Topical steroids in burn patients: A systematic review of the literature and a descriptive analysis of topical KENACOMB® use at a major tertiary burn centre

Background

Topical steroids are used widely to manage excessive inflammation and hypergranulation in burns; however, their use is controversial, and current evidence is largely anecdotal. Topical KENACOMB is a steroid preparation consisting of triamcinolone acetonide, neomycin, gramicidin, and nystatin, and it is standard of care at the Royal Brisbane and Women's Hospital burns unit. To our knowledge, there is no published literature that reports the use of KENACOMB to treat wound-associated inflammation and hypergranulation.

Objective

To synthesise current evidence surrounding the efficacy and safety of topical steroid use in treating inflammation and hypergranulation in burns patients. We also describe the use of topical KENACOMB in our burns unit.

Methods

A systematic review of PubMed, Cochrane, and EMBASE databases was performed. Articles published in English that reported the use of topical steroids for granulation tissue or inflammation in burn wounds or skin graft donor sites were included.

Results

We identified 350 articles, of which six met inclusion criteria. Four studies presented primary patient data, and two studies reported the results of surveys of burns unit professionals. A total of 54 patients were included across all studies, and no control group was reported in any study. Studies reported rapid improvements in healing, with 86.6%–100% of wounds showing complete reepithelialisation following treatment. Reported adverse outcomes included skin thinning, atrophy of granulation tissue, systemic side effects, and local wound infection.

Conclusions

This review highlights the paucity of conclusive evidence on the outcomes of topical steroids in treating inflammation and hypergranulation in burns and donor sites. While KENACOMB has shown efficacy in treating these wound types in our local experience, there is limited research available on the product. There is a clear need for quality research on the use of topical steroids in burns patients to better inform its ongoing clinical use.

Hypertrophic granulation wounds treated with silver nitrate sticks or with topical steroid: Rate of wound closure

Hypertrophic granulation (HG) is abnormal granulation tissue raised above the level of surrounding intact skin, and is thought to delay wound healing. Effective treatment to eliminate HG could speed healing, but this is not well studied. Two common treatments are chemical cautery with silver nitrate, and use of topical steroid. In a Midwestern burn and wound clinic, both of these treatments are employed. A quality improvement project compared wound size reduction for HG wounds undergoing the two treatment modalities. Retrospective chart review identified HG wounds treated during a one-year period, and compared wound size prior to and after one month of treatment (length, width and surface area). Results were presented to the clinic staff, and one year later the quality assurance project was repeated. The initial audit found data on 18 patients treated with silver nitrate cautery, and 16 patients treated with 1% hydrocortisone cream. Median length and width was decreased by 5 mm with silver nitrate cautery treatment, and by 14 mm with 1% hydrocortisone treatment (p<.05). The repeat audit one year later found 10 patients treated with silver nitrate, and 38 treated with hydrocortisone. Median length and width decreased by 0 and 2 mm respectively for silver nitrate cautery treatment, and 15 and 10 mm for 1% hydrocortisone treatment (p<.05). In conclusion, this uncontrolled review suggests faster healing in HG wounds treated with 1% hydrocortisone compared with those treated with silver nitrate cautery. Confirmation with controlled and randomized studies is warranted.