A Clinical Minute: New Management Strategy for the Treatment of Deep Partial-thickness Burns

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Ariel Aballay, MD, FACS, West Penn Burn Center, Pittsburgh, PA

  Caring for deep, partial-thickness burns can present unique challenges to the burn care team.

  The gold standard of care for such injuries, that are unlikely to heal within 3 weeks, remains early excision and autologous grafting.1,2 However, multiple clinical scenarios play out every day in a burn center that remove grafting and/or surgery as options. These include burns in patients that are immunocompromised, have significant comorbidities, neonates, elderly patients, and persons who decline surgery or have injuries affecting the face or neck where maximizing the best cosmetic and functional outcomes are essential. This creates a need for a topical, nonsurgical approach to help remove the devitalized tissue in these partial-thickness burns while promoting healing.

  In our clinic, we began trialing MEDIHONEY® with Active Leptospermum Honey (ALH) (Derma Sciences, Inc, Princeton, NJ) to determine its ability to aid debridement and healing. Although only a few case studies address the use of honey dressings for burn injuries in the United States, internationally there have been studies with positive results when comparing honey to silver sulfadiazine cream in first- and second-degree burns.3

  MEDIHONEY ALH works through two key mechanisms of action: 1) high osmolarity to draw fluid from deeper tissues to the wound surface to promote autolytic removal of devitalized tissue,4,5 and 2) a low pH (3.5–4.5) to help modulate the pH of the wound and contribute to a wound healing environment.6-8 In concert, these two mechanisms work to optimize conditions for granulation tissue formation and wound healing. In addition, MEDIHONEY is available in multiple forms, including a calcium alginate, hydrocolloidal sheet (HCS), gel, paste, and hydrocolloid, allowing selection based on exudate level.

  Two cases representative of our clinical experience using MEDIHONEY as part of our deep partial-thickness burn protocol are presented.

Initation of MEDIHONEY. Autolytic debridement of devitalized tissue. Burn injury healed.

  Case 1. A female patient suffered partial-thickness burns to her face after she attempted to light a cigarette while on oxygen. Ultrasonic debridement was performed, followed by an application of MEDIHONEY Gel (see Figure 1). The remaining devitalized tissue gradually softened and liquefied, leading to its easy removal to reveal healthy tissue by day 5 (see Figure 2). On day 11, the burn injury to the patient’s nose had healed and only minimal devitalized tissue remained (see Figure 3). Complete healing was achieved in less than 2 weeks.

Post-burn, wound is covered with slough. Decreased slough and increased granulation. Wound closure achieved with MEDIHONEY.

  Case 2. An elderly female with Crohn’s disease, chronic obstructive pulmonary disease, chronic renal failure, and short bowel syndrome suffered burns to her right hip caused by a heating pad. She was receiving total parenteral nutrition and high-dose prednisone. She was referred to our clinic 3 weeks after her injury, at which point her wound was covered with 95% yellow slough (see Figure 4). We initiated MEDIHONEY Gel covered with a nonadherent dressing. Ten days later, the slough was greatly reduced, new granulation tissue was developing, and wound edge advancement was observed. On day 25, a further increase in granulation tissue was noted (see Figure 5). The wound continued to progress until wound closure was achieved at day 75 without any other intervention or antibiotic required (see Figure 6).

  These two cases illustrate how MEDIHONEY can support the effective removal of devitalized tissue and promote granulation tissue formation without complications and with a positive impact on functional and cosmetic outcomes. Furthermore, our positive clinical experience with MEDIHONEY to date has prompted us to initiate a randomized, controlled trial of MEDIHONEY in deep partial-thickness burns.

  In summary, the inclusion of MEDIHONEY in our burn protocol in 2013 has provided us with an effective tool to meet our clinical objective of debridement and healing when grafting is not considered the best option, thus achieving positive outcomes in this specific patient population.

  For more cases on outcomes of the use of MEDIHONEY in partial-thickness burns, visit the MEDIHONEY Power Webinar series for a 30 minute case review by Dr. Ariel Aballay at: www.dermasciences.com/medihoney-webinars.

  A Clinical Minute is made possible through the support of Derma Sciences, Inc, Princeton, NJ. The opinions and statements provided in A Clinical Minute are specific to the respective authors and not necessarily those of OWM or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.

References: 

1. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10:1103–1108.

2. Engrav LH, Heimbach DM, Rues JL, Harnar TJ, Marvin JA. Early excision and grafting versus nonoperative treatment of burns of indeterminate depth: a randomized prospective study. J Trauma. 1983;23:1001–1004.

3. Malik KI, Malik, MN, Aslam A. Honey compared with silver sulphadiazine in the treatment of superficial partial-thickness burns. Int Wound J. 2010;7(5):413–417.

4. Acton C, Dunwoody G. The use of medical grade honey in clinical practice. Br J Nurs. 2008;17(20):S38–S44.

5. Chaiken N. Pressure ulceration and the use of active Leptospermum honey for debridement and healing. Ostomy Wound Manage. 2010;56(5):12–14.

6. Gethin G, Cowman S. Changes in pH of chronic wounds when honey dressing is used. Wounds UK Conference Proceedings. Aberdeen, UK. November 13–15, 2006.

7. Milne SD, Connolly P. The influence of different dressings on the pH of the wound environment. J Wound Care. 2014;23(2):53–57.

8. Leveen H, Falk G, Borek B, Diaz C, Lynfield Y, Wynkoop B, et al. Chemical acidification of wounds. An adjuvant to healing and the unfavourable action of alkalinity and ammonia. Ann Surg. 1973;178(6):745–750.