Management of partial thickness facial burns (comparison of topical antibiotics and bio-engineered skin substitutes)

Photodynamic activation of phytochemical-antibiotic combinations for combatting Staphylococcus aureus from acute wound infections

Staphylococcus aureus is characterized by its high resistance to conventional antibiotics, particularly methicillin-resistant (MRSA) strains, making it a predominant pathogen in acute and chronic wound infections. The persistence of acute S. aureus wound infections poses a threat by increasing the incidence of their chronicity. This study investigated the potential of photodynamic activation using phytochemical-antibiotic combinations to eliminate S. aureus under conditions representative of acute wound infections, aiming to mitigate the risk of chronicity. The strategy applied takes advantage of the promising antibacterial and photosensitising properties of phytochemicals, and their ability to act as antibiotic adjuvants. The antibacterial activity of selected phytochemicals (berberine, curcumin, farnesol, gallic acid, and quercetin; 6.25-1000 μg/mL) and antibiotics (ciprofloxacin, tetracycline, fusidic acid, oxacillin, gentamicin, mupirocin, methicillin, and tobramycin; 0.0625-1024 μg/mL) was screened individually and in combination against two S. aureus clinical strains (methicillin-resistant and -susceptible-MRSA and MSSA). The photodynamic activity of the phytochemicals was assessed using a light-emitting diode (LED) system with blue (420 nm) or UV-A (365 nm) variants, at 30 mW/cm2 (light doses of 9, 18, 27 J/cm2) and 5.5 mW/cm2 (light doses of 1.5, 3.3 and 5.0 J/cm2), respectively. Notably, all phytochemicals restored antibiotic activity, with 9 and 13 combinations exhibiting potentiating effects on MSSA and MRSA, respectively. Photodynamic activation with blue light (420 nm) resulted in an 8- to 80-fold reduction in the bactericidal concentration of berberine against MSSA and MRSA, while curcumin caused 80-fold reduction for both strains at the light dose of 18 J/cm2. Berberine and curcumin-antibiotic combinations when subjected to photodynamic activation (420 nm light, 10 min, 18 J/cm2) reduced S. aureus culturability by ≈9 log CFU/mL. These combinations lowered the bactericidal concentration of antibiotics, achieving a 2048-fold reduction for gentamicin and 512-fold reduction for tobramycin. Overall, the dual approach involving antimicrobial photodynamic inactivation and selected phytochemical-antibiotic combinations demonstrated a synergistic effect, drastically reducing the culturability of S. aureus and restoring the activity of gentamicin and tobramycin.

Autologous Skin Grafts, versus Tissue-engineered Skin Constructs: A Systematic Review and Meta-analysis

For over 100 years, autologous skin grafts have remained the gold standard for the reconstruction of wounds but are limited in availability. Acellular tissue-engineered skin constructs (acellular TCs) and cellular tissue-engineered skin constructs (cellular TCs) may address these limitations. This systematic review and meta-analysis compare outcomes between them.

Methods

A systematic review was conducted using PRISMA guidelines, querying MEDLINE, Embase, Web of Science, and Cochrane to assess graft incorporation, failure, and wound healing. Case reports/series, reviews, in vitro/in vivo work, non-English articles or articles without full text were excluded.

Results

Sixty-six articles encompassing 4076 patients were included. No significant differences were found between graft failure rates (P = 0.07) and mean difference of percent reepithelialization (p = 0.92) when split-thickness skin grafts were applied alone versus co-grafted with acellular TCs. Similar mean Vancouver Scar Scale was found for these two groups (p = 0.09). Twenty-one studies used at least one cellular TC. Weighted averages from pooled results did not reveal statistically significant differences in mean reepithelialization or failure rates for epidermal cellular TCs compared with split-thickness skin grafts (p = 0.55).

Conclusions

This systematic review is the first to illustrate comparable functional and wound healing outcomes between split-thickness skin grafts alone and those co-grafted with acellular TCs. The use of cellular TCs seems promising from preliminary findings. However, these results are limited in clinical applicability due to the heterogeneity of study data, and further level 1 evidence is required to determine the safety and efficacy of these constructs.

Hydrogels for the management of second-degree burns: currently available options and future promise

Burn wounds result from exposure to hot liquids, chemicals, fire, electric discharge or radiation. Wound severity ranges from first-degree injury, which is superficial, to fourth-degree injury, which exposes bone, tendons and muscles. Rapid assessment of burn depth and accurate wound management in the outpatient setting is critical to prevent injury progression into deeper layers of the dermis. Injury progression is of particular pertinence to second-degree burns, which are the most common form of thermal burn. As our understanding of wound healing advances, treatment options and technologies for second-degree burn management also evolve. Polymeric hydrogels are a class of burn wound dressings that adhere to tissue, absorb wound exudate, protect from the environment, can be transparent facilitating serial wound evaluation and, in some cases, enable facile removal for dressing changes. This review briefly describes the burn level classification and common, commercially available dressings used to treat second-degree burns, and then focuses on new polymeric hydrogel burn dressings under preclinical development analyzing their design, structure and performance. The review presents the follow key learning points: (1) introduction to the integument system and the wound-healing process; (2) classification of burns according to severity and clinical appearance; (3) available dressings currently used for second-degree burns; (4) introduction to hydrogels and their preparation and characterization techniques; and (5) pre-clinical hydrogel burn wound dressings currently being developed.

Management of Nasal Trauma

Facial trauma can have long-lasting physical and mental consequences. Trauma to the nose is commonly seen in the emergency department. Nasal lacerations account for 7% of all facial lacerations. Thorough examination and documentation including photographs is important for documentation and creating a reconstruction plan. Underlying damage to cartilage or bone must be reconstructed initially or in a delayed fashion to recreate the pretrauma anatomy and function. There are several options for soft tissue nasal reconstruction, including local flaps, skin grafts, pedicle flaps, and free flaps. At present there is no standard of care for postoperative facial trauma wound care.

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region. The face is the area central to a person's identity that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

In this first update, we included 12 RCTs, comprising 507 participants. Most trials included adults admitted to specialised burn centres after recent burn injuries. Topical agents included antimicrobial agents (silver sulphadiazine (SSD), Aquacel-Ag, cerium-sulphadiazine, gentamicin cream, mafenide acetate cream, bacitracin), non-antimicrobial agents (Moist Exposed Burn Ointment (MEBO), saline-soaked dressings, skin substitutes (including bioengineered skin substitute (TransCyte), allograft, and xenograft (porcine Xenoderm), and miscellaneous treatments (growth hormone therapy, recombinant human granulocyte-macrophage colony-stimulating factor hydrogel (rhGMCS)), enzymatic debridement, and cream with Helix Aspersa extract). Almost all the evidence included in this review was assessed as low or very low-certainty, often because of high risk of bias due to unclear randomisation procedures (i.e. sequence generation and allocation concealment); lack of blinding of participants, providers and sometimes outcome assessors; and imprecision resulting from few participants, low event rates or both, often in single studies. Topical antimicrobial agents versus topical non-antimicrobial agents There is moderate-certainty evidence that there is probably little or no difference between antimicrobial agents and non-antimicrobial agents (SSD and MEBO) in time to complete wound healing (hazard ratio (HR) 0.84 (95% confidence interval (CI) 0.78 to 1.85, 1 study, 39 participants). Topical antimicrobial agents may make little or no difference to the proportion of wounds completely healed compared with topical non-antimicrobial agents (comparison SSD and MEBO, risk ratio (RR) 0.94, 95% CI 0.68 to 1.29; 1 study, 39 participants; low-certainty evidence). We are uncertain whether there is a difference in wound infection (comparison topical antimicrobial agent (Aquacel-Ag) and MEBO; RR 0.38, 95% CI 0.12 to 1.21; 1 study, 40 participants; very low-certainty evidence). No trials reported change in wound surface area over time or partial wound healing. There is low-certainty evidence for the secondary outcomes scar quality and patient satisfaction. Two studies assessed pain but it was incompletely reported. Topical antimicrobial agents versus other topical antimicrobial agents It is uncertain whether topical antimicrobial agents make any difference in effects as the evidence is low to very low-certainty. For primary outcomes, there is low-certainty evidence for time to partial (i.e. greater than 90%) wound healing (comparison SSD versus cerium SSD: mean difference (MD) -7.10 days, 95% CI -16.43 to 2.23; 1 study, 142 participants). There is very low-certainty evidence regarding whether topical antimicrobial agents make a difference to wound infection (RR 0.73, 95% CI 0.46 to 1.17; 1 study, 15 participants). There is low to very low-certainty evidence for the proportion of facial burns requiring surgery, pain, scar quality, adverse effects and length of hospital stay. Skin substitutes versus topical antimicrobial agents There is low-certainty evidence that a skin substitute may slightly reduce time to partial (i.e. greater than 90%) wound healing, compared with a non-specified antibacterial agent (MD -6.00 days, 95% CI -8.69 to -3.31; 1 study, 34 participants). We are uncertain whether skin substitutes in general make any other difference in effects as the evidence is very low certainty. Outcomes included wound infection, pain, scar quality, adverse effects of treatment and length of hospital stay. Single studies showed contrasting low-certainty evidence. A bioengineered skin substitute may slightly reduce procedural pain (MD -4.00, 95% CI -5.05 to -2.95; 34 participants) and background pain (MD -2.00, 95% CI -3.05 to -0.95; 34 participants) compared with an unspecified antimicrobial agent. In contrast, a biological dressing (porcine Xenoderm) might slightly increase pain in superficial burns (MD 1.20, 95% CI 0.65 to 1.75; 15 participants (30 wounds)) as well as deep partial thickness burns (MD 3.00, 95% CI 2.34 to 3.66; 10 participants (20 wounds)), compared with antimicrobial agents (Physiotulle Ag (Coloplast)). Miscellaneous treatments versus miscellaneous treatments Single studies show low to very low-certainty effects of interventions. Low-certainty evidence shows that MEBO may slightly reduce time to complete wound healing compared with saline soaked dressing (MD -1.7 days, 95% CI -3.32 to -0.08; 40 participants). In addition, a cream containing Helix Aspersa may slightly increase the proportion of wounds completely healed at 14 days compared with MEBO (RR 4.77, 95% CI 1.87 to 12.15; 43 participants). We are uncertain whether any miscellaneous treatment in the included studies makes a difference in effects for the outcomes wound infection, scar quality, pain and patient satisfaction as the evidence is low to very low-certainty.

AUTHORS' CONCLUSIONS

There is mainly low to very low-certainty evidence on the effects of any topical intervention on wound healing in people with facial burns. The number of RCTs in burn care is growing, but the body of evidence is still hampered due to an insufficient number of studies that follow appropriate evidence-based standards of conducting and reporting RCTs.

Bioengineered Skin Substitutes: the Role of Extracellular Matrix and Vascularization in the Healing of Deep Wounds

The formation of severe scars still represents the result of the closure process of extended and deep skin wounds. To address this issue, different bioengineered skin substitutes have been developed but a general consensus regarding their effectiveness has not been achieved yet. It will be shown that bioengineered skin substitutes, although representing a valid alternative to autografting, induce skin cells in repairing the wound rather than guiding a regeneration process. Repaired skin differs from regenerated skin, showing high contracture, loss of sensitivity, impaired pigmentation and absence of cutaneous adnexa (i.e., hair follicles and sweat glands). This leads to significant mobility and aesthetic concerns, making the development of more effective bioengineered skin models a current need. The objective of this review is to determine the limitations of either commercially available or investigational bioengineered skin substitutes and how advanced skin tissue engineering strategies can be improved in order to completely restore skin functions after severe wounds.

3D Bioprinted BioMask for Facial Skin Reconstruction

Skin injury to the face remains one of the greatest challenges in wound care due to the varied contours and complex movement of the face. Current treatment strategies for extensive facial burns are limited to the use of autografts, allografts, and skin substitutes, and these often result in scarring, infection, and graft failure. Development of an effective treatment modality will greatly improve the quality of life and social integration of the affected individuals. In this proof of concept study, we developed a novel strategy, called "BioMask", which is a customized bioengineered skin substitute combined with a wound dressing layer that snugly fits onto the facial wounds. To achieve this goal, three-dimensional (3D) bioprinting principle was used to fabricate the BioMask that could be customized by patients' clinical images such as computed tomography (CT) data. Based on a face CT image, a wound dressing material and cell-laden hydrogels were precisely dispensed and placed in a layer-by-layer fashion by the control of air pressure and 3-axis stage. The resulted miniature BioMask consisted of three layers; a porous polyurethane (PU) layer, a keratinocyte-laden hydrogel layer, and a fibroblast-laden hydrogel layer. To validate this novel concept, the bioprinted BioMask was applied to a skin wound on a pre-fabricated face-shaped structure in mice. Through this in vivo study using the 3D BioMask, skin contraction and histological examination showed the regeneration of skin tissue, consisting of epidermis and dermis layers, on the complex facial wounds. Consequently, effective and rapid restoration of aesthetic and functional facial skin would be a significant improvement to the current issues a facial wound patient experience.

Head and Neck Reconstruction

Management of head and neck burns involves acute and intermediate phases. Acutely, the goals are establish a secure airway and treat life-threatening injuries. Then, optimize nutrition, assess extent of the burn, perform local wound care, and provide eye protection. Management depends on the degree of the head and neck burn. Postinjury splinting and rehabilitation are vital to healing. After the acute inflammation has resolved and the scars have matured, reconstruction begins with the goals of restoring both function and aesthetics. Reconstruction ranges from simple scar release, to skin grafting, and possibly free flap reconstruction.

Combined chemical and structural signals of biomaterials synergistically activate cell-cell communications for improving tissue regeneration

Biomaterials are only used as carriers of cells in the conventional tissue engineering. Considering the multi-cell environment and active cell-biomaterial interactions in tissue regeneration process, in this study, structural signals of aligned electrospun nanofibers and chemical signals of bioglass (BG) ionic products in cell culture medium are simultaneously applied to activate fibroblast-endothelial co-cultured cells in order to obtain an improved skin tissue engineering construct. Results demonstrate that the combined biomaterial signals synergistically activate fibroblast-endothelial co-culture skin tissue engineering constructs through promotion of paracrine effects and stimulation of gap junctional communication between cells, which results in enhanced vascularization and extracellular matrix protein synthesis in the constructs. Structural signals of aligned electrospun nanofibers play an important role in stimulating both of paracrine and gap junctional communication while chemical signals of BG ionic products mainly enhance paracrine effects. In vivo experiments reveal that the activated skin tissue engineering constructs significantly enhance wound healing as compared to control. This study indicates the advantages of synergistic effects between different bioactive signals of biomaterials can be taken to activate communication between different types of cells for obtaining tissue engineering constructs with improved functions.

STATEMENT OF SIGNIFICANCE

Tissue engineering can regenerate or replace tissue or organs through combining cells, biomaterials and growth factors. Normally, for repairing a specific tissue, only one type of cells, one kind of biomaterials, and specific growth factors are used to support cell growth. In this study, we proposed a novel tissue engineering approach by simply using co-cultured cells and combined biomaterial signals. Using a skin tissue engineering model, we successfully proved that the combined biomaterial signals such as surface nanostructures and bioactive ions could synergistically stimulate the cell-cell communication in co-culture system through paracrine effects and gap junction activation, and regulated expression of growth factors and extracellular matrix proteins, resulting in an activated tissue engineering constructs that significantly enhanced skin regeneration.

[Reconstruction of the ear in the burns patient]

Face burns are a singular pathology with great functional and psychological impact in the patients suffering them. The ears play a fundamental role in personal interactions and damage to this organ results in physical and emotional distress. The reconstructive treatment of the burned ear is a challenge. Multiple procedures have been described to achieve success in the reconstruction of the burned ear; immediate reconstruction with autologous rib cartilage, secondary reconstruction, alloplastic material reconstruction, tissue expansion, skin grafts and also microvascular flaps are some of the most common procedures used in this patients. All these techniques focus on giving a natural appearance to the patient. Burns to the ears affect 30% of the patients with facial burns, they require an excellent treatment given by a multidisciplinary team.

New Innovations for Deep Partial-Thickness Burn Treatment with ACell MatriStem Matrix

Objective: Burn injuries remain a large financial burden on the healthcare system. According to CDC statistics (2010), nonfatal and hospitalized burns in the U.S. cost $1.8 billion for an annual incidence of ∼486,000 cases. To date, no technique proves to be the ideal therapy of deep partial-thickness burns. In this study, we review a trial usage of ACell (ACell, Inc.) wound matrix on deep partial-thickness burns. Approach: Burn patients were admitted through the Vanderbilt Emergency Department. Three were consented to receive ACell therapy. Each patient suffered extremity burns, to which ACell MatriStem matrix was applied. Time to epithelialization and healing was monitored up to 1 month postintervention. Results: ACell MatriStem matrix use in deep partial-thickness burns enabled healing by 29 days on average without requiring autografts. The average total body surface area (TBSA) of injury was 7.2% with average TBSA treated with ACell equal to 2.5%. All burn sites underwent re-epithelialization after 5.6 days on average (range 4-7 days). Average length of stay after ACell placement totaled 2 days. All patients fully healed without the need for subsequent grafting or contracture development. No postoperative complications were noted. Innovation: To the extent of our knowledge, this is one of the first reported series to utilize ACell MatriStem product in deep partial-thickness extremity burns. Conclusion: Despite numerous products currently available for burn reconstruction, no one product embodies all the characteristics of an ideal graft. ACell biological extracellular matrix scaffolding appears promising, allowing for healing without use of an autograft.

MALDI-MSI for the analysis of a 3D tissue-engineered psoriatic skin model

MALDI-MS Imaging is a novel label-free technique that can be used to visualize the changes in multiple mass responses following treatment. Following treatment with proinflammatory cytokine interleukin-22 (IL-22), the epidermal differentiation of Labskin, a living skin equivalent (LSE), successfully modeled psoriasis in vitro. Masson's trichrome staining enabled visualization and quantification of epidermal differentiation between the untreated and IL-22 treated psoriatic LSEs. Matrix-assisted laser desorption ionization mass spectrometry imaging was used to observe the spatial location of the psoriatic therapy drug acetretin following 48 h treatments within both psoriatic and normal LSEs. After 24 h, the drug was primarily located in the epidermal regions of both the psoriatic and nonpsoriatic LSE models whereas after 48 h it was detectible in the dermis.

Full-thickness skin wound healing using autologous keratinocytes and dermal fibroblasts with fibrin: bilayered versus single-layered substitute

Split-skin grafting (SSG) is the gold standard treatment for full-thickness skin defects. For certain patients, however, an extensive skin lesion resulted in inadequacies of the donor site. Tissue engineering offers an alternative approach by using a very small portion of an individual's skin to harvest cells for propagation and biomaterials to support the cells for implantation. The objective of this study was to determine the effectiveness of autologous bilayered tissue-engineered skin (BTES) and single-layer tissue-engineered skin composed of only keratinocytes (SLTES-K) or fibroblasts (SLTES-F) as alternatives for full-thickness wound healing in a sheep model. Full-thickness skin biopsies were harvested from adult sheep. Isolated fibroblasts were cultured using medium Ham's F12: Dulbecco modified Eagle medium supplemented with 10% fetal bovine serum, whereas the keratinocytes were cultured using Define Keratinocytes Serum Free Medium. The BTES, SLTES-K, and SLTES-F were constructed using autologous fibrin as a biomaterial. Eight full-thickness wounds were created on the dorsum of the body of the sheep. On 4 wounds, polyvinyl chloride rings were used as chambers to prevent cell migration at the edge. The wounds were observed at days 7, 14, and 21. After 3 weeks of implantation, the sheep were euthanized and the skins were harvested. The excised tissues were fixed in formalin for histological examination via hematoxylin-eosin, Masson trichrome, and elastin van Gieson staining. The results showed that BTES, SLTES-K, and SLTES-F promote wound healing in nonchambered and chambered wounds, and BTES demonstrated the best healing potential. In conclusion, BTES proved to be an effective tissue-engineered construct that can promote the healing of full-thickness skin lesions. With the support of further clinical trials, this procedure could be an alternative to SSG for patients with partial- and full-thickness burns.

Clinical applications of skin substitutes

A unique understanding of the components of mammalian skin has led to the development of numerous skin substitutes. These skin substitutes attempt to compensate for functional and physiologic deficits present in damaged tissue. Skin substitutes, when appropriately applied in optimized settings, offer a promising solution to difficult wound management. The body of literature on skin substitutes increases as the understanding of tissue engineering and molecular biology expands. Given the high cost of these products, future randomized large prospective studies are needed to guide the clinical applications of skin substitutes.

Wound Healing: Biologics, Skin Substitutes, Biomembranes and Scaffolds

This review will explore the latest advancements spanning several facets of wound healing, including biologics, skin substitutes, biomembranes and scaffolds.

A novel biomaterial: bacterial cellulose and its new era applications

Bacterial cellulose (BC) is a promising natural polymer that is produced by bacteria and that has unique and desirable structural, physical, and chemical properties. From the time when the remarkable properties of BC were found 15 years ago compared with plant cellulose, interest has grown in BC and it has become an article of trade in diverse applications. Following this trend, this paper reviews the progress of relevant studies, including general information about cellulose, production by microorganisms as well as BC cultivation, and its properties. The applications reviewed in the present article comprise biological and nonbiological fields. The latest use of BC in the biomedical, environmental, agricultural, electronic, food, and industrial fields is discussed with its applications in composite form. The present article attempts to amass the assorted uses of BC under one umbrella. Thus, recent advances in BC applications in different fields are thoroughly reviewed. This article concludes with the need for future research of BC to make it commercialized as vital biomaterial.

Antibiotic prophylaxis for preventing burn wound infection

BACKGROUND

Infection of burn wounds is a serious problem because it can delay healing, increase scarring and invasive infection may result in the death of the patient. Antibiotic prophylaxis is one of several interventions that may prevent burn wound infection and protect the burned patient from invasive infections.

OBJECTIVES

To assess the effects of antibiotic prophylaxis on rates of burn wound infection.

SEARCH METHODS

In January 2013 we searched the Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE - In-Process & Other Non-Indexed Citations (2013); Ovid EMBASE; EBSCO CINAHL and reference lists of relevant articles. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated the efficacy and safety of antibiotic prophylaxis for the prevention of BWI. Quasi-randomised studies were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias, and extracted relevant data. Risk ratio (RR) and mean difference (MD) were estimated for dichotomous data and continuous data, respectively. When sufficient numbers of comparable RCTs were available, trials were pooled in a meta-analysis to estimate the combined effect.

MAIN RESULTS

This review includes 36 RCTs (2117 participants); twenty six (72%) evaluated topical antibiotics, seven evaluated systemic antibiotics (four of these administered the antibiotic perioperatively and three administered upon hospital admission or during routine treatment), two evaluated prophylaxis with non absorbable antibiotics, and one evaluated local antibiotics administered via the airway.The 11 trials (645 participants) that evaluated topical prophylaxis with silver sulfadiazine were pooled in a meta analysis. There was a statistically significant increase in burn wound infection associated with silver sulfadiazine compared with dressings/skin substitute (OR = 1.87; 95% CI: 1.09 to 3.19, I(2) = 0%). These trials were at high, or unclear, risk of bias. Silver sulfadiazine was also associated with significantly longer length of hospital stay compared with dressings/skin substitute (MD = 2.11 days; 95% CI: 1.93 to 2.28).Systemic antibiotic prophylaxis in non-surgical patients was evaluated in three trials (119 participants) and there was no evidence of an effect on rates of burn wound infection. Systemic antibiotics (trimethoprim-sulfamethoxazole) were associated with a significant reduction in pneumonia (only one trial, 40 participants) (RR = 0.18; 95% CI: 0.05 to 0.72) but not sepsis (two trials 59 participants) (RR = 0.43; 95% CI: 0.12 to 1.61).Perioperative systemic antibiotic prophylaxis had no effect on any of the outcomes of this review.Selective decontamination of the digestive tract with non-absorbable antibiotics had no significant effect on rates of all types of infection (2 trials, 140 participants). Moreover, there was a statistically significant increase in rates of MRSA associated with use of non-absorbable antibiotics plus cefotaxime compared with placebo (RR = 2.22; 95% CI: 1.21 to 4.07).There was no evidence of a difference in mortality or rates of sepsis with local airway antibiotic prophylaxis compared with placebo (only one trial, 30 participants).

AUTHORS' CONCLUSIONS

The conclusions we are able to draw regarding the effects of prophylactic antibiotics in people with burns are limited by the volume and quality of the existing research (largely small numbers of small studies at unclear or high risk of bias for each comparison). The largest volume of evidence suggests that topical silver sulfadiazine is associated with a significant increase in rates of burn wound infection and increased length of hospital stay compared with dressings or skin substitutes; this evidence is at unclear or high risk of bias. Currently the effects of other forms of antibiotic prophylaxis on burn wound infection are unclear. One small study reported a reduction in incidence of pneumonia associated with a specific systematic antibiotic regimen.

Topical treatment for facial burns

BACKGROUND

Burn injuries are an important health problem. They occur frequently in the head and neck region - the area central to a person's identity, that provides our most expressive means of communication. Topical interventions are currently the cornerstone of treatment of partial-thickness burns to the face.

OBJECTIVES

To assess the effects of topical interventions on wound healing in people with facial burns of any depth.

SEARCH METHODS

We searched the Cochrane Wounds Group Specialised Register (searched 12 November 2012); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to November Week 1 2012); Ovid MEDLINE - In-process & Other Non-Indexed Citations (searched November 12, 2012); Ovid EMBASE (1980 to 2012 Week 45); and EBSCO CINAHL (1982 to 9 November 2012) for relevant trials. We did not apply date or language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that evaluated the effects of topical treatment for facial burns were eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed and included the references identified by the search strategy. Included trials were assessed using a risk of bias form, and data were extracted using a standardised data extraction sheet. For dichotomous and continuous outcomes, we calculated risk ratios and mean differences, respectively, both with 95% confidence intervals (CI).

MAIN RESULTS

We included five RCTs, comprising a total of 119 participants. Two studies compared two different antimicrobial agents and three compared a biological or bioengineered skin substitute with an antimicrobial agent. All studies had small sample sizes and were at high risk of bias. Heterogeneity of interventions and outcomes prevented pooling of data. In three studies time to complete wound healing was significantly shorter for those using a skin substitute than for those using an antibacterial agent, but the quality of the evidence was low. Pain was significantly reduced with the use of skin substitutes in both studies that reported this outcome in all groups, range mean differences -2.00 (95% CI -3.82 to -0.18) to -4.00 (95% CI -5.05 to -2.95) on a 10-point scale.

AUTHORS' CONCLUSIONS

There is insufficient high quality research and evidence to enable conclusions to be drawn about the effects of topical interventions on wound healing in people with facial burns.

Facial burns - our experience

Facial burns are generally considered severe. This is due to the possibility of respiratory complications. First responders check the nostrils for singed hairs. In severe cases there may be soot around the nose and mouth and coughing may produce phlegm that includes ash. Facial and inhalational burns compromise airways. They pose difficulties in pre-hospital resuscitation and are challenge to clinicians managing surviving burn victims in the intensive care setting. Management problems - resuscitation, airway maintenance and clinical treatment of facial injuries are compounded if the victim is child. Inhalational burns reduce survivability, certainly in adult victim. In our retrospective study we found that facial burns dominated in male gender, liquids and scalds are the most common causes of facial burns in children whereas the flame and electricity were the most common causes of facial burns in adults. We came to the conclusion in our study that surgical treatment minimizes complications and duration of recovery.

Update on the critical care management of severe burns

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

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.

Moist occlusive dressing (Aquacel(®) Ag) versus moist open dressing (MEBO(®)) in the management of partial-thickness facial burns: a comparative study in Ain Shams University

INTRODUCTION

The face is the central point of the physical features; it transmits expressions and emotions, communicates feelings and allows for individual identity. Facial burns are very common and are devastating to the affected patient and results into numerous physical, emotional and psychosocial sequels. Partial thickness facial burns are very common especially among children. This study compares the effect of standard moist open technique management and a moist closed technique for partial thickness burns of the face.

PATIENTS AND METHODS

Patients with partial-thickness facial burns admitted in the burn unit, Ain Shams University, Cairo, Egypt in the period from April 2009 to December 2009 were included in this study. They were divided into two groups to receive either open treatment with MEBO(®) (n=20) or coverage with Aquacel(®) Ag (n=20). Demographics (age, gender, ethnicity, TBSA, burn areas), length of hospital stay (LOS), rate of infections, time to total healing, frequency of dressing changes, pain, cost benefit and patient discomfort were compared between the two groups. The long-term outcome (incidence of hypertrophic scarring) was assessed for up to 6 months follow-up period.

RESULTS

There were no significant differences in demographics between the two groups. In the group treated with the Aquacel(®) Ag, the mean time for re-epithelialization was 10.5 days, while it was 12.4 days in the MEBO(®) group (p<0.05). Frequency of changes, pain and patient discomfort were less with Aquacel(®) Ag. Cost was of no significant difference between the two groups. Scar quality improved in the Aquacel(®) Ag treatment group. Three and 6 months follow-up was done and long-term outcomes were recorded in both groups.

CONCLUSION

Moist occlusive dressing (Aquacel(®) Ag) significantly improves the management and healing rate of partial thickness facial burns with better long-term outcome compared to moist open dressing (MEBO(®)).

Effect of a Semisolid Formulation of Linum usitatissimum L. (Linseed) Oil on the Repair of Skin Wounds

The purpose of this study was to investigate the effects of a semisolid formulation of linseed oil, SSFLO (1%, 5%, or 10%) or in natura linseed oil on skin wounds of rats. We used wound models, incisional and excisional, to evaluate, respectively, the contraction/reepithelialization of the wound and resistance to mechanical traction. The groups (n = 6) treated with SSFLO (1% or 5%) began the process of reepithelialization, to a significant extent (P < .05), on the sixth day, when compared to the petroleum jelly control group. On 14th day for the groups treated with SSFLO (1% or 5%), 100% reepithelialization was found, while in the petroleum jelly control group, this was only 33.33%. Our study showed that topical administration of SSFLO (1% or 5%) in excisional wounds allowed reepithelialization in 100% of treated animals. Therefore, a therapeutic potential of linseed oil, when used at low concentrations in the solid pharmaceutical formulations, is suggested for the process of dermal repair.

Efficiency of microbial cellulose dressing in partial-thickness burn wounds

Microbial cellulose is a natural polymer that can hold a quantity of water without any disconformities. Therefore, it is proposed for use as wound dressing material. We report a case of 28% total body surface area partial-thickness flame burn: approximately 4.5% superficial partial-thickness burns on anterior face and 23.5% combined superficial and deep partial-thickness burns on both upper arms and anterior trunk. A microbial cellulose dressing, Nanocell (Thai Nano Cellulose Co Ltd, Bangkok, Thailand), was applied to the face wound only once, without any further dressing change. Progress of healing, until full epithelialization on the face, was observed for 2 weeks. During the treatment period, the patient did not show any irritation or allergic reaction to this new dressing, and wound swab culture showed no evidence of bacteria presence. This innovative material can be an alternative dressing for superficial partial-thickness burn wounds.

Randomized controlled single center study comparing a polyhexanide containing bio-cellulose dressing with silver sulfadiazine cream in partial-thickness dermal burns

OBJECTIVE

A prospective, randomized, controlled single center study was designed to evaluate clinical efficacy of a polyhexanide containing bio-cellulose dressing (group B) compared to a silver-sulfadiazine cream (group A) in sixty partial-thickness burn patients.

PATIENTS AND METHODS

Local ethics committee approval was obtained and patients consented. Parameters were: pain reduction (VAS), healing time and wound bed condition, comparing day 0 (start) versus day 14 (end), as well as, ease of dressing use and treatment costs.

RESULTS

All completed the study (n=30/n=30) and were included in the ITT analysis, with a total of 72 burns (group A: n=38, group B: n=34). We noted no differences in healing time. Pain reduction was significantly faster and better in group B (p<0.01). There were fewer dressing changes in group B, compared to group A. Ease of use for the bio-cellulose dressing was rated better compared to group A. In group B, € 95.20 was saved for a 10 day treatment period, compared to group A.

CONCLUSION

Group B demonstrated a better and faster pain reduction in the treated partial-thickness burns, compared to group A. The results indicate the polyhexanide containing bio-cellulose dressing to be a safe and cost effective treatment for partial-thickness burns.

Dried irradiated human amniotic membrane as a biological dressing for facial burns--a 7-year case series

BACKGROUND

Facial burns are common and have a significant impact on patient function and psychosocial well being. Human amnion has been used for many years as a temporary biological wound dressing in the management of partial thickness burns. The observed advantages of human amnion treatment include pain relief, ease of use, prevention of infection and acceleration of wound healing.

OBJECTIVE

This study evaluated our 7 years of working with dried irradiated human amnion in the treatment of facial burns.

METHOD

A review of patients, treated with dried human amnion for facial burns between 2001 and 2008. Demographic details collected included age, gender, total facial surface area burned, type of burn and cause of injury. The effectiveness of the treatment was determined by wound infection rate, frequency of dressing reapplication, healing time and resulting scarring.

RESULTS

Thirty-three patients with superficial partial thickness burn were identified (25 males, 8 females). The average age of the patients was 16.5 years (range: 8 months to 64 years). The causes included scalding (n=15), contact burning (n=13) and flash burning (n=5). The mean percent total facial surface area burned was 2.7% (range: 0.5-8.5%). None of the patients developed facial wound infections. Eighty-five percent (n=28) of the patients needed a single application of the dried amnion. The average healing time was 5.4 days (range: 2-14 days). Thirteen patients (39%) had burns confined to the facial area, of which three were discharged and treated as outpatients. Long-term follow up showed two hypopigmented scars, one hyperpigmented scar and one hypertrophic scar.

CONCLUSION

Superficial partial thickness facial burns can be effectively treated with dried irradiated human amnion membrane.

Prophylactic antibiotics for burns patients: systematic review and meta-analysis

OBJECTIVE

To assess the evidence for prophylactic treatment with systemic antibiotics in burns patients.

DESIGN

Systematic review and meta-analysis of randomised or quasi-randomised controlled trials recruiting burns inpatients that compared antibiotic prophylaxis (systemic, non-absorbable, or topical) with placebo or no treatment.

DATA SOURCES

PubMed, Cochrane Library, LILACS, Embase, conference proceedings, and bibliographies. No language, date, or publication status restrictions were imposed. Review methods Two reviewers independently extracted data. The primary outcome was all cause mortality. Risk or rate ratios with 95% confidence intervals were pooled with a fixed effect model if no heterogeneity was present.

RESULTS

17 trials were included. Trials that assessed systemic antibiotic prophylaxis given for 4-14 days after admission showed a significant reduction in all cause mortality (risk ratio 0.54, 95% confidence interval 0.34 to 0.87, five trials). The corresponding number needed to treat was 8 (5 to 33), with a control event rate of 26%. Perioperative non-absorbable or topical antibiotics alone did not significantly affect mortality. There was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. Staphylococcus aureus infection or colonisation was reduced with anti-staphylococcal antibiotics. In three trials, resistance to the antibiotic used for prophylaxis significantly increased (rate ratio 2.84, 1.38 to 5.83). The overall methodological quality of the trials was poor.

CONCLUSIONS

Prophylaxis with systemic antibiotics has a beneficial effect in burns patients, but the methodological quality of the data is weak. As such prophylaxis is currently not recommended for patients with severe burns other than perioperatively, there is a need for randomised controlled trials to assess its use.

The use of human deceased donor skin allograft in burn care

Burns are tissue wounds caused by thermal, electrical, chemical cold or radiation injuries. Deep injuries lead to dermal damage that impairs the ability of the skin to heal and regenerate on its own. Skin autografting following burn excision is considered the current gold standard of care, but lack of patient's own donor skin or unsuitability of the wound for autografting may require the temporary use of dressings or skin substitutes to promote wound healing, reduce pain, and prevent infection and abnormal scarring. These alternatives include deceased donor skin allograft, xenograft, cultured epithelial cells and biosynthetic skin substitutes. Allotransplantation is the transplantation of cells, tissues, or organs, sourced from a genetically non-identical member of the same species as the recipient. Human deceased donor skin allografts represent a suitable and much used temporizing option for skin cover following burn injury. The main advantages for its use include dermoprotection and promotion of reepithelialisation of the wound and their ability to act as skin cover until autografting is possible or re-harvesting of donor sites becomes available. Disadvantages of its use include the limited abundance and availability of donors, possible transmission of disease, the eventual rejection by the host and its handling storing, transporting and associated costs of provision. This paper will explore the role of allograft skin in burn care, defining the indications for its use in burn management and the future potential for allograft tissue banking.

Proliferation of fibroblasts cultured on a hemi-cellulose dressing

In recent times, hemi-cellulose dressing (HD) has been used clinically with satisfactory rates of success [Melandri D, De Angelis A, Orioli R, et-al. Use of a new hemicellulose dressing (Veloderm) for the treatment of split-thickness skin graft donor sites A within-patient controlled study. Burns 2006 Dec;32:964-72.]; however, the effect of cellulose dressings on the wound-healing process is unclear due to paucity of experimental data. This study aimed to determine the adhesion and proliferation of human skin fibroblasts, which were cultured in vitro using the explant technique, on HD. Cells were seeded onto HD discs and evaluated for cell adhesion and cell proliferation after 7, 14 and 21 days. Fibroblasts displayed 70% adhesion to HD after 24h. The HD discs seeded with a density of 5x10(4) cells per well showed a proliferation rate of 12% on day 7, 30% on day 14 and 75% on day 21. The results demonstrated that HD can sustain fibroblast proliferation--a highly desirable characteristic for an ideal skin substitute.

Skin tissue engineering

The major applications of tissue-engineered skin substitutes are in promoting the healing of acute and chronic wounds. Several approaches have been taken by commercial companies to develop products to address these conditions. Skin substitutes include both acellular and cellular devices. While acellular skin substitutes act as a template for dermal formation, this discussion mainly covers cellular devices. In addressing therapeutic applications in tissue engineering generally, a valuable precursor is an understanding of the mechanism of the underlying pathology. While this is straightforward in many cases, it has not been available for wound healing. Investigation of the mode of action of the tissue-engineered skin substitutes has led to considerable insight into the mechanism of formation, maintenance and treatment of chronic wounds. Four aspects mediating healing are considered here for their mechanism of action: (i) colonization of the wound bed by live fibroblasts in the implant, (ii) the secretion of growth factors, (iii) provision of a suitable substrate for cell migration, particularly keratinocytes and immune cells, and (iv) modification of the immune system by secretion of neutrophil recruiting chemokines. An early event in acute wound healing is an influx of neutrophils that destroy planktonic bacteria. However, if the bacteria are able to form biofilm, they become resistant to neutrophil action and prevent reepithelialization. In this situation the wound becomes chronic. In chronic wounds, fibroblasts show a senescence-like phenotype with decreased secretion of neutrophil chemoattractants that make it more likely that biofilms become established. Treatment of the chronic wounds involves debridement to eliminate biofilm, and the use of antimicrobials. A role of skin substitutes is to provide non-senescent fibroblasts that attract and activate neutrophils to prevent biofilm re-establishment. The emphasis of the conclusion is the importance of preventing contaminating bacteria becoming established and forming biofilms.

Burns: what are the pharmacological treatment options?

BACKGROUND

Many advances have been made in the understanding and management of burn injury, dramatically increasing pharmacological decision options for burn care professionals. Since burn injury is so multi-faceted, these advances cross many injury processes, both acute and chronic.

OBJECTIVE

The purpose of this review was to highlight the advances and decision options across the entire scope of the burn injury process. The burn-related processes with the most significant pharmacological options of approved products are highlighted.

METHODS

The scope of the current research is the most pertinent literature, which has been summarized with the addition of a personal perspective.

RESULTS/CONCLUSIONS

Many advances over the past decade in multiple fields have made pharmacological options plentiful in burn care. That said, there are many problems for the burn patient which persist, making burn injury still the most severe form of trauma. These issues range from management of a catabolic state with involuntary weight loss in the critical burn to severe itching in the rehabilitating patient. There are also many more treatment options available today. Two key reasons stand out as the most prominent. One reason is the fact that burn care has become much more proactive, by searching out new approaches to solve old problems. Now the treatment approach is altering its focus on manipulating the course of a burn. Examples include the use of temporary skin substitutes in partial thickness or second degree burns, decreasing pain and increasing the healing rate. Another is the use of slow release silver dressing as the topical burn wound antimicrobial of choice, markedly reducing discomfort, the need for dressing changes and an overall decrease in infection. In larger, deeper burns, the approach has changed from the chronic management of an open burn wound to rapid excision and wound closure, eliminating the burn as a source of complications. In addition, there has been a very aggressive approach to controlling the profound hypermetabolic, catabolic response to burns, rather than simply treating the outcome of this predictable post-burn complication. Approaching psychosocial stress again by prevention rather than treatment of established problems is another example. The second reason for increased options and differences in management involves the mindset of those individuals taking care of burns. Tremendous differences in experience are involved in decision-making. Different opinions are based on the expertise and also the personal preferences of those managing the burn.

Bioengineered skin substitutes for the management of burns: A systematic review

OBJECTIVE

To assess the safety and efficacy of bioengineered skin substitutes in comparison with biological skin replacements and/or standard dressing methods in the management of burns, through a systematic review of the literature.

METHODS

Literature databases were searched up to April 2006, identifying randomised controlled trials.

RESULTS

Twenty randomised controlled trials were included in this review. The numerous sub-group analyses and the diversity of skin substitutes limited the ability to draw any conclusions from it. However, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, Apligraf, autologous cultured skin, and allogeneic cultured skin, were at least as safe as biological skin replacements or topical agents/wound dressings. The safety of Integra could not be determined. For the management of partial thickness burns, the evidence suggested that bioengineered skin substitutes, namely Biobrane, TransCyte, Dermagraft, and allogeneic cultured skin, were at least as efficacious as topical agents/wound dressings or allograft. Apligraf combined with autograft was at least as efficacious as autograft alone. For the management of full thickness burns, the efficacy of autologous cultured skin could not be determined based on the available evidence. The efficacy of Integra could not be determined based on the available evidence.

CONCLUSIONS

Additional methodologically rigorous randomised controlled trials with long-term follow-up would strengthen the evidence base for the use of bioengineered skin substitutes.

Treatment of deep partial thickness and indeterminate depth facial burn wounds with water-jet debridement and a biosynthetic dressing

BACKGROUND

Debriding deep thermal injury to face and neck can be particularly challenging with cold knife techniques. Timely healing, a precondition for minimal scarring, is dependant upon optimal wound bed preparation.

OBJECTIVE

A new water-jet surgical tool (Versajet) (Smith & Nephew, Hull, UK) has been designed for wound debridement. Ex vivo histologic analysis of depth of debridement on human skin confirmed that predictable and controlled depth of debridement could be obtained by adjusting apparatus settings.

METHODS & MATERIALS

We prospectively studied the versatility of this instrument for the treatment of deep and indeterminate depth face and neck burns. Wounds were then covered with either a biosynthetic (Biobrane) (Bertek Pharmaceuticals Inc) or cultured biosynthetic dressing (TransCyte).

RESULTS

Patient follow-up demonstrated no adverse effects. Placement of biosynthetic dressings was compatible with water-jet debridement. Median healing time for wounds covered with biosynthetic dressings was 14 days, and 12 days for those which received the cultured biosynthetic dressing.

CONCLUSION

We have found the water-jet system to be a versatile instrument for surgical burn debridement with particular advantage in addressing the challenging and delicate contoured regions found in the face and neck. Accurate control of debridement depth facilitates wound bed preparation for simultaneous treatment with growth promoting biosynthetic dressings.

Use of Transcyte® and dermabrasion to treat burns reduces length of stay in burns of all size and etiology

BACKGROUND

With the cost of healthcare increasing, greater emphasis is placed on finding better ways to manage burn patients by increasing the quality of care while reducing length of hospital stay (LOS), thereby reducing overall cost. To date, this is the largest study to determine if Transcyte reduces LOS for partial thickness burns of any size or etiology.

METHODS

All consecutive patients with deep partial thickness burns from April 2002 to December 2002 were reviewed (n=110) with IRB approval. Ninety-two patients were treated with dermabrasion and Transcyte only. Eighteen patients were treated with a combination of STSG and dermabrasion and Transcyte where appropriate. Our data was compared to the American Burn Association Patient Registry, as reported by Saffle et al. 1995.

RESULTS

The data for percent TBSA and LOS are reported as mean+/-S.E.M. One-tailed t-test was used to analyze the data. Significant difference was found in patients who were treated with dermabrasion and Transcyte compared to the population reported by Saffle et al. Patients with 0-19.9% TBSA burn treated with dermabrasion and Transcyte had LOS of 6.1 days versus 9.0 days (p<0.001). Those with 20-39.9% TBSA burn had length of stay of 17.5 days versus 25.5 days. Patients treated with STSG and Transcyte who had 40-59.9% TBSA burn had length of stay of 39.7 days versus 44.6 days. Those treated with dermabrasion and Transcyte alone had length of stay of 31 days.

CONCLUSION

This is the first study comparing burns of all sizes treated with dermabrasion and Transcyte with a known population receiving standard therapy. The authors found this new method of managing patients with partial thickness burns to be more efficacious and significantly reduces length of stay compared to traditional management.

Clinical Approach to Wounds: D??bridement and Wound Bed Preparation Including the Use of Dressings and Wound-Healing Adjuvants

This is a clinical review of current techniques in wound bed preparation found to be effective in assisting the wound-healing process. The process begins with the identification of a correct diagnosis of the wound's etiology and continues with optimizing the patient's medical condition, including blood flow to the wound site. Débridement as the basis of most wound-healing strategies is then emphasized. Various débridement techniques, including surgery, topical agents, and biosurgery, are thoroughly discussed and illustrated. Wound dressings, including the use of negative pressure wound therapy, are then reviewed. To properly determine the timing of advance therapeutic intervention, the wound-healing progress needs to be monitored carefully with weekly measurements. A reduction in wound area of 10 to 15 percent per week represents normal healing and does not mandate a change in the current wound-healing strategy. However, if this level of wound area reduction is not met consistently on a weekly basis, then alternative healing interventions should be considered. There is a growing body of evidence that can provide guidance on the appropriate use of such adjuvants in the problem wound. Several adjuvants are discussed, including growth factor, bioengineered tissues, and hyperbaric medicine.

Management of Blisters in the Partial-Thickness Burn: An Integrative Research Review

Conflicting recommendations and clinical applications have been given concerning best practices for the management of burn blisters associated with partial-thickness burns. Arguments for the preservation of intact blisters center on the idea of naturally occurring biologic protection whereas the débridment of blisters has been advocated because of the perceived decreases in wound infection and complications. Recurring themes in burn wound management that are considered in this debate include infection, healing, functional and aesthetic outcome, patient comfort, ease of dressing care, and cost efficiency. The management of burn blisters should be supported by evidence across these six categories, should match the expertise of the provider, and should use the available resources in the practice setting. The purpose of this review is combine the findings of a comprehensive review of the published literature with respect to the management of blisters in the partial-thickness burn into a clinical guideline for best practice based on available evidence.

Tissue engineering of cultured skin substitutes

Skin replacement has been a challenging task for surgeons ever since the introduction of skin grafts by Reverdin in 1871. Recently, skin grafting has evolved from the initial autograft and allograft preparations to biosynthetic and tissue-engineered living skin replacements. This has been fostered by the dramatically improved survival rates of major burns where the availability of autologous normal skin for grafting has become one of the limiting factors. The ideal properties of a temporary and a permanent skin substitute have been well defined. Tissue-engineered skin replacements: cultured autologous keratinocyte grafts, cultured allogeneic keratinocyte grafts, autologous/allogeneic composites, acellular biological matrices, and cellular matrices including such biological substances as fibrin sealant and various types of collagen, hyaluronic acid etc. have opened new horizons to deal with such massive skin loss. In extensive burns it has been shown that skin substitution with cultured grafts can be a life-saving measure where few alternatives exist. Future research will aim to create skin substitutes with cultured epidermis that under appropriate circumstances may provide a wound cover that could be just as durable and esthetically acceptable as conventional split-thickness skin grafts. Genetic manipulation may in addition enhance the performance of such cultured skin substitutes. If cell science, molecular biology, genetic engineering, material science and clinical expertise join their efforts to develop optimized cell culture techniques and synthetic or biological matrices then further technical advances might well lead to the production of almost skin like new tissue-engineered human skin products resembling natural human skin.

Treatment of second degree facial burns with allografts—preliminary results

Facial burns are very common and have significant clinical impact. However, the treatment regimen for superficial to deep facial burns is not well defined. The purpose of this study was to investigate the effects of cadaver skin grafting in deep partial thickness facial burns in comparison to standard care. In a prospective open study design severely injured patients with superficial and deep partial thickness burns were randomized into the group receiving open treatment with silversulfadiazine (standard n=5) or into the group receiving early superficial debridement followed by coverage with glycerolized cadaver skin (n=5). The outcome measures were time and quality of wound healing, and incidence of hypertrophic scarring at 3 and 6 months post burn. There were no significant differences in demographics between groups. In the group treated with the allogenic material time to reepithelialization was 10.5 days, while it was 12.4 days in the silversulfadiazine group (p<0.05). Scar quality was found to be significantly improved in the allogenic treatment group. Three and 6 months postburn there were no patients with significant hypertrophic scarring in the allogenic group while there were two patients who developed hypertrophic scars in the silversulfadiazine group (p<0.05). In this study, we demonstrated that glyzerolized cadaver allograft skin represents a superior biological dressing for shallow and deep partial thickness facial burns. This is in concordance with other reports on scalds. It would be worthwhile to perform more clinical studies with a larger number of patients to further evaluate the effect and function of allogenic skin for facial burns.

The role of skin substitutes in the treatment of burn injuries

Extensive burn wounds are difficult to manage and repair. Several engineered skin substitutes have been developed to aid in this process. These substitutes are designed with particular objectives in mind which dictate the circumstances under which they can, and should, be employed to promote healing or prepare the burn wound for final closure with autograft. This article discusses some of the rationale behind the use of skin substitutes and reviews some of the substitutes in use at the present time. Current perspectives suggest that skin substitute use is still in its infancy and that there is some way to go before their role in clinical practice becomes clear. Nevertheless the prospect of being able to supply new wound repair components and to influence the healing process to modify outcome and improve the quality of the healed burn wound will ensure a continuing high degree of interest in these potentially useful and beneficial medical devices.

Pathophysiology and Current Management of Burn Injury

PURPOSE

To provide the physician and registered professional nurse with an overview of the pathophysiology and current management of burn injuries.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in learning about evidence-based prevention and management of burn wounds.

OBJECTIVES

After reading the article and taking the test, the participant should be able to: (1) Explain the pathophysiology of skin function. (2) Describe the different types of burn injuries. (3) Identify the treatment strategies for burn injuries.

Treatment of partial-thickness burns: a prospective, randomized trial using Transcyte

BACKGROUND

The purpose of the present study was to compare the effectiveness of three burns dressings (TransCyte, a bio-engineered skin substitute; Biobrane; and Silvazine cream (silver sulphadiazine and 0.2% chlorhexidine)), in treating children with partial-thickness burns. The primary objective was to determine the days until > or =90% re-epithelialization. The secondary objectives were to evaluate the number of wounds requiring autografting and the number of dressing changes/local wound care required.

METHODS

Study wounds were identified on each patient and the patients were randomized to receive TransCyte or Biobrane or Silvazine. Assessment of study wound closure began at 2 days after treatment and continued at least every other day thereafter until the wounds re-epithelialized or were autografted. A laser Doppler imaging system was used as an adjunct to assessing the depth of the burn.

RESULTS

Thirty-three patients with 58 wound sites enrolled in the study (TransCyte, n = 20, Biobrane, n = 17; Silvazine, n = 21). Mean time to re-epithelialization was 7.5 days for TransCyte, 9.5 days for Biobrane, and 11.2 days for Silvazine. The number of wounds requiring autografting were 5/21 (24%) for Silvazine, 3/17 (17%) for Biobrane, and 1/20 (5%) for TransCyte.

CONCLUSIONS

When used in partial-thickness burns in children, TransCyte promotes fastest re-epithelialization and required less overall dressings then Biobrane or Silvazine. Patients who received Silvazine or Biobrane require more autografting than those treated with TransCyte.

Use of a living dermal equivalent for a refractory abdominal defect after pediatric multivisceral transplantation

BACKGROUND

Primary closure is not always possible after pediatric multivisceral transplantation. Reepithelialization may require extended periods of postoperative time, which can be associated with significant morbidity.

OBJECTIVE

The objective was to accelerate secondary wound closure thereby minimizing infection or further complications in a pediatric multivisceral transplant patient.

METHODS

Five applications of human fibroblast-derived dermis (Dermagraft, Smith and Nephew) were applied to the postsurgical defect of a pediatric multivisceral transplant patient over the course of 8 months. Routine wound care and observation was performed between human fibroblast-derived dermis applications.

RESULTS

Human fibroblast-derived dermis stimulated healing and accelerated reepithelialization. Signs of clinical rejection or infection were not observed.

CONCLUSION

Reepithelialization can be aided in the postoperative period in pediatric multivisceral transplant patients with human fibroblast-derived dermis, thereby helping to deter complications associated with secondary wound closure. We have illustrated the successful use of a human fibroblast-derived dermis as an adjunct for wound healing in a complicated surgical defect.