Key Insights On Treating Burn Wounds In The Lower Extremity
Treating partial- and full-thickness burns present unique challenges for podiatrists. Although one may need to refer burns to a burn center, there are measures DPMs can take to treat burns and help relieve the patient’s pain. Accordingly, these expert panelists discuss their preferred modalities for wounds, methods of management and their thoughts on the role of bioengineered tissues and oral antibiotics. Q: What is your initial management of lower extremity burn wounds as far as partial-thickness (second degree) versus full-thickness (third degree) burns? A: When it comes to burns, especially those in compromised patients, Gerit Mulder, DPM, cautions that one should refer these patients to a burn center. In regard to partial thickness wounds, Dr. Mulder says podiatrists should use an appropriate wound cleansing agent. He adds one can usually treat such burns successfully with various agents depending on the wound depth and presentation. Dr. Mulder suggests using Collagenase (Smith & Nephew), silver sulfadiazene (Silvadene, Monarch Pharmaceuticals) or Xeroform. He also says one may use Acticoat (Smith & Nephew) on burns with clean wound bases and low to moderate exudate levels. When treating partial thickness burns, Stephanie Wu, DPM, says one should cool the burn under cold running water for about 15 to 20 minutes, long enough to reduce pain, and follow this with cold compresses. She cautions DPMs to avoid applying ice directly to the burn. For a more severe burn, Dr. Wu will subsequently apply bacitracin or neomycin ointment. She follows this with loose bandaging, which keeps air off the burn and reduces pain. Dr. Wu notes she tends not to drain the blisters and acknowledges this is a controversial topic. She frequently prescribes nonsteroidal antiinflammatory drugs (NSAIDs) for pain relief. “Partial thickness burns are at a low risk for infection, unless they are grossly contaminated, so I do not prescribe prophylactic antibiotics,” explains Dr. Wu. Full-thickness burns require excision and grafting, which are best left to the burn surgeon, according to Dr. Mulder. Dr. Wu agrees that early surgical excision and grafting will be needed. In the case of a full-thickness burn, Dr. Wu gently washes the wound to remove loose char and tissue. If the patient is not allergic to sulfa, she applies Silvadene to the burn area and subsequently adds a loose bandage. For a patient who is allergic to sulfa, Dr. Wu uses either another preparation containing silver or a triple antibiotic ointment. She points out that full-thickness burns are at a higher risk for infection due to the presence of dead tissues and lack of blood flow. However, Dr. Wu does not prescribe prophylactic antibiotics unless the burn’s surface area is high. Q: Is there any role for the use of Silvadene? A: Dr. Wu says research has shown Silvadene to be an effective agent in treating burn wounds contaminated with Pseudomonas aeruginosa and is an accepted topical treatment for burns. However, she notes concerns about the potential for silver toxicity when one uses Silvadene in patients with extensive burns. Dr. Wu also expresses concern about the product’s efficacy in rare cases of sulphadiazine-resistant bacteria. Dr. Wu usually reserves Silvadene for full-thickness wounds or deeper partial -thickness burns. “Silvadene is still a very acceptable topical antimicrobial agent for burn injury,” says Dr. Mulder. “The primary purpose of Silvadene is to reduce the risk of colonization progressing to true clinical infection.” He notes patients would usually reapply the product twice a day in the in-patient burn setting and notes that one still needs to observe the wound closely. Q: What topical wound products do you prefer in treating lower extremity burns? A: As Dr. Mulder emphasizes, he refers most of his patients, especially those with full-thickness burns, to a burn unit.