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Local treatment of burns: Topical antimicrobial agents and dressings
Authors:Mayer Tenenhaus, MD, FACS, Hans-Oliver Rennekampff, MD Section Editor:Marc G Jeschke, MD, PhD Deputy Editor:Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Jul 11, 2016.
INTRODUCTION — Local treatment of burns includes cleansing and debridement, topical antimicrobial agents, and dressings. However, there is no consensus on which topical antimicrobial agent or dressing is optimal for burn wound coverage to prevent or control infection [1-3]. Minor burns (eg, sunburns) and superficial partial-thickness burns with an intact epidermis generally do not require a topical antimicrobial agent or dressing [4,5].
The most frequently used topical antimicrobial agents and dressings for burns in adults and children will be reviewed here. The classification, emergent care of burns, and specialized management of burns to the hand are discussed elsewhere. (See "Classification of burns" and "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Treatment of minor thermal burns" and "Primary operative management of hand burns".)
LOCAL TREATMENT — Burn wound healing is a dynamic process, and local management may vary with the evolving clinical picture. Acute burn wounds should, if possible, be evaluated and treated by an experienced burn care provider. Nonoperative management includes cleansing, debridement, topical antimicrobial drugs, and dressing changes. This approach is ideal for patients with partial-thickness burns and as the initial approach for patients with deep second-degree burns and full-thickness burns.
Burn wound dressings serve three purposes :
●They absorb drainage
●They provide protection and a measure of isolation from the environment
●They decrease wound pain
Cleansing and debridement — Cleansing and debridement remove loose, devitalized, and necrotic tissue (eg, blister, foreign material, and debris). Burn wounds are initially gently and carefully cleansed with either skin disinfectants or mild soap and water, as minor and partial thickness burn wounds are painful. (See "Burn pain: Principles of pharmacologic and nonpharmacologic management" and "Paradigm-based treatment approaches for burn pain control".)
Debridement is typically performed using gentle mechanical techniques (eg, brushing, scraping, curetting, and cutting) . In our practice, we generally prefer to begin with well-moistened soft gauze or cotton laparotomy pads. When more aggressive debridements are required, we will often use well-moistened chlorhexidine surgical scrub brushes.
Following a burn, proteolytic activity increases at the burn site . Hence, a variety of proteolytic enzymes have been used for debridement of burn wounds to selectively debride the wound without damage to the normal tissue . These products may be beneficial for removing superficial eschar and pseudoeschar. However, they should not be used in infected sites or in areas in which there is a risk of ocular contamination. In addition, some patients can develop an allergic reaction to the enzymes. While treatment of burns with enzymatic debridement is safe , results are highly variable [8,10].
The following agents are examples of proteolytic enzymes used in burn wound management:
●Collagenase is the most commonly employed enzymatic debriding agent currently commercially available in the US. It is slow acting, requiring several days to a week to adequately debride or heal intermediate depth partial-thickness wounds. In a prospective study of 78 children sustaining partial-thickness burns and treated with collagenase A, 49 children (63 percent) had total removal of the eschar . There was no statistical difference in time to achieving a clean burn wound when compared with children with similar burns treated with excision and skin grafting and failing collagenase A treatment (n = 29) and historic controls treated with early excision and skin grafting (n = 41).
●Bromelain, a papain derivative, is a newer, more aggressive enzymatic agent. A preliminary study of 22 patients with acute deep burns showed that bromelain provided a rapid, effective, selective, and safe method of burn debridement . Patients did experience minor to moderate pain with this agent. A multicenter, open-label, randomized, clinical trial that included 156 adult and pediatric patients with deep partial and full-thickness burns (5 to30 percent TBSA [total body surface area]) found that patients treated with enzymatic debridement (n = 75) had a significantly reduced time for complete debridement compared with surgical excision (2.2 versus 8.7 days) . In addition, fewer patients undergoing enzymatic debridement had required a skin graft (17.9 versus 34.1 percent).
After judicious debridement, the wound site is typically treated with topical antimicrobial agents and nonadherent dressings. (See 'Topical antimicrobial agents' below and 'Dressings' below.)
Burn blisters — The management of burn blisters depends in part, upon whether or not the blister has ruptured. Ruptured blisters should be debrided, while the best treatment for an intact burn blister remains a matter of debate and experience as there is no accepted standard . In the absence of well-designed studies, experts may come to differing conclusions. As an example, some feel that there is an increased risk of infection in intact blisters, while others feel that the blister acts as a barrier to infection. We prefer not to disrupt very small blisters if they are maintained in a clean, protected, and moist environment. In our practice, we unroof larger blisters and treat accordingly.
Potential reasons to rupture intact blisters include:
●Large and expanding blisters may exert pressure on the underlying wound surface
●Intact blisters can hinder the assessment of burn depth
●Components of blister fluid are harmful to wound healing
●Blisters on the hands, feet, and joints hinder full range of motion
Potential reasons for preserving a burn blister include:
●Blisters may provide a natural barrier against infection
●Blister fluid may promote wound healing
●Wound desiccation may occur in the absence of topical antimicrobial agents and adequate dressings
Topical antimicrobial agents — Burn wound surfaces are prone to rapid bacterial colonization with the potential for invasive infection. The use of topical antimicrobial agents and aggressive wound care has reduced the incidence of invasive wound infections for superficial partial-thickness burns devoid of epithelium, superficial full-thickness burns, and deeper burns .
Topical antimicrobial agents and cytoprotective dressings are the best choices for wound coverage, although there is no consensus on which topical agent or dressing is best suited for burn wound management [1,3]. Randomized trials comparing different topical antimicrobials have been performed, but most had methodologic shortcomings
Minor burns (eg, sunburns) and superficial partial-thickness burns with an intact epidermis do not require a topical antimicrobial agent [4,5]. For these burns, coverage with bismuth-impregnated petroleum based gauze (eg, Xeroform) is satisfactory. (See 'Bismuth-impregnated petroleum gauze' below.)
Commonly used topical agents for partial-thickness burns include silver sulfadiazine, conventional antibiotics, chlorhexidine, povidone-iodine, mafenide, and bismuth-impregnated petroleum gauze [1,15]. These agents have variable degrees of local or systemic adverse effects, and may impede wound healing (table 1) [6,14].
The selection and application of topical antimicrobials are to a great degree reflected in the art of the science as well as costs. The preferred agent is dependent upon regional and individual preference and experience, a particular wound quality or state, and the patient’s allergy history. Over the past several decades, silver sulfadiazine and mafenide acetate dressings predominated. Widely available, relatively inexpensive, and with a long history and experience behind them, these products continue to be utilized by many countries and centers as standards of care for the treatment of burn injury.
Silver sulfadiazine — Silver sulfadiazine cream (SSD 1 percent) is the most commonly used burn wound dressing [1,16]. This thick white cream is applied once or twice daily, and can be soothing. SSD and related agents should not be used in women who are pregnant or breastfeeding, or in infants younger than two months old . SSD is also oculotoxic and should not be used near the eyes .
SSD cream has antibacterial activity as demonstrated by decreased colonization of burn wounds. However, there are no well-designed trials to confirm improved wound healing or a reduced rate of bacterial wound infection [1,16]. In addition, there are potential adverse effects. As an example, SSD will form a pseudoeschar that is loose at the edges, which can promote bacterial proliferation. The pseudoeschar requires removal or debridement to improve the ability to monitor the wound state and facilitate reepithelialization. For wounds covering more than 50 to 60 percent of total body surface area, SSD does not consistently prevent or suppress bacterial growth, particularly of Gram-negative bacteria [19,20]. SSD also impedes reepithelialization; as a result, SSD should be stopped when there is evidence of reepithelialization .
Combination antibiotics — Combination topical antibiotic agents are commonly used. Compared with silver sulfadiazine, the advantages of these are ease of application and of removal for wound cleansing.
Polysporin is a combination of bacitracin zinc and polymyxin B sulfate. It can be used to treat partial-thickness burns, particularly those that involve the face and perineum . For uncomplicated wounds, many clinicians apply polysporin ointment covered by a nonadherent dressing. However, its efficacy in the treatment of infected wounds has not been clearly established. In the setting of methicillin-resistant Staphylococcus aureus (MRSA), bactroban (mupirocin) ointment is effective . Areas near the eyes are generally managed with ophthalmic derivatives, such as neomycin or erythromycin ophthalmic ointment. Otherwise, the use of neomycin is generally limited to smaller burn areas. It is frequently mixed (diluted) with bacitracin and polymyxin to reduce absorption .
Bacitracin, neomycin, and polymyxin B have negligible systemic absorption after topical administration except when applied to large areas or for long periods of time. Polymyxin B has little absorption even when applied to open wounds. However, systemic absorption has been reported when bacitracin, neomycin, or gentamicin have been applied to damaged epithelium . If absorbed systemically, bacitracin, neomycin, or polymyxin B can cause nephrotoxicity and neurotoxicity. Caution should be used in patients with impaired renal function and in those taking additional medications with nephrotoxic or neurotoxic adverse effects. An alternative is to limit the duration of use and/or to alternate with topical agents that are not absorbed.
Chlorhexidine — Chlorhexidine gluconate, a long-lasting antimicrobial skin cleanser, is often used with a gauze dressing for burn wound coverage in superficial partial-thickness burns. Chlorhexidine dressings do not interfere with wound reepithelialization in contrast to silver sulfadiazine [1,6].
Mafenide acetate — Mafenide acetate, a potent carbonic anhydrase inhibitor, is used for treating patients with dense bacterial proliferation of the burn wound [23,24]. In a prospective study of 669 burn patients treated with 5 percent mafenide solution as either the initial topical antimicrobial agent (276 patients) or for chronic treatment, effective antibacterial activity was achieved, only 1 percent experienced pain severe enough to discontinue therapy, and there was a very low incidence of rash and pruritus and no cases of metabolic acidosis .
Mafenide acetate can also be applied as a cream, applied once or twice daily, at a thickness of approximately 1/16 of an inch . Treatment is typically continued until the burn site is healed or ready for skin grafting.
Adverse reactions associated with use of mafenide include metabolic acidosis, allergic reactions (eg, rash, pruritus, hives, erythema, eosinophilia), and respiratory complications (eg, tachypnea, decrease in arterial pCO2) [26,27] .
Povidone-iodine ointment — Povidone-iodine ointment, including a liposomal preparation, effectively combines antisepsis therapy with a desired moist wound environment. Despite a broad spectrum of antimicrobial activity [28,29], use of povidone-iodine containing products in burn care is controversial because of cytotoxicity and delay in wound reepithelialization . Another drawback to povidone-iodine ointment compared to other topical agents is that it must be applied four times a day for maximal antimicrobial effect.
Bismuth-impregnated petroleum gauze — Bismuth-impregnated petroleum based gauze (eg, Xeroform) is comparable to the topical antimicrobial agents previously described to prevent or control burn wound infection [4,5]. Bismuth-impregnated gauze is applied as a single layer over the burn and then covered with a bulky dressing . This is an excellent option for very small superficial partial-thickness burns where clinical judgement indicates that an antimicrobial agent is not necessary.
Bismuth-impregnated petroleum-based gauze is an often preferred dressing for use in clean partial-thickness wounds, donor sites, as well as a nonadherent dressing over skin grafts. It is rather inexpensive and affords mild antimicrobial properties [30,31].
Honey — Honey-derived wound care dressings heal superficial partial thickness wounds as well as or better than several other conventional treatment options such as polyurethane film, paraffin gauze, soframycin-impregnated gauze, sterile linen, or leaving the burns exposed . There are few high-quality studies, but evidence from low quality studies and anecdotal reports suggest that honey-derived wound care dressings are generally well tolerated and may show adjunctive efficacy in the treatment of a variety of wound types.
Dakin's solution — Dakin’s solution (0.025 percent sodium hypochlorite), a topical, broad spectrum antimicrobial with efficacy in the clinical setting of MRSA, Vancomycin-resistant enterococcus and other antibiotic resistant bacteria, is widely used in a variety of difficult wound types and has been advocated by some for the management of thermal injuries.
Proponents of Dakin’s solution note its broad spectrum of action, minimal cost and cytoprotective (little impact on fibroblast function) benefits. While to date there are few well defined papers to strongly advocate its use in burns, it may hold promise, particularly in settings where funding and availability of other standard dressing regimens are lacking. Pain control issues have been noted .
Other agents — Several other agents, such as silver nitrate and combinations of antimicrobials with topical antifungal agents, have demonstrated some efficacy for the local treatment of burns [34,35]. However, there is no official standard for testing efficacy and cytotoxicity of topical antimicrobial agents .
Dressings — The burn wound dressing provides a variety of benefits. It protects the wound from further trauma or infection, provides comfort and pain relief, and promotes healing. After the initial assessment and cleansing, superficial partial-thickness burn wounds can be dressed with a variety of dressing choices. There is no consensus on which topical agent or dressing is best suited for superficial partial-thickness burn wounds and a review of 26 randomized trials (most with methodologic shortcomings) did not identify an optimal dressing type .
Burn wounds are generally cleansed and dressed daily. More frequent dressing changes are performed if there is a large amount of exudate, weeping, or infection. Frequent dressings that are unnecessary can impair burn wound reepithelialization.
Four types of dressings can be used for burn management:
Compresses — There are several types of compress dressings: fine mesh gauze (preferably with topical antimicrobials), hydrocolloid dressings, and silver-containing dressings.
Fine mesh gauze — Fine mesh gauze in combination with antimicrobial agents is the most widely used compress dressing, providing a moister and less adherent dressing than fine mesh gauze alone. (See 'Topical antimicrobial agents' above.) This is one of the most common burn wound dressings.
Use of fine mesh gauze alone is more likely to lead to scab formation, and the gauze and scab will lift spontaneously as reepithelialization occurs. However, pain can be significant when the gauze is manually removed during dressing changes. As a result, gauze alone is primarily used when there are no other options (eg, topical antimicrobials are not available).
Hydrocolloid dressings — Hydrocolloid dressings contain gelatin, pectin, and sodium carboxymethylcellulose in an adhesive polymer matrix, which forms a gel whenever the inner layer contacts the wound exudate . In addition, some hydrocolloid wafers contain silver. These dressings are best used as a treatment of superficial partial-thickness burns that comprise a limited body surface area and are in the later phase of reepithelialization.
Five clinical trials that included 314 patients compared hydrocolloid dressings with other conventional burn wound dressings . The hydrocolloid dressings were changed every five days as per protocol whereas conventional comparator dressing changes varied from twice daily to every three to five days based upon an indication of leakage or infection. Hydrocolloid dressings significantly reduced mean healing time (10.2 versus 15.6 days) and pain score (1.1 versus 2.3 out of 10 as most severe), and had a better level of patient satisfaction when compared to silver sulfadiazine gauze dressings. There was no difference in healing rates, background pain, pain associated with dressing changes, or ease of removal when comparing hydrocolloid dressings with chlorhexidine impregnated paraffin gauze with or without silver sulfadiazine.
Silver-containing dressings — Silver-containing dressings slowly release silver into the wound. Activated silver has broad spectrum antimicrobial activity and may also have an antiinflammatory benefit . There are several silver containing preparations including nanocrystalline silver (eg, Acticoat, Aquacel Ag), silver sulfadiazine, and silver nitrate, each of which has its own management requirements. Nanocrystalline silver dressings are composed of a urethane film embedded with elemental silver that provides sustained release of silver into the wound. These dressings can be changed once per week, depending upon the amount of exudate . Some nanocrystalline silver dressings (eg, Acticoat) require frequent moistening with water to maintain activation. Older silver formulations that contain silver nitrate and silver sulfadiazine require more frequent dressing changes.
A variety of clinical trials has been performed with the different silver preparations:
●A meta-analysis of 13 trials of patients with burns compared dressings containing silver formulations (including silver sulfadiazine) with non-silver dressings . There were conflicting results regarding reduction of infections with silver-containing dressings and insufficient evidence to establish whether these dressings promote wound healing or prevent wound infection. Some trials in this review suggested that there may be a detrimental effect from silver-containing dressings.
●A meta-analysis of five clinical trials compared nanocrystalline silver dressings to older silver formulation dressings (silver sulfadiazine and silver nitrate) for evaluation of infection rate, pain, length of hospital stay, and costs . The nanocrystalline silver group had a significantly lower rate of infections (9.5 versus 27.8 percent), decreased pain, no clear effect on hospital length of stay, and a higher cost per patient.
●A prospective trial comparing Acticoat with Allevyn, an occlusive moist-healing environment material, found that skin graft donor sites dressed with Allevyn reepithelialized at a significantly faster rate, but that there was no difference in the incidence of positive wound cultures . A similar prospective trial found contrary information regarding reepithelialization of skin graft donor site wounds . In this study, Acticoat provided significantly faster reepithelialization and better comfort with Acticoat as a dressing for skin graft donor site wounds than Allevyn. Both studies are in agreement that there is no difference in bacterial colonization of the donor site.
●A retrospective review of 502 consecutive children (age 0 to 4 years) with partial-thickness scald burns up to 10 percent TBSA found that fewer children treated with hydrofiber dressings (Aquacel) required skin grafts compared with children treated with silver sulfadiazine (11.6 versus 20.7 percent, p<0.01) . Another advantage of a hydrofiber dressing is that daily dressing changes are typically not required.
Biosynthetic dressings — Biosynthetic dressings (semibiologic skin substitutes) are temporary dressings that have been developed in an attempt to reduce the number of dressing changes and facilitate healing [45,46]. The type of skin substitute depends upon the appearance of the wound, desired outcome, cost efficacy, availability, the clinician's experience, and cultural preferences as some contain a porcine product. The semipermeable nature of these dressings allows wound exudate to be absorbed by the external bulky dressing. A review of 20 clinical trials found that bioengineered skin substitutes were at least as effective as topical agents and wound dressings, or allografts for the management of partial-thickness burns . Biosynthetic dressings are contraindicated for use in infected wounds.
For burn patients under age 18 years of age, biologic dressings may be optimal coverage for partial-thickness burns. In a retrospective review of 51 retrospective reviews, prospective studies, and randomized trials, biologic dressings (eg, Biobrane, DuoDerm, amnion membrane) showed better results for eschar formation, length of hospital stay, healing time, and pain scores when compared with SSD . Overall, the most frequently used topical agents in this population were SSD and SSD plus chlorhexidine.
Biobrane — Biobrane is a bilaminate membrane that contains a thin semipermeable silicon membrane bonded to a layer of nylon fabric mesh and coated with a monomolecular layer of type 1 porcine collagen . The porcine collagen provides a hydrophilic coating for fibrin growth that promotes wound adherence. The membrane is porous and permits drainage of exudate and absorption of topical antimicrobial agents. Biobrane is versatile and has additional properties of flexibility, elasticity, and transparency for wound observation. Biobrane has no inherent antimicrobial activity.
Biobrane is used to treat excised full-thickness burns in adults, large surface area burns, and burns involving the hands, feet, and joints in adults and children [50-54]. Clinical experience with Biobrane is limited. The largest retrospective review evaluated 84 children with superficial partial-thickness burns or scalds, extending between 5 and 25 percent total body surface area; all were treated with Biobrane . Biobrane adhered to the wound in 71 (84 percent) and there were no infections. Five patients had local nonadherence with no evidence of infection in the aspirate. Cosmetic healing was favorable as 21 of 49 patients (43 percent) had no scars or limited hypopigmented or normal pigmented scars. Most scars that did occur were hypopigmented with softness between minimal and middle resistance.
Biobrane is applied by gently stretching the fabric over the burn surface to avoid wrinkles and is secured to non-burned skin with paper strips . Dry gauze is used to cover the Biobrane and the dressings are secured with an elastic bandage. The external dressings are changed every 24 hours, and any fluid accumulating under the Biobrane is aspirated. Biobrane can be left in place for up to 14 days, then removed in a warm bath or trimmed. Healed wounds are treated with topical agents or creams. If there is evidence of a wound infection, the Biobrane is removed and the burn treated with topical antimicrobials. (See 'Topical antimicrobial agents' above.)
Biobrane-like — There are biosynthetic dressings that either incorporate Biobrane or are of a similar nature including Transcyte (neonatal fibroblast incorporated into Biobrane), Suprathel (resorbable caprolactone based materials), and Omiderm (hydrophilized polyurethane membrane).
Ten clinical trials compared the effectiveness of Biobrane or Transcyte to twice a day application of silver sulfadiazine or other comparators . Overall, biosynthetic dressings resulted in a shorter time to healing, improved pain relief during dressing changes, lower requirement for pain medication, and a shorter length of hospital stay. Pooled data were not provided. A prospective trial of 30 patients with partial-thickness burns compared Suprathel to Omiderm . Suprathel provided significantly better attachment and adherence to wounds, improved pain score, and ease of application, but there was no difference in healing time and time to reepithelialization. Further comparative studies are required.
Polyhexanide containing bio-cellulose — A prospective trial of 60 patients with partial-thickness burns found that patients treated with a polyhexanide containing bio-cellulose dressing (BWD+PHMB) had significantly better and faster burn pain reduction compared with patients treated with silver sulfadiazine cream (day 0 <1 versus >5 by the Visual Analog Scale) . The reduction in pain with BWD+PHMB continued for 14 days of observation. BWD+PHMB was also more cost-effective. The material is available for clinical use in the European Union. A variety of interactive dressings have been used for the treatment of partial thickness wounds with none of them showing superiority.
Biologic dressings — Several biologic dressings are used as temporary coverage for burn wounds. Biologic dressings or bismuth-impregnated petroleum gauze are especially useful in children, as they are applied only once, decreasing the pain that typically accompanies wound dressing changes. Biologic dressings can be used on clean burn wounds, and they protect the wound from desiccation while promoting reepithelialization. These dressings will separate from the wound when it has reepithelialized.
Allogeneic skin grafts — Transient physiologic coverage can be achieved by allogeneic skin grafts (eg, from a non-genetically identical donor, also called homograft) . Allografts are distributed as either fresh or cryopreserved after glycerol preservation from cadavers. The application of an allograft over superficial partial-thickness wounds can minimize pain and facilitate reepithelialization. Allogeneic skin is generally used only in burn centers.
Human amnion — Human amniotic membrane has been successfully employed as a biologic dressing for partial-thickness wounds [45,46]. A retrospective review of 31 studies found that amniotic membrane promotes reepithelialization of the burn wound, has antimicrobial properties, and reduces pain, fluid loss, and scar formation. Concerns regarding pathogenic transmission have limited its use.
In addition, an allograft consisting of sterilized, dehydrated human amnion/chorion membrane (dHACM) is also used for burn patients . DHACM contains growth factors that promote wound healing, including platelet derived growth factor A and B, basic fibroblastic growth factor and transforming growth factor beta 1, and is stable at ambient temperatures for five years [60,61].
Skin xenografts — Skin xenografts (heterografts) are obtained from an unrelated species and used as temporary skin coverage, especially for large burn wounds. Only porcine grafts are currently used [62,63]. Xenografts are generally readily available, but may not be as effective as allografts.
Barrier, waterproof dressings — Multifunctional, sterile, waterproof, and breathable barrier dressings (such as polyurethane membrane Tegaderm transparent film) can be used for management of burns of various sizes . In addition, for smaller superficial partial-thickness wounds, occlusive dressings may be considered. Accumulations of serosanguinous fluid are generally drained as needed.
LOCAL TREATMENT OF PRURITUS — Severe pruritus occurs in as many as 87 percent of adult and 100 percent of pediatric burn patients during the healing process [65-67]. Pruritus tends to present early during wound healing and continues well after reepithelialization and scar maturation, but rarely persists beyond 18 months. An overview of the treatment of pruritus in general is presented elsewhere. (See "Pruritus: Overview of management".)
A variety of therapies, both systemic and topical, have been used for the treatment of post-burn pruritus. Proof of efficacy is primarily anecdotal as high quality randomized trials have not been performed [65,68]. Systemic first-line treatment for post-burn pruritus consists of H1 and H2 antihistamines (eg, diphenhydramine, cetirizine, cimetidine), but none has provided complete relief. Other systemic agents that may prove helpful include cyproheptadine, hydroxyzine, gabapentin, and tricyclic antidepressants (eg, doxepin).
Topical treatments, which may provide relief of pruritus, include [6,65,68-70]:
●Vaseline based creams
●Hydrogel sheets (eg, Tegagel, Vigilon, FlexiGel)
●Colloidal oatmeal in liquid paraffin
●UNNA boot (glycerin, zinc oxide, and calamine lotion)
●EMLA, which is a mixture of local anesthetics
●Silicone gel sheeting
The role of topical glucocorticoids (eg, hydrocortisone, triamcinolone) varies importantly with the stage of the burn. These agents can be applied to reepithelialized wounds. In contrast, topical glucocorticoids are not used on unhealed burns, since they can lead to thinning of the healing skin, infection, and systemic absorption.
Topical agents high in lanolin should be avoided, since they can worsen pruritus .
Other therapies that have been evaluated for the treatment of pruritus in burn patients include transcutaneous electrical nerve stimulation (TENS) [69,72] and pulsed dye laser [73,74]. TENS is a treatment option in patients who fail the above therapies. However, in clinical practice, TENS is rarely used as a treatment for pruritus and is experimental. Further assessment in clinical trials is needed before this can be a recommended treatment.
Conventional pulsed dye laser (585 nm) treatment, applied three times at monthly intervals, was evaluated in a study of 38 patients in whom the area of scar was divided randomly into treatment and control . Pruritus was evaluated on a score of 1 to 10 in adults and by signs of excoriation in children. Pruritus was significantly reduced following one laser treatment in comparison to the level of pruritus prior to treatment. Although pruritus was reduced in both treated and untreated areas of the burn, the improvement was significantly greater in the treated area at 1, 6, and 12 months. Other studies have reported alleviation of pruritus and burning sensation following a single laser treatment [75,76]. A variety of ablative and nonablative lasers and pulse dye therapies are experimental for the management of the burn wound management. While these results are promising, this approach is still experimental, and further assessment in clinical trials is needed before this can be a recommended treatment.
LOCAL TREATMENT OF BURN SCARS
Hypertrophic scarring is thought to be likely in any burn victim in whom complete or near complete reepithelialization takes longer than three to four weeks . As a result, burn patients should be promptly referred to a surgeon experienced in burn care at the first sign of hypertrophic scarring or if the wound fails to begin reepithelialization by two weeks .
Early application of moisturizing agents (as listed in the preceding section), silicon sheeting , and massage is generally advocated for healed burns, particularly those that presented initially as deep injuries or those that show signs of delayed healing . The role of pressure garment therapy is less clear. Pressure garments are routinely advocated by most burn centers, although there is no definitive evidence of efficacy. A review of six high quality clinical trials of pressure garment therapy found scar height was statistically significantly reduced, although this measurable difference is of questionable clinical significance .
Laser treatment, particularly fraxelated type, often in combination with local flap design and/or the application of steroids, is increasingly being advocated and appears to show promise. Definitive randomized controlled studies are still lacking.
SUMMARY AND RECOMMENDATIONS — For patients with superficial partial-thickness burns, or deeper burns prior to excision and skin grafting, there is no consensus on which topical antimicrobial agents and dressings provide the best burn wound coverage to prevent or control infection. Minor (eg, sunburn) and superficial partial-thickness burns with an intact epithelium do not require treatment with a topical antimicrobial agent or dressing.
●We suggest using a topical antimicrobial agent or bismuth-impregnated petroleum based gauze (eg, Xeroform) as the initial burn wound coverage for superficial partial-thickness burns devoid of epithelium and deeper burns (Grade 2C). These agents provide a moist environment conducive to wound healing. Commonly used topical antimicrobial agents include silver sulfadiazine, combination antibiotics, and chlorhexidine. In the absence of high quality data comparing agents, the choice can be made based on cost, availability, and provider familiarity. Silver sulfadiazine with cerium or alone, and povidone-iodine are contraindicated in newborns, pregnancy, and lactation. (See 'Topical antimicrobial agents' above.)
●We suggest using fine mesh gauze with a topical antimicrobial agent, as the dressing of choice for most superficial partial-thickness burns (Grade 2C). There is no consensus on which dressing provides the best coverage. (See 'Dressings' above.) In the absence of high quality data comparing other types of dressings (eg, hydrocolloid, silver-containing dressings, biosynthetic, and biologic dressings), the choice can be made based on cost, availability, phase of burn wound healing, frequency of dressing changes, and provider familiarity.
●No clear evidence exists to support any specific approach to the frequency of dressing changes, which range from twice daily to weekly. Dressing changes should be frequent enough to control exudate, but not so frequent as to interfere with wound reepithelialization. It appears best to change dressings whenever they become soaked with excessive exudate or other fluids, or if there are signs of infection. Topical antibiotics should be removed gently with dressing changes; scrubbing and sharp debridement is not necessary and may hinder healing. (See 'Dressings' above.)
●A variety of oral medications and topical agents are used to treat post-burn pruritus. Systemic first-line treatment for post-burn pruritus consists of H1 and H2 antihistamines (eg, diphenhydramine, cetirizine, cimetidine), but none has provided complete relief. Topical agents include aloe vera, vaseline based products, and cocoa butter. Proof of efficacy is primarily anecdotal as high quality randomized trials have not been performed. (See 'Local treatment of pruritus' above.)
●Burn patients should be referred to a surgeon with expertise in burn care if complete or near complete reepithelialization takes longer than three to four weeks as well as at the first sign of hypertrophic scarring or if the wound. (See 'Local treatment of burn scars' above.)
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