Duoderm, an alternative dressing for smaller burns

214

Burns (1986) 12,214219

Printedin

Great Britain

Duoderm, an alternative burns M. H. E. Hermans

dressing for smaller

and R. P. Hermans

Burns Centre, Rode Kruis Ziekenhuis,

Beverwjk,

Summary In this study Duoderm has been used for the treatment of superficial and deep partial thickness burns in 61 patients. In 15 patients a second similar burn was treated with human allografts or silver sulphadiazine cream. Five very small full skin thickness burned areas were also treated with Duoderm. Treatment with Duoderm had to be stopped before total epithelial cover had occurred in 3 patients. Duoderm is a very good alternative for the treatment of smaller superficial and deep partial thickness burns, since it provides very good results, both cosmetically and functionally, combined with fast re-epithelialization and comfort for the patients.

INTRODUCTION DCIODERM” is a new occlusive dressing, which provides: (1) a moist environment which is beneficial for the healing process (Winter, 1962; Hinman and Maibach, 1963); (2) occlusion that has a beneficial effect on collagen synthesis (Alvarez et al., 1983; Alvarez and Hefton, 1984) and (3) does not damage newly formed epithelium when the dressing is changed. The presence of exudate converts the dressing to a gel (Convatec, 1983), thereby creating a wound environment that promotes these conditions. Since Duoderm is adherent to normal skin no additional bandages are needed for fixation of the dressing. In 1983, a study was started to determine whether or not Duoderm could be used for the treatment of smaller superficial and

* In the UK Duoderm is available under the name of Granuflex. In Germany Duoderm is available under the name of Varihesive. Duoderm, Granuflex and Varihesive are trademarks owned by E. R. Squibb Inc.

The Netherlands

deep partial thickness burns (Hermans and Hermans, 1984; Hermans, 1985). This report describes a comparison between similar burned areas that were treated with either Duoderm or with silver sulphadiazine or human allografts. METHODS Before applying the dressing, the burn wound was cleaned with saline, and the surrounding skin was defatted with alcohol, to provide good adherence. No gloves were used during application of the dressing onto the wound. After 1 or 2 days, all the patients returned for changing the dressing, subsequently the dressing was changed every 5 days, and only earlier if there was fluid leakage from the gel. This protocol was followed until epithelial cover was complete. Patients with two comparable burned areas were treated with Duoderm on one area, and allografts or silver sulphadiazine on the other: in this way a patient could serve as his own control. To be able to make this comparison, the two burned areas had to be more or less similar in size and depth, and not in contact with each other, to avoid one dressing influencing the other. Age, sex and burned area as a percentage of the patients total body surface were taken into account, as well as depth, size, localization and healing time of the burn. Furthermore, after total epithelial cover had occurred, the patient’s opinion was sought concerning the comfort of the dressing and its cosmetic appearance. In addition, all patients were seen after 1, 3 and 6 months, so that the final cosmetic and functional aspects of the healed burn wound could be checked.

215

Hermans and Hermans: A dressing for smaller burns

When treatment with Duoderm had to be stoppcd before total epithelial cover had occurred, only the data about age, sex, total body surface area (TBSA), size and depth were taken into account. Five full thickness burns were treated with Duoderm. As these were all very small burns the (TBSA) was not used in the calculations of the average or minimum figures. RESULTS Sixty-six patients (17 female and 49 male) were treated with Duoderm. The average age was 20 years, with a range between 6 months and 57 years (Fig. I). The average burned surface was 2 per cent TBSA, with a range between 0.5 per cent and 6 per cent. The site of the burn injuries is shown in Fig. 2, the extent of the burned areas is comparable to the areas in other patients treated in our centre (Mackie, lY83. 1984). Superficial partial thickness burns (figs. 3-6) Thirty-two patients with superficial partial thickness burns were treated with Duoderm. Within this group, nine patients had a second burned cn

N = 66

341

area that could be treated with an alternative therapy, according to the criteria mentioned above. Within this group in three patients the second burn was treated with silver sulphadiazine, and in six patients with human allografts (Fig. I). The average re-epithelialization time was very different for each form of therapy (Fig. 7). Duoderm, 8.0 days; silver sulphadiazine, 114 days: human allografts, 12.0 days, with a statistically significant difference between Duoderm and allografts (P
thickness burns patients had very small full thickness burns than 10cm2) (Fig. I), localized on the upper of the foot or distal pre-tibia1 area. The

N:5

N:26

n

c 16 Fig. I. Distribution of the patients, showing depth of injury and the form of therapy. ssd, Silver sulphadiazine: allo, human allografts.

Number

of

Local1sations

DVODERM Head_--_--_ ems__-_-_-

3 32

Anlla----Trunk------

1 13

Legs-------

17

Fig.

2.

treated

with

ALLaGRAFTS or Hea&----__ ems-__---Axilla----Trunk-----&gs_______

FIAMAZINE 1 6 0 5 3

Number of patients treated with the differing forma of theranv and the sites of iniurv.

: : 2 : I :m

5 P,

14 12 10 6 6 4 2

? *“PertlCIa,

pa’tlat

d*eP

thick”.**

Fig. 7. Average to the differing

Pe,,,l.l

,“#I

,hlE*“..*

re-epithelialization depths of injury

thlc*ne*s

time, with rcspcct and the forms of

Fig. 3. Superficial partial thickness scald burn, due to hot tea, in a 4-year-old girl. Post-burn day 0.

the

Fig. 6. The cosmetic aspect of the wound, 2 weeks after total re-epithelialization. The wound had healed in 5 days. Post-burn day 21.

average re-epithelialization time in this group was 29.5 days (Fig. 7). No comparisons between Duoderm and another form of therapy could be made.

ma showed blisters and some necrotic tissue indicating an injury that was deeper than first thought. The Duoderm did not adhere to this injured tissue. The burn was treated with silver sulphadiazine and showed good healing.

Fig. 5. The

dressing had

typical appearance of the gel, when been removed. Post-burn day 2.

Fig. 4. Duoderm is very easy to apply, no additional bandages are needed to keep the material in place. Post-burn day 0.

Complications In three patients, therapy with Duoderm had to be stopped before total re-epithelialization was complete (Fig. 1). In one patient, infection of the burned area with Staph. aureus occurred, probably because this patient tried to remove the dressing, and then re-applied it to the wound in an unsterile way. The burn was treated with Furacine (Norwich Eaton Company, Utrecht, The Netherlands) and then showed proper healing. In one patient the burn became infected in spite of proper handling of the dressing (cultures: Staph. aureus). The burn was treated with Furatine, and then showed proper healing. In one patient, Duoderm was applied to a superficial partial thickness burn, which was surrounded by erythema. One day later this erythe-

DISCUSSION Duoderm is a synthetic hydrocolloid dressing, the outer layer of the dressing being impermeable to gases, vapour and fluids. The wound side of the dressing is adherent to healthy skin and no additional bandages or staples are needed to keep Duoderm in place. In the presence of wound exudate the dressing is converted into a gel. This gel creates a beneficial moist wound environment (Friedman and Daniel, 1983; Madden, 1984). When the dressing is removed, a thin film of gel stays over the wound and damage to the wound or newly formed epithelium can be avoided. Duoderm becomes flexible under the influence of the warmth of the body, the dressing following the contours of the body, and can therefore easily

Hermans and Hermans: A dressing for smaller burns

Fig. 8. Deep partial thickness burns of left digits II and 111 and superficial partial thickness burns of left digit IV. due to steam. Post-burn day 0.

Fig. IO. Re-epithelialization Post-burn day 14.

occurred

after

2 weeks

used in areas that are usually difficult to treat with traditional bandages. Duoderm is available in sizes up to 20~20cm in Europe and 20~30cm in the USA: larger burn wounds therefore have to be treated by applying the sheets ‘roofing-tile wise’, this can cause an earlier leakage of the gel. Duoderm has no antibacterial properties, so that it should not be used on (actually or potentially) infected burns. The opaque nature of the dressing prevents the daily visual inspection of the wound to determine whether there is any obvious infection. Human allografts and xenografts have gained a very important place in the treatment of superficial and deep partial thickness burns: human allografts offer relief from pain and excellent wound healing (Broekhuizen, 1981; Tjong Wai et al., 1983), resulting in less morbidity (C. R. Baxter, unpublished data). These advantages have also been recognized when xenografts are used (Burleson and Eiseman, 1973), with or without silver impregnation (Ersek and Denten, 1983). Allografts or xenografts reduce loss of fluids, electrolytes and proteins through the wound be

Q. 9. Duoderm can easily be applied on fingers. Only adhesive tape is required to avoid leakage of the gel from the top of the fingers. No additional bandages arc needed. The hand can still be used for simple movements: this patient could continue her job as a cashier. Post-burn day 0.

Fig. 11. Satisfactory cosmetic appearance and functional state of the healed burn 2 months after the injury.

(Wood and Hale. 1972). Because of the proven results with human allografts, IO patients with two similar burns were treated with Duoderm on one burned area and human allografts on the other: these patients served as their own control. Within this group, faster re-epithelialization took place under the Duoderm therapy. Concerning antibacterial solutions or ointments, silver sulphadiazine is considered the best choice (Hermans, 1984): this cream combines a good antibacterial spectrum with little discomfort for the patients and has less side-effects than its predecessors (Baxter, 1971; Bult, 1982). Five patients were treated with Duoderm on one burned area, and Flamazine (Duphar Company, Amsterdam, The Netherlands) on a second, similarly burned area. In this group, re-epithelialization was faster under Duoderm. Furthermore, Flamazine had to be changed every 3 days, whereas Duoderm can be left in

218

place for up to 5days. All the patients but one found Duoderm a very acceptable dressing. They considered the cosmetic appearance to be satisfactory, the dressing was comfortable to wear and had a good analgesic effect on the wound. Changing of the dressing was sometimes a little painful, when the patient had a considerable hair covering on the skin surrounding the burn: this was due to the epilating effect of the dressing. Most of the patients were able to continue their work. Only one patient considered the dressing to be less comfortable, although fully acceptable. This was due to the acknowledged unpleasant odour of the gel. All but three patients were reviewed after 1, 3 and 6months. In only two patients was hypertrophic scarring seen after 3 months, in one over an area lO per cent of the original burned area. Both patients were treated with pressure-garments (Tubigrip; Setan, Oldham, UK), and after 6 months only a very small area of hypertrophy remained in one patient. All the other patients showed excellently healed wounds, both cosmetically and functionally. We have also treated 27 patients with Duoderm who suffered from residual defects after other forms of therapy, including postgrafting with autograft or allograft or a combination of the two, septic wounds and very extensive burns covering up to SO per cent of the body surface area. Although no controlled studies were carried out, it is our impression that treatment with Duoderm provided better results than we would have expected from our past experience with other forms of dressings. CONCLUSIONS Disadvantages of Duoderm 1. It should not be used on infected wounds. 2. Larger wounds have to be treated with overlapping sheets of the dressing: this can cause more fluid leakage. 3. The opaque dressing prevents visual inspection of the state of the wound and the diagnosis of any change in the depth of injury or the onset of infection is virtually impossible. Advantages of Duoderm 1. It is easy to store. 2. It is easy to apply. It has an intrinsic adherence to healthy skin and follows the contours of the body very easily. 3. It is comfortable to wear, has a relatively neat appearance, and a good analgesic effect, thereby often allowing the patient to continue his/her job.

Burns

(1986)

Vol. 12/No.3

4. It encourages fast re-epithelialization, with an excellent cosmetic and functional result. 5. Compared with silver sulphadiazine, less frequent dressing changes are required, and compared with allografts, Duoderm is much cheaper. In this study, Duoderm has been shown to be an excellent alternative in the treatment of smaller superficial and deep partial thickness burns, as well as in the treatment of full thickness burns which are t6o small to be excised and autografted.

REFERENCES Alvarez 0. M. and Hefton J. M. (1984) Healing wounds: occlusion or exposure. I@&(. Surb. March, 173. Alvarez 0. M., Mertz P. M. and Eaglestein W. H. (1983) The effect of occlusive dressing on collagen synthesis and re-epithelialization in superficial wounds. J. Surg. Res. 35, 142. Baxter C. R. (1971) Topical use of I’% silvcrsulfadiazine. In: Stone H. H. (ed.) Confemporury Burn Management. Boston, Little B Brown. Broekhuizen A. H. (1981) Het biologische verhand en de huidbank. Ned. Tiidschr. Fvsiother. 14. 114. Bult A. (1982) Silversuifadiazinf and related antibacterial sulfanilamiden: facts and fiction. Pharmacy Inr. 3, (12), 400. Burleson R. and Eiseman B. (1973) Effect of skin dressings and topical antibiotics on healing of partial thickness skin wounds in rats. Surg. Gynecol. Ohsier. 136, 958. Convatec Company, Division of Squibb (1983) Duoderm Hydroactive Dressings. Technical Booklet, 4. Ersek R. A. and Denten D. R. (1983) Silver impregnated porcine xenograft for damaged or missing skin.

Contemp.

Surg.

Su. (1983) HydrocoNoid Occlusive Dressing Managemeni of Leg &ers. Para-

Friedman

S. J. and Daniel

dox Svmoosium Book 93. Heneelo. The Netherlands, buoprint. Hermans R. P. (1984) Topical treatment of serious infections with special reference to the use of a mixture of silver sulfadiazine and cerium nitrate: two clinical studies. Burns 11, 59. Hermans M. H. E. (1985) Comparison of hydrocolloid dressing, silver sulfadiazine and cadaver skin in the treatment of burns. In: An Environmentfor Healing, Royal Society of Medicine, International Congresses and Symposium series, No. 88, p. 129. Hermans M. H. E. and Hermans R. P. (1984) Preliminary report on the use of a new hydrocolloid dressing in the treatment of burns. Burns 11, 125. Hinman C. D. and Maibach H. (1963) Effect of air and occlusion on experimental skin exposure wounds. Nature 200. 377. Mackie D. P. (ed.) (1983) Beverwijk Burns Centre Annual Report. July 1983.

219

Hermans and Hermans: A dressing for smaller burns

Mackic D. P. (cd.) (10X4) Beverwijk Burns (‘cntrc Annual Report. July 19X4. Matldcn M. R. (19X4) Hydrocolloid dressing (HCD): an improved donorsitc dressing. American Burns Association Symposium Book. American Burn\ Association, p. 160. Tjong Wai R.. Hcrmana R. P.. Krcis R. W. ct al. (19X3)Rcsultatcn van dc hchandeling met allogenc huidtransplantatcn van vcrhranding door hctc vloci\toffcn hij kindcrcn. Nrd. Tijckhr. Gcwwkd. 7. 200.

Winter D. G. (1962) Formation of the scab and the rate of cpithclialisation of supcrticial wounds in the skin of the young domestic pig. Nuturc 193, 293. Wood M. and Halt H. W. (1972) The USC of pigskin in 124. the treatment of thermal burns. Am. .I. Suy. 720.

Paper accepted 22 Novcmhcr

19X5.