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A Comparative Study of Collagen Sheet Cover Versus 1% Silver Sulphadiazine in Partial Thickness Burns
Mukund B Tayade*, Girish D Bakhshi**, Nabakishor Haobijam***
 

Abstract
Introduction : Traditionally burn wound has been treated with an exposure method , but now with newer development of wound dressing, occlusive dressing is offering a better outcome in terms of faster healing time, decreased pain and cost effectiveness.

Aim : A prospective controlled trial was done to compare the efficacy of collagen sheet with 1% silver sulphadiazine (SSD) for partial thickness burns with respect to healing time, pain and complications.

Material and Methods : Patients with less than 15% partial thickness burns were divided into two groups of 25 each. One managed traditionally with a topical antibiotic (Control Group) and the other with occlusive collagen sheet dressing (Test Group). Patients were assessed for average healing time, pain level in the first 24 hrs, associated complications and average hospital stay if required.

Results : Results obtained were comparable with various authors. An average 12.64 days was recorded as healing time in Test group as compared to 18.44 days in Control group. This was attributable to the closed environment of the collagen sheet. Pain was significantly reduced post application with an average score of 1.2 in Test group as compared to 2.64 in the Control group. Only 1 patient got converted to 3rd degree wound due to infection in test group. Majority of the patients were managed as outpatients, with an average 2.4 days of hospital stay for those requiring admission in the Test group following complication as compared to 9.56 days in control group.

Conclusion : Collagen sheet is a better mode of treatment for superficial wounds provided it is applied early before contamination. It is beneficial to the patient in terms of comfort from pain, early healing and decreased hospital stay.

 

Introduction
Burn injuries are extremely complex, and optimal treatment requires an understanding of nutrition, immunology, psychological issues, the physiology and the metabolic interactions among all the major organ systems. When skin is burnt, its functions are lost and the loss of stratum corneum allows invasion of microorganisms.

Traditionally the management of superficial burn has been a method of exposure, but with the changing times now the impetus of management is towards closed dressing with newer type of dressing ( which has some properties of skin).
Collagen is an endogenous substance, which forms an important structural component in connective tissue and is of special importance in the skin.1,2 The importance of collagen in healing has been appreciated for many years for the simple reason that, the end result of repair in wound healing is always a scar which is composed of collagenous fibres.

In our study, we have compared the results of occlusive dressing of collagen sheet on superficial burns against the traditional method of open treatment using topical antibiotic. We have hypothesized that the early coverage of wound with the sheet provides a better environment for healing, thereby decreasing healing time and pain

METHODS
Aim
To compare the efficacy and safety of collagen sheet versus 1% silver sulphadiazine for partial thickness burns.

Material and Methods

A total of 50 patients attending the surgical outpatient department of a tertiary health care institute were enrolled during February 2002 to August 2004 after obtaining informed written consent. We have chosen patients of all age groups who had partial burns less than 15% total body surface area (TBSA), wounds not older than 24 hrs, thermal or scald types and which have not been contaminated.

These fifty patients were divided into two groups with twenty five in each group a) Control group managed by topical silver sulphadiazine and b) Test group which was managed by application of collagen sheet.

All of them had suffered superficial burns, not requiring any kind of graft. All were prepared after presentation with chlorhexidine solution and rinsed with saline. The wound was then dried. Each patient was then randomly allocated to either of the group with subsequent application of collagen sheet or silver sulphadiazine respectively. Majority of the patients were managed on outpatient basis. Only complicated patients were admitted.

The collagen sheet used was a branded material Kollagen, which is enzymetically prepared from cattle skin. The membrane is applied to the wound after thorough cleansing with chlorhexidine solution and thorough debridement of the blisters. A secondary dressing was kept for 24 hrs above this after which it was removed. The membrane as it dries up, attaches firmly to the wound and remained fixed. The control group was managed with topical siver sulphadiazine and kept exposed. No antibiotics were used with this treatment.

NSAIDs were used as first line analgesics with intramuscular (IM) pentazocine second line. 24 hr follow up were undertaken for assessment of “take up” of the collagen sheet, pain level and comfort. Using visual analogue pain scale, pain was recorded after application during this period, as most of the patients tolerated in the later stages. Pain assessment was done on a 0-5 visual analogue pain scoring system (VAS) with 0 meaning no pain and 5 meaning maximum unbearable pain.

Follow-Up and Assessment
Patients were followed up on days 1, 2, 7, 14, 21 and 28 or for more days in event of any adverse effect related to the medication or aggravation of symptoms or complications. All the patients were followed up till complete epithelisation which was considered as the end point. The cosmesis and functional components were evaluated at this time.

Complications in the form of rejection of collagen sheet, allergic or hypersensitivity reactions, infection like presence of pus and conversion to full thickness wound following infection were studied.

Results
This was a prospective study comprising of 50 patients divided in 2 groups. Maximum number of patients in both the groups were between 11-20 years of age followed by those in 21-30 years of age. In the control group male: female ratio was 16:9, however in the test group it was 18:7. Scald injuries were 9 and flame injuries were 16 in the control group. In the test group scald injury was seen in 10 patients and flame injuries in 15 patients. Majority of the patients had less than 10% burns in both the groups. Hence the two groups were compatible with each other in respect of age, sex ratio and type of burns (Table 1). The average pain levels were 2.64 in control group and 1.2 in test group using VAS system after 24 hours. 8 patients in control group whereas 1 patient in test group required additional analgesics. The healing time required in control group was an average of 18.44 days whereas in the test group it was 12.64 days. The complications observed were infection followed by conversion to 3rd degree burns in 2 patients in control group and 1 patient in test group. Majority of the patients were managed as outpatients, with an average 2.4 days of hospital stay for those requiring admission in the Test group following complication as compared to 9.56 days in control group.

Prominent scars were seen in patients who got converted following infection. Rejection of collagen sheet was seen in 1 patient. None of the patients had any allergy or hypersensitivity reactions.
Table 1 : Results shown in both groups
Variables Control Test
Total no of cases 25 25
No of males 16 18
No of females 9 7
Burn type Control Test
Scald 9 10
Flame 16 15
Pain level Control Test
1st 24hr 2.64 1.2
Complications Control Test
Infections 2 1
Conversion 2 1
Allergic reaction 0 0
Scar 2 2
Healing time Control Test
Average days 18.44 12.64
Hospital stay Control Test
Average days 9.56 2.48

Discussion
Many studies have demonstrated that collagen dressing is cost effective and associated with minimal infection. The healing rate is increased and patients have shorter hospital stay (Table 2).

Healing Time
The study of Gupta shows a healing time of range from 10-14 days. In another study the same author recorded a healing time of 5-10 days.1,2

Gerding et al in their study done in 1990 recorded a healing time of 10.6 days in those patients applied with collagen coverings (biobrane) whereas those patients managed by SSD had an average healing time of 15 days.3,4 These patients were managed as Outdoor patients. Grzybowski in 19955 in their study recorded a healing time of 11 days
Demling in his study recorded a healing time of 7.5 days in the patients managed with collagen cover. 13.4 days was the average healing time taken by the SSD patients. The author recorded 8.8 days and 18.8 days respectively in another study.6,7

Barret et al8 recorded a healing time of 9.5 days in collagen group and 16.1 days in the SSD group. Klein recorded a healing time of 9 days in collagen group in 1984.9 The current study shows an average healing time of 12.64 days in collagen group versus 18.44 days in the SSD group.

Pain scale
Gerding et al recorded an average pain scale of 1.6 in the collagen group whereas the value of 3.6 was recorded for the SSD group. In another study, pain level of 2.5 in collagen group and a level of 5 was recorded.3,4

Demling6,7 observed the same trend of decrease pain in the patients managed with collagen. He recorded a score of 2 in collagen group and a score of 4 in the SSD group. Barret et al8 recorded a score of 3.7 in SSD group and 2.4 in collagen group. The decreased pain associated with collagen dressing was also observed in the current study.

Hospital Stay
Shorter admission in the hospital was recorded by authors in the collagen group.6,7,8 In the current study, the shorter duration of hospital stay was evident in collagen group from the comparative average days of both the groups.

Fewer incidences of infection and conversion contributed to the shorter hospital stay.

Complications
Both the groups have infection rate quite low. The closed dressing of collagen dressing provided a better environment for the healing.

Summary and Conclusion
Collagen by its properties acts like a second skin to the burn wound and provides the ideal dressing in superficial burns.

Majority of the patients healed with complete epithelisation. The difference in the Test group was accounted by the fact that collagen sheet provided an optimum environment for early healing whereas the exposure method of SSD application exposed the raw injury surface to external stimuli, hampering the rate of healing. Thus, Collagen sheet promotes early healing, reduces pain and decrease the need of analgesics and decreases associated complications as compared to the conventional topical SSD dressing. The morbidity of the affected patients is reduced using collagen.  

Collagen is thus a better treatment option than conventional method, however, more studies are required to form a conclusion

References

  1. Gupta RL, et al. Fate of collagen sheet cover for artificially created raw areas-an experimental study. Indian J Surgery1978; 40 (12) : 641-45.
  2. Gupta RL, et al. Role of collagen sheet cover in burns – a clinical study. Indian J Surgery 1978; 40 (12) : 646.
  3. Gerding RL, Emerman CL and Effron D, et al. Outpatient management of partial thickness burns: biobrane versus 1% silver sulphadiazine. Annals of Emergency Medicine 1990; 19 : 121.
  4. Gerding RL, Fratianne R. Biosynthetic skin substitutes versus 1% silver sulphadiazine for treatment of inpatient partial thickness thermal burns. J Trauma 1988; 28 :1265.
  5. Sakiel S. Grzybowski J. Clinical application of new bovine collagen membrane as partial thickness burn wound dressing. Polimery W Medycynie 1995; 25 (3-4) : 19-24.
  6. Demling RH. Desanti L. Management of partial thickness facial burns (comparison of topical antibiotics and bioengineered skin substitutes). J Burn Care and Rehabilitation 1999; 25 : 256.
  7. Demling RH. Use of biobrane in management of scalds. J Burn Care and Rehabilitation 1999; 16 : 329.
  8. Juan P Barret, et al. Biobrane versus 1% silver sulphadiazine in second degree pediatric burns. Plastic and Reconstruction Surgery 1999; 105 (1) : 62-65.
  9. Klein Robert L, Rothman BF, et al. Biobrane a useful adjunct in the therapy of outpatient burns. J Pediatric Surgery 1984; 19 : 846-7.

COLLABORATIVE CARE IMPROVES LATE LIFE DEPRESSION

Tailored collaborative care management benefits depressed older patients in primary care not just in the short term but also in the longer term. Hunkeler and colleagues randomised 1801 primary care patients aged over 60 who had major depression to a programme that included a depression care manager, a primary care doctor, and a psychiatrist or to usual care for depression. They found that collaborative care actively engaged these patients in their treatment and delivered benefits - like less depression and better physical functioning - and that these benefits persist at least a year after the intervention has ended.

BMJ, 2006; 332 : 259.

 
*Associate Professor and Unit Head; **Lecturer; ***Resident, Department of Surgery, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai 400008.
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