Conservative Management of Full-thickness Burn Wounds Using Advanced Moist Dressings: A Case Report

Burn injuries are the most common type of skin injury.¹ Initial evaluation of burn depth and size is essential in determining treatment strategies.^1,2 Burn depth is conventionally classified into 3 main categories: superficial, partial-thickness, and full-thickness. Burn size is evaluated by estimating the patient’s total body surface area (TBSA) percentage. Minor burns, such as superficial or partial-thickness burns less than 10% of TBSA, can be managed by a primary care physician using topical agents or wound dressings in an outpatient setting.³ Full-thickness burns, however, require evaluation by a specialist in a burn center for excision and skin grafting.^1-3 Clinicians occasionally encounter patients who decline operative procedures. If the full-thickness burn in such a patient is minor, conservative treatment may be acceptable.⁴ Few published studies have reported the use of conservative treatment of full-thickness burns. This case report documents a small-area full-thickness burn injury managed conservatively with advanced moist dressings (Plus moist; Zuiko Medical Corporation) (Figure 1).

A 54-year-old female with left-sided hemiplegia due to the aftereffects of cerebral infarction that occurred at the age of 39 years experienced a fall indoors during which the left thigh touched a hot stove and sustained a burn injury. The patient was unable to move away from the stove quickly, and the left thigh was in contact with the hot plate for at least a few seconds. The patient initially left the burn wound untreated and did not seek treatment until the primary caregiver saw the wound 2 days later. The patient visited the authors’ wound care department. There were other comorbidities—hypertension, dyslipidemia, Sjögren syndrome, and symptomatic epilepsy—sustained at stable level under the ongoing outpatient care. Additionally, the patient was a current smoker.

At the initial visit, the patient presented with a burn wound with a vertical diameter of 7 cm and a horizontal diameter of 18 cm on the left thigh (Figure 2A). Burn size was estimated to be approximately 1% TBSA. Most of the wound surface was covered with pale white tissue, indicating a full-thickness burn. The patient was advised that surgical debridement and skin grafting were required; however, she declined hospitalization and surgery and opted for conservative treatment in the outpatient setting. Therefore, conservative treatment was started using an advanced moist dressing that can be used for various wounds (Figure 2B). Because immediate surgical debridement could result in excessive excision of healthy tissue, the authors waited for the extent of the necrotic tissue to become apparent over time. The treatment protocol consisted of covering the wound with advanced moist dressings and daily dressing changes. No ointments were applied to the wound. The patient was advised to wash the wound with warm water once every 1 to 2 days in the shower. Based on the wound care department guidelines at the treating institution, prophylactic antimicrobial agents and disinfectants were not used. Pain was assessed using the numerical rating scale (NRS),⁵ which has a scale range of 0 to 10, with a score of 0 meaning no pain and 10 indicating the worst pain. Five days after the injury (3 days after initiating treatment), thick necrotic tissue covered the entire wound (Figure 2C). At that time, the depth of the burn was reassessed and determined to be a full-thickness burn. Surgical debridement was recommended, but the patient declined. Thus, to aid exudate drainage, the authors instead made several linear superficial incisions on the necrotic tissue using an 18-gauge needle (Figure 2D). Coverage of the wound with advanced moist dressings was continued after the superficial incisions were made. The patient reported moderate pain (NRS score, 4) at day 5 after injury; acetaminophen at a daily dosage of 1200 mg was administered.

The patient returned to the authors’ department for evaluation and follow-up twice weekly for the first 4 weeks after injury. Autolysis of the necrotic tissue and growth of granulation tissue progressed over time and did so at an especially rapid rate at the site of the superficial incisions (Figure 2E–2G). Although there were no signs of infection (eg, redness, swelling, or local warmth) at 2 weeks, wound culture was obtained as part of the surveillance of resistant bacteria by the in-hospital infection control committee. Pseudomonas aeruginosa was detected from the culture; however, it was considered to be a colonization, not a local infection. Thus, topical antimicrobial agents such as silver sulfadiazine were not applied. The patient reported mild to moderate pain (NRS score, 2–4) for the first 2 weeks after injury. The pain gradually improved, and acetaminophen was discontinued on day 17. Four weeks after injury, almost all of the necrotic tissue was autolyzed, and patchy granulation had formed on the entire wound, with adequate drainage of the exudate (Figure 2H). Frequency of follow-up was decreased to once every 1 to 2 weeks.

Six weeks after injury, patchy granulation tissue had become flat, uniform granulation (Figure 3A). Epithelialization progressed gradually (Figure 3B, 3C) and was complete by 16 weeks (Figure 3D). The wound coverage using advanced moist dressings was discontinued at 16 weeks. No local or systemic infections occurred during the treatment period. At the time of epithelialization, brown pigmentation was observed on the wound margin, and the central area was pink. These skin pigmentations gradually lightened (Figure 3E–3G). Although the skin was hard immediately after epithelialization, wrinkles began to appear on the skin at approximately 28 weeks (Figure 3F), indicating that the epithelialized skin had gradually softened. The patient occasionally reported pruritus, but it was under control. She did not report any other sensory abnormalities of the epithelialized skin.

At the final follow-up vist at 2 years and 7 months, the skin pigmentation persisted; however, the overall color of the skin had become unobtrusive (Figure 3H). The patient did not want any medical intervention for the burn scar.

The authors conducted an interview with the patient to better understand her perspective on the conservative treatment used to manage the full-thickness burn. The patient stated the following:

I knew that this burn was at a level that required skin grafting. However, I did not want to have surgery, and I wanted to stay at home as much as possible. That is why I rejected the recommendation of skin grafting and desired to take conservative treatment. Consequently, it took 16 weeks to heal, but the long time to heal was no problem for me. This treatment did not hurt me at all. I am satisfied with the overall treatment outcomes.

In this case, conservative management of a full-thickness burn injury of the thigh with advanced moist dressings in an outpatient setting resulted in epithelialization of the burn wound at 16 weeks without severe complications. The epithelialized skin gradually softened, and skin pigmentation became unobtrusive over time.

Most partial-thickness burns are treated in an outpatient setting.^1,3 A full-thickness burn, however, requires referral to a burn center for surgical intervention, such as excision and skin grafting.^2,3,6 The patient in this case declined this approach and opted for conservative treatment in an outpatient setting; thus, conservative management using advanced moist wound dressings was performed. Such treatment was possible because of the small burn area (1% TBSA), based on the knowledge that generally, successful outpatient management of partial-thickness burns less than 10% TBSA is possible.^1,3

Wound dressings are widely used in the management of burn wounds, and a variety are available, including biosynthetic,⁷ hydrogel,⁸ and hydrocolloid dressings.⁹ Insufficient evidence exists and controversy persists concerning the type of wound dressings that optimize healing of burn injury.^10,11 Negative pressure wound therapy is commonly used as a skin graft bolster dressing in the management of full-thickness burns.^12,13 Such therapy can aid healing of a small-area full-thickness burn without skin grafting.⁴ The advanced moist dressings used in the case reported herein are popular wound dressings in Japan.¹⁴ These multilayered dressings are made of cellulose, polyethylene, and polypropylene. A single piece measures 25 cm × 20 cm in size, with a thickness of approximately 1.4 mm. The inner layer has an isolated cell structure in which small oval depressions measuring approximately 760 µm × 380 µm are evenly arranged (similar to a honeycomb). Excessive exudate is drained into the absorbent layer through these cells, maintaining a proper moist environment for the wound surface and preventing periwound moisture-associated dermatitis. Sufficient drainage of the exudate to the dressing side and the high exudate absorption capacity of the dressing were demonstrated in this case, as evidenced by the lack of serious periwound skin damage.

The protocol for conservative treatment using advanced moist dressings is simple: cover the wound with the dressing and change the dressing once daily. This approach was readily accepted by the patient and their caregiver. The function of the advanced moist dressing was to regulate the absorption of the exudate and provide a proper moist environment for the wound. This contributes to the autolysis of necrotic tissue, subsequent growth and contraction of granulation tissue, and epithelialization during the wound healing process. It is thought that full-thickness burns cannot heal successfully with conservative treatment due to the lack of the dermis in addition to the thought that skin grafting is always required.^1,4,6 However, this case shows that small-area full-thickness burns can become epithelialized using conservative management with advanced moist dressings, although with a longer healing time compared with skin grafting.

Surgical debridement of nonviable tissue via tangential excision is the standard of care for full-thickness burns.^2,15 Because conventional surgical debridement risks excessive removal of healthy tissue,¹⁵ hydrosurgery is becoming more common for selective debridement of necrotic tissue.¹⁶ In European countries, bromelain-based enzymatic debridement (NexoBrid; Mediwound, Ltd) is the standard for removing burn eschar.¹⁷ In the current case report, the patient declined surgical debridement, and the aforementioned bromelain-based enzymatic debridement was not available in the authors’ country; as an alternative, several linear superficial incisions were made to promote drainage of the exudate. The autolysis of necrotic tissue and growth of granulation tissue were faster at the incision sites than elsewhere, which supports the use of superficial incision in the management of necrotic tissue. However, evidence of the superiority of any particular debridement procedure in the management of burns is lacking, and further research is needed.¹⁸

P aeruginosa is a common cause of infection in burns,¹⁹ and it was detected in the wound culture in this case; however, it was deemed to be colonization because of the lack of signs of infection such as redness, swelling, and local warmth. Although silver sulfadiazine is commonly used as a topical antimicrobial agent for burns,^1,20 its use may be associated with slower wound healing and increased pain compared with other treatments.^3,11 In the case reported herein, the necrotic tissue was covered with advanced moist dressings without silver sulfadiazine. The necrotic tissue autolyzed without the occurrence of local or systemic infection, which suggests adequate exudate drainage alone was sufficient to prevent the progression of P aeruginosa from colonization to infection, even in the absence of a topical antimicrobial agent. The wound and patients’ general condition should be under careful observation, however, because of the risk for progression of microbial colonization to systemic infection.²¹

This case report has several limitations, including that it is a single case. The small-area full-thickness burn healed successfully with conservative treatment, but it is unknown whether such treatment would be successful in the management of wide-area burns. Covering necrotic tissue with moist dressings can result in infection. Additionally, time to healing of full-thickness burns is longer with the conservative approach of moist dressings than with skin grafting. Thus, such conservative treatment may not be suitable for patients who want a rapid recovery.

This case report suggests conservative management of a small-area full-thickness burn with advanced moist dressings and the use of superficial incisions to facilitate autolysis of the necrotic tissue can result in successful healing. These approaches may be an option for patients who do not want to undergo surgery. Time to healing is longer with conservative treatment than with skin grafting, however. Additional studies are needed to determine the type of wound dressing most suitable for the management of full-thickness burns, and studies are needed to determine whether conservative management is appropriate for large full-thickness burns. Further studies should also be conducted to compare the advantages and disadvantages of conservative treatment and skin grafting.