The Effectiveness of Silver-containing Hydrofiber Dressing Compared With Topical Silver Sulfadiazine Cream in Pediatric Patients With Deep Partial-Thickness Burns: A Retrospective Review

Burn injuries are a major cause of accidental injury in children worldwide and may be caused by several factors, including extreme heat, electricity, chemicals, friction or radiation.^1,2 The skin layers include the epidermis and the dermis. The epidermis is a stratified squamous epithelium, and the dermis is a dense connective tissue with many elastic fibers and collagen fibers.³ Burn severity is classified according to the degree of damage to the skin layers and the percentage of total body surface area (TBSA) that has been affected by the burn.^4,5

Accordingly, many burn injuries are superficial (affecting only the outer epidermis) or superficial partial-thickness burns (affecting the epidermis and part of the dermis) and can be treated by daily dressing changes on an outpatient basis. Full-thickness burns in which the epidermis and dermis are destroyed are unlikely to heal and need early excision and grafting, usually 1 to 7 days after injury.⁶ Deep partial-thickness (DPT) 

burn injuries involve damage to the epidermis and major portions of the dermis, and the prognosis for these burns largely depends on treatment. Lack of effective treatment results in a prolonged healing process, increased scar formation, and increased costs and caregiver burdens.^7-9 Optimal goals of burn wound therapy include improving healing by offering a barrier to infection, relieving patients of pain during wound treatment, and reducing cost burdens.¹⁰

A large range of ointments, creams, and structurally diverse dressings incorporating various active compounds is available for treating burn injuries. Among these, silver sulfadiazine (SS) cream (a sulfonamide-based topical agent) has been widely used as the standard treatment for DPT burns.^11,12 At the author’s institution, a large academic medical center located in northeast China, SS cream has been used as the primary layer in burn wound dressings because it is an inexpensive antibacterial and retains a film of moisture over the wound. However, previous studies have indicated that SS cream may delay healing compared with moisture-retentive dressing treatments.^13,14 Meanwhile, SS cream required daily painful gauze dressing changes and increased difficulty assessing healing.¹⁵

The Aquacel Ag Hydrofiber Dressing (ConvaTec Inc) is a silver-containing Hydrofiber dressing (SHD). It contains 1.2% ionized silver and has been shown to require a lower frequency of dressing changes while demonstrating greater overall comfort than similar products.¹⁵ This assimilates the wound exudate when the Hydrofiber layer is converted into gel, helping to maintain moisture balance within the wound and thereby leading to quicker healing and lower risk of infections.^16,17 In a prospective study of 100 adult patients with full- or partial-thickness burns involving ≤ 40% TBSA, Verbelen et al¹⁵ compared this dressing with Acticoat (Smith + Nephew Inc) silver nanocrystal dressing regarding wound healing, economics, and patient experience. The authors reported that the Hydrofiber significantly increased patient comfort due to fewer dressing changes and increased potential to leave the dressing in situ. Moreover, a 2010 literature review by Barnea et al¹⁸ found that SHDs were associated with good reepithelialization rates, reduced wound pain, fewer dressing changes, and reduced cost. However, additional research is needed to systematically study the therapeutic effect of SHD in children with burns.

Because topical SS cream continues to be used to treat burns, it is important to examine the clinical benefits of this treatment in relation to those of SHD. Therefore, the authors compared the effectiveness of the SHD with SS cream in treating DPT burns involving the trunk and extremities of pediatric patients.

The authors performed a 2-year retrospective review of data collected from pediatric patients treated from January 2018 through January 2020 in the Burns and Plastic Reconstruction Unit, First Hospital of Jilin University. Because this was a retrospective review, patient permission was not required.

To be included in the analysis, a patient was required to have DPT burns involving 5% to 10% TBSA diagnosed by a staff physician specializing in burn treatment or by an attending physician. Children aged from 2 months and to 18 years with no known medication or silver ion allergy were included. The authors limited their analysis to the facility’s management of scald, flame, and contact burns; electrical, chemical, and frostbite burns were excluded, as were any epidermal, superficial dermal, mid-dermal, and full-thickness burns. Patients with evidence of inhalational injury or concomitant fractures or neurological injuries were excluded from the review.

All patients included in the review had been treated with either topical SS cream (covered by sterile mesh gauze) or SHD; treatment selection was made at the discretion of each patient’s physician.

Therapeutic methods. The patients included in the analysis were divided into 2 categories: 1 group treated with conventional SS cream and 1 group treated with SHD. All included patients received standard care at the time of initial evaluation, including wound cleansing with lobenzine and sterile saline. Then, the wound dressing was applied, with appropriate auxiliary dressing if needed to control the exudate effectively. In the SHD group, the dressing was cut according to the shape of the wound after debridement so that the edge of the dressing extended 1 cm beyond the wound edge to overlap intact skin. After placement, the area was wrapped with gauze.

For patients included in the analysis, dressing changes were performed only by physical therapists during the treatment sessions, and wounds were observed until healing was complete. In the SS group, the SS-impregnated gauze was replaced when the outer dressing was saturated with wound exudate. In the SHD group, any areas of dry dressing attached to the wound were kept during dressing change. Any portions of the dressing soaked with wound exudate were trimmed and removed, and a new SHD dressing was placed over exposed wound areas, overlapping the original dressing. A fresh layer of thin gauze was then wrapped over the entire area.

Retrieval of evaluation data. The authors collected data from the First Hospital of Jilin University burn patient database and the hospital’s electronic medical records. The main outcome analyses included time to healing, rate of infection, pain scores, frequency of dressing changes, hospitalization expenses, complications and scarring, and caregiver satisfaction.

Time to complete wound healing. Wound measurements were assessed at the time of the initial examination and every 4 days thereafter until the affected area was 100% reepithelialized as determined by the attending physician. In the SHD group, the dressings spontaneously detached as healing occurred. Patients treated with SS cream were assessed for healing at the time of dressing changes. Wounds were considered fully healed when inspection revealed 100% epithelialization. The healing time of the 2 groups was calculated from the time of admission to the complete epithelialization of the wound.

Inflammation and infections. During hospitalization,  body temperature was measured every day and recorded on the daily nursing record. Results of C-reactive protein (CRP) measurements and bacterial cultures of wound exudate were extracted from the hospital electronic medical records. For the patient’s body tempera
ture and CRP data, the highest value in a specific time period (eg, 0–2 days, 3–5 days, 6–8 days, 9–11 days, 12–14 days) was taken as the final value.

Pain. In both groups, clinicians scored pain intensity during dressing changes (either complete or partial replacement of primary or secondary dressings) by rating five patient behaviors. The Face-Legs-Activity-Cry-Consolability (FLACC) scale is a 10-point observational index frequently used in pediatric settings that allows observers to score the distress of patients as 0, 1, or 2 according to descriptors for facial expression, leg position, activity, crying, and responsiveness to being consoled.¹⁹ A score of 0 to 3 represents mild pain, a score of 4 to 7 represents moderate pain, and a score of 8 to 10 represents severe pain (the higher the score, the greater the pain). Studies have shown the FLACC scale to be a sensitive and valid tool for measuring periprocedural pain 

in children.^20,21 When extracting data for the present study, the authors used the highest FLACC score as the final score.

Dressing changes and nursing care time. During every dressing change in both groups, the nurse recorded the time elapsed from opening the primary and/or secondary dressing to the completion of the dressing application. The number of dressing changes was the sum total of all dressing changes (both partial and complete replacements of primary and secondary dressings) from time of admission to 100% epithelialization. The nursing care time was tabulated for the total number of dressing changes for each patient.

Hospitalization expense. The total hospitalization expenses were calculated for each patient in both groups; these expenses included not only material costs but also other hospitalization expenses, including bed fee and nursing fee. For each patient in the SHD group, the cost of total dressing changes was calculated using the following formula:

($56.0963 × number of units needed) + (TBSA × $5.6096), in which $56.0963 represents a unit price of per SHD dressing and $5.6096 represents the cost of changing dressings.

For each patient in the SS group, these costs were calculated using the following formula:

($3.6463 × number of units needed) + (TBSA × $5.6096), in which $3.6463 represents a unit tube price of SSC (40 g per tube) and $5.6096 represents the cost of changing dressings.

Complications and scarring. Data regarding any patient’s complications were obtained from the hospital electronic medical records. After discharge, follow-up was conducted at the outpatient scar clinic located within the authors’ hospital; these outpatient records were available through the hospital burn registry database. Scar evaluation was performed at 6 months after wound healing, including location, size, and stability of the scar.

Caregiver satisfaction. After each patient had fully recovered, caregivers were asked to complete a questionnaire to provide feedback about the overall hospital treatment their child received. Within this questionnaire, caregivers were asked to rate their overall satisfaction with the SHD or the SS cream using a 4-point Likert scale in which 1 represented “not satisfied” and 4 represented “extremely satisfied.”

Data analysis. Statistical Package for Social Sciences (SPSS), version 23.0 software (IBM Inc) was used for statistical analysis. Continuous variables were expressed as mean ± standard deviation (SD). Student t-test was performed to compare the SS and SHD groups. Differences in the means of the 2 groups were measured using the Mann-Whitney U-test for unpaired data assuming a non-Gaussian distribution. Categorical variables were expressed as percentages and analyzed using the χ² test. P < .05 was considered statistically significant.

Patient characteristics. From January 2018 to January 2020, a total of 212 children were treated for burns in the authors’ hospital; of these, 92 patients met the inclusion criteria for further research. A total of 40 patients (18 males and 22 females) were treated with SS cream, and 52 (25 males and 27 females) were treated with the SHD. The mean age in the SS group was 56.05 months versus 46.83 months for the SHD group. The median burn areas (%TBSA) of the SS and SHD groups were 8 (interquartile range, 6–9) and 7 (interquartile range, 7–9), respectively. There was no significant difference in age, sex, burn areas, and burn location parameters between the groups (P＞> .05). Scald injuries were the most common burn injury type, affecting 33 children (82.5%) in the SS group and 39 children (75%) in the SHD group (Table 1).

Wound healing. The time to complete wound healing was defined as time from which the burn was initially evaluated to the point when the wound was fully epithelialized. The authors’ analysis indicated that the time to complete wound healing was significantly shorter in the SHD group versus the SS group (18.98 ± 2.21 days vs 22.45 ± 2.25 days; P < .05).

Inflammation and infection. Among 40 swab cultures obtained from patients in the SS group, 8 showed bacterial growth; a similar infection rate was seen in the SHD group, with 9 of 40 swab cultures showing the presence of bacteria (Table 2). Staphylococcus aureus was the most commonly detected organism.

Table 3 presents the body temperature and CRP values for both groups. Mean body temperatures in the 2 groups were not significantly different; after approximately 2 weeks of treatment (days 12–14), the mean body temperature in the SHD group was 36.96 ± 0.46°C versus 37.01 ± 0.62°C in the SS group (P = .688). Meanwhile, CRP levels in the SHD group were significantly lower than those in SS group (days 3–5, 19.04 ± 7.74 mg/L vs 33.58 ± 17.60 mg/L, respectively; P < .05; Table 3).

Pain. It was also found that 25 patients (62.5%) in the SS group had FLACC scores in the 8 to 10 range (severe pain), while fewer patients (n = 15; 28.8%) in the SHD group had sores in that range (Table 4). This finding indicated that the patients experienced less pain with the SHD than with SS cream.

Dressing changes and nursing care. The authors found that significantly fewer dressing changes (partial and complete) were required for patients in the SHD group than in the SS group (4 ± 0.74 vs 11.55 ± 0.88, respectively; P < .05). Consequently, the mean nursing care time expended in the SHD group was significantly less than that in the SS group (31.88 ± 8.75 min vs 117.90 ± 13.59 min; P < .05).

Hospitalization expense. Given the need for fewer dressing changes with the SFH, material and staff resource costs were significantly less in this group than in the SS group ($596.94 ± $113.95 vs $801.26 ± $116.52; P < .05) (Table 2).

Complications and scarring. Patients with hypertrophic scars required prolonged pressure garment or surgical excision. In this study, the authors found no significant difference in the incidence of hypertrophic scars between the 2 groups, with 5 patients in each group reporting such scarring (P = .742) (Table 2).

There were no adverse events, such as systemic infection or dressing change dysfunction, in either group. Once treatment began, no patient needed surgical debridement. All patients were eventually discharged home after the complete healing of wound.

Caregiver satisfaction. Overall, the SHD obtained significantly better satisfaction ratings from caregivers than SS cream with conventional dressings (Table 5). More than two-thirds of caregivers (67.31%) of patients in the SHD group were “extremely satisfied” (the highest possible rating) with the dressing choice, whereas fewer than half of caregivers (45%) in the SS group expressed this level of satisfaction (P = .032).

Recent research has shown that SHD may increase comfort for patients due to reduced pain and anxiety during dressing changes, less burning and tingling during wearing, and fewer dressing changes.¹⁵ However, few studies have focused on evaluating the effectiveness of the SHD for children. Similar to results seen in adults, the authors of the present study found that the SHD could significantly reduce the complete healing time, number of dressing changes, and nursing care time for pediatric patients with DPT burn injuries.

Previous studies have indicated that SS cream may delay healing compared with moisture-retentive dressing treatments.^9,10 In the present study, there were no cases of infected wounds or compromised healing, indicating that both SS cream and SHD were safe and feasible. Although SS cream has a therapeutic effect on burns, the authors found that patients treated with the SHD had shorter times to complete healing. Furthermore, CRP levels in this group were significantly lower than those in patients treated with SS cream. Landsdown²² reported that anions can interfere with bacterial cell walls and block the transport system of respiratory cytochromes.When silver ions combine with bacterial DNA, the structure and function of the DNA are destroyed, thereby inhibiting the replication of bacteria and finally achieving an antibacterial effect.

Moreover, the authors found that the SHD were associated with the need for fewer dressing changes, thereby reducing staff time expenditures. In a prospective study by Verbelen et al¹⁵ of 100 patients with partial-thickness burns involving > 5% TBSA, the SHD demonstrated increased comfort for patients and reduced cost when compared with an antimicrobial barrier dressing. A prospective study of 40 patients with partial-thickness burns involving the face (TBSA > 5%) by Mabrouk et al²³ also reported increased patient comfort and the need for fewer dressing changes, and further suggested that SHD may minimize the voids and spaces where bacteria can thrive.

Unlike the aforementioned studies that followed predominantly adult patients, the present study included only patients under the age of 18 years to determine how SHD compared with SS cream with respect to improving comfort for pediatric patients and providing satisfaction for their caregivers. Conservative treatment of burn injuries with SS cream is known to create a thick, exudative fatty layer that penetrates standard gauze dressings; as was suspected, the authors found that patients who were treated by this methods required more frequent dressing changes. This consequence not only increased the pain and burden to the patients but also increased the work demands for caregivers and medical personnel. In comparison, in the SHD group, dressing changes were not required as frequently because the SHD continuously provide a balanced concentration of dynamic active silver to maintain long-term bactericidal protection.²⁴ The dressing remains in close contact with the wound surface to reduce the formation of dead cavity, creating a soft, humid wound repair environment and thereby accelerating wound healing and epithelial repair.^15,25 Moreover, patients in the SHD group had lower pain scores during wound care compared with the SS group, likely because the wounds did not need to be washed repeatedly.

Several studies have examined the application of SHD in children with localized burns, but few reports have focused on the use of this dressing type in treating children with DPT burns.^{10,16,24,26-29} Unlike superficial partial-thickness burns, DPT burns are more susceptible to infection and slower healing. Therefore, wound management is very important in improving outcomes in this patient population and deserves more attention.

There are limitations to this retrospective study. Conducted in only one medical center, the study’s small sample size and homogeneous patient population prevent broad application of the findings. Although other studies in adult patients have reported limited instances of adverse effects during clinical treatment of SHD, such as local burning and stinging on initial application and dressing slippage,^28,30,31 no such events were found in the current analysis. A large number of pediatric cases would be needed to further evaluate the effectiveness of SHD and any potential drawbacks to their use. Additional prospective multicenter studies using a randomized, controlled study design are needed to objectively evaluate wound pain and healing in pediatric patients treated with this dressing type. By design, the authors did not include cases with burns of other degree and depth because superficial burn wounds are more likely to heal with less intervention, while full-thickness burns require excision and skin grafting. Whether the SHD could be beneficial in the above-mentioned cases is still a subject of future research.

This retrospective study reports an effective approach to treating burns in children patients. Compared with SS cream, the SHD were found to significantly reduce dressing changes, nursing time expenditures, and patient distress scores. Consequently, this modality was also associated with higher caregiver satisfaction ratings. The authors’ analysis suggests that SHD are safe, effective, economical, child-friendly treatment for burns that physicians may prefer to conventional SS cream regimens.

Drs Wang Liu, and Wu are doctors, Department of Neurovascular Surgery; Dr Yang is a doctor, Department of Thoracic Surgery; and Dr Zhang is a doctor, Department of Burn Surgery, First Hospital of Jilin University, Changchun, Jilin Province, PR China.

Address all correspondence to: Wei Wu, PhD, Department of Neurovascular Surgery, The First Hospital of Jilin University, Jiefang Road, Chaoyang District, Changchun, Jilin Province, 130000, PR China; email: wu_w@jlu.edu.cn.

This study was funded by the Special Project for Sanitary Talent of Jilin Province (JLSWSRCZX2020-001), PR China.