Human Amniotic Membrane vs Collagen in the Treatment of Superficial Second-Degree Burns in Children

Aureen Ruby DCunha, MBBS, MS, Mch; Susan Jehangir, MBBS, MS, Mch; Grace Rebekah, BSc, MSc, PhD; Reju J. Thomas, MBBS, MS, DNB, DNB, Mch

Disclosures

Wounds. 2022;34(5):135-140. 

In This Article

Abstract and Introduction

Abstract

Objective: The authors compared a 1-time application of bovine collagen and human amniotic membrane (HAM) to treat children with superficial second-degree burns.

Materials and Methods: A prospective, blinded, internally randomized trial of 43 children was conducted. Fresh HAM (prepared in-house at the Christian Medical College, Vellore) and bovine collagen were applied to different halves of each wound and dried naturally to form a hard, shell-like, so-called exoskeleton. The shell was shed as epithelialization occurred beneath it. Clinical examination and serial photographs were used to track progress until the wound healed completely, as well as at 3 and 6 months after the burn injury. Two burns surgeons blinded to the material used evaluated the resulting scars using the Vancouver Scar Scale.

Results: The 43 children presented 3 hours after burn injury on average. A 1-time application was successful in 40 children (93%). After the dressing dried, all parents reported that their child was pain free and the exoskeleton could be handled over the burned area. A total of 16 children (37%) with a low-grade fever at the time of application were treated with simple antipyretic agents. Eight children reported itching at the dressing site. The dressing did not take or was removed in 3 children (7%). Minor serous collections occurred in 8 children who subsequently underwent aspiration. The median time to healing was 10 days in both study arms, with no significant difference in scarring between the 2 materials. Children with earlier shedding of the shell had significantly better scar quality (P <.001).

Conclusions: Collagen and HAM are safe and provide a one-time ambulatory option for burn dressing with comparable time to healing and scarring. Earlier shedding of the dressing is predictive of better scar quality. Because HAM is inexpensive and simple to prepare and store, it is an excellent choice for use in economically disadvantaged areas where collagen may be unavailable.

Introduction

Scald burns in children are a common presentation to the emergency department (ED). Light et al[1] highlight several challenges in the management of burns in developing countries, including larger burn size, longer contact times, baseline malnutrition and anemia, lack of awareness of first aid, delayed presentation, refusal of care because of limited finances, and inability to access health care. Burn injury also has devastating long-term physical, psychological, and financial consequences for the child and family. The ideal dressing would require a 1-time application in the ED and would relieve pain, be readily available, be inexpensive, expedite healing, and reduce scarring.

Human amniotic membrane (HAM) is a byproduct of pregnancy that is typically discarded after birth. It has been used as a biologic wound dressing for centuries, and in 1913, Sabella[2] was the first to report its use in the management of burns. Human amniotic membrane contains fibronectin, proteoglycans, glycosaminoglycans, laminins, and type IV, V, and VII collagen, as well as fibroblasts and pluripotent stem cells, all of which are required for tissue growth and repair.[3] It also contains interleukin-4, -6, -8, and -10, and it is hypothesized that the immunosuppressive functions of these interleukins contribute to the immune-privileged properties of the amniotic membrane.[3] These biologic characteristics are thought to contribute to the clinical efficacy of HAM in terms of reduced pain and infection, faster healing, and decreased scarring.[3–5] Harvesting HAM has been described as labor intensive and time consuming, however.[5] A simplified method of harvesting HAM is described herein.

Commercially available collagen, which resembles HAM, is made from reconstituted bovine collagen (Xenoderm WT; Helix Pharma). This collagen is a thin, transparent, acellular sterile sheet that is devoid of growth factors and stem cells. Both materials have been used as the inner layer of burn dressings.[3–7]

This study describes a 1-time application of collagen and HAM that can dry naturally without the need to cover the application with additional dressing material. After these materials are completely dry, they form a hard, shell-like layer (hereafter referred to as exoskeleton); this process takes approximately 6 to 8 hours. The child is pain free once the exoskeleton is formed, and the exoskeleton can be touched without causing pain. However, the exoskeleton must be kept dry until reepithelialization takes place beneath it and the shell falls off or is shed. The purpose of this study was to determine whether HAM and collagen used in this manner are viable dressing options in children with second-degree burns by assessing percentage of the dressing take, need for reapplication, wound infection, time to wound healing, and scar quality.

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