Key Insights On Treating Burn Wounds In The Lower Extremity

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Here is a full-thickness grease burn suffered by a 36-year-old woman. Note the waxy white coloring due to the depth of the burn. (Photo courtesy of Alan J. Cantor, DPM)
Key Insights On Treating Burn Wounds In The Lower Extremity
Clinical Editor: Lawrence Karlock, DPM

   A: As Dr. Mulder emphasizes, he refers most of his patients, especially those with full-thickness burns, to a burn unit. However, when treating more superficial burns, he bases the choice of topical wound product on the wound depth, its appearance and the underlying medical status of the patient. His treatments of choice include Collagenase, silver sulfadiazene and Xeroform.

   As for Dr. Wu’s choice of topical wound products, she utilizes Silvadene, a triple antibiotic ointment and mafenide cream (Sulfamylon, Mylan Laboratories). She notes she has also used other silver-containing topical preparations and dressings including Acticoat, which permits fewer dressing changes.

   Q: Is there any role for bioengineered skin substitutes?

   A: Although bioengineered tissue has a role in treating burn wounds, Dr. Mulder says that role is usually more limited in the burn patient versus the chronic wound patient. He says one would usually debride full-thickness burns in the operating room. After achieving a healthy wound bed, Dr. Mulder says grafting is a standard procedure. Depending on the depth of the wound, he says clinicians may use additional products to assist with adequate granulation of the wound bed before placing a split-thickness skin graft. Trans-Cyte (Advanced BioHealing) and Integra (Integra Life Sciences) are helpful for this purpose, according to Dr. Mulder.

   When treating full-thickness and deep partial-thickness burns, Dr. Wu notes that autologous skin grafting is the gold standard. However, she adds that practitioners may alternatively use bioengineered skin substitutes with good results. As Dr. Wu points out, research has shown bioengineered skin substitutes help heal partial-thickness wounds faster than topical preparations.

   Q: What role do oral antibiotics play in the management of burns? Is there any prophylactic role? What are the most common pathogens?

   A: With the exception of expansive burns, Dr. Wu says prophylactic antibiotics are rarely necessary. Dr. Mulder concurs, noting that prophylaxis is not a common practice for burn wounds at his facility. Dr. Wu says regular wound care with topical antibiotics has been shown to be effective in reducing wound sepsis.

   Although Pseudomonas aeruginosa is the predominant burn wound pathogen, Dr. Wu says some patients may also develop fungal infections. She notes that previous studies have noted a significant association between increasing burn size and an increasing incidence of gram-negative invasive organisms.

   Dr. Mulder notes one should differentiate invasive pathogens from wound colonizing organisms via quantitative cultures. One would usually obtain such cultures following the excision of non-viable tissue in order to obtain more accurate results. Although Staph aureus and Pseudomonas are the most common bacterial isolates, clinicians may isolate other gram-positive and gram-negative organisms, according to Dr. Mulder.

Dr. Mulder is an Associate Professor of Surgery and Orthopedics at the Department of Surgery/Division of Trauma at the University of California-San Diego (UCSD). He is also the Director of the Wound Treatment and Research Center at UCSD.

Dr. Wu is the American Podiatric Medical Association/American Diabetes Association Senior Fellow at the Center for Lower Extremity Ambulatory Research (CLEAR) at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science in Chicago.

Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.

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