Abstract
Deep burns are characterized by the presence of a necrotic eschar that delays healing and results in a local and systemic inflammatory response and following healing by secondary intention: heavy scarring. Early surgical debridement followed by grafting was a major advance in deep burn care and is now the standard of care, reducing mortality and hypertrophic scarring. Eschars have alternatively been managed by non-surgical, autolytic debridement, which often results in infection-inflammation, slow epithelialization, granulation tissue formation and subsequent scarring. Studies based on these traditional approaches have demonstrated an association between delayed wound closure (beyond 21 days) and scarring. Early enzymatic debridement with NexoBrid (NXB) followed by appropriate wound care is a novel minimally invasive modality that challenges the well-accepted dictum of a high risk of hypertrophic scarring associated with wound closure that extends beyond 21 days. This is not surprising since early and selective removal of only the necrotic eschar often leaves enough viable dermis and skin appendages to allow healing by epithelialization over the dermis. In the absence of necrotic tissue, healing is similar to epithelialization of clean dermal wounds (like many donor sites) and not healing by the secondary intention that is based on granulation tissue formation and subsequent scarring. If and when granulation islands start to appear on the epithelializing dermis, they and the inflammatory response generally can be controlled by short courses (1-3 days) of topically applied low strength corticosteroid ointments minimizing the risk of hypertrophic scarring, albeit with wound closure delayed beyond the magic number of 21 days. Results from multiple studies and field experience confirm that while deep burns managed with early enzymatic debridement often require more than 21 days to reepithelialize, long-term cosmetic results are at least as good as with excision and grafting.
Highlights
The aim of burn care is to achieve the best functional and aesthetic outcome with minimal complications and costs to both patients and the healthcare system
Burns that are deemed to require more than 21 days to heal spontaneously are typically managed by surgical debridement followed by split thickness skin grafting (STSG)
(8) Many burns diagnosed as “deep” by laser Doppler imaging (LDI) when enzymatically debrided, were found to have enough viable dermis to allow spontaneous epithelialization resulting in a good final outcome
Summary
The aim of burn care is to achieve the best functional and aesthetic outcome with minimal complications and costs to both patients and the healthcare system. In the studies supporting the above principles, all the investigators employed pressure garments and silicone after wound closure regardless of their closure strategy This approach, which includes very early selective enzymatic debridement, preservation of the non-injured dermis that is treated towards spontaneous re-epithelialization, controlling granulation tissue, and autografting of only full thickness defects and non-healing wounds, has been termed the Minimally Invasive Modality (MIM) of burn care (ISBI Jerusalem meeting 1998) [29]. (3) Early, fast, and selective enzymatic debridement can complete eschar removal as early as the day of admission (vs ~1 week in the SOC treated patients), preventing eschar related complications and allowing accurate visual diagnosis of the remaining exposed wound bed (8) Many burns diagnosed as “deep” by LDI (in which excision and grafting were indicated based on the current standard of care) when enzymatically debrided, were found to have enough viable dermis to allow spontaneous epithelialization resulting in a good final outcome
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