Topical Burn Wound Management

Cutaneous burns challenge global health care systems with high patient morbidity and mortality rates.¹ One recent study of adults admitted for 2 to 60 days to a US burn center reported that more than 7.9% of burn patients experienced at least 1 hospital-acquired infection (HAI), extending the hospital length of stay and increasing the likelihood of complications and death.² Of these HAIs, most (35.8%) were skin and soft tissue infections, followed by respiratory (24.4%), bloodstream (18.1%), and urinary tract (17.8%) infections. A burn covering more than 5% of total body surface area (TBSA) multiplied HAI risk by 3, with higher risk as the burned TBSA increased. Other factors increasing HAI risk included inhalation injury, flame burn, patient age (≥ 60 years), and comorbidities (ie, diabetes, heart failure, myocardial infarction, renal disease, or peripheral arterial disease).² Topical 1% silver sulfadiazine cream (SSD), introduced into burn care in the mid 20th century by Dr. Charles Fox, improved global burned patient survival rates and outcomes by reducing the likelihood of burn-related infection.³ Research in later decades explored other topical treatments capable of reducing the incidence of burn-related infections. This month’s Evidence Corner describes 2 recent reviews comparing the effects of topical antiseptics⁴ or honey⁵ with SSD on burn wound healing and infections. 

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Reference: Norman G, Christie J, Liu Z, Westby MJ, Jefferies JM, Hudson T, Edwards J, Mohapatra DP, Hassan IA, Dumville JC. Antiseptics for burns. Cochrane Database Syst Rev. 2017;7:CD011821. doi: 10.1002/14651858.CD011821.pub2.

Rationale: Following resuscitation, more than 75% of deaths of burn patients result from infection. Various topical antiseptics are used to prevent burn-related infection and promote burn wound healing. 

Objective: A systematic review and meta-analysis of published literature explored the efficacy and safety of topical antiseptics to treat patients with burns in any care setting.

Methods: Two independent authors searched Cochrane, MEDLINE, Ovid Embase, CINAHL, In-Process & Other Non-Indexed Citations, and 3 clinical trial registries through September 2016 to identify and analyze any randomized controlled trial (RCT) that compared a topical burn antiseptic treatment with any other topical treatment of patients with skin burns.  

Results: Fifty-six qualifying RCTs returned by the search reported results on 5807 participants, with most patients having partial-thickness burns < 40% TBSA. Most RCTs enrolled too few participants and/or had too few infection events to obtain clear results without risk of bias. Incomplete reporting of outcomes and unclear measurement methodology resulted in uncertain conclusions about burn wound infection outcomes and low or very low certainty regarding healing outcomes.

For burn wounds dressed with silver-containing dressings as compared with those dressed with SSD gauze, low certainty evidence (10 RCTs, 1085 patients) supported 3.3-day faster healing with no clear difference in overall likelihood of healing (3 RCTs, 259 patients), infection (4 RCTs, 309 patients), or adverse events (6 RCTs, 440 patients).

More burn wounds healed when treated with topical honey (moderately certain evidence in 2 RCTs, 164 patients), with a 5-day faster healing (high certainty 5 RCTs, 1156 patients) than nonantibacterial dressings, with uncertain differences in the effects on infection or adverse events.

In RCTs comparing topical honey with SSD or mafenide, moderately certain evidence supported more likely healing with honey (5 RCTs, 580 patients), with uncertain differences in healing time, infections, or adverse events.

Low- or very low-quality evidence supported a 2-day faster healing of burns treated with sodium hypochlorite as compared with SSD and slower or less likely healing in burns treated with an iodophor or other iodine-containing dressings as compared with a hydrogel or other nonantibiotic topical agents. These comparisons found no clear effects on infections or adverse events. 

No clear differences in healing, infections, or adverse events were found in RCTs comparing topical Aloe vera with SSD or framycetin, comparing iodine-based treatments with SSD, silver-based dressings with petrolatum gauze, or chlorhexidine formulations with no antimicrobial treatment, SSD, or hydrocolloid dressings.

Authors’ conclusions: Except for the aforementioned healing differences comparing silver-based dressings with SSD or honey with SSD or other treatments, there is surprisingly little evidence informing choices of topical burn wound treatments. More clearly reported research is needed.

Reference: Aziz Z, Abdul Rasool Hassan B. The effects of honey compared to silver sulfadiazine for the treatment of burns: a systematic review of randomized controlled trials. Burns. 2017;43(1):50–57.

Rationale: The efficacy and safety of SSD and honey as topical burn treatments have been reviewed, but the 2 have not been compared specifically.

Objective: The authors conducted a systematic literature review to explore the efficacy of SSD compared with honey in burn wound healing.

Methods: Two reviewers searched the MEDLINE, CINAHL, Cochrane, and DARE databases from inception through 2014 for RCTs comparing the effects of SSD with honey on human burn wound healing. Quantitative results were analyzed for RCTs that measured burn wound healing and/or infection as primary outcomes, with pain or adverse events as secondary outcomes. For dichotomous outcomes (eg, healed vs. nonhealed), relative risk was calculated. For continuous variables (eg, healing time), weighted or standardized mean differences between SSD and honey groups were calculated. Differences were statistically significant if outside the 95% confidence interval. 

Results: Ten RCTs on 717 patients with a superficial and/or partial-thickness burn wound compared topical honey added to a wound dressing with 1% SSD cream applied topically alone or with gauze or other dressings. Meta-analyses reported a significantly higher proportion of burns healed with honey as compared with SSD (3 RCTs, 189 patients) in a mean 4.6-day shorter healing time (4 RCTs, 338 patients), with more honey-dressed, highly contaminated burns rendered sterile after 1 to 3 weeks of care (7 RCTs, 468 patients). Overall effects on partial- or superficial-thickness burns were significant at P ≤ .01. No significant differences in pain or adverse events were reported on the effects of honey as compared with SSD. These results should be interpreted with caution due to heterogeneity among studies, potential bias due to nonblinded treatment and outcome evaluation, and lack of consistent outcome definitions and measures across studies. 

Authors’ conclusions: Although the results of this analysis favored the use of honey on superficial and partial-thickness burns as compared with SSD, there is a need for higher quality RCTs with more rigorous measurement of clinically relevant outcomes to reinforce this conclusion. 

These 2 meta-analyses^4,5 illustrate how decades of science can enlighten current practice. They both suggest silver-containing dressings and/or honey may surpass SSD as the standard for topical partial-thickness burn management. However, hidden variables may be causing the differences reported. First, consider the vehicle and delivery system of 1% SSD, routinely administered in impregnated gauze or dressed with gauze after application. Well-designed and well-conducted RCTs have reported a decreased healing time, infection likelihood, and pain in wounds dressed with moisture-retentive dressings as compared with any form of dry or impregnated gauze dressings.^6-8 Gauze strands also can be enveloped by granulation tissue,⁹ potentiating infection and causing reinjury upon dressing removal. Before attributing delayed epithelization to SSD, one would do well to consider both the SSD dosage and delivery system. The myth that moisture-retentive wound dressings promote wound infection was dispelled decades ago.^7,8,10 Why are clinicians still applying antimicrobial agents in gauze dressings that adversely affect healing, pain, and wound infection? Perhaps it would make more sense to use moisture-retentive dressings as the delivery system for SSD, silver compounds, or other antimicrobial agents. It may be fruitful to test the hypothesis that a dressing’s moisture-retentive capacity may underlie the 3.3-day faster healing rates reported for silver dressings as compared with SSD-gauze.⁴ What if a moisture-retentive SSD delivery system were used?The same moist wound healing principles may explain the increased likelihood of healing of burns treated with honey compared with SSD or hydrogels compared with iodophor.⁴ Honey and hydrogels are both humectants, which can help preserve physiologically moist wound environments that permit healing and immune cell viability and function to foster healing and autolytic debridement.^11,12 Although the evidence could be stronger, and the effects of wound dressings from those of the topical agents they cover still need to be sorted out, the choices for topical treatment of superficial- and partial-thickness burns are becoming clearer.