Dressings for superficial and partial thickness burns
Wasiak J, Cleland H, Campbell F. Cochrane Database of Systematic Reviews. 2008, Issue 4. Art. No.: CD002106. DOI: 10.1002/14651858.CD002106.pub3.
- An acute burn wound is a complex and evolving injury. Extensive burns produce, in addition to local tissue damage, systemic consequences.
- Dressing selection should be based on their effects on healing, but ease of application and removal, dressing change requirements, cost and patient comfort should also be considered.
- Conventional dressings tend to adhere to the wound surface and their need for frequent changes traumatizes newly epithelialized surfaces and delays healing.
- Silver sulphadiazine (SSD) cream itself is also thought to delay wound healing due to a toxic effect on regenerating keratinocytes.
- Treatment of partial thickness burn wounds is directed towards promoting healing and a wide variety of dressings are currently available. Improvements in technology and advances in understanding of wound healing have driven the development of new dressings.
- To establish whether any type of dressing is more effective in promoting healing and minimizing discomfort and infection for patients with superficial and partial thickness burns through review of all randomised controlled trials. Economic analysis was not considered.
A total of 26 RCTs are included in this review and most were methodologically poor. A number of dressings appear to have some benefit over other products. This benefit relates to time to wound healing, the number of dressing changes and the level of pain experienced.
- Results indicate that burn wounds dressed with hydrogels, silicon coated dressings (Mepitel dressing - Bugmann, 1998; Gotschall, 1998), biosynthetic dressings and antimicrobial dressings healed more rapidly than those dressed with SSD or chlorhexidine impregnated gauze dressings.
- The results for hydrocolloids and polyurethane dressings also suggest an improved rate of healing although 5 studies (Phipps, 1988; Thomas, 1995; Wright, 1993; Afilalo, 1992; Poulsen 1991) found no statistically significant difference between the intervention and control groups.
- There was no evidence that fibre dressings improve rates of healing compared with SSD.
- There was no evidence of a difference in healing time between biosynthetic dressings and hydrocolloids.
- There was some evidence that the pain experienced by patients appeared to be reduced with the use of the intervention dressing when compared against SSD or chlorhexidine dressings. This finding was not statistically significant in all studies but was consistent for all intervention dressings except antimicrobial dressings where the difference was not significant.
- There was no significant difference in pain levels between biosynthetic dressings and hydrocolloids when compared directly.
Prevention of Infection
- The evidence for the effectiveness of the different dressings for protecting from wound infection is limited by the inconsistent measurement and reporting of this outcome.
- Where infection rates are reported there does not appear to be a significant difference between intervention dressings and comparison groups.
Frequency of Dressing Changes
- The number of dressing changes required appeared to favour hydrocolloid dressings, silicon coated dressings (Mepitel dressing - Bugmann, 1998; Gotschall, 1998) and silver impregnated dressings. When used these wounds required fewer dressing changes.
- This difference was however also a reflection of different protocol regimens with SSD gauze dressings requiring daily changes and intervention dressings changed as required.
Quality of Studies Reviewed
- There is a paucity of high quality RCTs on dressings for superficial and partial thickness burn injury. Therefore, the results must be interpreted with caution.
- The included studies were generally of poor quality, in many cases the number of people included in the trials was small and the time to wound healing data and subsequent statistical analysis was often not reported in a way that allowed the results to be reproduced by the review authors.
- A number of dressings appear to have some benefit over other products in the management of superficial and partial thickness burns. There is some research evidence to demonstrate the benefits of hydrocolloids, antimicrobial (silver containing), silicon coated, polyurethane film and biosynthetic dressings.
- This advantage relates to time to wound healing, number of dressing changes and its associated pain experience, although the study results are prone to methodological shortcomings.
- The use of SSD on burn wounds needs to be reconsidered as a number of studies showed delays in time to wound healing and an increased number of dressing applications.
- In order to differentiate between the products there is a strong case for high quality trials with a well-defined patient population coupled with clinically relevant end points.
- The studies summarised in this review evaluated a variety of interventions, comparators and clinical endpoints.
- Despite some potentially positive findings, the evidence is largely derives from trials with methodological shortcomings. It is therefore of limited usefulness in aiding clinicians in choosing suitable treatments.