Evolution of a concept with enzymatic debridement and autologous in situ cell and platelet-rich fibrin therapy (BroKerF)

Background Deep partial-thickness burns are traditionally treated by tangential excision and split thickness skin graft (STSG) coverage. STSGs create donor site morbidity and increase the wound surface in burn patients. Herein, we present a novel concept consisting of enzymatic debridement of deep partial-thickness burns followed by co-delivery of autologous keratinocyte suspension and plated-rich fibrin (PRF) or fibrin glue. Material and methods In a retrospective case study, patients with deep partial-thickness burns treated with enzymatic debridement and autologous cell therapy combined with PRF or fibrin glue (BroKerF) between 2017 and 2018 were analysed. BroKerF was applied to up to 15% total body surface area (TBSA); larger injuries were combined with surgical excision and skin grafting. Exclusion criteria were age <18 or >70 years, I°, IIa°-only, III° burns and loss of follow-up. Results A total of 20 patients with burn injuries of 16.8% ± 10.3% TBSA and mean Abbreviated Burn Severity Score 5.45 ± 1.8 were identified. Of the patients, 65% (n = 13) were treated with PRF, while 35% (n = 7) were treated with fibrin glue. The mean area treated with BroKerF was 7.5% ± 0.05% TBSA, mean time to full epithelialization was 21.06 ± 9.2 days and mean hospitalization time was 24.7 ± 14.4 days. Of the patients, 35% (n = 7) needed additional STSG, 43% (n = 3) of whom had biopsy-proven wound infections. Conclusion BroKerF is an innovative treatment strategy, which, in our opinion, will show its efficacy when higher standardization is achieved. The combination of selective debridement and autologous skin cells in a fibrin matrix combines regenerative measures for burn treatment. Lay Summary Patients suffering from large burn wounds often require the use of large skin grafts to bring burned areas to heal. Before the application of skin grafts, the burned skin must be removed either by surgery or using enzymatic agents. In this article, we describe a method where small areas of skin are taken and skin cells are extracted and sprayed on wound areas that were treated with an enzymatic agent. The cells are held in place by a substance extracted from patients’ blood (PRF) that is sprayed on the wound together with the skin cells. We believe this technique can be helpful to reduce the need of skin grafts in burned patients and improve the healing process.

Burn injury from filling balloons with nitrous oxide

We present the case of a female teenager who sustained nitrous oxide burns to the medial aspect of both thighs from contact with a nitrous oxide canister being used to fill balloons. There was a delay in presentation as the injury was not initially recognised. These burns were initially assessed as being superficial partial-thickness burns but took a prolonged time to heal despite regular wound care. This was complicated by a lack of adherence to recommended treatment for much of the patient care as well as the patient testing positive for COVID-19 during their management, which prevented surgery and significantly extended time to healing. While small numbers of similar cases have been previously described this is the first reported case outside of the Netherlands and in a child. Being aware of such cases ensures early referral to specialist burn care for appropriate management to give patients the best possible outcome.

Comparison of the effectiveness of Aloe Vera gel with 2% Nitrofurazone ointment on the healing of superficial partial-thickness burns: A randomized clinical trial study

Background & Aim: Routine treatment of burn injuries is dressing with Nitrofurazone ointment. It has several complications, including sensitivity. Aloe Vera is a traditional treatment for wound healing. This study aimed to compare the effectiveness of Aloe Vera gel with Nitrofurazone ointment in the healing of superficial partial-thickness burns. Methods & Materials: The present study was a split body controlled clinical trial which was carried out on 30 patients with superficial partial-thickness burns. The study was conducted in the Shafa Hospital in Kerman, Iran, in 2016. The sample was recruited from patients who had at least two burns, each burn on an alternate side of the body. On their burns, samples were allocated to two groups that received Aloe Vera gel or 2% Nitrofurazone ointment. Bates-Jensen Wound assessment tool was used to evaluate the healing of burns. Statistical analysis was conducted by SPSS-16 and using the repeated measure ANOVA. Results: The repeated measure ANOVA showed that there was a significant change in the score of BWAT in all areas during the intervention period (p=0.001), but the trend of healing in the two groups during the intervention period was not significantly different (p=0.098). Conclusion: Based on this study, it looks like Aloe vera gel is as effective as 2% Nitrofurazone ointment in healing wounds.

Keratin-Alginate Sponges Support Healing of Partial-Thickness Burns

Deep partial-thickness burns damage most of the dermis and can cause severe pain, scarring, and mortality if left untreated. This study serves to evaluate the effectiveness of crosslinked keratin–alginate composite sponges as dermal substitutes for deep partial-thickness burns. Crosslinked keratin–alginate sponges were tested for the ability to support human dermal fibroblasts in vitro and to support the closure and healing of partial-thickness burn wounds in Sus scrofa pigs. Keratin–alginate composite sponges supported the enhanced proliferation of human dermal fibroblasts compared to alginate-only sponges and exhibited decreased contraction in vitro when compared to keratin only sponges. As dermal substitutes in vivo, the sponges supported the expression of keratin 14, alpha-smooth muscle actin, and collagen IV within wound sites, comparable to collagen sponges. Keratin–alginate composite sponges supported the regeneration of basement membranes in the wounds more than in collagen-treated wounds and non-grafted controls, suggesting the subsequent development of pathological scar tissues may be minimized. Results from this study indicate that crosslinked keratin–alginate sponges are suitable alternative dermal substitutes for clinical applications in wound healing and skin regeneration.

An unusual presentation to the burn’ unit – a cautionary tale

We report a case of a 34-year old female with systemic lupus erythematosus (SLE) and lupus nephritis who was referred to the regional burns service with a suspected contact burn to the left flank and hypogastrium from a hot water bottle. The patient had been applying a hot-water bottle to the area at night for pain relief and after 3-days she noticed a localised area of erythema which became larger and began to blister over a period of 5-days. The blistered areas were erythematous and wet, however the capillary refill time was sluggish. The lesion was initially diagnosed and treated as a superficial partial thickness burn that had developed secondary to prolonged contact with a hot water bottle. However, due to the history of immunosuppression as well as elements of the lesion being unusual for a burn, we consequently diagnosed this as herpes zoster infection. This case highlights the importance of always thinking of alternative diagnoses. There are several cases in the literature where shingles has been dangerously misdiagnosed, furthermore leading to patients being mistakenly treated and even operated on. In the early stages, abdominal shingles may present very similarly to superficial partial thickness burns, both with neuropathic pain, erythema and blistering. It is important for the burns surgeon to be aware of this diagnosis as a differential in atypical presentations, and to pay particular attention to the timeline of events is the key to diagnosis.

Injectable Small Intestinal Submucosa and Adipose-Derived Stem Cells Composite Gel Promoting The Deep Partial-Thickness Burns Repair

Backgroud: Burns wound treatment remains a significant clinical challenge around the world. Although stem cell-based scaffold therapies are promising strategy for burn wounds, its clinical therapeutic effect is still not satisfactory nowadays. Herein the aim of this study is to evaluate the therapeutic efficacy of injectable small intestinal submucosa (SIS) and rat adipose-derived mesenchymal stem cells (ADSCs) composite gel to repair the deep partial thickness burns in rats. Methods The deep partial-thickness burns model in rats were made by contacting the dorsal surface SIS memberance directly with boiled water for 10 seconds. After scalding, the wound edge and the central area were injected for phosphate-buffered saline (PBS) solution, ADSCs, injectable SIS and injectable SIS/ ADSCs composite gel, respectively. At 3, 7, 14 and 21 days post injection treatment, the burn wound closure percentages were evaluated. Moreover, micro-vascular density and epidermal thickness assessment in burn wound were performed by histopathology examination or immunofluorescence. Besides, the expression of genes related to wound angiogenesis and re-epithelialization were determined in vitro. Results Our data revealed that that injectable SIS gel could provide a well-grown microenvironment for ADSCs in vitro, and the ADSCs-SIS composite gel could synergistically promote the deep partial-thickness burn repair via paracrine and differentiation mechanisms. Conclusions Taken together, this study shows the ADSCs-SIS composite gel is a promising candidate for burn wound regeneration.

Porcine Xenograft and Epidermal Fully Synthetic Skin Substitutes in the Treatment of Partial-Thickness Burns: A Literature Review

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

Collagen dressing versus silver sulfadiazine dressings in partial thickness burns-prospective study

Background: Occurrence, pathophysiology and management of burns is complex. It is a painful condition and topical management of burns is a challenging task. An ideal topical dressing which allows faster healing with reduction of pain, prevent infection, leads to a good scar formation and which is cost effective is required. Thus, there is a need to study the effectiveness of collagen dressing in comparison with conventional silver sulphadiazine dressing (SSD) in terms of pain score, healing time and cost efficiency.Methods: This prospective randomized comparative study includes patients with partial thickness burns, <40% BSA and not older than 48 hours, admitted to department of surgery of RL Jalappa hospital and research centre Tamaka Kolar during the period December 2019 to March 2020. 34 patients were studied, these patients were randomized into collagen dressing or silver sulphadiazine dressing group of 17 each.Results: The 34 patients admitted with partial thickness burns, <40% BSA were divided into two equal and comparable groups. Patients subjected to collagen dressings were classified under group I and those who underwent 1% silver sulphadiazine dressings were classified as group II.Conclusions: The collagen dressing is more cost effective than SSD. SSD has disadvantage of the large number of dressings prolonged hospital stay, amount pain, loss of time and labour of the patient and the accompanying person which make collagen dressing more cost effective as it is most of the time a single dressing.