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Three Part Question

In [patients presenting with superficial partial thickness thermal burns to extremities] is [the use of simple (petroleum gauze impregnated) dressing better than antimicrobial dressing] at [rapid healing and preventing infection]?

Clinical Scenario

A 25 years old lady presented to emergency department screaming with pain due to superficial burn and scald to her left hand. She dropped the full kettle of boiling water and in trying to hold it she spilled all the boiling water on her left hand. She was scared to put her hand under running tap water as it was painful but agreed to put her hand in saline in a tub. She had some blisters and was asking for antiseptic dressings on it. You wonder whether simple petroleum gauze impregnated dressing would be better than using antimicrobial or iodine dressing?

Search Strategy

Medline via OVID interface 1950 – Nov 1st 2010
CINAHL via Health Information resources NHS Evidence interface
(Formerly National library of Health) 2008 – March 2010
EMBASE via Health Information resources NHS Evidence interface
(Formerly National library of Health) 2008 – March 2010

exp Burns/ or Burns$.mp.OR Blister$.mp. or exp Blister/OR superficial.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier] OR partial thickness.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]OR first degree.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
AND
exp Bandages, Hydrocolloid/ or exp Occlusive Dressings/ or exp Bandages/ or hydrogel dressing$.mp.OR foam dressing.mp.OR antiseptic dressing$.mp.OR inadine.mp.OR mepitel.mp. [mp=title, original title, abstract, name of substance word, subject heading word, unique identifier]
limit to (english language and humans)

Search Outcome

Medline: 1499 articles were found, out of which 6 were relevant & critically appraised.

CINAHL: Total of 100 articles and papers but no new relevant papers or articles.

EMBASE : No new papers or related articles were found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wasiak J et al 2009 Australia & UK	(Cochrane review) Extensive Search of 4 databases (The Cochrane Central Register of Controlled Trails & Cochrane Wounds Group of Specialised Register; Ovid Medline; Ovid EMBASE; Ovid CINAHL) all to May 2008. 26 randomised controlled trials (RCTs) that evaluated the effects of burns wounds dressings used in the treatment of superficial and partial thickness burns. Included in it are patient of all ages with superficial and partial thickness burns & wound dressing used singly and in combination to treat superficial and partial thickness burns. Trials with full thickness burns were excluded.	Level 1a : Systematic review (with homogeneity of RCTs) & meta-analysis. They used fixed effect model where there was no evidence of significant heterogeneity between studies (I2 less than 40%) & employed a random effect model when heterogeneity was likely (I2 more than 40%).	Time (days) to Complete Healing	Hydrocolloid vs chlorhexidine impregnated paraffin gauze. n = 3(236) Median 12 v 12 p 0.89 Mean 11 v 11	Most RCTs were methodologically poor ; ie. In many cases number of people included in trial was small & time to wound healing & statistical analysis was often not reported. Poor clinical definition of superficial and partial thickness burns in many studies. Unreported burn wound depth estimates or no formal assessments of burn wound depths. Failure to report on randomisation techniques, allocation concealment, small sample sizes, subjective outcome assessment & poor reporting of withdrawal and adverse event data. Poor measurements of outcomes such as pain, patients satisfaction, wound infection, scar appearance. Most studies were conducted mainly on paediatric population. Despite some potentially positive findings, the evidence derived from trials, is of limited usefulness in aiding clinicians in choosing suitable treatments.
				Hydrocolloid vs SSD n =1(42) Mean 10 v 16 p <0.01
				Polyurethane film vs paraffin gauze n=1(55) Median 7 v 10 p>0.05
				Polyurethane film vs chlorhexidine impregnated paraffin gauze n = 1(51) Mean 10 v 14 p 0.02
				Hydrogel vs usual care n = 2(155) Mean 12 v 14 p<0.02 Mean 14 v 15 p 0.07
				Silicon coated nylon vs SSD n = 2(142) Mean 8 v 11 p<0.01 Median 11 v 28 p<0.001
				Biobrane vs SSD n = 4(209) Mean 10 v 16 p<0.001 Mean 14 v 21 p<0.01 Mean 8 v 19 p<0.02
				Biobrane vs Hydrocolloid n = 1(72) Mean 12 v 11 p 0.45
				Transcyte vs SSD n = 2(69) Mean 11 v 18 p 0.002 Mean 8 v 11 p<0.001
				Transcyte vs Biobrane vs SSD n = 1(33) Mean 8 v 10 v 11 p<0.001
				Hydron vs SSD or other agents n = 3(95) Mean 7 v 12 p<0.05
				Silver impregnated dressing vs SSD n = 3(162) Mean 12 v 16 p<0.05
				Calcium alginate vs SSD n = 1(59) Mean 12 v 12
			Incidence of Infection	Hydrofibre vs SSD n = 1(47) Median 16 v 17 p 0.517
				Hydrocolloid vs chlorhexidine impregnated paraffin gauze. n = 3(236) Withdrawal due to wound infection 1case (68) Wright 1993 No bacterial isolates in 2RCTs (168) Thomas 1993 p 0.12 Phipps 1988 p 0.02
				Hydrocolloid vs SSD n = 1(48) 18 participants lost in follow up (possibility of bias) No wound infections reported (Afilalo 1992) but 3 people developed cellulites were excluded from RCT.
				Polyurethane film vs paraffin gauze n = 1(55) No significant difference in the rates of wound infection between two groups 10% v 8% p 0.80 Relative risk (RR) 1.25 95% CI 0.23 to 6.90
				Polyurethane film vs chlorhexidine impregnated paraffin gauze n = 1(51) No significant difference in the rates of wound infection between two groups 4% v 8% p 0.54 Relative risk (RR) 0.48 95% CI 0.05 to 4.98
				Hydrogel vs usual care n = 2(155) Incidence of infection not addressed
				Silicon coated nylon vs SSD n = 2(142) No signs of infections were exhibited in the dressing changes.
				Biobrane vs SSD n = 4(209) Wound infection reported in 2 out of 4 studies. Gerding 1988 reported bacterial growth in 4 wounds in each group, of which 2 infected wound in each group requied excision & grafting. Gerding 1990 noted 3 infections in Biobrane & 2 infections in SSD group Relative risk (RR) 0.68 95% CI 0.21 to 2.24
				Biobrane vs Hydrocolloid n = 1(72) Incidence of infection not addressed.
				Transcyte vs SSD n = 2(69) Noordenbos 1999 noted 6 patient developed mild cellulites in SSD group & all responded to intravenous antibiotics.
				Transcyte vs Biobrane vs SSD n = 1(33) Incidence of infection not reported. 3 wounds in Biobrane & 1 wound in Transcyte required autograft because of infection. 5 wound in SSD required autografting because of delay epitheliazation but no infection
				Hydron vs SSD or other agents n= 3(95) 30% v 16% p 0.11 RR 1.88 95% CI 0.87 to 4.02
				Silver impregnated dressing vs SSD n = 3(162) Varas 2005, No wound infection reported in either group. Muangman 2006, 6% v 8% p>0.05 Li 2006, 56 bacterial strains found in 166 wounds cleared 6th & 12th day post antibiotic treatment.
				Calcium alginate vs SSD n = 1(59) Incidence of infection not reported
				Hydrofibre vs SSD n = 1(47) 19% v 15% RR 1.27 95% CI 0.48 to 3.34
Tan PWW et al 2009 Singapore	25 patients were included, out of which 2 were not followed up (dropped out), so 23 patients completed the study (92%). Total 46 study wounds (24 partial thickness burns and 22 split skin graft donor sites). 23 dressed with Urgotul dressing (lipido-colloid dressing impregnated with hydrocolloid particles dispersed in a petroleum jelly matrix) & 23 dressed with Tulle gras (greasy neutral dressing). The patient served as his own control & had two separate sites of similar burn depth or one confluent burn area divided by an imaginary line or SSG sites randomised to either Urgotul or Tulle gras, for comparison.	Level 1b: Prospective randomised control trial (with Institutional Review Board (IRB ) approved study protocol.	Healing time	Mean 9.6 days for Urgotul vs 11.9 days for Tulle gras p <0.05	Trial included Split- thickness Skin grafts(SSG) Both dressings compared were non – antiseptic dressings. Incidence of infection not evaluated though 2 wounds developed superficial infections.
			Incidence of Infection	Not reported But 2 wounds one from each group developed superficial infections that resolved with antibiotics (not mentioned whether burn wounds or SSG wounds) = 4.3% RR 1
M. Subrahmanyam 1993 India	92 patients with partial thickness burns <92% were randomly assigned to 2 equal sized groups. Studied at General Hospital, Solapur during January 1990 – June 1991. Group-1 (n=46), sterile honey impregnated gauze was applied & Group-2 (n=46), polyurethane dressing Opsite was applied after washing with normal saline.	Level 1b: Prospective Randomised Control Trial	Healing Time	Mean 10.8 days for Honey impregnated gauze vs 15.3 days for Opsite. P<0.001	Small, unblinded study with subjective outcome. Though systemic bias is avoided by random allocation into 2 groups but still performance bias, exclusion & detection bias cannot be excluded. No mention about approval of the trial from ethical committee, & no mention about consent of patients.
			Incidence of Infection	Its mentioned 25 patients with infection (54.3%) But not mentioned how many patient’s from honey impregnated dressing & how many from opsite. RR 0.99
Wilson et al 1986 UK (Nottingham)	Inadine compared with Petroleum jelly gauze dressing (control), in 100 dressings, out of which 71 dressing completed the study because 1 patient excluded due to iodine sensitivity developed in the trial, 17 patients excluded as the burns not healed by 14 days & 14 lost in the trial as patient failed or were unable to attend. n=40 in control group, mean age 4.3 years (with 26 patients under age of 4 years). n=31 in inadine group, mean age 6.1 years (with 24 patients under 4 years). 6 patients had 2 discrete areas so were dressed with both.	Level 1b: Prospective Clinical Trial	Number of days to healing	No significance difference Control group (Petroleum gauze dressing) = 7.56 + 3.10 Inadine group = 8.43 + 3.85	Randomisation not done. Used mixed population, paediatric & adults. Unblinded & small study.
			Incidence of Infection	No significance difference No Bacterial growth = 33% (control) vs 35% (inadine). RR 0.955 Absolute risk reduction = -0.0298 NNT = 33.557
			Number of Positive bacteriological cultures	Streptococcus Pyogenes: 8% vs 10%
				Non haemolytic Streptococcus: 5% vs 3%
				Coliforms: 28% vs 16%
				Staphylococcus aureus: 40% vs 48%
P H Fong , K L Wong 1985 Singapore	150 patients with partial thickness burns admitted to Plastic Surgery of Singapore General Hospital, were treated with Opsite. All areas of body were used except head, genitalia & perineum. Bacteriological cultures taken before cleansing patients & at each dressing change or if there is suspicion of infection. 50% patients had <5% burns, 33.3% had 5%-10% burns, 12.6% had 10%- 20% burns & 4% patients had 20% or more burns (upto35%burns)	Level 2b: Cohort study	Healing time	98% healed on conservative treatment & had average hospital stay of 12 days, though in 7.3% opsite was abandoned & hospital stay was 16 days. 1.33% required skin grafting for deeper burns.	All cases were given antibiotic spray before applying opsite. Used 30% paediatric population. All areas of body were used (not localised to limbs) 4% patients had extensive burns (upto 35%) were included. Not a randomised trial. No comparison with conventional dressing regarding healing time & infection rate. No mention about approval of the trial from ethical committee, & no mention about consent of patients.
			Incidence of Infection	Infection reported in7.3% cases. Major infective organism has been Pseudomonas aurogenosa. Also in complications excessive leakage of fluid been reported in 1.33% & bad odour in 2.66%, which are risk factors for developing infection as well. 16% reflected the difficulty in applying opsite to burns of the leg & feet.
Hart, N B, Lawrence, J C 1984 UK. (Birmingham)	72 patients were admitted to trial presenting with minor burns suitable for treatment in outpatient clinic. Alternate cases were allocated modified Tulle-gras dressing & remainder the standard Tulle-gras dressing. n = 36 (male: female) 21:15 were treated with Tulle-gras plus polyvinyl alcohol film & n = 36 (23:13) were treated with conventional tulle-gras.	Level 2b: Clinical Trial (without blinding & randomisation)	Mean Discharge Time (excluding self discharge)	14.3 days (Tulle-gras plus soluble polyvinyl alcohol film) vs 13.6 days (standard Tulle-gras)	No randomisation & Unblinded small study & with subjective outcome.
			Incidence of Infection	No growth = 66.66% (modified) vs 55.55 % (standard ) R R 0.75 ARR – 0.111 NNT = 9.009

Comment(s)

Superficial partial thickness burns are blistered, painful, moist, erythematous surface. Thermal injury is the most common form of burn injury, with electrical injuries making the next common burn injuries. Depth and extent are important factors in determining outcome from burn injury. Superficial and partial thickness burns can progress to deeper burn if the wound dries out or becomes infected. An important factor in the healing of superficial and moderate partial thickness burns is early and effective coverage with a dressing that protects the wound from trauma and desiccation and acts as a bacterial barrier while the wound re-epithelializes. There is need for high quality randomised control trials (RCTs) on dressing for superficial and partial thickness burns. Despite of having extensive Cochrane review of RCT’s and some potential positive findings the evidence is of limited value in helping clinicians in choosing suitable treatments. Evidence from small trials, many with methodological limitations, suggests that superficial and partial thickness burns may be managed with hydrocolloid, silicon nylon, polyurethane film and biosynthetic dressings. There is no evidence to support the use of silver sulphadiazine dressings or Inadine dressings, as the outcome of time to healing is better with simple petroleum jel gauze dressing and the rate of infection is same. Simple sterile petroleum gauze dressing or Tulle – gras dressing (Gelonet, mepitel) are better using for superficial partial thickness burns.

Editor Comment

Although simple dressing with petroleum jel looks promising but there is lack of high quality trials. The loss of skin barrier after thermal injury results in increased susceptibility to infection. Patient and parental satisfaction and expectation could also be problematic – especially when they demand antimicrobial dressing. There is need for high quality trials with well defined patient population and clinically relevant end points. A number of dressings available for superficial partial thickness burns relate to have advantages of having rapid wound healing, less pain and preventing infections. Looking at outcome of superficial partial thickness burns treated on outpatient basis, infection rate and healing time are the important factors. Pain relief, ease of change of dressing, number of dressing changes, cost of dressing and patient’s level of satisfactions are also important predictor for choosing the burn dressings. Recommendations from European Burns Association (EBA), in ‘Guidelines for management of partial thickness burns in a general hospital or community setting’ (July 2006), a good wound dressing should essentially; maintains a moist wound environment, contours easily, non-adherent but retains close contact with the wound, easy to apply and remove, painless application and removal, cost-effective & protects against infection. Desirably they should last for 10 days (one application), with minimal dressing changes and be waterproof to allow for washing and bathing. Modern wound dressings available these days fulfill many of essential and desirable criteria, the most important being the maintenance of moist environment. The final choice of dressing depends on local availability and personal preference of physician. A broad knowledge of characteristics, strengths and weaknesses of both modern and traditional dressings can greatly help clinical decision making.

Clinical Bottom Line

No evidence was found showing a definitive improvement in outcome in terms of infection rates or healing time with antimicrobial dressing compared to simple gauze dressing impregnated with petroleum jel. Local advice should be followed.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Wasiak J, et al Dressings for Superficial and Partial Thickness Burns (Review) Cochrane Wounds Group, The Cochrane Collaboration Issue 1, 2009
2. Tan P.W.W., et al The use of Urgotul in the treatment of partial thickness burns and split-thickness skin graft donor sites: a Prospective control study. International Wound Journal 2009; Volume 6, Issue 4, Pages 295 – 300.
3. Subrahmanyam, M. Honey impregnated gauze versus polyurethane film (OpSite) in the treatment of burns – a prospective randomised study British Journal of Plastic Surgery 1993; Volume 46, Issue 4, Pages 322-323
4. Wilson, G.R et al Evaluation of a new antiseptic dressing in minor burns Burns October 1986; Volume 12, Issue 7, Pages 518-520
5. P H Fong , K L Wong Opsite, A synthetic Burns Dressing Annals of the Academy of Medicine, Singapore April 1985; 14, Issue 2, Pages 387 – 390.
6. Hart, N B, Lawrence, J C Tulle-gras dressings Burns October 1984; Volume 11, Issue 1, Pages 26-30