Hendrik Hoeksema

Assessment of burn depth and burn wound healing potential

The depth of a burn wound and/or its healing potential are the most important determinants of the therapeutic management and of the residual morbidity or scarring. Traditionally, burn surgeons divide burns into superficial which heal by rapid re-epithelialization with minimal scarring and deep burns requiring surgical therapy. Clinical assessment remains the most frequent technique to measure the depth of a burn wound although this has been shown to be accurate in only 60-75% of the cases, even when carried out by an experienced burn surgeon. In this article we review all current modalities useful to provide an objective assessment of the burn wound depth, from simple clinical evaluation to biopsy and histology and to various perfusion measurement techniques such as thermography, vital dyes, video angiography, video microscopy, and laser Doppler techniques. The different needs according to the different diagnostic situations are considered. It is concluded that for the initial emergency assessment, the use of telemetry and simple burn photographs are the best option, that for research purposes a wide range of different techniques can be used but that, most importantly, for the actual treatment decisions, laser Doppler imaging is the only technique that has been shown to accurately predict wound outcome with a large weight of evidence. Moreover this technique has been approved for burn depth assessment by regulatory bodies including the FDA.

Honey in modern wound care: A systematic review

Honey, known for centuries as a topical treatment for a wide range of wounds, has recently known a revival in modern wound care. The objective of this systematic review is to evaluate the available evidence and the role of honey in contemporary wound care. The search strategy was developed in the databases PubMed and ISI Web of Science. Fifty-five studies of any design, evaluating the use of honey in human burns, ulcers and other wounds, written in English, French, German or Dutch were eligible for inclusion. In all three wound categories honey seems to be a dressing with wound healing stimulating properties. In burns there is also evidence for its antibacterial capacity. In general, honey is also been mentioned to have deodorizing, debridement, anti-inflammatory and wound pain reducing properties, although the evidence for these properties is rather limited. Many of the included studies have methodological problems, and the quality of certain studies is low, making it difficult to formulate conclusive guidelines. This review reveals several gaps in the research of honey in modern wound care, and recommendations are suggested for future research.

Burn scar assessment: A systematic review of objective scar assessment tools

PURPOSE All deep second and third degree burns are at risk to develop hypertrophic scars which can severely undermine the quality of survival. To assess the severity of scarring, several technical devices or tools have been introduced to evaluate one or more aspects of the scar, enabling comparison of different treatment protocols and allowing an objective follow-up. The objective of this study was to review which tools can be used in objective burn scar assessment. BASIC PROCEDURES The Systematic literature search involving PubMed, the Web of Science (incl. Science Citation Index). MAIN FINDINGS 51 articles with burn scar assessment as main topic were found. Several characteristics of the scar can be assessed, such as color, metric features and elasticity, but none of the available tools covers the whole aspect of the scar. Especially subjective factors such as pain and itching cannot be assessed with those tools, in spite of their great impact on the patients quality of life. CONCLUSIONS Scar tools enable objective and reproducible evaluation of scars, which is essential for scientific studies and medico-legal purposes, and in selected cases for the clinical follow-up of an individual patient. Further studies to evaluate these tools on scars are nevertheless required.

Burn Scar Assessment: A Systematic Review of Different Scar Scales

BACKGROUND Scars can be devastating and disfiguring, because they are clearly visible, stigmatizing, and permanent reminders of the initial accident or surgical event. Yet, there is still no consensus about the optimal scale or tool to assess the characteristics and evolution. Our aim was to evaluate the clinical importance of scar scales specifically developed for burn scars. MATERIALS AND METHODS The systematic literature search involved PubMed and the Web of Science (including Science Citation Index). RESULTS The search resulted in 29 articles (including seven reviews) dealing with a new, modified, or validated scale. Scar scales assess several characteristics, of which color, pliability, and thickness were considered the most important. Physical limitation, pain, and pruritus are often more disturbing than the appearance of the scar, and are therefore also introduced in scar evaluation, as well as the interference with daily life activities (e.g., psychologic impact). CONCLUSION In contrast to the more objective scar assessment tools, scar scales usually cover more aspects of the scars and are less time-consuming in clinical practice. However, no strong conclusions can be made about their efficacy and validity. In addition to digital photography, scar scales are a valuable instrument in the clinical evaluation and follow-up of scars.

Burn wound healing time assessed by laser Doppler imaging (LDI). Part 1: Derivation of a dedicated colour code for image interpretation

INTRODUCTION Laser Doppler imaging produces a colour-coded image of dermal blood flow, which can be used to quantify the inflammatory response in a burn. The original colour palette had arbitrary boundaries, which inexperienced clinicians found difficult to interpret. The aim of this study was to define clinically useful boundaries that would assist in the prediction of burn healing potential. METHOD We conducted a prospective, multi-centre study of burns in adults and children. LDI scans were performed between 48 h and 5 days after injury. The burns were assessed clinically and photographed on day of scan, day 14 and day 21 post-injury. Areas healed at day 14, healed between day 14 and 21 and unhealed at day 21 were identified on the LDI scan. The flow values for the pixels in these regions were analysed to calculate boundaries between the three healing categories. RESULTS We recruited 137 patients (ages 1-88 years, 65% male); 392 LDI scans contained 433 different burn sites; 109 regions of interest were studied. Analysis allowed us to define ranges for the three healing categories: HP14 colour coded red, >600 PU; HP14-21, yellow, 260-440 PU; HP>21, blue, <200 PU; separated by two overlap regions pink, 440-600 PU and green, 200-260 PU. Blue was subdivided to show the very high association between LDI<140 PU and non-healing at day 21. CONCLUSION We have devised a new colour palette for LDI burn imaging based on healing times of a series of burns. Validation of this palette is described separately, in Part 2.

Aquacel(®) Ag dressing versus Acticoat™ dressing in partial thickness burns: a prospective, randomized, controlled study in 100 patients. Part 1: burn wound healing.

INTRODUCTION Studies comparing contemporary silver dressings in burns are scarce. METHODS In a prospective, randomized, controlled study, counting 50 patients/research group, we compared two frequently used silver dressings, Acticoat™ and Aquacel(®) Ag, in the management of partial thickness burns with a predicted healing time between 7 and 21 days as assessed by laser Doppler imaging between 48 and 72h after burn. Variables investigated were related to baseline research group characteristics, wound healing, bacteriology, economics, nurse, and patient experience. RESULTS Both research groups were comparably composed taking into account gender, age and burn characteristics. Similar results were obtained as to healing time and bacterial control with both silver dressings. A statistically significant difference in favor of the Aquacel(®) Ag dressing was found for average ease of use (p<0.001), average ease of application (p=0.001), patient pain (p<0.001), patient comfort with the dressing (p=0.017), silver staining (p<0.001), and cost effectiveness (p<0.001). CONCLUSION Both silver dressings resulted in comparable healing times and bacterial control but the Aquacel(®) Ag dressing significantly increased comfort for patients as well as nurses and was significantly more cost-effective than the Acticoat™ dressing for the given indication.

The Efficacy of a Polyhydrated Ionogen Impregnated Dressing in the Treatment of Recalcitrant Diabetic Foot Ulcers : a Multi-centre Pilot Study

Abstract Objective: Assessing the efficacy of a polyhydrated ionogen impregnated dressing in the treatment of recalcitrant diabetic foot ulcers. Summary Background Data: Diabetic Foot Ulcers (DFU) continue to present a formidable challenge in terms of morbidity and health care costs. Increasing evidence ascertains the important role of Matrix MetalloProteinases (MMPs) and their tissue inhibitors, TIMPs, in wound healing. Imbalance of MMPs in the DFU microenvironment has been associated with poor wound healing. Current research is directed towards therapeutic agents that could redress the imbalance of MMPs/TIMPs. Poly Hydrated Ionogen (PHI) formulation is based on metallic ions and citric acid. PHI application aims to positively restore MMP ratios within chronic wounds. This initial multi-centre pilot study aimed to investigate the efficacy of the PHI formulation in achieving stable wound closure in recalcitrant DFUs. Material and methods: Twenty patients with therapy resistant DFUs of at least 1 cm2 and 3 months duration were treated with PHI formulation in an acetate carrier dressing. Wound debridement, digital imaging and wound perimeter tracing was performed weekly. Off-loading was performed by the use of appropriate shoe-wear (cut-out sandals) and crutches. Patient satisfaction was assessed with a questionnaire. A detailed evaluation sheet was kept for every patient and updated at each visit. Results: Stable wound closure with high patient satisfaction was achieved in 16 (80%) DFUs. The mean time to full closure was 18 weeks. A stable wound epithelization was seen in all full closure patients up to latest follow-up of one year. Conclusions: Encouraging results of this pilot study prompt us to further investigate the PHI efficacy in DFU treatment in a multi-centre, randomized controlled trial.

Scar management by means of occlusion and hydration: A comparative study of silicones versus a hydrating gel-cream

Despite the worldwide use of silicones in scar management, its exact working mechanism based on a balanced occlusion and hydration, is still not completely elucidated. Moreover, it seems peculiar that silicones with completely different occlusive and hydrating properties still could provide a similar therapeutic effect. The objective of the first part of this study was to compare the occlusive and hydrating properties of three fluid silicone gels and a hydrating gel-cream. In a second part of the study these results were compared with those of silicone gel sheets. Tape stripped skin was used as a standardized scar like model on both forearms of 40 healthy volunteers. At specific times, trans epidermal water loss (TEWL) and the hydration state of the stratum corneum were measured and compared with intact skin and a scar-like control over a 3-4h period. Our study clearly demonstrated that fluid silicone gels and a hydrating gel-cream have comparable occlusive and hydrating properties while silicone gel sheets are much more occlusive, reducing TEWL values far below those of normal skin. A well-balanced, hydrating gel-cream can provide the same occlusive and hydrating properties as fluid silicone gels, suggesting that it could eventually replace silicones in scar treatment.

Glyaderm® dermal substitute: Clinical application and long-term results in 55 patients

INTRODUCTION Glycerol preserved acellular dermis (Glyaderm(®)) consists of collagen and elastin fibers and is the first non-profit dermal substitute derived from glycerol-preserved, human allogeneic skin. It is indicated for bi-layered skin reconstruction of full thickness wounds. METHODS A protocol for clinical application and optimal interval before autografting with split thickness skin graft (STSG) was developed in a pilot study. A phase III randomized, controlled, paired, intra-individual study compared full thickness defects engrafted with Glyaderm(®) and STSG versus STSG alone. Outcome measures included percentage of Glyaderm(®) take, STSG take, and scar quality assessment. RESULTS Pilot study (27 patients): Mean take rates equaled 91.55% for Glyaderm(®) and 96.67% for STSG. The optimal autografting interval was 6 days (±1 day). Randomized trial (28 patients): Mean Glyaderm(®) take rate was 88.17%. STSG take rates were comparable for both research groups (p=0.588). One year after wound closure, Glyaderm(®)+STSG was significantly more elastic (p=0.003) than STSG alone. Blinded observers scored Glyaderm(®) treated wounds better in terms of scar quality. DISCUSSION The efficacy of Glyaderm(®) as a suitable dermal substitute for full thickness wounds is attested. Currently a procedure for simultaneous application of Glyaderm(®) and STSG is adopted, allowing for further widespread use of Glyaderm(®).

A new, fast LDI for assessment of burns: A multi-centre clinical evaluation

INTRODUCTION Laser Doppler imaging (LDI) provides early accurate determination of wound healing potential. LDI can scan large areas of up to 2500 cm2 within 2 min. This duration may require additional sedation in a mobile, uncooperative child. In five burn centres a faster Laser Doppler Line Scanner (LDLS) was assessed. This new imager scans 300 cm2 in 4s with potential benefit for patients and operators. The aim of this study was to assess the accuracy and convenience of the LDLS and to compare this with an established LDI imager. METHODS Outpatients and admitted patients were included. LDI and LDLS images were obtained between 2 and 5 days post burn (PB). Photographs and records of wound and healing were obtained on day of scan and at 14 and 21 days PB. This provided data on three categories of burn wounds: healing within 14 days, 14-21 days and not healed within 21 days. RESULTS The analysis included 596 burn areas from 204 burns patients. An accuracy of 94.2% was found with use of the LDLS compared with 94.4% for the original LDI imager. CONCLUSIONS The high accuracy of the new line-scan imager was comparable to that of the traditional LDI. Its size and mobility enabled easier ward and outpatient use. The higher scan speed was particularly beneficial for scans in paediatric patients.