CASE STUDY
A 31-year-old female patient was admitted to the local district hospital with burn injuries of unknown aetiology to bilateral lower limbs, approximately 12% of total body surface area. The patient was known to have Down's syndrome and had no other comorbidities. Her index presentation was to the local health-care clinic where the wounds were initially dressed with dressings regularly changed thereafter. Two weeks later, as there was no progress in wound healing, the patient was referred to the district hospital. On admission she reported significant pain affecting her mobility and, as a result, she was using a wheelchair to mobilize (Figure 1).
Full thickness burn wounds with areas of overlying thick slough on the lower limb, on the day of admission
The central hospital, which is only 10 km from the admitting district hospital, would have been the optimal hospital setting for this patient, but no beds were available. At the district hospital, there was neither the necessary surgical equipment nor the expertise needed to perform surgical debridement. Surgical units from the central hospital have daily elective lists for small uncomplicated cases at the district hospital, thus a consultant surgeon is present in the district hospital on most weekdays. Advice from one of these visiting consultant surgeons was chemical debridement of the wounds with Iruxol® ointment which is an enzymatic debriding agent, containing clostridiopeptidase A and associated proteases.(2)
Fortunately, Iruxol® was available in the district hospital and serial dressings with this chemical debriding agent were commenced. At every dressing change, which was performed in the surgical ward under sedation, the wounds were cleaned, scrubbed to remove loose necrotic tissue, and Iruxol® reapplied. After approximately 3 weeks of this regimen the wound slough had softened significantly and, in some areas, had completely cleared, exposing the underlying healthy wound bed (Figure 2). Dressings were changed every second day.
Photograph showing the progress of enzymatic debridement with Iruxol®, the slough is separating from the underlying wound bed
As all dressing changes were carried out under sedation in the ward, this was a labour-intensive process that required consistent dedication and commitment from the nursing team and health-care professionals allied to medicine and included physiotherapists, occupational therapists and dieticians.
After 4 weeks, once the slough had completely separated from the wound bed, re-epithelialization was evidently occurring from the wound edges, with areas of over- granulation also visible. As wound debridement was complete, dressings were changed to foam dressing impregnated with ibuprofen (Biatain® Ibu). At this stage the patient was able to mobilize in the ward using a walking frame. After 2 weeks of foam dressings with alternate day changes, a marked improvement of the overgranulation tissue, as well as larger areas of re-epithelialization, was visible.
At 6 weeks post admission, the patient was deemed fit to go home to her family. She continued to have dressing changes three times a week at her local clinic. She also returned to the district hospital as an outpatient for regular scar management with the occupational therapist. Three months after discharge from the hospital, the patient came to the ward for review by the surgical team. Her wounds showed significant areas of healing (Figure 3) and she walked into the ward pain-free, without the use of any walking aids.
DISCUSSION
Chemical debridement as an alternative to surgical debridement had its foundations laid in the World War II, where the non-operative debridement of burn eschar was achieved using enzymes from plant extracts or bacteria, thereby hastening wound bed readiness for skin grafting. Although each compound had its own associated risk profile, the benefit was that these novel debriding agents were more selective for necrotic tissues than was careful surgical debridement.(3) Early excision and grafting, utilising techniques to decrease blood loss, has become well established as the gold standard for treatment of burn wounds but is not without its own risk.(4)
In 2019, a systemic review and meta-analysis of six studies on the use and efficacy of clostridial collagenase ointments (components of Iruxol®) when applied to burn wounds reported a decrease in wound healing time, minimal pain and no increased risk of infection as compared to surgical debridement.(5) These ointments were deemed to be a safe and effective method of debridement. However, the review recommended that the decision to use these ointments should be made on a case-by-case basis.(5) As there are risks associated with either surgical or chemical debridement, we also had to consider which option was available within our health-care setting.
Undoubtedly, 3 months to complete wound healing in this case study is a significant time frame. When considering the logistics involved in a surgical procedure and the prolonged hospital stay from non-operative management, high-income countries have shown that surgical management is more cost effective.(6) This also holds true for South Africa, a middle-income country, as a costing model predicted a saving of at least 10 million rand when the cost of surgical management of burns was compared to the cost of the non-operative approach of chemical debridement.(6) However, both surgical and non-operative management seem to be labour intensive for all clinical staff involved.
An earlier meta-analysis comparing early excision and grafting to non-operative treatment of minor or major burns in both children and adults showed a reduction in mortality in patients without inhalation injury that undergo early excision.(1) This group of patients also had greater blood transfusion requirements, but shorter hospital stays. No significant differences were found with regards to duration of sepsis, wound healing time and skin graft take when comparing early excision groups and non-operative management groups.(1) However, many of the randomized control trials in this meta-analysis lacked uniformity in the variables studied. In a prospective randomized trial in India, early tangential excision and skin grafting was shown to be superior to honey dressings and delayed skin grafting. The early excision group had a higher skin graft take rate (99% vs 74%) and a better cosmetic and functional status at follow-up after 3 months (92% vs 55%).(7)
These studies are only two of many that reiterate the advantages of early tangential excision and grafting. Our case study does not attempt to advocate moving away from the internationally accepted standard of care for burn wounds but instead highlights that when this is not feasible, chemical debridement is an option in a resource- limited setting.
CONCLUSION
Guidelines are often developed in a high-income “first world” setting, which is very different to the setting of low- and middle-income countries. Thus, such guidelines may be unattainable in resource-limited settings. If guidelines for clinical care are to be effective globally, an essential component of the guideline should be recommendations that can be followed when the optimal environment is not encountered. The gold standard of burns management is early tangential excision and grafting and this should be adhered to wherever possible. However, in a resource- constraint setting, chemical debridement is a feasible option as highlighted in this case report, when the necessary surgical expertise or equipment is not available.