When it Doesn't Pay to Be Patient: Aggressive Treatment of Non-Healing Burns
by Michel H.E. Hermans, MD
Recently I paid a visit to one of the better known wound care centers in the North East. As I expected, treatment of the common lesions seen in this center, such as venous leg ulcers and diabetic foot ulcers, was top notch. The use of compression and offloading, proper wound debridement and modern dressings (including, where indicated, biologics and matrices), in combination with the option for vascular, plastic and orthopedic (i.e. for Charcot foot) reconstruction resulted in good healing results, with high percentages of reepithelialization within a relatively short time frame.
However, amongst the patients with non-chronic lesions were two with smaller burns. Originally these traumatic lesions were diagnosed as partial-thickness burns, one on the back of the hand and, for the second patient, on the lower arm. Both had been treated with silver sulfadiazine cream: treatment had been going on for about 5 weeks with granulation tissue now filling both wounds…
This treatment period is too long! A partial-thickness burn in otherwise healthy patients (in these case both patients were healthy indeed and in their early twenties) should not take more than 2-3 weeks to reepithelialize.
Wound Depth Assessment and Burn Healing Time
That the burns had not even healed after 5 weeks means that either the initial depth diagnosis was incorrect (which happens even to experienced burn-care people) or that the wounds had become deeper over time. This secondary deepening has to do with physiological changes in the wound and happens when wounds desiccate or infect: it is indeed a well-known phenomenon in burn care. With proper treatment (preferably a moisture retentive dressing or a biologic) desiccation can often be prevented and, as stated, the wound should then heal rapidly.
The depth diagnosis of the burn and maximum healing time are important since deep burns and burns that take too long to heal by themselves will virtually always result in an ugly, often hypertrophic, scar. Not only may these scars lead to problems for the patient's social interactions (most people are put off by scars), but they may also cause contractures when they occur over a joint. Thus, the rule in burn care is that "everything that is not healed within 2-3 weeks and that is larger than a silver dollar" should be excised and grafted and patients with these type of lesions should be referred to a specialist.
Grafting and Burn Treatment
It is important to realize that the success rate of grafting of an excised burn is much higher than the grafting of, say, a diabetic foot ulcer: since a burn does not have an underlying physiological cause (as opposed to a venous or diabetic ulcer) excision of the injury creates a healthy, uncompromised wound bed which will, indeed, readily and easily accept an autograft.
Whereas patience is a good thing in the care of ulcers (chronic wounds) a more aggressive treatment approach is often the preferred way in dealing with burns and other trauma.
About the Author
Michel H.E. Hermans, MD, is an expert in wound care and related topics, trained in general surgery, trauma care and burn care in the Netherlands. He has more than 25 years of senior management experience in the wound care industry. He has conducted a large number of clinical trials relating to devices and drugs aimed at wound care and related indications and diseases. Dr. Hermans speaks internationally and has authored many published works relating to wound management.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.