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Suttipong Tianwattanatada, M.D.*, Nantaporn Namviriyachote, Ph.D. *, Kusuma Chinaroonchai, M.D. *,
Natthida Owattanapanich, M.D. *, Harikrishna K.R. Nair, M.D. **, Pornprom Muangman, M.D.*
*Division of Trauma, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
**Wound Care Unit, Dept of Internal Medicine, Kuala Lumpur Hospital, Malaysia.
Clinical Efcacy Test of Polyester Dressing
Containing Herbal Extracts and Silver Sulfadiazine
Cream Compared with Silver Sulfadiazine Cream in
Healing Burn Wounds: A Prospective Randomized
Controlled Trial
ABSTRACT
Objective: e most common method of burn wound care is the application of silver sulfadiazine cream with
sterilized gauze covering. However, conventional gauze fabric with a large pore size may stick to the wound bed
and cause wound trauma, leading to the delay of healing and pain. e non-adherent property of a hydrocolloid
dressing coated with herbal extract (SI-HERB) can promote wound healing as well as reduce pain. us, this study
aims to compare clinical ecacy between a “polyester dressing containing herbal extracts and silver sulfadiazine
cream” and “silver sulfadiazine cream” alone in second degree burn wound healing.
Materials and Methods: is study compared the two methods of burn wound treatment in the same patients, who
were randomly split into a “treatment group”, which were applied both silver sulfadiazine cream and hydrocolloid
dressing, and “control group”, which were applied only silver sulfadiazine cream. e studied outcomes were the
number of days for wound closure, the percentage epithelialization, and the pain score. In total, 24 patients at the
Burn Unit, Siriraj Hospital were enrolled in this study.
Results: e wound areas were initially ranged from 210–220 cm
2
. e treatment group exhibited signicant results
regarding faster wound healing, referring to the number of days of wound closure (18 days in the control group
vs. 15 days in the experimental group) and the percentage epithelialization compared to the control group. e
average pain score in the experimental group was also lower on days 9, 12, and 15 aer treatment (p < 0.05). No
adverse eects were observed during the study.
Conclusion: e combination of hydrocolloid dressing and silver sulfadiazine cream could reduce the wound shearing
force and wound bed injury, accelerating the rate of wound closure and decreasing the pain during changing the
dressing. is technique could improve upon the standard burn wound treatment.
Keywords: Burn; wound; silver sulfadiazine cream; hydrocolloids dressing (Siriraj Med J 2021; 73: 752-757)
Corresponding author: Pornprom Muangman
E-mail: pornprom.mua@mahidol.ac.th
Received 9 September 2020 Revised 22 September 2021 Accepted 25 September 2021
ORCID ID: https://orcid.org/0000-0001-9828-0060
http://dx.doi.org/10.33192/Smj.2021.97
INTRODUCTION
Wounds involve a breakdown of the protective
function of the skin and the loss of continuity of the
epithelium, with or without the loss of underlying connective
tissue (i.e., muscle, bone, nerves). Although the body
system itself has the ability to heal, there are many factors
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that can aect wound healing, such as age, nutritional
status, immunization status, co-morbidity, and the types
of wound. Wound care aims to accelerate the healing
process and prevent complications that could prolong
the wound healing process and length of hospital stay.
Wide, open wounds, especially burn wounds, can easily
become infected and require a prolonged hospital stay.
is can cause an increase in the cost of burn wound care
by up to 15,000 USD on average per person.
1
Previous
studies have reported a correlation between the area and
depth of the burn wound and the cost of treatment.
2,3
erefore, shortening the healing process may lead to
less complications, a decrease length of hospital stay
and hospital costs, and also better quality of life of the
patients.
4
Burn wounds are categorized into 3 degrees of burn
according to the depth. A rst degree burn can heal itself
without intervention in a week. A second degree burn
can heal with an epithelialization process; however, it
can turn to a third degree burn if not properly managed.
5
A third degree burn needs surgical intervention for
promoting the healing process. is study focuses on
second degree burn wounds.
e most common method of burn wound care
in Asia is the application of silver sulfadiazine cream
(SSD) with sterilized gauze covering. SSD is composed
of silver nitrate, which provides a bactericidal eect,
and sodium sulfadiazine for its bacteriostatic property.
SSD has a broad spectrum antimicrobial action with
wound healing nurture.
6
However in clinical application,
there are various factors that are hard to control, such
as the thickness of the cream and the amount of cream
per area, which are varying in practitioner. Also, the
gauze absorbs the SSD, it can dry up and adhere to the
wound bed. While peeling the gauze out to change the
dressing, this can create a shearing force on the wound
bed, causing wound bed trauma and thus slowing the
wound healing process.
Lipido-colloid dressing was developed to increase the
interval of wound dressing, reduce pain during dressing,
due to the decrease adherence between the wound and
the gauze dressing.
7
However, the major problem for
this treatment is the cost since these products have to
be imported.
Our previous study investigated a product comprising
a hydrocolloid dressing coated with herbal extract, called
SI-HERB.
12
is product has absorption capacities, drainage
abilities, and it does not stick to the wound. Furthermore,
it is locally made in ailand and only costs one dollar
per piece. It has no clinical side eects and it has already
been approved by the ai FDA. e herbal extracts in
this material comprise Centella asiatica and Aloe Vera,
which show anti-microbial eects, accelerate wound
healing, moisten the wound, and show anti-inammatory
eects.
8,9
Some studies have indicated that these two
substances can heal a wound faster than SSD.
10,11
Research
from Muangman et al. in 2016 compared SI-HERB with
old fashioned polyester (Bactigras), and showed that
SI-HERB was superior in wound healing and improving
tissue regeneration, with a lower cost of treatment and
less pain during wound care.
12
Consequently, this study used a hydrocolloid dressing
coated with herbal extract (SI-HERB) combined with
SSD on a dermal burn wound, which had some part of
the eschar remaining on the wound surface, compared
with using SSD alone. We hypothesized that the results
would show better wound healing than using SSD alone.
Objective
e objective of this study was to compare the
clinical ecacy between a “polyester dressing containing
herbal extracts and silver sulfadiazine cream” and “silver
sulfadiazine cream” alone in second degree burn wound
healing regarding the number of days for wound closure,
the percentage epithelialization, and the pain score of
patients.
MATERIALS AND METHODS
Population
In total, 24 patients were included in this study. e
patients, aged between 18 to 60 years old, had at least
two second degree burn wounds. Each patient’s burn
wound was at least 150 cm
2
in area (approximating to
10% of body surface area by Wallace’s rule of nine). e
patients were ASA class I or II and ECOG 0 before getting
burn wounds. Patients with history of allergy to silver,
sulfadiazine or herbal products were excluded. Pregnant,
breastfeeding, diabetes, or immunocompromised patients
were also excluded from the study.
Study design
is was a single-center, prospective, randomized
controlled study comparing wound dressing with a
polyester dressing containing herbal extracts and silver
sulfadiazine cream with silver sulfadiazine cream alone
in second degree burn wound healing. is study was
conducted at the Burns Unit, Division of Trauma Surgery
Department of Surgery, Faculty of Medicine Siriraj
Hospital, Mahidol University, Bangkok. e data were
obtained between January 2019 and June 2020.
e second degree burn wounds of at least 150 cm
2
with some areas of eschar in the recruited patients were
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randomly allocated to one of two treatment groups. In
each patient, aer an accurate debridement and cleaning
of the burn wound with appropriate steriled normal
saline solution, each burn wound size was evaluated by
a registered nurse uninvolved with the dressing wound
team. Photos of the burn wound were taken and evaluated
in terms of size using the Image J program. Burn wound
dressing was performed according to the treatment
group. In the experimental group, patients were covered
with SSD and a polyester dressing containing the herbal
extracts. In the control group, they were covered with
SSD. All the burn wounds were covered with steriled
gauze, gamgee, and tape.
Evaluation was done every 3 days. Photos of each
burn wound were taken and the size evaluated using
the Image J program. Pain was evaluated by using the
visual analog scale (VAS) range 0-10. Complications
and other intervention needs were assessed by medical
doctors. e evaluation and assessment team were not
involved in the dressing procedure.
Wound healing was measured as the %epithelialization
calculated by the formula below.
e dierences between the treatment groups were
evaluated using the paired t-test or Wilcoxon signed ranks
test. e dierence at each point in time was analyzed by
repeated-measure ANOVA. For the qualitative variables,
we used Pearson’s Chi-square test or Fisher’s exact test.
All the statistical tests for ecacy were two-sided, with
an alpha level = 0.05.
RESULTS
ere were 24 second degree burn wound patients
eligible for this study. Most were male patients (62.5%).
e average age of the patients was 40.13 ± 14.20 years
old. e total burn surface area was 35.35% in average.
e average hospital stay was 41.96 ± 22.39 days. e
most common cause of the burn wounds was scald burns
in 35.35 ± 17.49% of cases, as shown in Table 1.
(Area of initial wound
-
Area of wound at exam
date)
___________________
Area of initial wound
%Epithelialization =
x 100
Ethics and material safety
Written informed consent was obtained from each
patient or relatives prior to their participation in this
study. e study was conducted in accordance with
the international code of medical ethics. Patients could
withdraw their consent whenever they felt uncomfortable
and wished to nish the trial. e trial protocol and
subsequent amendments including ethical approval
were reviewed and approved by the Human Research
Protection Unit, Siriraj Institutional Review Board (SIRB),
ailand.
is product, the polyester dressing containing
herbal extracts, is already approved by the ai FDA.
ere was no clinical side eects in the previous study
utilizing this product.
12
Statistical analysis
Demographic data are described with descriptive
statistics. Quantitative data are described in terms of
the mean ± standard deviation, or median (P25, P75).
Quantitative data are described in frequency (percentage)
TABLE 1. Demographic data of the burn wound patients
included in the study.
Demographic data
Male patients 15 (62.50%)
Age (year) 40.13 ± 14.20
Burn percentage (%) 35.35 ± 17.49
Hospital stay (day) 41.96 ± 22.39
Causes
Flame burn 9 (37.50%)
Scald burn 14 (58.33%)
Electrical burn 1 (4.17%)
Underlying diseases
Hypertension 4 (16.67)
Hypercholesterolemia 1 (4.17)
e burn wounds of each patient were randomly
assigned in both treatment groups. e experimental
group was applied polyester dressing containing the
herbal extracts and silver sulfadiazine cream. e control
group was applied silver sulfadiazine cream alone. e
initial burn wound area was not statistically signicantly
dierent between the two treatment groups: 219.15 ±
52.09 and 211.04 ± 46.18 cm
2
in the experimental and
control group, respectively.
e percentage epithelialization calculated using
the formula above is shown in Graph 1. e percentage
epithelialization was similar in both groups at day 3 aer
treatment, at 10%. Aer that, the percentage epithelialization
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rose, especially in the experimental group, as shown in
Graph 1. e dierences in the percentage epithelialization
were statistically dierent at days 12, 15, and 18 (p<0.05).
e wounds were more than 90% healed aer 12 days
and 15 days in the experimental group and control group,
respectively. e wounds in the experimental group were
completely healed in 15.04 ± 3.76 days on average. is
was signicantly faster than in the control group, which
took 18.04 ± 3.74 days to heal on average (p < 0.05).
Graph 1. Percentage epithelialization and days for treatment comparing
the experimental group and the control group.
e pain scores were rated by each patient every
three days of the experiment and the scores are shown
Graph 2. Pain scores every three days of treatment comparing the
experimental group and the control group.
Some examples of burn wound patients and the
wound healing progression are shown in Figs 1-6. ese
pictures show the progression of the burn wound from
initial of treatment until completely heal.
in Graph 2. e initial pain scores were not dierent in
the experimental group and the control group (6.0 ± 1.0
and 6.1 ± 1.0, sequentially). e pain score decreased as
time goes on. e experimental group had signicantly
lower pain scores on days 9, 12, and 15 (p<0.05).
Fig 1. Example photos of the
rst patient in the control group
Fig 2. Example photos of the
rst patient in the experimental
group
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Fig 3. Example photos of the second patient
in the control group
Fig 4. Example photos of the second patient
in the experimental group
Fig 6. Example photos of the third patient
in the experimental group
Fig 5. Example photos of the third patient
in the control group
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DISCUSSION
is study showed that wound dressing with polyester
dressing containing herbal extracts and SSD had a better
outcome compared to SSD alone in terms of the days
taken for wound closure, the percentage epithelialization,
and the pain scores of the patients. is was due to the
non-adhesive properties of the dressing to the wound,
causing less trauma to the newly generated epithelium.
is study showed similar results for the days taken
for wound closure as our previous study in 2016, which
reported an average of 15 days for wound closure, which
was 2 days faster than the group with the wound not
covered with the polyester dressing containing herbal
extracts.
12
e herbal extracts in this product, namely Centella
asiatica and Aloe vera, had antimicrobial properties. Such
an antimicrobial property has previously been reported in
an Aloe vera-containing dressing (Barkat et al., 2017 and
Khorasani et al., 2009) and Centella asiatica-containing
dressing, with both showing signicant ecacy.
e limitation of this study to note is that the study
was not double-blinded. Patients inevitably knew the
treatment of each burn wound. Another limitation is the
pain scores that were rated by the patients. Sometimes
it can be dicult to distinguish pain from each burn
wound part in the body.
CONCLUSION
is study can conclude that for second degree
burn wounds with some degree of eschar on top of
the wounds, the use of a polyester dressing containing
herbal extracts combined with silver sulfadiazine cream
can promote better wound healing and cause less pain
without any clinical side eects.
is treatment strategy might be included in the
standard burn wound care protocol in the future to improve
burn wound care. Further cost-analysis research might
be helpful in future implementation of this treatment
in the protocol.
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