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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 27  |  Issue : 2  |  Page : 127-131

Comparative study between conventional dressing and collagen-based dressing in burn patients


Department of General Surgery, Government Medical College, Kozhikode, Kerala, India

Date of Submission09-Apr-2021
Date of Decision10-Apr-2021
Date of Acceptance11-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Thomas Kurien
Department of General Surgery, Government Medical College, Kozhikode, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_26_21

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  Abstract 


Introduction: Burn is a devastating emergency with many physical and psychological disabilities, mortality and morbidity. The conventional treatment of burns is by daily washing of wound, removal of dead tissue and saline and silver sulfadiazine dressing till formation of granulation tissue. The current trend has shifted to more holistic approach of improvement in the long-term form and function of the healed wounds and quality of life. This has demanded the emergence of various skin substitutes. The biological skin substitutes may allow the construction of a more natural new dermis and allow excellent re-epithelialisation characteristics due to the presence of a basement membrane. This study aims to compare the efficacy of collagen dressing (a biological dressing) in treating burn wounds with that of conventional dressing materials. Objectives: The objective was to study the efficiency of collagen dressing in reducing pain, scar formation and infection in burn patients as compared to conventional dressing. Methodology: A comparative study was conducted for a period of 1 year which included 42 cases in burn intensive care unit in a tertiary care hospital on patients admitted with first-degree and second-degree burns covering 10%–50% of total body surface area (BSA). Half of the patients were dressed with collagen dressing and other half received conventional silver sulfadiazine dressing. They were interviewed with series of questions and laboratory parameters were compared. The data obtained were statistically analysed. Results: About 43% were male and the rest were female. Majority were in category 3 (31–40 years). Almost 86% were not having any co-morbidities. Majority had category 3 BSA burns (21%–30%). Haemoglobin (Hb) on the 5th day of dressing showed that in patients with collagen dressing, only 9.5% have anaemia, as against 38% anaemic in conventional dressing, which was found statistically significant. About 62% of patients with collagen dressing and 71% of patients with conventional dressing had low albumin value. On comparing both the dressings 52.4% of patients had no pain in collagen dressing and 28.6% of patients had no pain in conventional dressing which is nearly half of collagen dressing. Only 29% of patients developed infection with collagen dressing and 57% of patients developed infection with conventional dressing. Nearly 71% of patients with collagen dressing produced less scar when compared to conventional dressing where 52% developed bad scars. Conclusion: Collagen-based dressing is a safe and effective alternative for treating burns. Use of collagen for dressing causes rapid epithelialisation and decreased pain though statistically not significant over conventional dressing. Other advantages of using collagen-based dressing for burn wounds include ready availability commercially; simple storage and application; prevents protein/blood loss through wound and it combats infection.

Keywords: Albumin, burns, epithelialisation, infection, pain, Wallace's rule of nine


How to cite this article:
Kurien T, Muhammed Basheer O T. Comparative study between conventional dressing and collagen-based dressing in burn patients. Kerala Surg J 2021;27:127-31

How to cite this URL:
Kurien T, Muhammed Basheer O T. Comparative study between conventional dressing and collagen-based dressing in burn patients. Kerala Surg J [serial online] 2021 [cited 2021 Nov 30];27:127-31. Available from: http://www.keralasurgj.com/text.asp?2021/27/2/127/330395




  Introduction Top


Burn is a devastating emergency with many physical and psychological disabilities, mortality and morbidity. For survivors, scarring and multiple surgeries for their correction are still problem-posing psychological and economical effects to burn patients and their families.[1] The conventional treatment of burn is by daily washing of wound, removal of dead tissue and saline and silver sulfadiazine dressing till formation of granulation tissue. The current trend has shifted to more holistic approach of improvement in the long-term form and function of the healed burn wounds and quality of life.[2] This has demanded the emergence of various skin substitutes in the management of acute burn injury. Skin substitutes aid in wound closure and replace the functions of the skin, either temporarily or permanently, depending on the product characteristics. These substances are alternatives to the standard wound coverage in circumstances when standard therapies are not desirable.[3] Skin substitutes are best classified as temporary or permanent and synthetic or biological. Biological skin substitutes which act temporarily like skin have the advantages of being relatively abundant in supply and not expensive. While the synthetic skin substitutes can be synthesised on demand, the biological skin substitutes have a more intact and native extracellular matrix structure which may allow excellent re-epithelialisation characteristics due to the presence of a basement membrane.[4] The most widely used biological substitutes worldwide are cadaveric skin allograft, porcine skin xenograft, bovine collagen and amnion.[5]

Collagen is a biological skin substitute, i.e., natural, easily available, ready to use, non-immunogenic and non-pyrogenic. Biological dressings create the most physiological interface between the wound surface and the environment, enabling the body's reparative and immune systems to function most effectively.[6] Collagen sheets are very useful in first- and second-degree burns. The cost factor comes down, and the pain associated with dressing can be avoided. It is especially useful in children since the trauma of dressing can be avoided. Collagen sheets are produced from bovine tissues comprising mostly type I and III collagen, packed in a neutral glass vial containing sterile preserving liquid medium (a mixture of isopropyl alcohol and water) sterilised with ethylene oxide.[7] This study aims to compare the efficacy of collagen dressing in treating burn wounds with that of conventional dressing materials.


  Methodology Top


It was a comparative study in the burn intensive care unit of a tertiary care hospital conducted in patients admitted with first-degree and second-degree burns covering 10%–50% of total body surface area from September 2019 to August 2020. Percentage of burns was assessed by Wallace's rule of nine. The sample size was calculated as 42. All cases of first- and second-degree burns except isolated facial and genital burns belonging to both sexes, between ages 13 and 60, were included after written informed consent. Patients more than 60 and below 13 years, those with history diabetes or underlying skin disorder (SLE, psoriasis, contact dermatitis), chemical burns, electric burns, burns >50% or full-thickness burns were excluded.

After washing thoroughly using normal saline, collagen sheets, available commercially, were applied over the area and kept for 7 days. Control cases are given silver sulfadiazine dressing, where the dressings are changed every day. Pain and itching score was determined by visual analogue scale 1–10 score (box whisker plot) in a daily examination in patients and recorded in questionnaire. 0 means no pain and 10 is the most severe pain the patient has ever experienced. The pain status on day 5 was compared (score 1–3 considered no pain and 4–10 as pain present). Healing was assessed on day 7 in both the groups, and complete healing (evidenced by appearance of epithelisation in 90% of wound) was compared in both the groups. Any complication such as infection, scarring and incomplete healing was documented. Any microorganism isolated from the burn site (except skin colonisers) along with evidence of fever (temperature >99°F) and/or TC >11,000 cells/mm is on day 5/7 was considered as infection. Scar was assessed after 1 month using the Manchester scale. Score <10 was considered as acceptable/no scar and >10 as bad scar. Ethical issues were cleared by obtaining informed written and valid consent. Analysis was performed using appropriate statistical tests.


  Results Top


Out of 42 patients studied, 18 (43%) were male and the rest 24 (57.1%) were female. Age wise, majority was in the fourth decade – 12 (28.6%), followed by the fifth decade – 9 (21.4%) and the rest were equally distributed in the second, third and sixth decades with 7 (16.7%) each. The type of dressing, collagen or saline/antibiotic dressing was equally distributed to 21 patients each. There were no co-morbidities in 36 (85.7%) patients. Hypertension and hypothyroidism were present in 2 each (4.8%) and coronary artery disease and seizures in one each (2.4%). Percentage of burns ranged from 21 to 30 in 16 (38.1%), followed by 11–20 and 31–40 in 10 (23.8%) each % and 0–10 in 6 (14.3%). Twenty-nine (69%) patients studied have a normal range of 18.9–24.8 kg/m2, followed by 25–29.9 in 12 (28.6%) and 30–34.9 in 1 (2.4%). The total blood count was <11,000 cells/μL in 32 (76.2%) patients and above than in 10 (23.8%). The haemoglobin (Hb) level was >10 g/dL in 32 (76.2%) and the rest 10 (23.8) had <10 g/dL on post-admission day 5. The serum albumin was <3.5 g/dL in 28 (66.7%) and > 3.5 5 g/dL in 14 (33.3%). During the study, 18 (42.9%) patients developed infection. Thirty (71%) patients developed fever during study, rest of patients were normal. Thirty-five (83%) patients complained of pain during study period. Seventeen (40%) patients developed itching during study. Twenty-five (59.5%) patients had acceptable scarring and 17 (40.5%) had bad scars.

Hb was checked on 5th day of dressing. In patients with collagen dressing, only 9.5% had anaemia, and in saline dressing, 38.1% were anaemic. Chi-square test showed a statistically significant difference (P = 0.03), as detailed in [Table 1].
Table 1: Dressing types versus haemoglobin category

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On comparing collagen and saline dressing, 62% of patients with collagen dressing and 71% of patients with saline dressing had low albumin value. This difference was not statistically significant (P = 0.513), as shown in [Table 2].
Table 2: Dressing type versus albumin

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Nearly 24% of both collagen and saline dressing had high total count, but there was no statistically significant difference (P = 0.641) in total count [Table 3].
Table 3: Dressing type versus total count

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About 38% of patients with collagen dressing did not have fever, 19% of patients with saline dressing did have fever. There is a difference when comparing both the dressings, but the difference is not statistically significant (P value of 0.172), as detailed in [Table 4].
Table 4: Dressing type versus fever

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On comparing both the dressings, 52.4% of patients had no significant pain in collagen dressing and 28.6% of patients had no significant pain in saline dressing, which is nearly half of collagen dressing. There was a difference in pain, but the difference was not statistically significant (P value of 0.116), as seen in [Table 5].
Table 5: Dressing type versus pain category

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About 67% of patients did not develop itching in collagen dressing and 52% of patients with saline dressing did not have itching. There is a difference in both the dressings, but the difference is not significant (P value of 0.346), as seen in [Table 6].
Table 6: Dressing type versus itching

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Only 29% of patients developed infection in patients with collagen dressing and 57% of patients developed infection in patients with saline dressing. There is a difference in both the values, but the difference is not statistically significant (P value of 0.061), as seen in [Table 7].
Table 7: Dressing type versus infection

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Nearly 71% of patients with collagen dressing produced no scar/acceptable scar when compared to saline dressing where 52% developed bad scars. There is a difference in comparing both the groups but not statistically significant (P value of 0.116), as shown in [Table 8].
Table 8: Dressing type versus scar

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  Discussion Top


Patients with age between 13 and 60 years were studied. Patients were classified according to the BMI, total count, Hb, infection, fever, pain, itching and bad scars. On comparing both the dressings on post-admission day 5 after application of dressing, 2 out of 19 patients (9.5%) with collagen dressing and 8 out of 21 (38.1%) with saline/antibiotic dressing were found to be anaemic with a P value of 0.030. The difference in Hb value on comparing both the dressings is significant. The low Hb value in saline dressing may be due to daily intervention (change in dressing)/low baseline Hb.

Serum albumin levels, total blood count, fever and infection were not statistically significantly different in the two groups. This may be due to the small sample size. Collagen film adheres closely to burn wound beds due to its pliability that reduces fluid exudates and protects from environmental germs which result in pain relief and prevent bacterial colonisation.

Singh et al.[7] retrospectively compared collagen dressing and conventional dressings in burn and chronic wounds including burns wound and found that 60% of the “collagen group” wounds and only 42% of the “conventional group” wounds were sterile, which was a statistically significant finding (P = 0.03). Healthy granulation tissue appeared earlier over collagen-dressed wounds than over conventionally treated wounds (P = 0.03) but no statistically significant better results in healing of burns between collagen dressing and conventional dressing.

Twenty-five patients out of 42 developed pain during dressing. Pain was evaluated using a box whisker plot and categorised into two. Ten out of 21 (47.6%) in patients with collagen dressing and 15 out of 21 (71.4%) in patients with saline dressing developed pain with a difference of 24%. On Chi-square analysis, the difference is not significant with a P value of 0.116. This may be due to the small sample size. The increased pain in saline dressing may be due to daily change of dressing. Seventeen patients out of 42 patients developed itching. Seven (33%) were from collagen category and 10 (47.6%) patients were from those with saline dressing developed itching. There is a difference in value, but the difference is not significant on Chi-square analysis (P = 0.346). Horch and Stark[8] compared the effect of a collagen dressing and a polyurethane dressing on the healing of split-thickness skin graft donor sites in terms of rates of epithelialisation and the discomfort experienced by the patients and found that the median time from operation to the observation of complete healing was 7.5 (±2.5) days for the donor sites dressed with the collagen membrane and 12.5 (±3.4) days for donor areas dressed with a polyurethane film (P < 0.001). The discomfort experienced by the two groups of patients was significantly less after wound coverage with collagen (P < 0.005). Ramesh et al.[9] conducted a comparative study of collagen dressing versus petrolatum gauze dressing in reducing pain at the donor area. The pain was analysed using statistics in both the groups on days 1, 2, 3, 4, 5, 10 and 14. The average pain score in the study group (i.e., collagen sheet dressing) was found to be less compared to the control group (i.e., petroleum gauze dressing).

One of the most annoying problems in burn patients is pruritus. Pruritus may be severe and disabling and can interfere with concentration or sleep. Pruritis is found to be present in the rehabilitation phase as high as 87% in adults and 100% in children. The aetiology is not well understood and physicians are confronted with difficulties in the management.[10]

Scar was assessed after 1 month using the Manchester scar scale. It is a visual analogue scale. Patients are divided as having an acceptable/no scar and with hypertrophied/bad scar. Twenty-five out of 42 patients developed acceptable scarring out of which 15 patients (71.4%) used collagen dressing and 10 patients (47.6%) used saline dressing. There is a difference of 24%. On evaluation, P value obtained is 0.116. This difference is not significant due to the small sample size. Collagen dressing accelerates re-epithelialisation and leads to profuse granulation. Collagen dressing needs no redressing as compared to antibiotic dressing which needs to be changed at least once a day. This results in less traumatisation, less pain, less bleeding and less chance of scar formation. A cross-sectional was study conducted by Thakur et al.[11] compared collagen dressing and conventional dressings in burns at a tertiary health care centre. Twenty-five were enrolled to collagen treatment group, Group A, and the remaining into conventional treatment group, i.e., Group B. Collagen dressing was found to be superior with an average less time required for granulation tissue to appear (P < 0.001, df = 48, t = 4.56); average less time requires for sterile wound swab culture (weeks) (P < 0.05, df = 48, t = 3.45); less discomfort score (0–10) (P < 0.001, df = 48, t = 6.78); less dressing removal pain score (0–10) (P < 0.0001, df = 48, t = 9.87) and less average time required for complete healing (days) (P < 0.001, df = 48, t = 7.79).

Veves et al.[12] conducted a randomised controlled trial of Promogran® (a collagen/oxidised regenerated cellulose dressing) versus standard treatment in the management of diabetic foot ulcers. After 12 weeks of treatment, 51 (37.0%) collagen-treated patients had complete wound closure compared with 39 (28.3%) control patients, but this difference was not statistically significant (P = 0.12). The difference in healing between treatment groups achieved borderline significance in the subgroup of patients with wounds of <6 months' duration.


  Conclusion Top


Collagen-based dressing is a safe and effective alternative for treating burns. It seems that the use of collagen for dressing causes rapid epithelialisation and wound healing and can improve pain in initial days though statistically not significant over the conventional dressing. The advantages of using collagen-based dressing as a biological dressing for burn wounds include it is readily available commercially; storage and application are simple; prevents protein and blood loss from wound surface; combats infection; promotes healing and relieves pain.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO (2012) Burns – Fact sheet. Available from: http://www.who.int/mediacentre/factsheets/fs365/en/. [Last accessed on 2018 Mar 10].  Back to cited text no. 1
    
2.
Halim AS, Khoo TL, Mohd Yussof SJ. Biologic and synthetic skin substitutes: An overview. Indian J Plast Surg 2010;43:S23-8.  Back to cited text no. 2
    
3.
Shores JT, Gabriel A, Gupta S. Skin substitutes and alternatives: A review. Adv Skin Wound Care 2007;20:493-508.  Back to cited text no. 3
    
4.
Sheridan RL, Moreno C. Skin substitutes in burns. Burns 2001;27:92.  Back to cited text no. 4
    
5.
Kumar P. Classification of skin substitutes. Burns 2008;34:148-9.  Back to cited text no. 5
    
6.
Chvapil M, Kronenthal L, Van Winkle W Jr. Medical and surgical applications of collagen. Int Rev Connect Tissue Res 1973;6:1-61.  Back to cited text no. 6
    
7.
Singh O, Gupta SS, Soni M, Moses S, Shukla S, Mathur RK. Collagen dressing versus conventional dressings in burn and chronic wounds: A retrospective study. J Cutan Aesthet Surg 2011;4:12-6.  Back to cited text no. 7
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8.
Horch RE, Stark GB. Comparison of the effect of a collagen dressing and a polyurethane dressing on the healing of split thickness skin graft (STSG) donor sites. Scand J Plast Reconstr Surg Hand Surg 1998;32:407-13.  Back to cited text no. 8
    
9.
Ramesh BA, Jayalakshmi BK, Mohan J. A comparative study of collagen dressing versus petrolatum gauze dressing in reducing pain at the donor area. J Cutan Aesthet Surg 2017;10:18-21.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Willebrand M, Low A, Dyster-Aas J, Kildal M, Andersson G, Ekselius L, et al. Pruritus, personality traits and coping in long-term follow-up of burn-injured patients. Acta Derm Venereol 2004;84:375-80.  Back to cited text no. 10
    
11.
Thakur PB, Ramachandrudu T, Takalkar AA. A study of collagen dressing versus conventional dressings in burns at tertiary health care centre. Int Surg J 2020;7:1061.  Back to cited text no. 11
    
12.
Veves A, Sheehan P, Pham HT. A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. Arch Surg 2002;137:822-7.  Back to cited text no. 12
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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