Amniotic Membrane Dressing Versus Nitrofurazone-impregnated Dressing in the Treatment of Second-degree Burn Wounds

A Randomized Clinical Trial

Jafar Kazemzadeh, MD; Awat Yousefiazar, MSc; Afshin Zahedi, MD

Disclosures

Wounds. 2021;33(8) 

In This Article

Abstract and Introduction

Abstract

Introduction: Both the amniotic membrane biologic dressing and nitrofurazone-impregnated dressing are treatment options for burn wounds.

Objective: To compare the efficacy of these treatments in healing second-degree burns, a randomized clinical trial was conducted among patients with second-degree burns who had no comorbidities or history of addiction and were referred to a burn center in Urmia, Iran, between December 2017 and September 2019.

Materials and Methods: Patients were randomly assigned to one of 2 study groups. Wounds were dressed in either amniotic membrane covered with moistened gauze/petrolatum or nitrofurazone-impregnated gauze. Comparative groups were matched according to percentage of burn (total body surface area). The dressing application occurred once daily in the nitrofurazone group and once weekly in the amniotic membrane group. The study was conducted until all wounds healed. The study outcomes included the infection rate of the wound, pain severity related to dressing changes, dressing change frequency, epithelialization rate, hospitalization length of stay, morphine use, and scarring. Data were collected in real time by the researcher via observation, interview, examination of the patient, and, eventually, completion of a checklist. Analyzed quantitative and qualitative variables were reported as mean ± standard deviation and percentage (frequency).

Results: Each group included 35 participants (24 men, 11 women; age, 20.05 ± 3.60 years in the amniotic dressing group; and 20 men, 15 women; age, 21.60 ± 2.02 years in the nitrofurazone-impregnated gauze group). Assessment was performed on days 1, 7, 14, and 30 from the initial treatment and at discharge. No significant difference was noted in the rate of infection between the 2 groups. Epithelialization was complete (100%) by day 7 in the amniotic membrane group, versus 77% in the nitrofurazone group. Pain following dressing application, length of hospitalization, morphine use, and scarring at day 14 were significantly lower (P < .05) in the amniotic membrane group.

Conclusions: This study indicated that the use of amniotic membrane dressing improved factors key to healing in second-degree burn wounds compared with nitrofurazone-impregnated dressing. Further research with a larger sample is warranted.

Introduction

Burns are common causes of trauma in economically developing countries, accounting for substantial health care costs.[1] The mortality rates due to fire and burns have declined in the last few decades for several reasons, one of which is decreased wound inf1ections because of improved wound dressings and antibiotic administration.[2,3] Globally, advanced burn treatment centers apply biological dressings at the beginning of burn management, which has decreased the mortality rate from 30% to 8%; however, this method is not frequently used in economically developing countries.[3]

Dressings

In general, a burn dressing should protect damaged epithelium, reduce bacterial and fungal colonization rates, and provide a layer of protection to reinforce the integrity of the dressing. In addition, a dressing should cover the wound to prevent heat from dissipating, reduce cold stress, and provide patient comfort.[4] When dressing burns, the degree of the burn needs to be considered. First-degree burn wounds have minimal tissue damage and should not require a dressing, and second-degree burns can be treated using dressings that incorporate local antibiotics, gauzes, and elastic bands, changed daily.[5,6] An ideal burn dressing should be tailored to the patient, including cost and comfort level; daily dressing replacement contributes to the debridement of necrotic tissues and isolated scars in addition to cleaning the dressing.[7]

Topical Treatment

Nitrofurazone. Several topical treatments are available for burn wounds. Nitrofurazone, previously approved by the FDA (now discontinued), as a water-soluble ointment for the treatment of burn wounds is used in various dressings; it inhibits the enzymes involved in carbohydrate metabolism and works as bactericidal agent, penetrating into burns eschars.[8] However, it is not without side effects, including hypersensitivity, itching, dermatitis, and delayed wound healing.[9]

Amniotic Membrane. In patients with first-degree and second-degree burns, where a wide total body surface area (TBSA) is burned and therefore there is limited skin to graft from, the amniotic membrane may be an effective alternative wound covering. The rate of skin graft rejection has been shown to be much lower when using amniotic dressings compared with other materials, such as xenografts, homografts, and allografts.[10] Human amniotic membrane constitutes the innermost embryonic layer. It comprises epithelial cells, a basement membrane, and a vascular stromal matrix.[11] Human amniotic membrane was first used in skin grafts to cover wounds in 1910; in 1974, this method was used to treat third-degree burns with good results.[12,13] Since then, amniotic membrane has been commonly used to treat up to second-degree burn wounds.[14,15] Clinical trials have shown dressing a burn with amniotic membrane can alleviate pain and decrease bacterial infections.[16,17] Studies also have shown the use of amniotic membrane contributes to the prevention of severe fluid loss and electrolyte disorders, helping prepare the wound bed to accept skin grafts.[19]

A majority of studies have been concerned with burns of a higher degree (more severe), but few investigations have been performed on the role of amniotic membrane use in second-degree burns. Biological dressings may offer key therapeutic options. In a systematic review by Witt et al,[20] an amniotic membrane dressing used on acute and chronic burns was found to be effective due to the presence of antibacterial agents and human growth factors in the amniotic membrane. Thompson et al[18] showed amniotic membrane causes rapid epithelialization of the burn without any risk of metalloproteinase accumulation, improving the outcome and quality of life of patients with partial-thickness and full-thickness burns.

To enhance the research on biological dressing use in second-degree burns, the authors designed a randomized clinical trial (RCT) to compare an amniotic membrane dressing covered with a wet gauze dressing and petrolatum with a nitrofurazone-impregnated gauze dressing in the treatment of second-degree burns.

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