of burn wounds in humans. The exclusion criteria included articles, editorials and letters published in the form of abstracts, unpublished reports and case series, cross-sectional, observational experimental studies, and the use of sulfadiazine for other types of wounds. The search identified 873 references, and 24 studies were included in accordance with the eligibility criteria. The results showed a statistically favorable difference related to the time of healing for silver dressings (p<0.0001; MD 3.83; 95% CI 2.03-5.62) and dressings without silver (p<0.007; MD 2.9; 95% CI 0.81-5.00) in comparison with SSD. The rate of infection showed no difference in the group treated with SSD compared with the group treated with dressings containing silver (p>0.05). The rate of infection was significantly higher in the SSD group compared with the group treated with dressings without silver (p<0.005; MD 25.29% and MD 12.97%). Considering the clinical trials conducted up to the present time, the authors concluded that new dressings with and without silver show better results than SSD for wound healing, and burns treated with dressings without silver are less likely to become infected than burns with SSD. No differences between SSD and new silver materials were observed in relation to infection prevention.

Antiseptics for burns

BACKGROUND

Burn wounds cause high levels of morbidity and mortality worldwide. People with burns are particularly vulnerable to infections; over 75% of all burn deaths (after initial resuscitation) result from infection. Antiseptics are topical agents that act to prevent growth of micro-organisms. A wide range are used with the intention of preventing infection and promoting healing of burn wounds.

OBJECTIVES

To assess the effects and safety of antiseptics for the treatment of burns in any care setting.

SEARCH METHODS

In September 2016 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions based on language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that enrolled people with any burn wound and assessed the use of a topical treatment with antiseptic properties.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We included 56 RCTs with 5807 randomised participants. Almost all trials had poorly reported methodology, meaning that it is unclear whether they were at high risk of bias. In many cases the primary review outcomes, wound healing and infection, were not reported, or were reported incompletely.Most trials enrolled people with recent burns, described as second-degree and less than 40% of total body surface area; most participants were adults. Antiseptic agents assessed were: silver-based, honey, Aloe Vera, iodine-based, chlorhexidine or polyhexanide (biguanides), sodium hypochlorite, merbromin, ethacridine lactate, cerium nitrate and Arnebia euchroma. Most studies compared antiseptic with a topical antibiotic, primarily silver sulfadiazine (SSD); others compared antiseptic with a non-antibacterial treatment or another antiseptic. Most evidence was assessed as low or very low certainty, often because of imprecision resulting from few participants, low event rates, or both, often in single studies. Antiseptics versus topical antibioticsCompared with the topical antibiotic, SSD, there is low certainty evidence that, on average, there is no clear difference in the hazard of healing (chance of healing over time), between silver-based antiseptics and SSD (HR 1.25, 95% CI 0.94 to 1.67; I² = 0%; 3 studies; 259 participants); silver-based antiseptics may, on average, increase the number of healing events over 21 or 28 days' follow-up (RR 1.17 95% CI 1.00 to 1.37; I² = 45%; 5 studies; 408 participants) and may, on average, reduce mean time to healing (difference in means -3.33 days; 95% CI -4.96 to -1.70; I² = 87%; 10 studies; 979 participants).There is moderate certainty evidence that, on average, burns treated with honey are probably more likely to heal over time compared with topical antibiotics (HR 2.45, 95% CI 1.71 to 3.52; I² = 66%; 5 studies; 140 participants).There is low certainty evidence from single trials that sodium hypochlorite may, on average, slightly reduce mean time to healing compared with SSD (difference in means -2.10 days, 95% CI -3.87 to -0.33, 10 participants (20 burns)) as may merbromin compared with zinc sulfadiazine (difference in means -3.48 days, 95% CI -6.85 to -0.11, 50 relevant participants). Other comparisons with low or very low certainty evidence did not find clear differences between groups.Most comparisons did not report data on infection. Based on the available data we cannot be certain if antiseptic treatments increase or reduce the risk of infection compared with topical antibiotics (very low certainty evidence). Antiseptics versus alternative antisepticsThere may be some reduction in mean time to healing for wounds treated with povidone iodine compared with chlorhexidine (MD -2.21 days, 95% CI 0.34 to 4.08). Other evidence showed no clear differences and is of low or very low certainty. Antiseptics versus non-antibacterial comparatorsWe found high certainty evidence that treating burns with honey, on average, reduced mean times to healing in comparison with non-antibacterial treatments (difference in means -5.3 days, 95% CI -6.30 to -4.34; I² = 71%; 4 studies; 1156 participants) but this comparison included some unconventional treatments such as amniotic membrane and potato peel. There is moderate certainty evidence that honey probably also increases the likelihood of wounds healing over time compared to unconventional anti-bacterial treatments (HR 2.86, 95% C 1.60 to 5.11; I² = 50%; 2 studies; 154 participants).There is moderate certainty evidence that, on average, burns treated with nanocrystalline silver dressings probably have a slightly shorter mean time to healing than those treated with Vaseline gauze (difference in means -3.49 days, 95% CI -4.46 to -2.52; I² = 0%; 2 studies, 204 participants), but low certainty evidence that there may be little or no difference in numbers of healing events at 14 days between burns treated with silver xenograft or paraffin gauze (RR 1.13, 95% CI 0.59 to 2.16 1 study; 32 participants). Other comparisons represented low or very low certainty evidence.It is uncertain whether infection rates in burns treated with either silver-based antiseptics or honey differ compared with non-antimicrobial treatments (very low certainty evidence). There is probably no difference in infection rates between an iodine-based treatment compared with moist exposed burn ointment (moderate certainty evidence). It is also uncertain whether infection rates differ for SSD plus cerium nitrate, compared with SSD alone (low certainty evidence).Mortality was low where reported. Most comparisons provided low certainty evidence that there may be little or no difference between many treatments. There may be fewer deaths in groups treated with cerium nitrate plus SSD compared with SSD alone (RR 0.22, 95% CI 0.05 to 0.99; I² = 0%, 2 studies, 214 participants) (low certainty evidence).

AUTHORS' CONCLUSIONS

It was often uncertain whether antiseptics were associated with any difference in healing, infections, or other outcomes. Where there is moderate or high certainty evidence, decision makers need to consider the applicability of the evidence from the comparison to their patients. Reporting was poor, to the extent that we are not confident that most trials are free from risk of bias.