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. 2020 Sep 30;33(3):233–238.

Management Of Superficial Partial Thickness Burn With Collagen Sheet Dressing Compared With Paraffin Gauze And Silver Sulfadiazine

A Singh 1,∗, A Bhatnagar 1
PMCID: PMC7680202  PMID: 33304214

Summary

Burn injury is a global problem that equally concerns under-developed and developing countries. An ideal dressing material has to maintain a moist environment, act as a bacterial barrier and as a medium for free exchange of gases, while providing a barrier against toxic contaminants. Sixty-eight consecutive patients with fresh acute superficial partial thickness burns ≤ 15% BSA, registered in two tertiary care teaching hospitals in North India between January 2015 to December 2019, were divided into two groups: a collagen dressing group (group A) and a paraffin gauze (PG) plus silver sulfadiazine (SSD) group (group B). Forty-four patients received collagen dressing and 24 patients received conventional paraffin gauze (PG) plus silver sulfadiazine (SSD) dressing. Patients were followed up for clinical outcome until burn wounds healed. We observed complete healing in 5-7 days for 26 cases (59%) in group A, in 8-12 days for 16 cases (66.66%) in group B. A total of 95.5% of group A patients required analgesia only for ≤ 2days, while 90.90% of group B patients required analgesia for ≥ 6 days. Ninety percent of group A patients required none or a single dressing change with shorter hospital stay. In group B, 22 cases required 3-5 dressing changes. Collagen dressing has proved to be highly advantageous for acute small areas of partial thickness burns (< 15% BSA). It confers better pain relief, and minimal or no dressing change with better rate of wound healing. Pediatric patients preferred collagen sheet dressing. Conventional dressings tend to adhere to the wound surface, and their need for frequent changes traumatises newly epithelialized surfaces and may delay healing.

Keywords: burn, wound, collagen, aesthetic

Introduction

Burns are a serious morbid health problem affecting adults and children. Superficial burns affect the epidermal skin layer and superficial layer of dermis. Deep or full thickness burns may involve damage to deeper structures of the dermis and structures such as blood vessels and nerves.1 The aim of treatment in burn injury is to control infection and promote healing with good aesthetic results. To achieve these goals, a wide variety of wound care products are currently available.1 Secondary wound infection often results in delayed wound healing, longer hospital stays and higher treatment costs.2 The antimicrobial properties of silver have been known since ancient times. Silver sulfadiazine (SSD) was introduced in the 1970s, when silver was complexed to propylene glycol, stearyl alcohol, and isopropyl myrislate. Antibiotic sulfadiazine was added to this complex, hence the inhibitory action of silver and anti-bacterial effect of sulfadiazine was combined into a single product. This reduced the frequency of application of the drug to twice daily. This silver complex acted on the bacterial wall in contrast to the silver ions which acted on the bacterial energy system.3 However substantial experiences with adverse reactions and side effects to silver sulfadiazine are also being documented.3 Recently-introduced collagen-based dressings for acute burn wound management have been extensively used in India. Wound healing and regeneration involves cell proliferation, cell migration, cell differentiation and interaction between the different components. Collagen may affect healing not only at the final stage but also in the very early stage of healing.4-8

Materials and methods

After receiving permission from the institute’s Ethics Committee, we retrospectively studied the records of 68 consecutive patients with fresh acute superficial partial thickness burns ≤ 15% BSA, registered in two tertiary care teaching hospitals in North India between January 2015 to October 2019. Any patient who presented late, i.e. > 24 hrs post injury, had signs of wound infection or had received prior treatment at another centre, had a significant co-morbidity such as diabetes mellitus, hypertension, chronic renal disease, immunocompromised status etc. was excluded from the study. Patients with history of inhalational, electrical contact and chemical burns were also excluded. All patients had been given the choice of both treatments as per our policy, and chose their treatment modality on their own. These patients were divided into two groups on the basis of their chosen treatment strategy of type of dressing material used: group A - collagen dressing, group B - paraffin gauze (PG) plus silver sulfadiazine (SSD). After fluid resuscitation as per Parkland formula, wounds of both the groups were washed with normal saline before application of the dressing. Out of 68 patients, 44 patients received collagen dressing and 24 patients received conventional PG plus SSD. The aim of our study was to assess the clinical effectiveness of collagen dressings compared with paraffin gauze and silver sulfadiazine in adults and children with superficial partial thickness burns, in terms of infection control, length of stay (LOS) in hospital, frequency of change of dressing, time to complete healing, surgical procedures and pain management. Patients were regularly followed up for clinical outcome until burn wounds healed. Commercial collagen of bovine origin, SSD ointment and PG routinely available in hospital pharmacies were used. Short-term healing was identified in terms of number of days after which the patient became dressing free, and long-term as regards scar quality and development of contractures.

Results

A total of 68 consecutive patients during the study period were divided into group A (collagen dressing, n. 44) and group B (PG & SSD, n. 24). In group A and group B, 81.81% and 58.33% of patients were under 10 years of age respectively (Table I). In group A, 59% of cases had good healing in the form of reepithelialization of wounds, and discontinuation of any dressing was seen in 5-7 days, while in group B it took 8-12 days for 66% of cases to achieve good wound healing and be dressing free (Figs. 1 & 2).

Table I. Demographic profile.

Table I

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Fig. 1. A) Thermal burn; B) Application of collagen dressing; C) After removal of collagen dressing and healed wound.

Fig. 1

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Fig. 2. A) Thermal burn wound with collagen dressing; B) Healed wound.

Fig. 2

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Hospital stay for group A patients was comparatively lower as collagen application was a one-time process while SSD dressings were repeated daily. In group A, 95.5% of cases required oral analgesic for two days, while in group B 90.90% cases required oral analgesic support for ≥ 6 days (Table II). In group A, 90% of the cases required single dressing at the time of collagen sheet application, while in group B multiple dressing changes (50% of cases 5 times, 41.66% of cases 3 times) were needed (Table II). There was no significant difference in rates of secondary wound infection in both groups. Long-term aesthetic results were better in group A, however none of the patients had poor results in the form of development of raw areas and systemic sepsis (Figs. 3 & 4). Ibuprofen tablets or syrups were the routinely prescribed analgesic. All patients were provided antibiotics in the form of amoxicillin/clavulanate potassium in the prescribed dose. Antibiotics were continued for 7 to 14 days depending on wound healing time. No cultures were done in either of the groups as all patients healed within 2 weeks.

Table II. Observation value.

Table II

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Fig. 3. A) Scald burns; B) Application of collagen sheets; C) After removal of collagen sheets.

Fig. 3

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Fig. 4. A) Electric flash burns; B) Application of collagen sheet; C) After complete healing.

Fig. 4

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Discussion

The ultimate goal in the management of burn wounds is to obtain complete healing in the shortest period and regain near normal cutaneous texture and colour in the long duration. Nowadays, with the advent of various treatment and dressing modalities, finding the right method for the right patient can be a challenge. Traditional burn wound management involved cleaning, debridement and provision of a moist environment to encourage the process of natural healing. Hence, an ideal dressing material has to maintain a moist environment, and act as both a barrier against bacteria and toxic contaminants and as a medium for free exchange of gases. SSD is still considered the standard antimicrobial treatment for burn wounds in many parts of the world. Patient comfort during dressing change is also an important consideration in managing burn wounds.9 Advances in technology have led to newer silver dressings with improved forms of delivery systems, aimed at improving efficacy while minimising side effects. The antimicrobial properties of silver have been recognised since Roman times.10 This heavy metal has a broad spectrum of activity against bacteria, yeasts and fungi and has been used in modern day wound healing since the early 1960s, when 0.5% silver nitrate aqueous solution was used as an alternative to antibiotics in the management of major burns.11

However, application frequencies could be up to 12 times per day to ensure that sufficient levels of silver ions were available to reduce the bacterial load, because of its rapid inactivation by protein and chloride in the burn wound.3,12 The unique structure of the nano crystalline silver dressing dictates activity which releases silver as an initial bolus followed by a sustained release over extended time periods.13

Substantial experiences with adverse silver sulfadiazine reactions and side effects have been observed in the literature. It is appropriate to keep the possibility of a toxic silver effect in burn patients treated, with slow sustained release, silver-coated newly developed wound dressings in mind.3 Such dressings have a prohibitive cost, thus making them out of reach in limited resource settings. Hence in many such areas conventional dressing with SSD cream and gamzee barrier is still the preferred mode.

Research and development in the field of wound dressing has resulted in the fabrication and production of biological dressings. Until 1990, human amnion was extensively used as a temporary biological cover for superficial and deep partial thickness burns, providing good healing and epithelialisation.14-16

This membrane was efficient in wound healing but had the disadvantage of being a blood product that could transmit HIV and hepatitis infections. Continued research for good functional biological dressings resulted in the evolution of collagen-based dressings for burn wounds, which have proven to be superior and more advantageous. The development of collagen dressings is only logical given its unique structural and functional characteristics. These are manufactured from bovine sources, mainly from animal skin and Achilles tendon. The importance of collagen in burn wound healing has been appreciated for a long time.

The collagens form an essential substrate for cellular adhesion and migration, in addition to providing mechanical support to the connective tissue. Therefore, collagen is considered to be an important factor in the regenerative process.4,17 Collagen is haemostatic, has low antigenicity, and supports cellular growth. This qualitative study on the advantages of collagen membrane on partial thickness burn wounds (≤ 15% BSA) targeted the time taken for complete epithelialisation. This study also looked at the number of dressings needed, how easily they were applied or removed, the patient’s analgesia requirements, wound healing and scar quality. In our study, one of the observations that stood out was that, in patients with collagen dressing, the need for analgesia was significantly less. This can be attributed to less frequent dressing change and early healing in the collagen group. Dressing change involves removal of the old dressing, washing with saline to remove exudates, followed by reapplication of SSD cream and paraffin gauze over the wound. In the SSD group alternate day dressing was done and each dressing change involved manipulation of raw, sensitive skin surface, leading to pain and discomfort. In the collagen group most cases had a single dressing after collagen sheet application, and with epithelialization, residual collagen gets spontaneously removed. This also led to a decrease in hospital stay as patients could be managed at home. Most parents of pediatric patients opted for collagen dressing (81% of group A patients < 10 years). This could be attributed to decreased dressing changes and a shorter hospital stay for this group.

In our study, ease of application and removal of the collagen dressing, reduced healing time and decreased hospital stay are the real advantages when compared to paraffin gauze and SSD. A single application of collagen sheet was done in 90% of the total number of cases. Infection was observed as redness on the wound and purulent discharge under the adherent membrane in 4.5% of cases. In all cases discharge was minimal and responded to routine antibiotics. This was seen in areas of second-degree burn only. A total of 95.45% of all cases healed without any infection. No cultures were done as the wounds healed well in 15 days, with no signs of systemic sepsis in any of the patients. The advantages of collagen membrane over the paraffin gauze and silver sulfadiazine are: ease of availability in various sizes, ease of removal, ability to remain stable at room temperature for 3 years. Multiple studies are going on to develop the ability to incorporate drugs and growth factors within the collagen sheet, which can be delivered then to the wound in a controlled manner.18 It is recommended that collagen sheet application should be avoided in wounds with active infection or significant bacterial colonization.19 There are also some disadvantages to the collagen membrane: it is not advisable for a single stretch of membrane to be placed on flexor surfaces as it cracks when it becomes dry; and wounds visible through the membrane have given rise to apprehension amongst care givers.19 The cost of a single collagen sheet is more than SSD cream dressing. However, the cost of collagen is much lower than silver impregnated dressings. Since collagen sheet is used only once or twice, we feel that decreased dressing change and reduced hospitalization can easily offset the cost factor.20 Another limitation of our study is the small sample size and hence a larger study cohort could be attempted in the future to further confirm the findings of the study.

Conclusion

Collagen dressing has proven to be highly advantageous for burn patients, especially for small areas of superficial partial thickness burns in all age groups. Patients with collagen dressing had better pain relief so less analgesia was required. Most of the time no dressing change was needed before the wound completely healed. Rate of wound healing is better, with better scar quality, while the conventional dressings tend to adhere to the wound surface. The need for frequent changes of dressing traumatises newly epithelised surfaces, delaying healing. This is painful, and more analgesia is required for longer duration. However, collagen dressings should be avoided in the presence of wound infection with significant bacterial colonization, when conventional SSD or nano crystalline silver impregnated dressings should be used.

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