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9 Dressing: Indications onApplications
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99
a
b
c d
Fig. 9.3 (a) Ulcer secondary to septic embolism. Pre-
debridement. (b) After surgical debridement. Treatment
with enzymatic debridement and with absorbent dress-
9.4 Conclusions
A large variety of dressing materials are currently
available, and new dressings with specic and
mixed properties will be continually created
thanks to technological advancement. Despite the
abundance of therapeutic options, it is apparent
that few high-quality RCTs have been performed
to evaluate wound dressings, with even fewer
demonstrating a clear-cut benet of a particular
dressing or treatment modality.
Until new data are received, clinicians must
continue to systematically evaluate, categorize,
and treat each wound using the guiding principles
of debridement, managing exudates, and preventing microbial colonization. Each type of ulcer
should be treated with the most appropriate
dressing material. The ulcer’s clinical appearance
ings. Subsequent application of VAC therapy for stimulation of the granulation tissue. (c) 5days after split-thickness
skin graft. (d) 3weeks after skin graft
is the main parameter in determining the most
suitable dressing.
References
1. Gurtner GC, Werner S, Barrandon Y,
Longaker MT. Wound repair Regen. Nature.
2008;453(7193):314–21. https://doi.org/10.1038/
nature07039.
2. Gantwerker EA, Hom DB.Skin: histology and physiology of wound healing. Facial Plast Surg Clin North
Am. 2011;19(3):441–53.
3. Kirschner CM, Anseth KS. Hydrogels in healthcare: from static to dynamic material microenvironments. Acta Mater. 2013;61(3):931–44. https://doi.
org/10.1016/j.actamat.2012.10.037.
4. Jones RE, Foster DS, Longaker MT.Management of
chronic Wounds-2018. JAMA. 2018;320(14):1481–2.
https://doi.org/10.1001/jama.2018.12426. PMID:
30326512
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5. Ayello EA, Cuddigan JE.Debridement: controlling
the necrotic/cellular burden. Adv Skin Wound Care.
2004;17(2):66–75.
6. Broughton G 2nd, Janis JE, Attinger CE.A brief history of wound care. Plast Reconstr Surg. 2006;117(7
Suppl):6S–11S.
7. Ovington LG. Hanging wet-to-dry dressings out to
dry. Home Healthc Nurse. 2001;19(8):477–83.
8. Lawrence JC.Dressings and wound infection. Am J
Surg. 1994;167(1A):21S–4S.
9. Vermeulen H, Ubbink D, Goossens A, de Vos R,
Legemate D.Dressings and topical agents for surgical wounds healing by secondary intention. Cochrane
Database Syst Rev. 2004;2:CD003554.
10. Ubbink DT, Vermeulen H, Goossens A, Kelner
RB, Schreuder SM, Lubbers MJ. Occlusive vs
gauze dressings for local wound care in surgical
patients: a randomized clinical trial. Arch Surg.
2008;143(10):950–5.
11. Ovington L.The well-dressed wound: an overview of
dressing types. Wounds. 1998;10(Suppl A):1A–11A.
12. Klasen HJ.A historical review of the use of silver in
the treatment of burns. II.Renewed interest for silver.
Burns. 2000;26:131–8.
13. Seaman S.Dressing selection in chronic wound management. J Am Podiatr Med Assoc. 2002;92(1):24–33.
14. Thomas S. Surgical dressings and wound management. Cardiff, South Wales: Medetec Publications;
2010.
15. Robinson BJ. The use of a hydrobre dressing in
wound management. J Wound Care. 2000;9(1):32–4.
16. Barnea Y, Amir A, Leshem D, Zaretski A, Weiss J,
Shar R, Gur E.Clinical comparative study of aquacel and parafn gauze dressing for split-skin donor
site treatment. Ann Plast Surg. 2004;53(2):132–6.
17. Warriner R, Burrell R. Infection and the chronic
wound: a focus on silver. Adv Skin Wound Care.
2005;18(Suppl 1):2–12.
18. Tomaselli N.The role of topical silver preparations in
wound healing. J Wound Ostomy Continence Nurs.
2006;33(4):367–78.
19. Durani P, Leaper D.Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation.
Int Wound J. 2008;5(3):376–87.
20. Davis DA, Arpey CJ.Porcine heterografts in dermatologic surgery and reconstruction. Dermatol Surg.
2000;26:76–80.
21. Burke JF, Yannas IV, Quinby WC Jr, etal. Successful
use of a physiologically acceptable articial skin in
the treatment of extensive burn injury. Ann Surg.
1981;194:413–28.
22. Postlethwaite AE, Seyer JM, Kang AH.Chemotactic
attraction of human broblasts to type I, II, and III
collagens and collagen-derived peptides. Proc Natl
Acad Sci U S A. 1978;75:871–5.
23. Voytik-Harbin SL, Brightman AO, Kraine MR,
et al. Identication of extractable growth factors
from small intestinal submucosa. J Cell Biochem.
1997;67:478–91.
24. O’Connor NE, Mulliken JB, Banks-Schlegel S,
et al. Grafting of burns with cultured epithelium
prepared from autologous epidermal cells. Lancet.
1981;1:75–8.
25. Teepe RG, Keobrugge EJ, Ponec M, etal. Fresh versus cryopreserved cultured allografts for the treatment
of chronic skin ulcers. Br J Dermatol. 1990;122:81–9.
26. Jones JE, Nelson EA, Al-Hity A. Skin grafting for venous leg ulcers. Cochrane Database
Syst Rev. 2013;1:CD001737. https://doi.
org/10.1002/14651858.CD001737.pub4.
27. Perkins K, Davey RB, Wallis KA.Silicone gel: a new
treatment for burn scars and contractures. Burns Incl
Therm Inj. 1983;9(3):201–4.
28. Expert Working Group. Vacuum assisted closure: recommendations for use. A consensus document. Int
Wound J. 2008;5(Suppl 4):iii–19.
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Carlesimo B.The effectiveness of negative pressure
therapy on infected wounds: preliminary results. Int
Wound J. 2017;14(06):909–14.
30. Hinchliffe RJ, Valk GD, Apelqvist J, Armstrong DG,
Bakker K, Game FL, Hartemann-Heurtier A, Löndahl
M, Price PE, van Houtum WH, Jeffcoate WJ.A systematic review of the effectiveness of interventions
to enhance the healing of chronic ulcers of the foot
in diabetes. Diabetes Metab Res Rev. 2008;24(Suppl
1):S119–44.
31. Körber A, Franckson T, Grabbe S, Dissemond
J. Vacuum assisted closure device improves the
take of mesh grafts in chronic leg ulcer patients.
Dermatology. 2008;216:250–6.
32. Geller SM, Longton JA.Ulceration of pyoderma gangrenosum treated with negative pressure wound therapy. J Am Podiatr Med Assoc. 2005;95:171–4.
Dressing inBurns
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AntongiulioMangia, AgostinoRodda,
andAntonioDi Lonardo
10
10.1 Introduction
Burn wound healing depends on the depth and
surface involved, cause of damage (thermal,
chemical, or electric), general condition of the
patient, and associated comorbidities; therefore,
the rst evaluation of wound dressing approach
requires an initial assessment of the burn based
on depth, extent, and anatomical site [1, 2].
10.2 Full-Thickness Burns
Burn injury may involve one or both skin layers
and may extend deep into the subcutaneous fat,
muscles, and even bony structures. Deep partialthickness (dermal burns), extending into the
reticular dermis, generally will take three or more
weeks to complete healing process. When pressure is applied to the burn, capillary rell appears
slow or absent. By the second day, the wound
may be white-colored and is usually fairly dry.
As a rule, deep partial-thickness burns that would
not heal within 3 weeks should be completely
excised and grafted.
Full-thickness burns involve entirely the dermis and extend deep into subcutaneous tissue.
These wounds are insensitive to light touch and
pinprick, usually have a dry and white appearance, and should be excised and grafted
(Fig.10.1). Autologous skin grafting (autografts)
is still the rst choice for treatment and involves
the transplantation of healthy skin from the
patient’s undamaged donor site to cover the
wound site. Autograft can be harvested fullthickness, consisting of epidermis and dermis or
split-thickness, consisting of the epidermis and
upper part of the dermis. Despite the possibility
of amplication of the graft with meshes, lack of
unharmed skin in a severely burned patient constitutes therefore a concrete limitation to the
autograft; furthermore, deep burns or presence of
A. Mangia · A. Di Lonardo (*)
U.O.C.Burn Center A.O.U.Pisana, University of
Pisa, Pisa, Italy
e-mail: antdil@inwind.it
A. Rodda
Plastic Surgery Clinic, ASUGI, University of Trieste,
Trieste, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_10
Fig. 10.1 Full-thickness burn of legs with areas of
carbonization
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A. Mangia et al.
infected tissue do not predispose to autograft, and
in these cases, coverage with skin substitutes
should be considered, with allo- or xenograft or
advanced dressings.
Skin substitutes could protect large burn
wounds when donor skin is limited, enhancing
wound healing and reducing inammatory
responses and subsequent scarring [3].
10.2.1 Skin Substitutes
Skin substitutes can be categorized into biological ones, synthetic substitutes, or a combination
of both.
Biological substitutes can be further categorized into:
1. Allografts: The cadaveric skin graft is a stan-
dard biomaterial for temporary skin replacement in burn patients. Cadaveric skin is able
to implement wound bed preparation before
autograft placement and can decrease pain
and wound infection rates. Other benets of
the cadaver allograft are represented by reduction in uid, electrolyte, and protein loss,
together with energy requirements. This graft
also prevents tissues from desiccation, stimulates epithelialization, prepares wounds for
denitive closure, and provides a dermal template for epidermal grafts [4–6]. Disadvantages
of the cadaver skin include serious infectious
disease risks (such as HIV and hepatitis,
transmitted to the recipient patient) and a
rejection time between 7 and 14days due to
different complexes of histocompatibility by
the host [7].
2. Xenografts: Graft is harvested from animals
and used to replace lost skin. Despite a large
availability compared to allograft, they have a
shorter rejection time and produce greater
inammation [8].
3. Natural scaffolds, such as de-cellularized and
dermal human matrix: These materials are
composed of a mixture of dermal elastin and
collagen, free of cellular components, and
their use can be associated with ultra-thin
split-thickness grafts (0.1–0.2 mm), thus
avoiding donor site morbidity of split-
thickness autograft and guaranteeing an equal
thickness to the autograft one, minimizing at
the same time scarring contracture [9]. The
dermal matrix is able to support broblast
inltration, keratinocyte migration, and neovascularization as well [10].
4. Biosynthetic wound dressings: These are
increasingly employed in supercial and
moderate-depth partial burns, aiming to cover
the wound and optimize healing in terms of
time, pain, complications, and costs. Dermal
and epidermal substitutes can be applied to
supercial and partial depth burns, able to
guarantee a rapid dermal regeneration associated with proper wound coverage and protection [11].
Bilayer-composed dressings can be applied
for partial depth burns management: The inner
layer, for example, made of xenogeneic materials (e.g., Porcine collagen [12] and bovine
collagen [13]) is able to stimulate wound healing, while the outer layer, usually an impermeable silicone lm, is able to control moisture
loss from the wound and prevent infections,
remaining pervious to gases and transparent
for a better wound evaluation. Adherence to
the wound is to be achieved, by careful xing
and movement reduction, to prevent dressing
shearing from the wound surface and provide
mechanical coverage [14]. These medications
are provided in sheets, which can be cut
according to the wound shape, and are to be
rmly applied and xed, eventually using
stitches; however, there are bilaminate biosynthetic dressings provided in glove shape
(Fig. 10.2), with specic indication on hand
localized supercial or partial deep burns and
scalds. The latter, produced in different sizes
to t both adults and pediatric patients, are
able to reduce both healing time and pain
(Figs.10.3 and 10.4), providing easier tting
and less bulky dressings [15].
Furthermore, these dressings need a cautious selection of wound application, as previous accurate debridement shall be performed,
and possible infection evaluated, in order to
prevent delayed healing and the need for further surgery; high costs have to be taken into
consideration.
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Fig. 10.2 Supercial partial-thicknessburn of the back
hand
Fig. 10.3 Biosynthetic wound dressing constructed of a
silicone lm with a nylon fabric with collagen in a glove
shave
103
In addition, tridimensional hyaluronic acid
ester matrix bilayer dressings can be used on
deep and chronic wounds, but also for the
adequate management of deep and partial
depth burns, associated with massive tissue
loss where healing process has dropped, preparing adequate tissues for skin grafting [16].
5. Cultured scaffolds, such as cultured epithelial
graft, autologous cultured broblasts, and
keratinocytes. In some massively burned
patients the burns are so extensive that donor
site availability is limited and human epidermal cells from a small skin-biopsy sample can
be cultured to produce coherent epithelial
sheets. Nevertheless, the production of a thin
sheet of epithelial cells with high production
costs and risk of ulceration must be considered [17].
6. Allogenic amnion, derived from fetal membrane, can be particularly effective if applied
on partial-thickness burn wounds; it can be
used as protective dressing, guaranteeing the
preservation of wound bed in prevision of secondary skin grafting coverage. Allogenic
amnion is fragile and difcult to handle and
needs sterilization processes in order to cut
off biological transmission probability, as it is
contaminated by denition [18].
10.3 Partial-Thickness Burns
Fig. 10.4 Biosynthetic wound dressing application and
removal at 14 days with complete re-epithelialization
below
10.3.1 Supercial Burns
Burns involving only the epidermis are erythematous and very painful, however do not form blisters. Most sunburns t this category of supercial,
epidermal injury. Within 3–4days, the dead epidermis sloughs and is replaced by regenerating
keratinocytes.
Many different ointments can be applied on
this type of lesion after accurate cleansing, based
on antibacterial principles; silver sulfadiazine,
for example, can be applied for bacteriostatic
action and able to alleviate pain as well [19];
preparations containing these substances are to
be applied with a 1–2 mm layer on the wound
daily, until complete re-epithelialization.
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10.3.2 Supercial Partial-Thickness
Burns
Supercial partial-thickness burns extend instead
into the papillary dermis and characteristically
form blisters. Once the blister is removed from a
supercial partial-thickness burn, the wound
shows up pink, wet, and hypersensitive to touch.
With appropriate wound care, supercial dermal
burns usually heal within 2–3weeks, without risk
of scarring, furthermore do not require operation.
Supercial dermal burns or graft donor site have
a raw area of the body lacking epithelial covering; topical antibacterial agents are not necessary
[20] and require instead epithelium reconstitution
through a re-epithelializing ointment, hydrogel,
or alternative coverage with advanced dressings.
10.3.3 Blister Management
Management of blisters is a complicated issue.
Most guidelines and studies recommend deroong of blister, followed by its coverage with
biological or modern dressing, as this was associated with better recovery. One valid advantage of
de-roong blisters is the possibility to visualize
and assess the wound, as in some cases vesicles
might hide a deep dermal burn underneath
(Figs.10.5 and 10.6). Moreover, it is very common for patients to present with already sheared
A. Mangia et al.
Fig. 10.6 Evacuation of vesicles with leakage of serous
blisters, either intentionally or unintentionally.
Another valid reason to de-roof is that large vesicles impede the mobility and comfort of the
patient [21]. Theoretically, de-roong with modern dressing application, when available, seems
to be the safest and most convenient choice: This
helps avoid a deep-dermal burn hidden under
vesicles, which might lead to esthetic problems
as well. Modern dressing treatment or biological
membranes lead to the best quality of healing and
allow for excellent mobilization of the patient
and his/her burned areas too. When modern
dressings or biological membranes are not available, snipping blisters open seems to be the next
best alternative. This shares the advantages of deroong in not impeding movement and in reducing pain, and at the same time, it gives a “biologic”
dressing that ensures the best moisture and sealing effects. Applying an antimicrobial cream
with an interface ensures the prevention of infection and mechanical trauma during uffy dressing change.
Fig. 10.5 Vesicles with serous content on supercial
partial-thickness uid burns
10.3.4 Hydrogel Dressings
Advanced wound treatment is often based on
controlled delivery of active substances into the
burn site. Hydrogels are widely available on the
market as the most ideal wound dressings with
numerous advantages for burn wounds, including
the ability to provide a moist and cooling environment (benecial for burn wounds) non-
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adhesiveness to wounds and the ability to absorb
excess wound exudates. Additionally, hydrogels’
high-water content mimics the physiological
wound conditions, favoring tissue regeneration
with excellent biocompatibility, and the capability to encapsulate a variety of antimicrobial
drugs. Clinically, hydrogels are used as wound
debridement agents, moist dressings, and components of wound treatments. In burn wound management, hydrogels act as a moisture donor and
can accelerate wound healing through autolytic
debridement and moisture regulation [21].
While many natural hydrogels have inherent
antimicrobial properties (e.g., chitosan, β-chitin,
cellulose, and dextran), many have been loaded
with synthetic antibiotics and antibacterial agents
including metal-ion loaded hydrogels, metallicnanoparticle, AMP-based hydrogels, and natural
polymer-based hydrogels bearing synthetic antimicrobials [22].
Biopolymers have been utilized for their
development due to their non-toxic, biodegradable, and biocompatible properties. Hydrogels
have been prepared from biopolymers such as
cellulose and chitosan, by crosslinking with
selected synthetic polymers resulting in improved
mechanical, biological, and physicochemical
properties. Although biopolymer-based hydrogels present interesting features in the series of
in vitro and in vivo studies reported for wound
management, very few of them have reached
clinical trials [23].
pathogenic organisms at the same time, without
interfering with wound healing [24].
Indications are multiple, starting from
increased infection risk wounds, various etiologies ulcers, oncology wounds, and burns.
Specically, hydrober dressings can be
applied to supercial dermal burns, creating a
moist environment able to absorb wound exudates and prevent tissue infection by stimulating
the formation of collagen and re-epithelization
(Figs.10.7, 10.8 and 10.9).
Hydrober dressing may be left in place for
up to 14days if adhered, eventually covered with
Fig. 10.7 Deep and supercial partial thickness burns of
thigh without brin
10.3.5 Hydrober Dressings
Hydrober technology, based on sodium carboxymethylcellulose layers eventually associated
with the use of ionic silver, a proven broadspectrum microbial, produces a high-absorbing
and soft wound coverage medication, able to
remove non-viable tissue from the area, controls
bacterial infection, and supports the healing process at the same time.
Hydrober dressings, as a matter of fact, are
able to absorb biolm and prevent its formation,
create a barrier protecting the wound bed, and kill
Fig. 10.8 Application of carboxymethylcellulose to
areas of dermal burn
Fig. 10.9 Removal of sheet and underlying reepithelialization
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A. Mangia et al.
secondary absorbing dressings, as they guarantee
a vertical absorption of exudate, avoiding maceration. If the dressing is not adherent or saturated, it should be removed and replaced. The
evaluation of hydrober dressings adherence and
wetness during the rst days may also be taken
into consideration for the burn deepness
assessment.
These medications shall not be used on sensitive or allergic to carboxymethylcellulose, nylon,
or silver, when associated, with individuals.
10.3.6 Alginates
Alginate dressings, originally derived from
brown seaweed and so composed of polymers of
alginic acid, are able to provide a soft and exible
high-absorbing medication (can absorb up to 20
times their own weight in uid). When in contact
with wound exudate, they form a gel, which can
be easily removed by soft irrigation, guaranteeing normal healing processes and atraumatic
dressing changes. It can be associated with other
materials, particularly with silver as antibacterial
adjuvant, or psyllium bers, which can contribute
to swelling absorption.
Alginates are indicated for moderate to large
amounts of exudate production wounds and can
be left in place until 4days, shall be changed if
saturated and fully gelled. The same application
can be used for donor site of autograft, using the
Fig. 10.10 Complete re-epithelialization at day 14 under
removal of the adherent alginate sheet
hemostatic and absorption properties of the alginates, which are left in place until complete reepithelialization (in this case the removal of the
alginate is quite easy) or in case of poor adhesion
to the tissue due to excess exudate with transformation into gel (Fig.10.10).
Alginates shall not be used on dry or necrotic
wounds, like deep burns in this case, as in the
absence of exudate no gel can be formed, and
thus no moist healing environment.
10.4 Deep Partial-Thickness
Burns
Deep partial-thickness burns are characterized
by loss of whole-thickness epidermis and part of
dermis; thus, complete barrier loss makes these
areas more prone to contamination and infection. It is therefore of utmost importance to
completely seal these wounds in order to prevent infection and promote healing processes
[25, 26]. Raw areas are considered always contaminated, due to the absence of mechanical
skin barrier and sweat and bacterial commensals
presence, both of which inhibit many pathogens. Therefore, cleansing through pressurized
irrigation is of utmost importance to wash away
these bacterial contaminants and debris. After
cleansing, if necrotic tissue is still present,
debridement can be performed by surgical,
autolytic, or enzymatic methods.
The most difcult management decision
involves partial-thickness burns that are intermediate in depth. These burns are more aptly called
“indeterminate” burns, as their healing potential
becomes evident with serial assessments over
several days, and require careful specialist evaluation for the possibility of bromelain-based type
of enzymatic debridement; its advantages, compared to the standard of care, include decreased
surgical morbidity and blood loss, length of hospital stay, rates of infection, need for skin grafting, and costs [27, 28]. More importantly, this
product permits eschar removal without sacricing viable or healthy tissue, returning entirely
vital dermal or subcutaneous tissue.
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Autolytic debridement is exploited when surgery is not suitable for the wound type. It is not
only a natural process occurring at some level in
all wounds, but also highly selective, involving
macrophages and proteolytic enzymes that liquefy and separate necrotic tissue from healthy
one [23]. The use of proteolytic enzymes, in particular collagenase, possibly associated with antibiotics, is well documented in the topical
treatment of ulcers and burns, where a surgical
approach is not deemed practical.
Topical collagenase preparations, available
for necrotic tissue debridement from ulcers and
burns, contain the proteolytic enzyme
collagenase, derived from Clostridium histolyti-
cum; this enzyme digests denatured collagen,
which is the principal constituent of necrotic tis-
Fig. 10.11 Supercial partial-thickness burns of the
back of the foot
107
Fig. 10.13 Application of petrolatum gauze
sue, and destroys the strands of endogenous collagen, which tend to anchor necrotic residues to
the bed of the lesion. After the ointment application, it is helpful to cover the wound with a nonadherent gauze, a sterile dressing of parafn-based
tulle, formed by an open weave gauze
(Figs.10.11, 10.12 and 10.13) with a low adherence and allows free drainage of the wound, by
permitting the passage of exudate to an absorbent
secondary dressing; it also prevents the sterile
covering gauze adhesion directly on the deepithelialized area, which causes pain and
removal of the newly formed epidermis. Parafnbased tulle is not medicated and is therefore ideal
for use in association with local antiseptics or
antibiotics. Alternatively, other medications can
be applied, like white petrolatum-impregnated
ne mesh or porous mesh gauze, or 10x10 cm
gauze impregnated with 4g of 2 mg hyaluronic
acid sodium salt cream, or again specic extract
of Triticum vulgare impregnated gauze [29].
The dressing is then covered by a sterile gauze
and can be held in place with a gauze bandage
wrapped, applying sufcient tightness to hold the
gauze in place but not so tightly as to impede
circulation.
Fig. 10.12 Application of collagenase ointment
10.5 Facial Burns
For practical reasons, most facial burns are
treated without dressing. These wounds may also
be treated without topical medication, allowing
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the involved area to dry and form a crust. Because
the dry wound is often uncomfortable and heals
more slowly than moist wounds, many physicians prefer to use a thin layer of bland ointment
combined with a topical antibiotic [30]. The ointment is applied to the wound after gentle cleansing with water once or twice daily, or more
frequently as needed, particularly in a dry climate. Bacitracin has activity against grampositive bacteria. Occasionally, it may cause
contact dermatitis that impedes wound healing.
Alternatively, already used for more than
40years, silver sulfadiazine 1% is considered as
standard therapy for conservative treatment of
burn wounds [31]. Silver nitrate and silver sulfadiazine have been widely used in wounds topical
chemoprophylactic treatment, especially for
burns and ulcers. Topical application of silvercontaining agents can result inlocalized argyria,
as well as systemic side effects in cases of greater
skin areas involved. Silver sulfadiazine should be
applied to small burn areas of the face and for
acute treatment, in order to avoid side effects of
local argyria or antibiotic resistance [32].
10.5.1 Burn Cleansing
Cleansing with gentle washing is the rst and
most important step of burn wound care. Burn
wounds should be cleansed to remove any debris
or contamination, reducing the risk of infection
or biolm formation. A Cochrane review did not
nd any evidence that saline is superior to tap
water for cleansing acute traumatic wounds,
although the review did not specically take into
consideration burn wounds [33]. In a systematic
review performed by Cooper etal., three trials
mentioned that saline is signicantly more advantageous than tap water [34]. Hospital water supplies are, as a matter of facts, commonly
colonized with Pseudomonas Aeruginosa:
Therefore, ltered tap water is preferable, and
this last can be achieved by point-of-use water
ltration devices.
A difference must be made regarding hydrotherapy, useful for removing skin necrosis, predominantly applied using tap water, but also
A. Mangia et al.
Fig. 10.14 Hydrotherapy tub
antiseptic solutions, which are preferred after the
initial acute period when burn wounds are more
likely to be colonized by various microorganisms
(Fig.10.14).
Wound cleansing is an important step
regarding infection prevention and treatment,
contributing to initial wound healing processes
as well.
Irrigation, even if it is as effective as swabbing, has proven to be signicantly more satisfactory to patients. Regarding clean wounds (and
most burns are clean), cleansing should be performed as gently as possible to avoid the injury of
the lower layers of epidermis, responsible for
regeneration and healing.
On the other hand, in heavily contaminated or
infected wounds, cleansing should be performed
aggressively, thoroughly, and as frequently as
possible to eliminate biolm. Antiseptics are
used for clinically infected wounds to slow or
halt the spreading of infection; however, they
may also be applied on wounds that do not display clear signs of infection, in order to prevent
its onset.
Some examples of applicable antiseptics are:
• Hypochlorous solutions: They (0.5% solution
of unbuffered sodium hypochlorite) have been
recognized as effective antiseptic agents for
wounds.
• Dakin’s solution: It is a buffered solution of
0.5% NaOCl, but is cytotoxic to keratinocytes
and broblasts.
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