Time for a change in paradigm in clinical wound care: a review of literature and role of acetic acid dressing

Mr  Eric Tan1,2, Dr Wei Lun Wong1,2, Mr Terrence Creagh1,2

1Christchurch Hospital, Christchurch , New Zealand, 2University of Otago, Christchurch, New Zealand


Introduction:The balance between anti-bacterial activity and tissue toxicity with the final impact on wound healing for every antimicrobial agent ever proposed has been raised in literature but difficult to quantify in clinical practice.
Acetic acid (AA) is not commonly used in New Zealand for burn care.
We would like to investigate the medical literature on the role of AA in burn and outline our proposal to address any paucity of information.

Method: A Pubmed search using keywords ‘antimicrobial acetic acid’ and ‘wound’ was performed. 307 articles were produced but after initial review only 17 were suitable for analysis.
Only one randomised study has been conducted comparing AA against saline dressing in 32 patients with better outcome in AA group (P<0.001).

Results: 12 in vitro study were performed with 4 directly on burn wounds. AA is effective at 0.1666% concentration (2015) and determined to be non-cytotoxic at 1% (2017). A single in vitro study (2010) found suprathel-acetic acid matrix having better anti-MRSA and Pseudomonas aeruginosa activity in comparison to silver and suprathel-silver combination.
A 2018 wound consensus described AA as a future promising agent.

Conclusion:Our proposal for a randomised controlled trial comparing AA against silver dressing and saline dressing as control in a single burn unit in New Zealand will be of utmost clinical relevance.


Mr Eric Tan is a current fellow in the department of plastic surgery in Christchurch hospital. He has a special interest in evidence based burn practice and has produced educational curriculum for emergency department and junior doctors in UK on burns. He has also chaired sessions on burns in European Burns Association meetings with a special interest in chemical burns.

Setting up evidence-based cost-effective and clinically efficacious wound care service in a tertiary hospital in New Zealand: lessons learned

Mr Eric Tan1,2, Dr Wei Lun  Wong1,2, Mr Terrence Creagh1,2

1Department of Plastic Surgery, Christchurch Hospital, Christchurch , New Zealand, 2University of Otago, Christchurch, New Zealand


Introduction:Commonly used antimicrobial dressing (AD) are not robustly tested and have been adopted into clinical practice from a combination of marketing efforts from distributors, individual clinician’s preference and traditional departmental practice.
We would like to evaluate the level of EB practice at our workplace and its’ consequential health economics.

Methods: A standardised survey was sent to different medical and nursing staff involved in wound care in Christchurch Hospital.
A Pubmed/Medline systematic review was conducted using keywords “antimicrobials”, “silver dressing”, “acetic acid” and “wound”.

Results: 100/101 staff who completed the survey use silver based dressing for most wounds in general without correlation to previous and/or concurrent international consensus (Chi squared test p<0.00001). 95 out of 101 are unfamiliar with alternative AD like acetic acid (Chi squared test p<0.00001).
46 papers were included in systematic review. There are no randomised clinical trial comparing silver based dressing with other antimicrobial dressing in clinical practice. 2 Cochrane review groups found no evidence that silver based dressing improves healing rate.
In vitro studies suggest cytotoxic properties identified in silver based dressing and 1% acetic acid being to be non-cytotoxic but retain antimicrobial properties at 0.16% concentration.
A cost analysis based on 10 patients with 10% burn admission and 200 minor burn service in 6 months found that a predominantly acetic acid based dressing service reduces the estimated expenditure of NZD48,000 to NZD42.

Conclusion: A carefully design standardised treatment pathway will reduce cost but also ensure patients continue to receive the best concurrently recommended treatment.


Mr Eric Tan is a current fellow in the department of plastic surgery in Christchurch hospital. He has a special interest in evidence based burn practice and has produced educational curriculum for emergency department and junior doctors in UK on burns. He has also chaired sessions on burns in European Burns Association meetings with a special interest in chemical burns.

Honey dressing versus foam dressing on paediatric burns: Comparison of healing rate

Mrs Nurazlin  Mohd Azman1, Mrs Herni Lutfiah Hussein1, Mrs Joanne Jovina SH Cheng1

1Kk Women’s And Children’s Hospital, Singapore, Singapore


Background:KK Women’s and Children’s Hospital is the referring paediatric hospital in Singapore for a wide variation of paediatric burns. The Department of Plastic, Reconstructive and Aesthetic Surgery consults an average of thirty-five paediatric burns a month, of which most patients require some form of dressing coverage. Burns dressing has been shown to be painful and traumatizing, and the average recovery time for deep partial thickness burn is around four to six weeks using foam dressing. People with burn wounds have a higher chance of having wound infection, especially with Singapore’s humid climate.
Honey had been used since ancient times as a recommended treatment for healing wounds. It is known to accelerate wound healing, debriding action with antibacterial, anti-inflammatory and antioxidant properties. Recent Cochrane review in 2017 showed a moderate to high certainty that honey accelerates wound healing compared to those with non-bacterial treatment.

Aim:The aim of this review is to compare the healing rate of burn wound using of honey dressing versus plain foam dressing. Other variables such as burn wound infection and pain score will be looked into.

Method: Retrospective data from (Jan 2016 – Jan 2018) of 20 paediatric patients with a total burn surface area (TBSA) between 5 – 10% with partial thickness burns to deep partial thickness were selected. The age group was within >6months of age to 16 years of age. 10 patients were treated with honey-dressing while the 10 patients were treated with foam dressing.

Results: Patients with honey dressing took an average of 3-4 weeks to heal, while foam dressing took an average of 4-6 weeks to heal completely. There was an increased chance of hypergranulation with patients on foam dressing, while no incidence of hypergranulation occurred in the honey dressing group. Findings of increased pain occur in honey dressing with a pain score ranging from 6-10.


Working At KK Women’s and Children’s Hospital for 6 years in the Department of Plastics, Reconstructive and Aesthetics.

Biobrane versus Acticoat: A Retrospective 2-year review of the treatment of mid-dermal burns of the torso in children at The Children’s Hospital Westmead.

Dr Dharshini Selvarajah1, Dr Bapesh Krishna Bollu1, Professor John Harvey1, Dr Susan Jehangir1, Ms Claire Toose1, Professor Andrew Holland1, Ms Madelene Jacques1

1The Children’s Hospital Westmead, Westmead, Australia


Purpose:Scalds involving toddlers commonly involve the torso and are frequently mid-dermal in depth. Initial management of a mid-dermal burn is conservative, progressing to grafting if healing has not been achieved in 10-14 days. Biobrane has been reported as having a more favourable outcome compared to Acticoat. The Burns Unit at the Children’s Hospital at Westmead (CHW) uses both dressings on a regular basis, providing the opportunity to compare the results of the dressings in a cohort of patients with mid-dermal burns of the torso.

Methods:A retrospective review was undertaken of all paediatric mid-dermal torso burns admitted to CHW between 2015 and 2016. Patients requiring grafts for full-thickness burns or with other dressings were excluded. The primary outcomes were: time to complete healing and the need for grafting. Secondary outcomes included: operating theatre time, clinic visits, length of stay in hospital, scar outcomes and cost.

Results:Eight-one of the 124 children reviewed met the study criteria; 64 (79%) were treated with Acticoat and 17 (21%) with Biobrane. In total, 27/64 (42%) children in the Acticoat group and 11/17 (58%) children in the Biobrane group healed without grafting (p= 0.27). There was no difference between the groups in healing time, or scar outcome. Patients treated with Biobrane required longer operating time, a longer hospital stay and more clinic visits.

Conclusion: This study suggests that Biobrane does not significantly improve the outcome of mid-dermal torso burns in children compared to Acticoat, but appears to be more time consuming and expensive.


Dr Dharshini Selvarajah- burns registrar from The Children’s Hospital Westmead NSW


Study of Negative Pressure Wound Therapy as an Adjunctive Treatment for Acute Burns in Children (SONATA in C): study protocol for a randomised controlled trial

Mr Cody Frear1, Dr Bronwyn Griffin1, Dr Leila Cuttle2, A/Prof Steven McPhail3, Prof Roy Kimble1

1Centre For Children’s Burns And Trauma Research, The University Of Queensland, St Lucia, Australia, 2Centre for Children’s Burns and Trauma Research, Queensland University of Technology, Institute of Health and Biomedical Innovation at Centre for Children’s Health Research, South Brisbane, Australia, 3Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Kelvin Grove, Australia


Background: Although Negative Pressure Wound Therapy (NPWT) has become widely used in the management of several wound types, its efficacy as an adjunctive therapy for acute burns has never been adequately investigated, with research in children particularly lacking. The purpose of this trial is to determine whether NPWT in conjunction with standard therapy accelerates healing, reduces wound progression, and decreases pain in paediatric burns patients more effectively than routine treatment alone.

Methods: A total of 96 children will be recruited for this trial. To be eligible, candidates must be under 17 years of age and present with a thermal burn covering <5% of their total body surface area to the participating hospital within 7 days post-injury. Following a randomised controlled, parallel design, participants will be allocated to either an active control or intervention group. The former will receive standard therapy consisting of Acticoat™ and Mepitel™, secured with Hypafix™. The intervention arm will be treated with silver-impregnated dressings in addition to NPWT. Participants will undergo dressing changes every 3-5 days until the point of healing. The primary endpoint will be time to re-epithelialisation. Secondary outcomes include pain, wound progression, pruritus, cost effectiveness, treatment satisfaction, and adverse events. Wound fluid collected during NPWT will also be analysed to generate a proteomic profile of the burn microenvironment.

Discussion: The study will be the first randomised controlled trial to explore the effects of NPWT on paediatric burns, with the aim of determining whether the therapy warrants implementation as an adjunct to standard burns management.


Cody C. Frear is an MD/PhD candidate at the University of Queensland whose research focuses on paediatric burns.

Dressilk®: A Series of Case Reports on Partial Thickness Burns and Donor Sites.

Mr Jozef Verbelen1, Mr. Hendrik Hoeksema1, Dr. Karel Claes1, Prof. Stan Monstrey1

1University Hospital Gent, Gent, Belgium


Objectives:The management of both split thickness donor sites and partial thickness burns with healing potential within 21 days is often considered to be similar.
A new dressing consisting of 100% silk, seems a promising treatment option.

Methods:In a preliminary test, above mentioned wounds were treated with Dressilk® which was applied directly on the skin defect and covered with a secondary gauze dressing.
The silk dressing was left in situ until it separated spontaneously from the healed wound. Parameters taken into account for dressing evaluation were patient comfort and pain (assessed by patient), bacterial load, time to wound healing, ease of use and general satisfaction (assessed by nurses).

Results:4 patients with partial thickness burns and 4 patients with donor sites had their wounds treated with Dressilk®.
On average patients found Dressilk® to be comfortable and reported no or mild pain with the dressing.
Bacterial problems were mainly caused by Staphylococcus Aureus, but easy to deal with by applying an antiseptic solution on the primary dressing.
Average time to wound healing was 18 days in case of the donor sites and 11 days for the burn wounds treated in this test.
Nurses were satisfied about the dressing and assessed Dressilk® as easy to use.

Discussion / Conclusion: In this preliminary test Dressilk® was assessed as a suitable dressing for both split thickness donor sites and partial thickness burns with healing potential within 21 days.
A more elaborate study, also investigating cost effectiveness, will be performed in the near future.


1989: Graduated as a nurse
2006: Master degree in Nursing
2009: Burn Care Coordinator (Burn Centre University Hospital Gent, Belgium)

Autologous skin cell suspensions and Partial thickness Paediatric burns: The BRACS Trial Protocol

Dr Anjana Bairagi1,2, Dr Bronwyn Griffirh1,2, Dr Zephanie Tyack1,3,6, A/Prof Steven  McPhail2,3,4, Prof  Roy  Kimble1,2,5,6

1Centre for Children’s Burns and Trauma Research, Centre for Children’s Health Research, Brisbane, Australia, 2Queensland University of Technology, Brisbane, Australia, 3Centre for Functioning and Health Research, Metro South Health, Brisbane, Australia, 4School of Public Health & Social Work and Institute of Health Biomedical Innovation, Brisbane, Australia, 5Pegg Leditschke Children’s Burns Centre, Lady Cilento Children’s Hospital, Brisbane, Australia, 6University of Queensland, Brisbane, Australia


Background and Aims: Time to re-epithelialisation is associated with scar formation and burn depth(Cubison et al., 2006). At the study site, children most commonly present with scald thermal injuries(Stockton et al., 2015). Management of these often mixed- depth partial thickness burns include silver impregnated dressings, biosynthetic skin substitutes and autologous skin suspensions. The Biobrane®, RECELL® Autologous Skin Cell Suspension and Silver Dressings trial aims to address the existent clinical equipoise amidst these three modalities. This study will compare the effect of each dressing on re-epthelialisation time in paediatric superficial partial to mid-dermal thickness burns (primary outcome) and on pain, pruritis, subjective scar severity, scar characteristics, dressing application ease, wound intervention fidelity, and health resource utilisation (secondary outcomes).

Methods: This is a three-armed, parallel-grouped, prospective, single-centre, randomised trial. New patients (0 – 16 years) presenting with thermal injuries of burn surface area ≥ 5%, <48 hours old and superficial partial to mid-dermal thickness depth will be included. Participants (n= 84) will be randomised to: Standard silver dressings or Biobrane® with or without RECELL®. Initial dressing will be applied under a general anaesthetic and subsequent dressing changes every three to five until the wound is > 95% re-epithelialised. Secondary outcomes will be assessed at dressing change and the three, six and 12-month clinic review. Recruitment started in May 2018.

Conclusions:Findings from this study will provide data to potentially identify the most ideal option that will optimise the re-epithelialisation of paediatric superficial and mid-dermal burns.

CUBISON, T. C. S., PAPE, S. A. & PARKHOUSE, N. 2006. Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury. Burns, 32, 992-999.
STOCKTON, K. A., HARVEY, J. & KIMBLE, R. M. 2015. A prospective observational study investigating all children presenting to a specialty paediatric burns centre. Burns, 41, 476-83.


Anjana is a South African trained Paediatric Surgeon currently working as an Honorary Research Fellow ( Paediatric Surgery ) at the CCBTR and is also a QUT PhD Candidate.

Review of the safety of use of silver dressings for burns in children under 4 years of age.

Dr Charlotte Blau1,2,  Dr Jessica Papalii-Curtin,1, Mr Barnaby Nye1,2

1Christchurch Hospital, Christchurch, New Zealand, 2University of Otago, Christchurch, New Zealand


BACKGROUND: Silver (Ag) dressings are commonly used in management of paediatric burns. Adverse events such as leukopenia, hepatotoxicity and renal impairment post application of silver dressings, and silver deposition in internal organs in animal studies could be of concern. Guidance for the use of Ag products on children under 4 does not appear to be well described. We review the literature to describe the safety of silver dressings in children under 4 years.
METHODS: A search on Medline was performed with the subject headings [“child” OR “paediatric” OR “Neonate”] AND “burns” AND [“silver” or “mepilex Ag” or “acticoat” or “aquacel Ag” or “silver sulfadiazine”]. The inclusion criteria were: English, burns, paediatric population, use of silver dressings and reporting of wound outcomes.
RESULTS: 26/145 articles met the inclusion criteria and were included in the review. Two studies explicitly reported use of Ag dressings on under 4 year olds. Two studies reported on neonates, and one on premature neonates. EIghteen concluded positive outcomes with Ag dressings, while three reported better outcomes with membrane dressings. Six studies reported silver-specific outcomes in children (leukopenia, detectable serum silver)
CONCLUSION: This review highlights the absence of any firm evidence to deter practitioners from using Ag in the use in burns for under 4 year olds, including neonates, questions remain regarding long term safety of use in this population.


Dr Blau is a NZ plastics SET trainee currently based at Christchurch hospital.

Honey as an alternative dressing to reduce infections in Wounds – A literature review

Mr Peter Stone1, Miss Hana Menezes1, Dr Natasha  Jennings1

1Alfred Hospital, Melbourne, Australia


1] What is the evidence for knowledge translation on the modality of honey dressings used to decrease infections by antibiotic-resistant bacteria?
2] Do honey dressings provide a moist healing environment; reduce slough formation, and odor in wounds?
3) Do honey dressings improve healing time while delivering greater patient comfort and contentment while reducing healing time?
Patient presentations for skin and wound management significantly contribute to emergency department (ED) workload. Appropriate decision making for dressing modalities is often ad hoc and infrequently evidenced based. There is a suggestion of a lack of clarity around best practice standards for wounds in the ED. Honey has been considered as one alternative to standard dressings as it may reduce resistance to antibiotics and have less side effects.
A literature review will be undertaken to investigate if honey dressings are an alternative to current standard practice in relation to wounds dressings in the ED. Key outcomes will be: Use of honey on ED wounds, healing time and other benefits. A PICO framework audit question will be used.
P: infected wounds in people presenting to emergency department aged 16-98
I: Honey type of dressing for the treatment of infected wounds
C: silver sulfadiazine dressings or Vaseline impregnated gauze dressing
O: cost effective dressings, that offer patient comfort, and durability/longevity, and acceptability, and an effective treatment against bacterial infection.
an analysis of the literature will provide an opportunity to synthesize the current literature and make recommendations for further research being an interventional study.


Peter Stone is a Nurse Practitioner at the state emergency and trauma center, Victoria, with an interest in wound care, burns, and Dermatology.
started trauma nursing 2003 in the UK
started at the Trauma center Alfred Center Victoria 2008, completing a Masters and becoming an endorsed critical care nurse practitioner in 2017

‘Kenacomb Ointment’ for hypergranulation tissue in burns: a review of efficacy and adverse effects

Dr Nicholas Tang1

1Royal Melbourne Hospital, 300 Grattan St, Australia


Background: Hypergranulation tissue has been described in the literature as a deterrent to complete wound healing following skin-grafting to burns1. ‘Kenacomb Ointment’, a combination of triamcinolone acetonide, neomycin sulfate, gramicidin and nystatin, is often used following skin-grafting for management of hypergranulation tissue. This likely stems from the hypothesized effect of topical steroids on granulation tissue as well as its anti-microbial properties. Its use has been widely accepted in the treatment of burns, however evidence regarding its efficacy and side effects is lacking.

Methods: We performed a literature search of Medline, Pubmed, Embaseand the Google Scholar library for ‘Kenacomb’ with granulation tissue and burns. Clinical studies on the topical use of these medications on wounds were included.

Discussion: There is much lacking in current literature, with no articles describing the use of ‘kenacomb’ in burns management and only a handful of case reports or series’ describing the use of topical steroids in the management of hypergranulation tissue. At the same time there are a number of case reports and series’ describing the severe side effects of ototoxicity and nephrotoxicity following topical administration of Neomycin to burn wounds.

Conclusion: There is a paucity of clinical evidence in the literature that advocates for the use of topical ‘Kenacomb’ on burns wounds and, given its potential side effect profile, further research is required to assess its safety for ongoing clinical use.

1. Jewell L, Guerrero R, Quesada AR, Chan LS, Garner WL. Rate of healing in skin-grafted burn wounds. Plast Reconstr Surg. 2007 Aug;120(2):451-6.


Nicholas Tang is currently a HMO at the Royal Melbourne Hospital



ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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