Results of an Internet Survey on the Treatment of Partial Thickness Burns, Full Thickness Burns, and Donor Sites:

Spincare System Demonstrates Safety and Efficacy in Treating Partial-Thickness Burns

Partial-thickness burns are the most common form of burns, affecting the dermis and possibly resulting in scarring and infection. The Spincare System is a new device that uses electrospinning technology to create a temporary skin-like matrix that can be applied to wounds. This study evaluated the performance, safety, and efficacy of Spincare in treating superficial to partial-thickness burns not considered for surgery. A prospective single-arm, open-label, multicenter study was conducted in 3 adult burn units across Israel. Forty-four patients with superficial to intermediate burns of up to 10% of TBSA were enrolled. Spincare was applied to the wounds, and follow-up visits were performed on days 7, 14, and 21 and months 3 and 6 posttreatment. Thirty-one patients with 36 wounds completed the day 21 visit. The mean wound healing area on day 21 was 97.26 ± 9.41%, and the mean healing time was 12.8 ± 4.3 days. Only one moderate adverse event was observed concerning the treatment, and it is important to acknowledge the potential progression of this hypertrophic scar into a keloid. This study demonstrated that Spincare is a safe and effective device for treating superficial to intermediate partial-thickness burns. Spincare achieved rapid and complete wound healing with a low incidence of adverse events.

Fat Grafting and Regenerative Medicine in Burn Care

Regenerative therapies such as fat grafting and Platelet Rich Plasma (PRP) have emerged as new options to tackle burn-related injuries and their long-term sequelae. Fat grafting is able to promote wound healing by regulating the inflammatory response, stimulating angiogenesis, favoring the remodeling of the extracellular matrix, and enhancing scar appearance. PRP can enhance wound healing by accelerating stages including hemostasis and re-epithelization. It can improve scar quality and complement fat grafting procedures. Their cost-effectiveness, minimal invasiveness, and promising results observed in the literature have made these tools as therapeutic candidates. The current evidence on fat grafting and PRP in acute and reconstructive burns is described and discussed in this study.

Consensus on the treatment of second-degree burn wounds (2024 edition)

Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

Phytochemical-Based Nano-Pharmacotherapeutics for Management of Burn Wound Healing

Medicinal plants have been used since ancient times for their various therapeutic activities and are safer compared to modern medicines, especially when properly identifying and preparing them and choosing an adequate dose administration. The phytochemical compounds present in plants are progressively yielding evidence in modern drug delivery systems by treating various diseases like cancers, coronary heart disease, diabetes, high blood pressure, inflammation, microbial, viral and parasitic infections, psychotic diseases, spasmodic conditions, ulcers, etc. The phytochemical requires a rational approach to deliver the compounds to enhance the efficacy and to improve patients’ compatibility. Nanotechnology is emerging as one of the most promising strategies in disease control. Nano-formulations could target certain parts of the body and control drug release. Different studies report that phytochemical-loaded nano-formulations have been tested successfully both in vitro and in vivo for healing of skin wounds. The use of nano systems as drug carriers may reduce the toxicity and enhance the bioavailability of the incorporated drug. In this review, we focus on various nano-phytomedicines that have been used in treating skin burn wounds, and how both nanotechnology and phytochemicals are effective for treating skin burns.

Advances in the use of electrospun nanofibrous polymeric matrix for dermal healing at the donor site after the split-thickness skin graft excision: a prospective, randomized, controlled, open-label, multicenter study

Dressings used to manage donor site wounds have up to 40% of patients experiencing complications that may cause suboptimal scarring. We evaluated the efficacy and safety of a portable electrospun nanofibrous matrix that provides contactless management of donor site wounds compared with standard dressing techniques. This study included adult patients who underwent an excised split-thickness skin graft with a donor site wound area of 10-200 cm 2. Patients were allocated into two groups; i.e., the nanofiber group managed with a nanofibrous polymer-based matrix, and the control group managed using the standard of care such as Jelonet® or Biatain® Ibu dressing. Primary outcomes were postoperative dermal healing efficacy assessed by Draize scores. The time to complete re-epithelialization was also recorded. Secondary outcomes included postoperative adverse events, pain, and infections during the first 21-days and extended 12-month follow-up. The itching and scarring were recorded during the extended follow-up (months 1,3,6,9,12) using Numerical-Analogue-Score and Vancouver scores, respectively. The nanofiber and control groups included 21 and 20 patients, respectively. The Draize dermal irritation scores were significantly lower in the nanofiber vs. control group (Z=-2.509; P=0.028) on the first postoperative day but became similar afterward (Z≥-1.62; P≥0.198). In addition, the average time to re-epithelialization was similar in the nanofiber (17.9±4.4 days) and control group (18.3±4.5 days) (Z=-0.299; P=0.764), so were postoperative adverse events, pain, and infection incidence, itching and scarring. The safety and efficacy of electrospun nanofibrous matrix are similar to standard wound care allowing its use as an alternative donor site dressing following the split-thickness skin graft excision.

Clinical Impact of Cryopreservation on Split Thickness Skin Grafts in the Porcine Model

Vital, genetically engineered, porcine xenografts represent a promising alternative to human cadaveric allografts (HCA) in the treatment of severe burns. However, their clinical value would be significantly enhanced if preservation and long-term storage-without the loss of cellular viability-were feasible. The objective of this study was to examine the direct impact of cryopreservation and the length of storage on critical in vivo and in vitro parameters, necessary for a successful, potentially equivalent substitute to HCA. In this study, vital, porcine skin grafts, continuously cryopreserved for more than 7 years were compared side-by-side to otherwise identically prepared skin grafts stored for only 15 minutes. Two major histocompatibility complex (MHC)-controlled donor-recipient pairs received surgically created deep-partial wounds and subsequent grafting with split-thickness porcine skin grafts, differentiated only by the duration of storage. Clinical and histological outcomes, as well as quantification of cellular viability via a series of 3-4,5-dimethylthiazol-2-yl]-2,5 diphenyltetrazolium bromide (MTT) assays, were assessed. No statistically significant differences were observed between skin grafts cryopreserved for 15 minutes vs 7 years. Parametric distinctions between xenografts stored for short- vs long-term durations could not be ascertained across independent clinical, histological, or in vitro evaluative methods. The results of this study validate the ability to reliably preserve, store, and retain the essential metabolic activity of porcine tissues after cryopreservation. Plentiful, safe, and readily accessible inventories of vital xenografts represent an advantageous solution to numerous limitations associated with HCA, in the treatment of severe burns.

Histological Studies on a Newly Isolated Bacillus subtilis D10 Protease in the Debridement of Burn Wound Eschars Using Mouse Model

Background: Proteases are among the most important industrial enzymes, playing a critical role in the physiological, biochemical, and regulatory processes of all living organisms. This study evaluated the histological effects of a Bacillus subtilis D10 protease in combination with the antibacterial ointment silver sulfadiazine (SSD) on the burned skin of mice. Materials and Methods: The bacterial proteolytic enzyme was produced and purified through DEAE-Sepharose CL-6B and Sephadex G-100 FF. The in vitro protease specificity was then determined. The dorsal skin of albino mice was burned with 80% HCl solution, then treated under three conditions: cold cream, SSD, and SSD combined with the tested protease. After 15 days of daily treatment, the mice were sacrificed and skin tissue samples were histopathologically examined using hematoxylin eosin, and Masson trichrome staining. Results: The D10 protease hydrolyzed the proteinaceous components of eschars (fibrin, normal collagen, and denatured collagen) in vitro. Mice skins treated with protease and SSD mixture showed promising results, with more rapid healing than the other treatments. This group regenerated epidermis and dermis with newly formed granulated follicles, fibroblasts and blood capillaries in the dermis, and collagen fibers in the hypodermis. Conclusions: These results suggest that the serine protease produced by B. subtilis D10 promotes wound healing of mice skin burnt with HCl and restores the normal architectural pattern in a shorter time than the standard treatments.

The treatment of paediatric burns with concentrated surfactant gel technology: a case series

Objective:

To assess the safety and efficacy of a surfactant-based technology for the management of burns.

Method:

In a retrospective review, paediatric patients with different types of burns were treated with the gel technology. In some patients, the treatment was combined with a topical antimicrobial agent. Primary objectives of the review were the assessment of healing, healing times and ease of use of the material.

Results:

The wounds of 15 paediatric patients with different types of burns, particularly with regard to depth and anatomical location, were evaluated using a retrospective chart review. It was found that the surfactant gel technology, with or without the topical antimicrobial agent, assisted in autolytic debridement, and that time to re-epithelialisation was short and within the range of those obtained with other established treatments.

Conclusion:

The number of patients and wounds in this evaluation is small but the study indicates that the gel technology provides a safe and effective way to treat smaller burns in paediatric patients.

Burn injury

Burn injuries are under-appreciated injuries that are associated with substantial morbidity and mortality. Burn injuries, particularly severe burns, are accompanied by an immune and inflammatory response, metabolic changes and distributive shock that can be challenging to manage and can lead to multiple organ failure. Of great importance is that the injury affects not only the physical health, but also the mental health and quality of life of the patient. Accordingly, patients with burn injury cannot be considered recovered when the wounds have healed; instead, burn injury leads to long-term profound alterations that must be addressed to optimize quality of life. Burn care providers are, therefore, faced with a plethora of challenges including acute and critical care management, long-term care and rehabilitation. The aim of this Primer is not only to give an overview and update about burn care, but also to raise awareness of the ongoing challenges and stigmata associated with burn injuries.

The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample

BACKGROUND

Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.

METHODS

Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.

RESULTS

After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).

CONCLUSIONS

Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.

Use of a novel chitosan-based dressing on split-thickness skin graft donor sites: a pilot study

OBJECTIVE

Split-thickness skin graft (STSG) donor site dressings can play an integral role in reducing donor site morbidity. This study tested a novel, chitosan-based wound dressing, Opticell Ag, as an STSG donor site dressing for wounds <10% total body surface area (TBSA).

METHOD

Between January and December 2016, the chitosan-based dressing was placed on participating patients' donor sites immediately following graft harvest and covered with a transparent occlusive dressing. Pain was evaluated on postoperative day one, before dressing change between days 5-7, and before and after dressing removal between days 10-14 using the Visual Analog Scale (VAS). The extent of re-epithelialisation was determined between day 10-14 and at one month, and healing quality was also evaluated at one month post-operatively using the Vancouver Scar Scale (VSS).

RESULTS

A total of 19 patients were recruited, of which 16 completed the study. Patients experienced mild-to-moderate pain in their donor sites when the chitosan-based dressing was used. Pain decreased significantly between postoperative day one and days 10-14, as well as between days 5-7 and 10-14. The mean percentage of re-epithelialisation on days 10-14 was 92% and by one month was 99%. The mean VSS at one month was 3.2±1.4. There were no statistically significant differences between patients' re-epithelialisation rates or VSS scores. There were unplanned dressing changes in four patients. No donor site infections or other adverse events were identified.

CONCLUSION

The chitosan-based dressing tested in this study is safe, effective, and associated with reasonable pain control and acceptable healing quality. The results suggest that it is a promising STSG donor site dressing.

Postsurgical Treatment of Split Skin Graft Donor Sites in Dermatological Departments

The surgical removal of split skin grafts (SSGs) leads to superficial wounds that can be covered with different wound dressings. Currently, international guidelines that recommend a standard treatment of the donor sites are not yet established. We developed a questionnaire to evaluate the treatment of SSG donor sites and sent it to all dermatological departments in Germany. Altogether 78 of the 115 contacted departments in Germany participated in our cross-sectional trial. Our analysis reveals that multiple wound dressings with different frequencies of replacement are used. On an average, complete reepithelialization of the donor site takes 14-21 days. Foams and coated gauzes are used in 73% of all surgical procedures for postsurgical treatment of SSG donor sites. Still, neither a significant faster reepithelialization nor a lower rate of wound healing disorders can be assigned to any of the wound dressings. The results of our study indicate that a large number of wound care products and treatment strategies are currently applied on SSG donor sites in dermatological departments in Germany. The selection of the wound dressing is not based on scientific data but rather on the experience of individual experts.

Variations in Burn Excision and Grafting: A Survey of the American Burn Association

It is unknown whether variations in burn care affect outcomes or affect the success of emerging therapeutics. The purpose of this study was to assess burn surgeons' preferences in excision and grafting to determine if surgical technique affects outcomes. A 71-item survey evaluating skin grafting techniques and preferences was emailed to members of the American Burn Association in July and August 2015. The survey was anonymous and voluntary. Relationships between variables were evaluated using Fisher's exact test. A P-value of ≤.05 was deemed statistically significant. The survey was sent to 607 burn surgeons, and the response rate was 24%. Clinical judgment is the most widely used method to determine depth of injury. Surgeons who practice in the United States and surgeons who are board certified in general surgery are more likely to determine depth of the burn based on clinical judgment alone (P < .001). Fifty-six percent of surgeons will perform excision as early as postburn day 1 and 73% will excise greater than 20% TBSA in one setting. Surgeons at centers with bed number of ≤10 (P = .024) or surgeons with board certification in plastic surgery (P = .008) are more likely to excise deep partial-thickness burns with an attempt to retain viable dermis. Geographic location, board certification, and burn unit size all contribute to variations in practice. Strong individual preferences make standardization of therapies challenging and may affect the success of new technologies. Burn surgery continues to be an art as much as a science, and accurate documentation of techniques and outcomes is essential for optimizing successes and documenting failures of new treatment methods.

Immediate Regrafting of the Split Thickness Skin Graft Donor Site Assists Healing

BACKGROUND

Delayed or even lack of healing of a split-thickness skin graft (STSG) donor site is a potential problem with elderly patients or those with poor wound healing capabilities. A proactive solution that may minimize this risk is to regraft that donor site using otherwise discarded skin graft remnants.

METHODS

A prospective, nonrandomized, consecutive study was designed to compare the time to healing of the commonly used anterior thigh STSG donor site in patients who had routine dressings (n = 113) versus those with comorbidities known to adversely affect wound healing and had planned regrafting (n = 204). Those comorbidities included age (≥65 years), diabetes mellitus, peripheral vascular disease, chronic renal disease, and chronic steroid use.

RESULTS

The average number of comorbidities in the regrafted subgroup versus those not regrafted was 1.41 and 0.31, respectively. This was considered to be a significant difference (P < 0.0001) confirming the validity in predicting patients at risk for adverse donor-site healing that would benefit by regrafting. The mean time required for donor-site reepithelialization of those regrafted was 17.2 days compared with 17.8 days for those not regrafted (P = 0.2395), which was not significantly different.

CONCLUSIONS

Regrafting the STSG donor site of patients with known comorbidities, that is, those expected to have delayed healing in general, had a mean time to reepithelialization comparable with conventionally treated individuals. This was considered a direct consequence of recycling rather than discarding any excess skin graft materials when so indicated and can be a proactive solution to a potentially cumbersome dilemma.

Cytotoxicity testing of burn wound dressings: first results

Topical antimicrobial therapy represents an essential part of burn wound care. In order to prevent and treat burn wound infection dressings with antimicrobial properties are applied directly on the wound surface. Not only the infection control but also promotion of healing is very important in burn wound management. It is well known, that a dressing in bactericidal concentration might also delay wound healing. This study was aimed to evaluate the potential toxic effect of topical antimicrobial agents on murine and human dermal cells. For toxicity testing the method by Vittekova et al. was used to evaluate potential toxic effects of 16 agents and 6 control samples on two in vitro cultured cell systems [3T3 cells and dermal fibroblasts] during the first 24 h. Following the 24 h cell culture with the tested agents the live cell counts were evaluated. According to results obtained on both cell systems, the tested samples were divided into three groups-nontoxic, semi-toxic and toxic. Nontoxic samples included Acetic acid 1%, Acticoat^®, Dermacyn^®, Framykoin^®, Silverlon^®, gauze, acellular human allodermis and acellular porcine xenodermis. Semi-toxic group included Algivon^®Plus, Aquacel^®Ag, Betadine^®, Nitrofurazone, Octenisept^®, Suprasorb^® A and a porcine dermal scaffold Xeno-Impl. Finally, the toxic group included Algivon^®, Dermazin^®, Ialugen^®Plus, Prontoderm^®, Suprasorb^® A Ag and 20% SDS. As the preliminary results of this study have shown, our findings may serve as a potential guide to selection of the most appropriate topical antimicrobial dressings for treatmet of burns. However before they can be translated into clinical practice recommendations, more research on antimicrobial dressings cytotoxicity testing will be necessary.

Analysis of the microcirculation after soft tissue reconstruction of the outer ear with burns in patients with severe burn injuries

Reconstruction of soft tissue defects of the ear with burns remains one of the most difficult tasks for the reconstructive surgeon. Although numerous reconstructive options are available, the results are often unpredictable and worse than expected. Besides full and split skin grafting, local random pattern flaps and pedicled flaps are frequently utilized to cover soft tissue defects of the outer auricle. Because of the difficulty and unpredictable nature of outer ear reconstruction after burn injury, a case-control study was conducted to determine the best reconstructive approach. The microcirculatory properties of different types of soft tissue reconstruction of the outer ear with burns in six severely burned Caucasian patients (three men and three women; mean age, 46 years (range, 22-70)) were compared to those in the healthy tissue of the outer ear using the O2C device (Oxygen to See; LEA Medizintechnik, Gießen, Germany). The results of this study revealed that the investigated microcirculation parameters such as the median values of blood flow (control group: 126 AU), relative amount of hemoglobin (control group: 59.5 AU), and tissue oxygen saturation (control group: 73%) are most similar to those of normal ear tissue when pedicled flaps based on the superficial temporal artery were used. These findings suggest that this type of reconstruction is superior for soft tissue reconstruction of the outer ear with burns in contrast to random pattern flaps and full skin grafts regarding the microcirculatory aspects. These findings may improve the knowledge on soft tissue viability and facilitate the exceptional and delicate process of planning the reconstruction of the auricle with burns.

Topical antibiotic ointment versus silver-containing foam dressing for second-degree burns in swine

OBJECTIVES

Second-degree burns are very common but their management is controversial. These burns may be treated with either topical antimicrobial agents or advanced occlusive dressings; however, there is no established treatment comparator for preclinical studies. This study was designed to determine which of two commonly used comparator therapies (a silver-containing advanced dressing or a topical antibiotic ointment) resulted in faster reepithelialization and less scarring. The hypothesis was that second-degree burns treated with a topical antimicrobial ointment would heal faster and with less scarring than those treated with a silver-containing occlusive foam dressing in a porcine model.

METHODS

Deep partial-thickness burns were created on the flanks of three anesthetized female domestic pigs (20 to 25 kg) using a 150-g aluminum bar preheated in 80°C water bath and applied to the skin for 20 seconds using a force of 2 kg. The burn eschars were excised 48 hours later with an electric dermatome set at a depth of 0.75 mm. The wound beds were treated with a thin layer of triple-antibiotic petrolatum-based ointment (changed three times weekly) or a silver-containing foam dressing (changed once weekly). Full-thickness punch biopsies were obtained at 9, 11, 14, 16, 18, and 21 days for determination of percentage complete wound reepithelialization and at 28 days for measurement of scar depth.

RESULTS

At all dressing changes the wounds treated with the topical antibiotic appeared moist, while those treated with the silver-based dressings appeared dry. At day 21 all wounds treated with the ointment were completely reepithelialized, while only 55% of those treated with the silver dressing were reepithelialized (p < 0.001). Scar depth at day 28 was also significantly less in wounds treated with the topical antibiotic ointment (4.3 mm vs. 5.1 mm, difference = 0.7 mm; 95% confidence interval [CI] = 0.1 to 1.4 mm). There was less scar contraction in wounds treated with the topical antibiotic compared with the silver-based dressing (mean ± SD = 25.0% ± 14.6% vs. 38.9% ± 16.9%, difference = 13.9%; 95% CI = 5.7% to 22.0%).

CONCLUSIONS

In this model of excised deep partial-thickness burns, a triple-antibiotic ointment enhanced reepithelialization and reduced scar depth and contraction compared with a silver-based foam dressing. This triple-antibiotic ointment should be considered as a control for studies evaluating novel topical burn therapies.

Evaluation of Six Split-thickness Skin Graft Donor-site Dressing Materials in a Swine Model

Background:

Numerous dressings for split-thickness skin graft donor sites are commercially available with no conclusive evidence-based consensus regarding the optimal dressing choice. This study was conducted to identify which of 5 commonly used materials promotes wound healing most effectively for use on split-thickness donor sites in comparison with our standard dressing, Xeroform (petrolatum gauze).

Methods:

Twenty-four partial-thickness wounds were created on the backs of 4 pigs using a dermatome. Wounds (n = 4 per dressing type per pig) were treated with Xeroform, Opsite (polyurethane film), Kaltostat ( calcium sodium alginate), DuoDERM (hydrocolloid), Aquacel (hydrofiber), and Mepilex (silicone foam). Full-thickness skin samples were excised at 3 or 5 days and evaluated histologically for reepithelialization and inflammation. Comparisons also included incidence of infection, ease of use, and cost analyses.

Results:

DuoDERM elicited the greatest percent reepithelialization (81%) and Mepilex the lowest (33%) after 3 days (P = 0.004). All dressings demonstrated complete reepithelialization except Mepilex (85%) at 5 days. There were no infections and inflammation was mild among all treatments. Mepilex was easiest to use, whereas Aquacel, Kaltostat, and Opsite were most difficult (P = 0.03). Xeroform was most cost-effective and Aquacel most expensive. Combined scoring revealed DuoDERM = Xeroform > Opsite = Mepilex > Kaltostat > Aquacel.

Conclusions:

DuoDERM and Xeroform were most effective overall. DuoDERM tended to outperform all dressings in reepithelialization at 3 days, while Xeroform was least expensive, easy to use, and demonstrated rapid reepithelialization. These findings suggest that Xeroform may be preferred for use on large donor-site areas. DuoDERM may be more appropriate for small donor sites when healing time is a priority.

Porcine xenografts vs. (cryopreserved) allografts in the management of partial thickness burns: is there a clinical difference?

Porcine xenografts and cryopreserved allografts are used for the management of partial thickness burns and both biological materials have strong advocates with regard to clinical performance, the possibility of disease transfer from donor to recipient and other clinical aspects. A literature analysis was performed in an attempt to investigate whether true (statistically significant) differences exist on clinical performance and on other determinants for use. Comparing the results of this study with a similar, previously published study performed on possible differences amongst different types of allograft in the management of partial thickness burns, both allografts and porcine xenograft seem to perform equally well clinically with regard to healing related outcomes. In addition, the risk of disease transfer, in real life, was shown to be minimal. Consequently, clinical aspects being equal, other aspects such as price and availability should be used to decide which material to use for the management of partial thickness burns.

Randomized clinical trial of donor-site wound dressings after split-skin grafting

Background

The aim was to study which dressing material was best for healing donor-site wounds (DSWs) after split-skin grafting as there is wide variation in existing methods, ranging from classical gauze dressings to modern silicone dressings.

Methods

This 14-centre, six-armed randomized clinical trial (stratified by centre) compared six wound dressing materials in adult patients with DSWs larger than 10 cm2. Primary outcomes were time to complete re-epithelialization and pain scores measured on a visual analogue scale (VAS) over 4 weeks. Secondary outcomes included itching (VAS, over 4 weeks), adverse events and scarring after 12 weeks rated using the Patient and Observer Scar Assessment Scale (POSAS).

Results

Between October 2009 and December 2011, 289 patients were randomized (of whom 288 were analysed) to either alginate (45), film (49), gauze (50), hydrocolloid (49), hydrofibre (47) or silicone (48) dressings. Time to complete re-epithelialization using hydrocolloid dressings was 7 days shorter than when any other dressing was used (median 16 versus 23 days; P &lt; 0·001). Overall pain scores were low, and slightly lower with use of film dressings (P = 0·038). The infection rate among patients treated with gauze was twice as high as in those who had other dressings (18 versus 7·6 per cent; relative risk 2·38, 95 per cent confidence interval 1·14 to 4·99). Patients who had a film dressing were least satisfied with overall scar quality.

Conclusion

This trial showed that use of hydrocolloid dressings led to the speediest healing of DSWs. Gauze dressing should be discontinued as they caused more infections. Registration number: NTR1849 (http://www.trialregister.nl).

Burn wound care

The goals of burn wound care are removal of nonviable tissue, prevention of infection, and facilitation of wound healing, while controlling pain and maximizing outcome. This article reviews the basic pathophysiology of burn wounds; describes the evaluation of the depth, location, and extent of the wound; and discusses the myriad of wound care products on the market including their strengths and weaknesses. This article guides the reader through wound assessment and designing the appropriate treatment plan.

Preservation methods of allografts and their (lack of) influence on clinical results in partial thickness burns

Allografts, cadaver skin and amnion membrane are considered the golden standard in the management of partial thickness burns. However, debate on whether the tissue needs to be viable is on-going, since many believe that viable grafts result in better healing. The objective of this literature survey was to analyse the evidence on the method of preservation of allografts (cadaver skin or amnion membrane, glycerol, cryopreservation, lyophilisation) having a clinical impact on the healing of partial thickness burns. The survey focussed on preservation techniques and clinical outcomes (reepithelialisation) in partial thickness burns, as well as on differences in viability, immunogenicity and antimicrobial properties of the preservation methods. Most studies on allograft treatment of partial thickness burns are observational, with only one study of a (historical) comparative nature. A true meta-analysis was not performed and the results of this survey are observational in nature as well: they indicate that there is no evidence that viability of the graft influences healing outcomes. Thus, instead of viability, other aspects, such as intrinsic antimicrobial safety of the preservation method and cost should be the primary criteria for the choice of preservation method to be used for allografts.

Is the red-yellow-black scheme suitable to classify donor site wounds? An inter-observer analysis

BACKGROUND

The red-yellow-black-scheme (RYB) is a well-known and validated scheme to classify chronic and acute wounds, based on wound color and moistness. We investigated whether this RYB-scheme is also useful to classify donor site wounds uniformly (DSW).

METHODS

Twenty-three digital photographs of DSWs in various stages of wound healing were presented to internationally renowned wound scientists (n=11), surgical doctors (n=31), specialized wound nurses (n=55), and surgical nurses (n=28). These observers classified the color and moistness of the wound according to the RYB-scheme, yielding seven wound categories. Inter-observer agreement (IOA) was expressed as a kappa (κ) value.

RESULTS

IOA's among specialized wound nurses were moderate when based on wound color and moistness (κ=0.41; 95% CI 0.33-0.49), wound color only (κ=0.41; 95% CI 0.29-0.53), or moistness only (κ=0.54; 95% CI 0.45-0.64). However, these IOA's tended to be better than those among the scientists, doctors and nurses. Scientists showed the lowest agreement (k-values between 0.17 and 0.25). Doctors scored slightly better than nurses.

CONCLUSION

Clinicians and scientists have difficulty with classifying DSWs by means of the RYB-scheme. Therefore, this scheme does not appear useful to classify donor site wounds in a uniform manner.

Systematic review of skin graft donor-site dressings

BACKGROUND

Debate continues about what split-thickness skin graft donor-site dressing provides the best outcomes for patients at the lowest cost. The goal of this systematic review was to determine which donor-site dressings are associated with the best outcomes for the following: pain, infection rate, healing quality, healing rate, quality of life, and cost.

METHODS

A comprehensive literature review and assessment was undertaken by two independent reviewers. Articles were selected using specific inclusion criteria. Split-thickness skin graft donor-site dressings were classified as either moist or nonmoist based on the state of the dressing upon initial application. Methodological quality of randomized controlled trials was assessed using the Jadad scale.

RESULTS

Seventy-five relevant articles were included in the final analysis, three of which were review articles. The most commonly measured outcome was healing rate (64 of 72), followed by pain (58 of 72), infection rate (40 of 72), healing quality (40 of 72), and cost (15 of 72). No studies measured quality of life. The majority of articles were randomized controlled trials (35 of 75), followed by observational studies (22 of 75), unsystematic clinical observations (15 of 75), and review articles (three of 75). It was difficult to compare moist and nonmoist dressings in this review because of the methodological heterogeneity of the included articles. The available evidence suggests, however, that moist dressings are superior in terms of pain.

CONCLUSIONS

Some weak evidence exists that supports "wet dressings." To determine the best split-thickness skin graft donor-site dressing, more methodologically sound randomized controlled trials are needed. Trials with parallel economic evaluations should be undertaken to answer this question.

The use of Urgotul in the treatment of partial thickness burns and split-thickness skin graft donor sites: a prospective control study

The use of paraffin-impregnated gauze for burns and skin graft donor sites is commonly associated with wound adherence with consequent pain and trauma upon removal. This prospective clinical study was performed to evaluate a new class of lipido-colloid dressings (Urgotul) in promoting healing and in reducing tissue adherence. In a 6-month period, 25 consecutive patients were recruited. Two separate burn or donor sites on each patient were dressed with tulle-gras (TG) or Urgotul and covered with standard secondary dressings. Objective assessment of wounds by two reviewers, and patients' subjective assessments were recorded. Twenty-three (92%) patients were followed up for a mean of 3 months. Mean time to complete epithelialisation was 9.6 and 11.9 days for the Urgotul and TG sites respectively (P < 0.05). Bleeding was seen in 52% of Urgotul sites compared with 100% of the TG sites at first dressing change (P < 0.05). Patients reported 'moderate pain' during dressing change in 22% and 57% in the Urgotul and TG groups respectively (P < 0.05), with 35% of TG sites being 'very painful' requiring extra analgesia. We found that compared with TG, Urgotul was associated with faster epithelialisation, less pain and trauma (bleeding) during dressing changes.

Procutase versus 1% silver sulphadiazine in the treatment of minor burns

The purpose of this randomised comparative study was to evaluate the use of silver sulphadiazine (SSD) 1% cream (Group A) with the use of Procutase (Group B) in treating burns with a TBSA <10% and a depth not greater than 2nd degree burns and thus suitable for outpatient management. The two groups were similar in age, gender, race, and extent of burn. Procutase is an ionic hydrogel composed of natural hydrophilic polymers in an active ionic solution with an inhibitor of matrix metalloproteinases MMP-1, -3 and -9 (collagenase/gelatinase). Subjects were seen in follow-up biweekly, and wounds of patients in SSD group were compared with those of Procutase group for healing time, pain score at dressing change, compliance with therapy and complication rate. The result of this study showed that Procutase treated patients had statistically significantly less pain and shorter wound healing time. Procutase can be used successfully in patients with burns that do not require hospital admission.