Assessing the Effect of Enzymatic Debridement on the Scar Quality in Partial-Thickness Burns to Deep Dermal Burns of the Hand: A Long-Term Evaluation

Abstract

Background and Objectives: Burn surgery on the hands is a difficult procedure due to the complex anatomy and fragility of the area. Enzymatic debridement has been shown to effectively remove burn eschar while minimizing damage to the surrounding tissue and has therefore become a standard procedure in many burn centers worldwide over the past decade. However, surprisingly, our recent literature review showed limited valid data on the long-term scarring after the enzymatic debridement of the hands. Therefore, we decided to present our study on this topic to fill this gap. Materials and Methods: This study analyzed partial-thickness to deep dermal burns on the hands that had undergone enzymatic debridement at least 12 months prior. Objective measures, like flexibility, trans-epidermal water loss, erythema, pigmentation, and microcirculation, were recorded and compared intraindividually to the uninjured skin in the same area of the other hand to assess the regenerative potential of the skin after EDNX. The subjective scar quality was evaluated using the patient and observer scar assessment scale (POSAS), the Vancouver Scar Scale (VSS), and the "Disabilities of the Arm, Shoulder, and Hand" (DASH) questionnaire and compared interindividually to a control group of 15 patients who had received traditional surgical debridement for hand burns of the same depth. Results: Between January 2014 and December 2015, 31 hand burns in 28 male and 3 female patients were treated with enzymatic debridement. After 12 months, the treated wounds showed no significant differences compared to the untreated skin in terms of flexibility, trans-epidermal water loss, pigmentation, and skin surface. However, the treated wounds still exhibited significantly increased blood circulation and erythema compared to the untreated areas. In comparison to the control group who received traditional surgical debridement, scarring was rated as significantly superior. Conclusions: In summary, it can be concluded that the objective skin quality following enzymatic debridement is comparable to that of healthy skin after 12 months and subjectively fares better than that after tangential excision. This confirms the superiority of enzymatic debridement in the treatment of deep dermal burns of the hand and solidifies its position as the gold standard.

Keywords: bromelain; comparison of enzymatic versus surgical debridement; dermis preservation; enzymatic debridement; eschar removal; functional and aesthetic outcome; hand burn; scarring.

Figure 1

Flow diagram of CONSORT study phase progression.

Figure 2

Standard of care: enzymatic debridement treatment.

Figure 3

Process of enzymatic debridement of deep dermal hand burn, (A) Mechanical cleaning of wound bed after pre-soaking and creation of debridement border by applying paraffin; (B) homogenization of Nexobrid© substrate; (C) homogenized Nexobrid© substrate ready to use; (D) application of Nexobrid© to the wound bed; (E) occlusive dressing during process of enzymatic debridement; (F) wound bed after removal of the occlusive dressing showing selective debridement: punctate bleeding and white dermis.

Figure 4

Injury pattern, acute treatment, and healing process: (A) burn on arrival; (B) wound bed after enzymatic debridement (punctate bleeding and white dermis); (C) wound after application of Suprathel©; (D) wound after 1 week; (E) wound after 2 weeks; (F) wound after 3 weeks; (G) outcome after 6 months; (H) aesthetic and functional outcome 12 months after injury with comparison to other side.