Helping Thermal Burns Heal With Nutrient-Rich Skin Care

Burns are the fourth most common injuries worldwide,¹ and it’s estimated that more than 6 million people per year experience burn injuries.² Although the overall prevalence for burns continues to decrease and treatments continue to improve, the prevention of scarring has not improved.^2,3 There has also been an increase in the incidence of burn injuries among the elderly.⁴ In addition, burn injuries among patients living with diabetes is significant,⁵ and infection continues to be an important problem in the treatment of burns. The emotional and psychological distress resulting from burns can be substantial as well.^5-7

More than 500,000 people in the United States visit emergency departments for burns each year.^2,8 Thermal burns from fire and scalds from steam account for approximately 80% of burns.⁹ According to the American Burn Association, the breakdown of different thermal burns that commonly occur, based on hospital admissions, is 44% from fire injury, 33% from scald injury, and 9% from injury with hot objects.¹⁰ The severity of a burn injury is related to its depth and the percentage of the total body surface area affected. The depth of the burn is dependent upon the temperature of the heat source and the amount of time the skin is in contact with that source.¹¹ Burn depth is classified in the following manner: 

• Erythema (first degree) involving only the epidermis, skin that’s moist and pink or red that’s perfused (indicated by blanching with applied pressure);
• Superficial partial thickness (second degree) involving the epidermis and upper dermis; or 
• Full thickness (third degree) involving epidermis, dermis, and damage to appendages.^8,12 

Minor burn wounds include first- and second-degree burns that affect less than 15% of the total body surface. Most minor burns occur in the home, with less than 5% requiring hospital treatment.¹² 

Burn Management In The Wound Clinic

More than 95% of burn wounds can be successfully managed in the outpatient setting. The objectives of burn management include fast healing, pain control, and restoration of full function and aesthetics to the damaged area.⁸ Burns over joints affect the patient’s range of motion, which may be exacerbated later by scarring.¹⁰ Another challenge is a compromised immune system that may be related to obesity, aging, diabetes, cancer, chemotherapy, or other medications, including systemic steroids, which can delay wound healing and increase the risk of infection.^{6, 13-15} Immune suppression in burn patients has been attributed to the presence of reactive oxygen species that can lead to oxidative stress.¹⁶ As delineated in an important burn model, a burn wound can be divided into three zones based on tissue damage and changes in blood flow. The central part of the wound is the zone of coagulation that is exposed to the greatest amount of heat. Skin proteins (and other proteins) denature at temperatures above 100^o F, and heat at these temperatures results in coagulation and tissue necrosis. Oxidative stress probably plays a key role in the necrosis since antioxidant treatment has been shown to decrease burn necrosis. Surrounding this central zone of coagulation is a zone of stasis or ischemia characterized by decreased perfusion; the outermost zone of hyperemia receives increased blood flow by inflammatory vasodilation.⁹

Decreasing Oxidative Stress & Inflammation

Inflammation is important for burn wound healing (as with all wound healing), but can also lead to pruritus.^9,17 Edema initiated by vasodilation, extravascular osmotic activity, and increased microvascular activity often corresponds with inflammation. Unfortunately, excess edema and inflammation can exacerbate pain.⁹ In addition, prolonged oxidative stress and inflammation can lead to impaired wound healing.^9,16 Topical small molecule technology (found in AtHome^™ Viniferamine^® skin and wound care products, McCord Research, Coralville, IA) has been used to improve burn wound outcomes. 

Many ingredients found in Viniferamine skin products counteract oxidative stress, including the important small molecule polyphenols oleuropein, resveratrol, and epigallocatechin-3-gallate (EGCG) from olives, grapes, and green tea, respectively, as well as L-carnosine, melatonin, and L-glutathione.^18-23 Several of these ingredients also decrease inflammation, including oleuropein, resveratrol, EGCG, melatonin, carnosine, and L-glutathione.^{18,20,21,24-26} In addition, asiaticoside in titrated extracts of Centella asiatica, dipotassium glycyrrhizate from licorice, avenanthramides in oats, aloe vera, panthenol, and shea butter possess anti-inflammatory activities.^27-32 

Reducing the Risk of Bacterial & Fungal Infections

Damage to the skin barrier that occurs with burns disrupts the innate immune system and increases susceptibility to bacterial and fungal infections.^7,9 Some common pathogens found in burn wounds include Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas aeruginosa, and Acinetobacter and Klebsiella species,⁸ as well as the fungus Candida albicans.⁶ In fact, the use of broad-spectrum antibiotics during the treatment of burns leads to the elimination of the natural skin bacterial flora and the enhancement of opportunistic species.⁷ In addition, old age, obesity, and diabetes causes patients to be more susceptible to bacterial or fungal infections.^5,6,7,13

The AtHome Antifungal Skin Care Kit can help burn patients who are at risk for fungal skin infections. The antifungal cream included in the kit contains miconazole, which has a long-standing history of successful use against fungal infections, including C. albicans skin infections. Topical miconazole is well tolerated and has the added advantage of delivering the active compound to the desired area without systemic effects that oral antifungal medications have.³³ In addition, the Viniferamine small molecule ingredients oleuropein, resveratrol, and EGCG have antifungal activities.^34-41 In fact, in one study, an olive leaf extract with oleuropein as its major component exhibited antifungal activity against C. albicans.³⁴ Other studies have demonstrated that resveratrol has inhibitory and fungicidal activity against C. albicans, including the induction of apoptosis (programmed cell death).^35-38 EGCG has been shown to inhibit the growth of C. albicans, including biofilm formation.^39,40 In addition, EGCG has been found to synergistically enhance the antifungal effects of miconazole, including activity against C. albicans biofilms.⁴¹ Moreover, oat extract found in the antifungal cream includes avenanthramides that possess antifungal activities.⁴² The kit also includes an antiseptic skin cleanser that contains benzalkonium chloride, which is a gentle, broad-spectrum antimicrobial.⁴³

Enhancing Immune Function, Improving Wound Healing, Reducing Scarring

Burn patients who live with diabetes are particularly at risk for infections such as cellulitis due to compromised immune systems and reduced peripheral sensations and circulation.^5,6 In addition, numerous reports of diabetic foot burns from electric heating pads, foot spas, and water baths have been documented due to reduced sensations.⁵ Burns to the feet can cause significant complications because of the specialized anatomy found in that area of the skin. For example, glabrous skin on the sole of the foot has a thicker epidermis and a compact, less elastic dermis that is difficult to restore after injury, which may be exacerbated by impaired wound healing that is common with diabetes.^14,44

Elderly patients are another growing population with increased susceptibility to burn injuries due to thinning skin, decreased sensations, and mental alterations.⁴⁵ In addition, elderly patients often have increased skin inflammatory responses and oxidative stress.⁴⁶ Moreover, elderly patients typically have compromised immune systems and preexisting medical conditions that affect burn wound healing. Elderly patients and those living with diabetes can have increased risks of infection and chronic wounds with delayed wound healing.^14,47 Hydrogels have been used successfully to treat burns and have a high water content that produces a cooling, soothing effect on burns.⁴⁸ Aloe vera found in Viniferamine products including Wound Hydrogel and Wound Hydrogel Ag (with antimicrobial silver) has been shown to enhance wound healing and immune function.^49,50 Acemannan is a key polysaccharide found in aloe vera that stimulates macrophage activity, including killing activity against certain skin pathogens such as C. albicans. It also stimulates wound healing.^51,52 In fact, aloe vera has been shown in several studies to stimulate collagen production, which is critical for wound healing.⁵³ Hydration is vital for reducing scarring since it restores homeostasis to the scar, reducing excessive collagen deposition and excessive scar formation.⁵⁴ Aloe vera improves skin hydration by increasing levels of hyaluronic acid (HA), which has a high capacity for retaining water, and the presence of HA is likely related to reduced dermal scarring.^{50, 55,56} Keeping burn wounds moist is also important for reducing pain and promoting healing.⁸ In fact, evidence indicates that topical application of aloe vera reduces pain that accompanies burn wounds.⁵⁷ In addition, dipotassium glycyrrhizate helps maintain levels of HA in skin⁵⁸ and C. asiatica has been shown to improve burn wound healing.⁵⁹

Summary

Use of topical small molecule technology with respect to burn wound care involves providing burn-injured skin with small molecule nutrition to help strengthen damaged skin and improve wound healing. The antifungal cream and antiseptic cleanser included in the AtHome Viniferamine Antifungal Skin Care Kit can help protect burns from fungal infections and decrease the risk of bacterial infections. In addition, many of the nutritional ingredients included in Viniferamine skin and wound products have been shown to hydrate skin and reduce oxidative stress and inflammation that can lead to pruritus or excessive scarring. 

D. Elizabeth McCord, senior researcher at McCord Research, Coralville, IA, is a renowned biochemist in the field of skin and wound care. She has been awarded six patents and two medical devices, and has more than 60 health products marketed globally. She previously commercialized wound and skin care products under the Remedy^® Olivamine^® brand. Kyle D. Hilsabeck is vice president of pharmaceutical affairs at McCord Holdings and licensed by the Iowa Board of Pharmacy. He completed bachelor’s degrees in biology and biochemistry at Wartburg College and his doctorate at the University of Iowa College of Pharmacy. He completed a community pharmacy residency through the University of Iowa and taught for the University of Iowa College of Pharmacy. Nancy B. Ray is science officer at McCord Research. She currently writes and presents on diabetes, skin care, and other topics to advance skin care and wound healing awareness. She received her PhD in biochemistry and biophysics at Oregon State University and was a postdoctoral fellow at the National Institutes of Health, Harvard University, Dana-Farber Cancer Institute, and the University of Iowa. She also earned bachelor’s degrees in chemistry and microbiology from the University of Montana.

References 

1. Peck MD. Epidemiology of burns throughout the world. Part I: distribution and risk factors. Burns. 2011;37:1087-1100.

2. Penn JW, Grobbelaar AO, Rolfe KJ. The role of the TGF-beta family in wound healing, burns and scarring: a review. Int J Burn Trauma. 2012; 2(1):18-28.

3. Mehta M, Branford OA, Rolfe KJ. The evidence for natural therapeutics as potential anti-scarring agents in burn-related scarring. Burns & Trauma. 2016;4(15):1-12.

4. Bezuhly M. Fish JS. Acute burn care. Plast Reconstr Surg. 2012;130(2):349e-358e.

5. Memmel H, Kowal-Vern A, Latenser BA. Infections in diabetic burn patients. Diabetes Care. 2004;27(1):229-33.

6. Sharma S, Bajaj D, Sharma P. Fungal infections in thermal burns: a prospective study at a tertiary care centre. J Clin Diagn Res. 2016;10(9); PC05-PC07.

7. Struck MF, Gille J. Fungal infections in burns: a comprehensive review. Ann Burns Fire Disasters. 2013;26(3):147-53.

8. Lloyd ECO, Rogers BC, Michener M, Williams MS. Outpatient burns: prevention and care. Am Fam Physician. 2012;85(1):25-32.

9. Rowan MP, Cancio LC, Elster EA, et al. Burn wound healing and treatment: review and advancements. Crit Care. 2015;19(243):1-12.

10. Culleiton AL, Simko LM. Caring for patients with burn injuries. Nursing. 2013;43(8): 26-34.

11. Hyland EJ, Connolly SM, Fox JA, Harvey JG. Minor burn management: potions and lotions. Aust Prescr. 2015;38(4):124-27.

12. Wasiak J, Cleland H. Burns (thermal). Clin Evid. 2009;10(1903): 1-23.

13. Goutos I, Sadideen H, Pandya AA, Ghosh SJ. Obesity and burns. J Burn Care Res. 2012;33(4):471-82.

14. Guo S, DiPietro LA. Factors affecting wound healing. J Dent Res. 2010;89(3):219-29.

15. Teah F, Pavelka N. How chemotherapy increases the risk of systemic candidiasis in cancer patients: current paradigm and future directions. Pathogens. 2016;5(6):1-16.

16. Adjepong M, Agbenorku P, Brown P, Oduro I. The role of antioxidant micronutrients in the rate of recovery of burn patients: a systematic review. Burns & Tauma. 2016;4(18):1-7.

17. Goutos I, Dziewulski P, Richardson PM. Pruritus in Burns: review article. J Burn Care Res. 2009;30(2):221-8.

18. Barbado B, Toietta G, Maggio R, et al. Effects of the olive-derived polyphenol oleuropein on human health. Int J Mol Sci. 2014;15(10):18508-24.

19. Ido Y, Duranton A, Lan F, Weikel KA, Breton L, Ruderman NB. Resveratrol prevents oxidative stress-induced senescence and proliferative dysfunction by activating the AMPK-FOXO3 cascade in cultured primary human keratinocytes. PLOS ONE. 2015; 10(2):1-18.

20. Oyetakin White P, Tribout H, Baron E. Protective mechanisms of green tea polyphenols in skin. Oxid Med Cell Longev. 2012; doi:10.1155/2012/560682. Epub 2012. 

21. Reddy VP, Garrett MR, Perry G, Smith MA. Carnosine: a versatile antioxidant and antiglycating agent. Sci Aging Knowl Environ. 2005;(18):pe12.

22. Fischer TW, Slominski A, Zmijewski MA, Rester RJ, Paus R. Melatonin as a major skin protectant from free radicals to DNA damage repair. Exp Dermatol. 2008;17(9): 713-30.

23. Kopal C, Deveci M, Ozturk S, Sengezer M. Effects of topical glutathione treatment in rat ischemic wound model. Ann Plast Surg. 2007;58(4):449-55.

24. Guo R, Liu B, Wang K, Zhou S, Li W, Xu Y. Resveratrol ameliorates diabetic vascular inflammation and macrophage infiltration in db/db mice by inhibiting the NF-kB pathway. Diab Vasc Dis Res. 2014;11(2):92-102.

25. Hardeland R. Melatonin and the theories of aging: a critical appraisal of melatonin’s role in antiaging mechanisms. J Pineal Res. 2013;55(4):325-56.

26. Ghezzi P. Role of glutathione in immunity and inflammation in the lung. Int J Gen Med. 2011;4:105-13.

27. Rosen H, Blumenthal A, McCallum J. Effect of asiaticoside on wound healing in the rat. Proc Soc Exp Biol Med. 1967;125 (1): 279-80.

28. Ishida T, Mizushina Y, Yagi S, et al. Inhibitory effects of glycyrrhetinic acid on DNA polymerase and inflammatory activities. Evid Based Complement Altern Med. 2012; 2012:650514. Epub 2011.

29. Sur R, Nigam A, Grote D, Liebel F, Southall MD. Avenanthramides, polyphenols from oats, exhibit anti-inflammatory and anti-itch activity. Arch Dermatol Research. 2008;300(10):569-74.

30. Vogler BK, Ernst E. Aloe vera: a systematic review of its clinical effectiveness. Br J Gen Pract. 1999;49(447):823-8.

31. Proksch E, Nissen HP. Dexpanthenol enhances skin barrier repair and reduces inflammation after sodium lauryl sulphate-induced irritation. J Dermatol Treat. 2002;13(4):173-8.

32. Akihisa T, Kojima N, Kikuchi T, et al. Anti-inflammatory and chemopreventive effects of triterpene cinnamates and acetates from shea fat. J Oleo Sci. 2010;59(6):273-80.

33. Pierard GE, Hermanns-Le T, Delvenne P, Pierard-Franchimont C. Miconazole, a pharmacological barrier to skin fungal infections. Expert Opin Pharmacother. 2012; 13(8):1187-94.

34. Pereira AP, Ferreira IC, Marcelino F, et al. Phenolic compounds and antimicrobial activity of olive (Olea europaea L. Cv. Cobrançosa) leaves. Molecules. 2007;12(5)1153-62.

35. Jung HJ, Seu YB, Lee DG. Candicidal action of resveratrol isolated from grapes on human pathogenic yeast C. albicans. J Microbiol Biotechnol. 2007;17(8):1324-9.

36. Okamoto-Shibayama K, Sato Y, Azuma T. Resveratrol impaired morphological transition of Candida albicans under various hyphae-inducing conditions. J Microbiol Biotechnol. 2010; 20(5):942-5.

37. Jung HJ, Hwang IA, Sung WS, et al. Fungicidal effect of resveratrol on human infectious fungi. Arch Pharm Res. 2005;28(5):557-80.

38. Lee J, Lee DG. Novel antifungal mechanism of resveratrol: apoptosis inducer in Candida albicans. Curr Microbiol. 2015;70(3):383-9.

39. Steinmann J, Buer J, Pietschmann T, Steinmann E. Anti-infective properties of epigallocatechin-3-gallate (EGCG), a component of green tea. Br J Pharmacol. 2013; 168(5):1059-73.

40. Evensen NA, Braun PC. The effects of tea polyphenols on Candida albicans: inhibition of biofilm formation and proteasome inactivation. Can J Microbiol. 2009; 55(9):1033-9.

41. Ning Y, Ling J, Wu CD. Synergistic effects of tea catechin epigallocatechin gallate and antimycotics against oral Candida species. Arch Oral Biol. 2015;60(10):1565-70.

42. Sur R, Nigam A, Grote D, Liebel F, Southall MD. Avenanthramides, polyphenols from oats exhibit anti-inflammatory and anti-itch activity. Arch Dermatol Res. 2008;300(10):569-74.

43. McBain AJ, Ledder RG, Moore LE, Catrenich CE, Gilbert P. Effects of quaternary-ammonium-based formulations on bacterial community dynamics and antimicrobial susceptibility. Appl Environ Microbiol. 2004;70(6):3449-56.

44. Lawrence E, Li F. Foot burns and diabetes: a retrospective study. Burns & Trauma. 2015;3(24):1-4.

45. Jeschke MG, Patsouris D, Stanojcic M, et al. Pathophysiologic response to burns in the elderly. EBioMedicine. 2015;(2910):1536-48.

46. Rani M, Schwacha MG. Aging and the pathogenic response to burn. Aging and Disease. 2012;3(2):171-80.

47. Sgonc R, Gruber J. Age-related aspects of cutaneous wound healing: a mini-review. Gerontology. 2013;59(2):159-64.

48. Madaghiele M, Demitri C, Sannino A, Ambrosio L. Polymeric hydrogels for burn wound care: advanced skin wound dressings and regenerative templates. Burns & Trauma. 2014;2(4):153-61.

49. Reynolds T, Dweck AC. Aloe leaf gel: a review update. J Ethnopharmacol. 1999;68(1-3):3-37.

50. Chithra P, Sajithlal GB, Chandrakasan G. Influence of aloe vera on the glycosaminoglycans in the matrix of healing dermal wounds in rats. J Ethnopharmacol. 1998;59(3):179-86.

51. Stuart RW, Lefkowitz DL, Lincoln JA, Howard K, Gelderman MP, Lefkowitz SS. Upregulation of phagocytosis and candidicidal activity of macrophages exposed to the immunostimulant acemannan. Int J  Immunopharmacol. 1997;19(2):75-82.

52. Sierra-Garcia GD, Castro-Rios R, Gonzalez-Harta A, Lara-Arias J, Chavez-Montes A. Acemannan, an extracted polysaccharide from aloe vera: a literature review. Nat Prod Commun. 2014;9(8):1217-21.

53. MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev. 2003; 8(4):359-77.

54. Widgerow AD, Chait LA, Stals PJ, Stals R, Candy G. Multimodality scar management program. Aesthetic Plast Surg. 2009;33(4):533-43.

55. Hoffmann A, Hoing JL, Newman M, Simman R. Role of hyaluronic acid treatment in the prevention of keloid scarring. J Am Coll Clin Wound Spec. 2013;4(2):23-31.

56. Edward M, Quinn JA, Sands W. Keratinocytes stimulate fibroblast hyaluronan synthesis through the release of stratifin: a possible role in the suppression of scar tissue formation. Wound Rep Reg. 2011;19(3):379-86.

57. Hashemi SA, Madani SA, Abediankenari S. The review on properties of aloe vera in healing of cutaneous wounds. BioMed Res Int. 2015:2015:714216. Epub 2015.

58. Dupont E, Gomez J, Leveille C, Bilodeau D. From hydration to cell turnover: an integral approach to aging. Cosmetics & Toiletries. 2010;125(3):1-9.

59. Wu F, Bian D, Xia Y, et al. Identification of major active ingredients responsible for burn wound healing of Centella asiatica herbs. Evid Based Complement Alternat Med. 2012;2012:848093. Epub 2012.