Efficacy of laser debridement with autologous split-thickness skin grafting in promoting improved healing of deep cutaneous sulfur mustard burns

The consequences of receiving a cutaneous sulfur mustard (SM) burn are prolonged wound healing and secondary infection. This study was undertaken to find a treatment that promotes quick healing with few complications and minimal disfigurement. Multiple deep SM burns (4 cm diameter) were generated on the ventrum of weanling pigs and treated at 48 h. Four treatments were compared: (1) full-thickness CO₂ laser debridement followed by skin grafting; (2) full-thickness sharp surgical tangential excision followed by skin grafting, the “Gold Standard” used in deep thermal burns management; (3) partial-thickness laser ablation with no grafting; and (4) partial-thickness sharp excision with no grafting. A computer controlled, raster scanned, high-powered continuous wave (cw) CO₂ laser was utilized. Ulceration, wound geometry, and wound contraction were evaluated during a 36-day healing period. Histopathological evaluations were conducted at the end of the healing period. Engraftment rates were similar between both methods of debridement. Laser debridement followed by skin grafting was as efficacious in improving the wound healing of deep SM burns as the “Gold Standard.” Full-thickness laser debridement of these small total body surface area (TBSA) burns was time efficient and provided adequate beds for split-thickness skin grafting. Laser debridement offered additional benefits that included hemostatic control during surgery and minimal debridement of normal perilesional skin. Mid-dermal debridement by sharp excision or laser ablation without grafting produced less desirable results but was better than no treatment.     

Randomized, multicenter, double-blind, and placebo-controlled trial using topical recombinant human acidic fibroblast growth factor for deep partial-thickness burns and skin graft donor site

Wound healing is a dynamic and complex biologic process that could be accelerated by growth factors. To investigate the efficacy of topical recombinant human acidic fibroblast growth factor (rh-aFGF) treatment in deep partial-thickness burn or skin graft donor sites, we designed a randomized, multicenter, double-blind, and placebo-controlled clinical trial. The healing rate, fully healed rate, and healing time were evaluated to assess the efficacy of rh-aFGF application. Laboratory examinations and abnormal signs were used to assess the side and toxic effects. The results showed that the healing rate of burn wounds and skin graft donor sites treated by rh-aFGF was significantly higher than that by placebo, and the mean healed time of burn wounds and skin graft donor sites in the rh-aFGF group was significantly the shorter than that in the placebo group. In conclusion, topical administration of rh-aFGF can accelerate the wound healing process and shorten the healed time. It is a potential therapeutic application for promoting healing of deep partial-thickness burns or skin graft donor sites.     

Epidermal-cell-based therapy as an adjunct to healing second degree burns—A randomized controlled pilot study

BackgroundHealing of partial-thickness (2a and 2b) burns is notoriously unpredictable as far as healing time, scarring and (hypo)pigmentation is concerned. Epidermal blister grafting is an autologous grafting technique involving transfer of epidermal islands without dermal elements. Cellutome™ is an FDA-acknowledged epidermal harvesting device. This proof-of-concept study evaluates whether blister grafting of partial-thickness burns results in improved healing compared to standard acellular treatment.MethodsThis is a randomized controlled trial with 8 patients in which each patient received both treatments randomized to different burn sites. Healing was assessed at regular intervals. Twelve months after treatment, outcomes were measured with the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS), photography, spectrometry, Semmes-Weinstein Filaments, cutometry and high-resolution ultrasound.ResultsAreas treated with epidermal blister grafting healed slightly faster than acellular treatment. Epidermal treatment yielded healing with less erythema, closer to that of surrounding normal skin (p = 0.0404). Donor sites were not visible and not measurably different than normal skin.ConclusionsResults favor cellular over acellular technique for the treatment of partial-thickness (2a and 2b) burns. Significant improvement in erythema implies a higher quality healing process. Further studies should look primarily at larger areas of treatment, and larger sample size.     

Multiple graft harvestings from deep partial-thickness scald wounds healed under the influence of weak direct current

The time required for wound healing, contraction, and hypertrophic scarring often limit the use of deep partial-thickness burn wounds as donor sites for split-thickness grafts. We have examined the effects of weak direct current and silver nylon dressings on the healing of partial-thickness scald burns, split-thickness grafts taken from these wounds when healed, and the resulting donor sites in a guinea pig model. Dorsal scald wounds treated with weak direct current reepithealized by 12 days postinjury. Split-thickness grafts taken from healed scald wounds showed more rapid revascularization with direct current treatment than did control grafts. Grafts and donor sites treated with direct current showed more rapid reepithelialization, decreased contraction, improved hair survival, and decreased dermal fibrosis when compared to controls not treated with direct current. Only donor wounds treated with weak direct current were reusable as donor sites.     

Full-thickness skin columns: A method to reduce healing time and donor site morbidity in deep partial-thickness burns

The current standard of care for the coverage of large wounds often involves split thickness skin grafts (STSGs) which have numerous limitations. One promising technique that has gained traction is fractional autologous skin grafting using full-thickness skin columns (FTSC). Harvesting occurs orthogonally by taking numerous individual skin columns containing the epidermis down through the dermis and transferring them to the wound bed. The purpose of this porcine study was to investigate the efficacy of implanting FTSCs directly into deep partial-thickness burn wounds, as well as examining donor site healing at the maximal harvest density. It was hypothesised that by utilising FTSCs, the rate of healing in deep partial thickness burns can be improved without incurring the donor morbidity seen in other methods of skin grafting. Deep partial-thickness burns were created on the dorsum of female red duroc swine, debrided 3 days later and FTSCs were implanted at varying expansion ratios directly into the burn wounds. At day 14, 1:50 expansion ratio showed significantly faster re-epithelialisation compared to the debrided burn control and 1:200. Donor sites (at 7%–10% harvest density) were 100% re-epithelialised by day 7. Additionally, the maximal harvest density was determined to be 28% in an ex vivo model, which then five donor sites were harvested at 28% density on a red duroc swine and compared to five STSG donor sites. At maximal harvest density, FTSC donor sites were significantly less hypopigmented compared to STSGs, but no significant differences were observed in re-epithelialisation, contraction, blood flow or dermal thickness. In conclusion, implantation directly into deep partial-thickness burns is a viable option for the application of FTSCs, favouring lower expansion ratios like 1:50 or lower. Little difference in donor site morbidity was observed between FTSC at a maximal harvest density of 28% and STSGs, exceeding the optimal harvest density.     

Hyperbaric oxygen in burn management: a controlled study.

Using the methods and protocol outlined, we have found that hyperbaric oxygen functions as a mild antiseptic agent and provides no advantage in the treatment of full-thickness and partial-thickness burns, alone or in combination with topical treatment with silver sulfadiazine. No effects were observed on metabolic balance in the postburn state determined by percentage of weight change, the time to complete healing in partial-thickness burns or the rate of eschar separation and vascular proliferation in granulation tissue formation in full-thickness burns.     

The use of superficial and deep partial-thickness burned tissue for flap fabrication

Abstract. When flaps are indicated for early wound closure in extensive burns, and there is limited unburned local tissue to design these, one option may be to use a partial-thickness burned area as a flap for construction in the acute phase. This study examined the proportions of superficial and deep partial-thickness burned skin that can safely be included in an island flap. Eighty male Wistar rats were divided into four groups, with varying extent of burning of the right epigastric flap site: group 1, 50% superficially burned; group 2, 100% superficially burned; group 3, 50% deeply burned; and group 4, 100% deeply burned. In each group the left epigastric flaps served as controls. The superficially burned flaps in groups 1 and 2 healed at 2-4 weeks, and the deeply burned flaps in groups 3 and 4 healed at 4-6 weeks postoperatively. In all cases hair grew on the burned flap sites, and the flaps healed in such a way that they were almost impossible to distinguish, even after the hair was shaved at week 8. It was observed that the superficially burned flaps healed perfectly without scarring, but small portions of the deeply burned flaps developed scars. In conclusion, superficially and deeply burned island flaps survived completely in this animal model, even when the entire flap surface was burned. In the future, under appropriate conditions the transfer of partial-thickness burned tissue as flaps may provide a good alternative for reconstruction of the acute burn wound.     

Clinical effects of inhibiting leukocyte adhesion with monoclonal antibody to intercellular adhesion molecule-1 (enlimomab) in the treatment of partial-thickness burn injury

BACKGROUND: A randomized, prospective, multicenter, double-blind, placebo-controlled, phase II clinical trial was performed to determine whether inhibition of leukocyte adherence by administration of monoclonal antibody directed against intercellular adhesion molecule-1 would improve burn wound healing. METHODS: One hundred ten patients with burn injury ranging from 10% to 30% total body surface area were enrolled. Fifty-six patients received placebo (saline) and 54 patients received murine monoclonal antibody to the human intercellular adhesion molecule-1 (enlimomab). Treatment was initiated within 6 hours of injury. Patients had three distinct partial-thickness wound sites assessed. Laser Doppler flowmetry was used to stratify wounds on the day of injury. Wounds were assessed for healing status on day 21 postburn and categorized as healed, nonhealed, or grafted. RESULTS: Patients treated with enlimomab had a significantly increased percentage of wounds that healed spontaneously in less than 21 days overall and when stratified by burn wound laser Doppler blood flow readings for those wounds at greatest risk for nonhealing. CONCLUSION: These results support the concept that leukocyte adherence is involved in the pathogenesis of burn wound necrosis and suggest a therapeutic mechanism for modulating the inflammatory response after the burn injury that may improve wound healing.     

Plantar burns in children: epidemiology and sequelae

Pediatric plantar burns present with significant and unique characteristics. The treatment of choice remains controversial, and any alteration of the anatomy will lead to alteration in gait. To study the outcome of conservative treatment of plantar burns and determine risk factors, 40 pediatric patients affected with isolated plantar burns were studied. All burns were treated with silver sulfadiazine and early ambulation, and those that did not heal within 3 weeks were autografted. Twenty-eight patients (70%) had partial-thickness burns and 12 patients (30%) full-thickness burns. Complications during the acute period included 1 episode of cellulitis and 1 patient with prolonged difficulties with ambulation. Three patients required excision and autografting, and none of them developed late sequelae. Five patients presented with late sequelae, and all had in common complete healing with conservative treatment, young age, and a longer healing time (24.4 days). We conclude that conservative treatment of pediatric plantar burns has a negligible complication rate. Burns that do not heal within 3 weeks are best managed with excision and autografting, which had a 0% incidence of complication rate in this series.     

The fate of the dorsal metacarpal arterial system following thermal injury to the dorsal hand: A Doppler sonographic study

Hands are involved in over 70% of all serious burns. This study comprised 80 hands in 41 patients with burns of the dorsum of the hand. Eighty percent of the hands in our study had deep partial-thickness and full-thickness burns that had to be grafted. This study was performed to evaluate the patency of the dorsal metacarpal artery (DMCA) system in burn-injured hands. Sixteen hands healed spontaneously; 62 had to be excised and grafted. Doppler mapping of the dorsum of the hand was completed using an 8-MHz probe. Patent vessels were found in a pattern similar to that of a normal population in spontaneously healed and grafted partial-thickness burns. The incidence of dorsal arteries decreased from 100% for the first DMCA to 80% for the DMCA in the fourth web space. In full-thickness burns the correlation of burned hands to normal volunteers was only 80%. It can be concluded from the data that the DMCA system is not damaged by deep partial-thickness burns that are excised and grafted. The DMCA system is still intact in 80% of patients with full-thickness burns. The potential for elevating a DMCA flap is therefore preserved after burn excision and grafting. Preoperative Doppler examinations are recommended before planning the flaps.     

Effectiveness of Biobrane for treatment of partial-thickness burns in children

Purpose

Wound care for partial-thickness burns should alleviate pain, decrease hospital length of stay, and be readily applied to a variety of wounds. The effectiveness of Biobrane (UDL Laboratories, Rockford, IL) is compared with that of Beta Glucan Collagen (BGC; Brennan Medical, St. Paul, MN) in a retrospective cohort study.

Methods

A retrospective chart review of all children treated at a tertiary care pediatric hospital between 2003 and 2009 identified patients with partial-thickness burns treated with Biobrane. These patients were compared with historical controls treated with BGC.

Results

A total of 235 children between the ages of 4 weeks and 18 years with an average of 6.0% body surface area partial-thickness burns were treated with Biobrane. In a multivariate statistical analysis, patients treated with Biobrane healed significantly faster than those treated with BGC (Biobrane vs BGC: median, 9 vs 13 days; P = .019; hazard ratio, 1.68). In addition, patients who required inpatient treatment trended toward having shorter length of hospital stay in the Biobrane group (2.6 vs 4.1 days, P = .079).

Conclusion

Partial-thickness burn care consists of early debridement and application of a burn wound dressing. Biobrane dressings result in faster healing compared with BGC and may decrease hospital length of stay for patients requiring inpatient admission.     

Comparisons of wound healing among excisional, laser-created, and standard thermal burns in porcine wounds of equal depth.

The present study was designed to characterize similarities and differences among three wounding modalities in partial-thickness porcine wounds. We hypothesized that inherent differences, such as endogenous cytokine delivery into excisional wounds or ablation of eschar during laser vaporization, should accelerate the magnitude and sequence of reparative events above the delayed repair that is frequently observed in patients with burns. A constant mid-dermal depth of injury was created by a Padgett dermatome, a computer-controlled pulsed CO(2) laser, or a temperature-controlled metal template. Wounds were harvested after 5, 10, or 15 days. After 5 days, significant resurfacing differences were apparent with values of 54% in excisions, 29% in lasers, and 12% in standard thermal burns. Sequences of fibroblastic proliferation were measurably different among the three wound modalities. At day 5 the bromodeoxyuridine labeling index for fibroblasts showed laser wound levels greater than excision wound levels, which were greater than burn wound levels; but by day 10, the proliferative profiles indicated that burn wound levels were greater than excision wound levels, which were greater than laser wound levels. Capillary areas (an assessment of angiogenesis) differed among the three wound types throughout the study. Peak values were observed at day 5 in both excisional and laser injuries; however, standard thermal burns did not peak until day 10. Both the magnitude and sequence of expression of three matrix metalloproteinases (-1, -2, and -9) differed among the three types of injuries. Laser wounds showed the earliest peak in matrix metalloproteinase-1 expression, whereas burns showed the least expression at day 5. In conclusion, although the three types of wounds undergo similar reparative processes such as reepithelialization, fibroblastic proliferation, angiogenesis, and expression of matrix metalloproteinases, the magnitude and temporal sequences are measurably altered among the three wound modalities. A greater understanding of specific differences within wound environments may lead to more insightful design of interventional wound therapies.     

Carbon dioxide laser ablation of cutaneous metastases from malignant melanoma

Multiple cutaneous and superficial subcutaneous metastases from malignant melanoma in 30 patients were treated palliatively by carbon dioxide laser ablation when lesions were to numerous, too large or recurring too rapidly for multiple local excisions. The number of lesions per patient ranged from three to 250 (median 30). Patients were treated under local or general anaesthetic and as day cases or inpatients. After a median follow-up interval of 8 months fewer than 1 per cent of lasered metastases have recurred locally. Sixteen patients have developed cutaneous metastases at other sites requiring further treatment. Approximately 2000 lesions have been treated on 64 occasions. Patients reported little or no pain after the operation and required only simple dry dressings. Wounds were completely healed in 2-6 weeks with good cosmetic results. This simple and effective treatment is becoming an alternative to isolated limb perfusion.     

Studies in burns: XIV, Heling in burn wounds treated with Ethyl Linoleate alone or in combination with selected topical antibacterial agents.

Studies of the efficacy, in terms of burned wound healing, of a mixture of Ethyl Linoleate (ethyl 9-12 (cis, cis) octadecadienoate) with alpha-1-histidine, alpha-tocopherol, and TBHQ (hELate) was undertaken in 12 swine. The species was selected so as to study an animal with skin anatomy similar to the human. Statistically significantly greater healing occurred in 730 C/7sec contact burns (20% BSA) treated with hELate than in untreated burns in pigs. Further, there was no contracture noted in the hELate treated lesions, while marked contracture occurred in the untreated burns. Additionally, we noted that there was a proportional increase in weight gain amongst swine studied as their burn lesions epithelialized. In order to evaluate the compatibility of hELate with selected, currently-used topical antibacterial agents, 154 rabbits with 20% 730 C/7 sec contact burns were studied. The lipid was applied (0.01 ml/cm2 burn) at 1 hour postburning; the topical agent was applied at 2 hours post-burn and every 24-hours. All animals were washed once daily. hELate was applied only once. We found no statistical difference in the number of subjects healed or in the mortality between animals treated with hELate alone and those treated with the agent plus Gentamycin cream, Neosporin cream, and silver sulfadiazine 1% in Unibase USP (compounded at Medical College of Georgia specifically and only for this study.) We suggest that Ethyl Linoleate agent (hELate) may be used safely in combination with selected antibacterial substances. Further, these selected combinations seem to be non-toxic and appear to allow the calorie-saving and healing effects of the lipid to proceed unimpeded.     

Treatment of Multiple Eruptive Hair Cysts with Erbium:YAG Laser

BACKGROUND: Eruptive vellus hair cysts (EVHC) frequently resist a variety of treatment modalities. While pulsed carbon dioxide (CO2) laser has been used effectively for facial EVHC, this laser presents significant risks for hypertrophic scarring when used on truncal sites. Due to absorption of 2940 nm energy by both tissue water and protein, the erbium:yttrium-aluminum-garnet (Er:YAG) laser ablates more cleanly and creates less residual thermal injury in the wound bed. This laser might prove efficacious and safe in treating nonfacial EVHC. OBJECTIVE: To assess treatment efficacy and wound healing after Er:YAG laser ablation of EVHC. METHODS: Two patients with 32 truncal EVHC were treated with pulsed Er:YAG laser using a drilling technique followed by second intention healing. RESULTS: Laser treatment sites healed without permanent dyspigmentation or hypertrophic scarring. No lesion recurrence was observed. CONCLUSION: Er:YAG laser ablation is an effective method for treating EVHC at anatomic sites prone to hypertrophic scar formation.     

The use of homograft compared to topical antimicrobial therapy in the treatment of second-degree burns of more than 40% total body surface area

The traditional approach for the treatment of partial-thickness burns has been the application of topical antimicrobial therapy to control bacterial colonization, avoid progression to invasive infection, and allow healing of the underlying burn wound. Infection is associated with apparent conversion of a second-degree burn to full-thickness injury that requires autografting, to say nothing of a source of sepsis, which has been associated with multiorgan failure and death. We postulated that early debridement and coverage of large partial-thickness burns (>40% total body surface area) with homograft would preserve underlying tissue, improves healing, and decreases morbidity. We present data obtained in 16 patients treated with the application of homograft compared to 13 patients treated with the traditional approach consisting of twice daily applications of silver sulfadiazine. The treatment of massive second-degree burns with homograft reduced hospital length of stay (P < 0.01). We thus conclude that in patients with >40% total body surface area burns, early debridement and wound coverage with homograft is an alternative method to the conservative non-operative approach with topical antimicrobial therapy.     

Moist exposed therapy of partial-thickness burn wounds. A multi-center study

Summary In laser-induced partial-thickness burns of pig skin, moist exposed burn ointment (MEBO) produces a moist environment, allows drainage of exudates, reduces eschar formation, and accelerates debridement and wound healing. A prospective multi-center study was conducted to evaluate the effect of MEBO on the healing of partial-thickness burn wounds. We included 52 patients with 100 burn sites ranging from 0.5% to 15% total body surface area in the study. Treatment efficacy was assessed on physical examination of the wound, the course of time of trans-epidermal water loss (TEWL) and moisture values, bacterial wound colonization and the degree of pain experienced by patients during and between dressing changes. Using the Visual Analogue Thermometer device (VAT) a progressive decrease of pain was found throughout the treatment which was statistically significant at 6, 9 and 12 post-burn days. TEWL, as an indicator of re-epithelialization, demonstrated a decreasing trend on day 3, and the reduction became significant from the 6th post-burn day. Moisture was significantly decreased during the first 5 post-burn days. As re-epithelialization progressed there was a net decrease in moisture paralleling TEWL. After 1 week of MEBO treatment, bacterial wound colonization decreased to 10% in the immediate group and to 61% in the late group of application. By the second week, colonization dropped to 5% and 23% respectively. Topical ointment application contributed to the debridement of the wound bed facilitating rapid epithelialization within 2–6 days, depending on the burn depth. MEBO is an ointment that can effectively produce a moist and wet environment for optimal healing of partial-thickness burns.     

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.     

A newly developed hydrofibre dressing, in the treatment of partial-thickness burns

A newly developed, carboxymethylcellulose based hydrofibre dressing, Aquacel, was tested for the treatment of partial thickness burns. In this study 84 patients with mainly partial thickness burns were included, 76 patients received 1 or 2 days pre-treatment with a topical antimicrobial agent. Clinical behaviour showed a strong resemblance with cadaver skin treatment with respect to adherence to the wound. Adverse reactions, incidence of clinical wound infection, healing time and the need for wound excision and grafting were analysed, as was the final outcome using the 'Vancouver Scar Scale'. The mean size of the wounds treated with the hydrofibre dressing was 6.0% body surface area (min: 1%, max: 18%). Two patients clinically showed signs of a wound infection during treatment, but in general wound cultures were low or negative. In 42 patients (50%) the wounds healed completely within 10 days, in six patients (7%) small defects remained that healed by further treatment with a topical antimicrobial cream. In 36 patients (43%) excision and grafting of the remaining deeper parts of the wounds was performed as this is the standard therapy in the centre for all burned areas that have not healed within 2-3 weeks post-injury. The extent of the surgical procedures was limited since 66.1% of the wound area had healed already at the end of the hydrofibre treatment. In 54 patients the outcome of the treatment after 2-3 months was analysed by means of the Vancouver Scar Scale, which showed favourable results in general, and especially for patients who did not require surgery. Compared to earlier experience with allograft skin it was concluded that hydrofibre dressing is a safe, suitable and easy to use material for treatment of partial thickness burns.