COMPARISON OF VARIOUS DRESSING MATERIALS USED FOR OUT- PATIENT BURN TREATMENT AT OUR CENTRE*

Ann. Medit. Burns Club - voL VII - n. 3 - September 199

Ugar N, Haberal M.

Baskent University Hospital, Ankara, Turkey

SUMMARY. In the present prospective study a comparison was made between various dressing materials commonly used for ambulatory bum treatment at our Centre. Fifty-two out-patients were included in the study, divided into groups of 11-14 individuals. 'Me patients in each group were treated by application of one of the following dressing materials: nitrafurazone embedded gauze (NEG), silver nitrate incorporated amniotic membrane (SNIAM), WaterJel and Orniderm. Healing time in days was 14.7 ± 1.4, 12.5 ± 1.5, 12.1 ± 2.2 and 14.3 ± 1.3 for NEG, SNIAM, WaterJel and 0miderm respectively. The clinical wound infection rate was observed to be lowest in the SNIAM group. The 0miderm group showed a slightly lower infection rate than the NEG and Water-Jel groups. Two patients in each group deve-loped major complications such as hypertrophic scar or contracture. Water-Jel was found to be the most effective dressing material for pain relief in emergency situations. No patients needed grafting. In the present study the dressing materials provided almost identical end-results with approximately the same complication rates. Although each dressing material had its advantages and disadvantages, the bum wounds healed in about the same length of time, with the same results, if a relatively sterile and moist environment was maintained for the wounds and if epitbelial regeneration was not disturbed either during dressing changes or by topical agents.

Introduction

The majority of burns are treated on an out~patient basis, and various dressing materials have been recommended for the treatment of out-patient burns. In this prospective study, four materials commonly used in outpatient treatment of burns were compared with regard to healing time, pain on application, frequency of dressing changes, occurrence of infection, and scar formation.

Materials and methods

Fifty-two patients with partial-thickness burns were included in this randomized study. The patients, divided into groups of 11-14 individuals, were treated by application of one of the dressing materials: nitrafurazone embedded gauze (NEG), silver nitrate incorporated amniotic membrane (SNIAM), Water-Jel and Omiderm. The numbers of the patients and the percentages of the burn wound are summarized in Table I.

	1-5%	6-10%	11-15%	Total
NEG	8	4	1	13
SNIAM	9	2	3	14
Water-Jel	9	4	-	13
Omiderm	8	3	-	11

Table I - Distribution of patients according to dressing materials and % TI3SA burned

Silver nitrate incorporated membranes were prepared by the method described by the senior author of this paper.

* Paper presented at the 7th MBC Meeting at Perpignan, December 1993

Nitrofurazone embedded gauze was prepared by autoclaving nitrofurazone soaked gauze. Omiderm and WaterJel were obtained from commercial sources.

Following premedication, the wounds were cleansed with povidone iodine solution, and the dressing material or agent was applied. If the material adhered to the wound surface, it was not removed until complete epithe~ lialization. Dressing changes were made three times a week.

The data concerning clinical wound infection, healing time, complications and subjective interpretation of the advantages and disadvantages of these materials were evaluated.

Results

The healing time, in days, was 14.7 ± 1.4, 12.5 ± 1.5, 12.1 ± 2.2 and 14.3 ± 1.3 for NEG, SNIAM, Water-Jel and Omiderm, respectively (Table II).

Days
NEG	14.7 ± 1.4
SNIAM	12.5 ± 1.5
WaterJe	12.1 ± 2.2
Omiderm	14.3 ± 1.3

Table II - Mean healing time

Clinical wound infection was observed to be lowest in the SNIAM group. The Omiderm group showed a slightly lower infection rate than the NEG and Water-Jel groups. No statistical difference was noted between the NEG and Water-Jel groups (Table III).
Two patients in each group developed major complications, such as hypertrophic scar or contracture.

	Infected	Non-infected	Total
NEG	3(23.1%)	10(76.9%)	13
SNIAM	2(14.3%)	12(85.7%)	14
WaterJel	3(23.1%)	10(76.9%)	13
Omiderm	2(18.2%)	9(81.8%)	11
Total	10	41	51

Table III - Clinical wound infection

Water-Jel was found to be the most effective dressing material for pain relief in emergency situations. SNIAM and Omiderm caused no increase in pain on application. Some patients suffered from itching while NEG was being applied, and one patient presented allergic dermatitis following its use. SNIAM and Omiderrn eased dressing changes to some extent. The dressing changes were however found to be tolerable by the patients also for the other methods (Table IV).

Pain relief Cost Availability Dressing changes

NEG Itching Low Easy Tolerable

SNIAM Good Low Difficult Easy

Water-Jel Very good High Easy Tolerable

Orniderm Good High Easy Easy

Table IV - Advantages and disadvantages interpreted by patient and physician

Discussion

Various topical dressing materials and agents are used in the treatment of bum wounds. These can be classified as biological materials, antimicrobial agents, synthetic materials and cooling agents. In this study, a comparison was made between materials from each group that are,widely used in the ambulatory treatment of burns in our Centre.
When healing time is taken into consideration, SNIAM and Water-Jel show some slight advantages. Our previous studies also found that SNIAM was effective in burn wound treatment (1, 2). It has subsequently been suggested that biological membranes may protect burn wounds from bacterial contamination, prevent heat, protein and fluid losses, and provide a suitable environment for epithelialization. Although there are not many comparative clinical stu~ dies in the literature concerning Water-Jel as a dressing material (not only for emergency cases), experimental studies (3, 4) have shown its beneficial effects in limiting the extent of burn injuries. Water-Jel may exert its effect on healing in the initial phase, since cooling can prevent the release of some destructive mediators.
Infection was observed least frequently in the SNIAM group, followed by the Omidenn group. This showed that synthetic materials do not increase infection rates (5, 6, 7, 8, 9). Although NEG and WaterJel have antibacterial properties they were unable to prevent clinical wound infection. The antibacterial properties of the dressing materials do not seem to be so vitally important.
The subjective evaluation of the patients and physicians indicated that Water-Jel alleviated pain in the early phase, although other materials were also to a variable degree effective for pain relief. Nitrofurazone allergy occurred, although only rarely, and this may be acceptable because of considerations of cost-efficiency. SNIAM is one of the best dressing materials, but it is not easily available and preparable; there may also be the risk of disease transmission, although this has not been demonstrated by scientific studies. We only use amniotic membranes obtained from serologically negative persons.
In the present study all the dressing materials provided almost the same end-results with approximately the same complication rates. No patients needed grafting. All the dressing materials used can therefore be recommended for ambulatory burn treatment. Clinical experience will lead to the correct selection of the dressing material suitable for individual cases.
It is our opinion that if certain conditions can be maintained no significant differences will be noted in the success of out-patient treatment, even using a simple dressing material. These conditions are as follows:

Maintenance of a sterile environment by cleansing with a solution that is effective against bacterial, fungal and viral agents and also leaves blisters intact.

Application of a topical agent or dressing that does not interfere with epithelial regeneration and wound healing.

If possible, use of any kind of occlusive dressing for prevention of further contamination and capillary thrombosis, desiccation, superficial necrosis and subsequent increase in burn depth.

Meticulous debridement and dressing changes without causing loss of newly generated epithelium.

Conclusion

Every dressing material has its advantages and disadvantages. However, burn wounds will heal in almost the same time and with the same results if a relatively sterile and moist environment can be maintained for the burn wound and if epithelial regeneration is not disturbed during dressing changes or by topical agents.

RESUME. Les auteurs, dans cette étude prospective, ont comparé divers matériaux communément usés pour la médication des lésions des patients brûlés traités enconsultation externe dans lent Centre. Cinquante-deux malades ambulatoires ont été inclus dans l'étude, divisés en groupes de 11-14 sujets. Les patients dans chaque groupe ont été traités avec Fappjicgfion de l'un des matériaux de médication suivants: la gaze fixée avec nitrafurazone (sigle anglais: NEGj,'Ia' inembrani amniotique avcc'nitrate d'argent incorporé (SNIAM), le Water-Jèl et l'Omiderm. Le temps de guérison, calculé en jours, était 14.7 ± 1.4, 12.5 ± 1.5, 12.1 ± 2.2 et 14.3 ± 1.3 pour NEG, SNIAM, Water-Jel and Omiderm, respectivement. Le taux d'infection clinique des lésions était le plus bas dans le groupe SNIAM. Le groupe Omiderm a montré un taux d'infection légèrement plus bas des groupes NEG et Water-Jel. Deux patients dans chaque groupe ont développé des complications importantes comme la cicatrisation hypertrophique ou les contractures. Le Water-Jel s'est montré le matériau de médication le plus efficace pour le soulagement de la douleur dans les situations d'urgence. Aucun patient n'a eu besoin de greffe. Dans cette étude les matériaux de médication ont donné presque les mêmes résultats finals avec un taux de complications presque identique. Tous les matériaux ont montré des avantages et des désavantages, mais les lésions se sont quand même cicatrisées dans presque la même période de temps, et avec les mêmes résultats, à condition que l'on maintienne pour les lésions un environnement rélativement stérile et humide et que la régénération épithéliale ne soit pas gênée pendant les changements de la médication ou par les agents topiques.

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