Superficial Partial thickness thermal burns

Date First Published:
November 25, 2009
Last Updated:
April 29, 2010
Report by:
Faheem Shah, Speciality Doctor Emergency Medicine (Royal Albert Edward Infirmary, WWL NHS Foundation Trust)
Search checked by:
Helen Goldrick, Royal Albert Edward Infirmary, WWL NHS Foundation Trust
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
Search Details:
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)
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):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Dressings for Superficial and Partial Thickness Burns (Review) 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.
Incidence of Infection 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
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
The use of Urgotul in the treatment of partial thickness burns and split-thickness skin graft donor sites: a Prospective control study. Tan P.W.W., 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
Honey impregnated gauze versus polyurethane film (OpSite) in the treatment of burns – a prospective randomised study Subrahmanyam, M. 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
Evaluation of a new antiseptic dressing in minor burns Wilson, G.R 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%
Opsite, A synthetic Burns Dressing 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.
Tulle-gras dressings 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
Author Commentary:
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.


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)
  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.
  3. Subrahmanyam, M.. Honey impregnated gauze versus polyurethane film (OpSite) in the treatment of burns – a prospective randomised study
  4. Wilson, G.R et al . Evaluation of a new antiseptic dressing in minor burns
  5. P H Fong , K L Wong. Opsite, A synthetic Burns Dressing
  6. Hart, N B, Lawrence, J C. Tulle-gras dressings