Burn Care in the Era of Rapid Enzymatic Debridement: Challenging the Dogma that Healing Beyond 21 Days Results in Hypertrophic Scarring

Lior Rosenberg, Yaron Shoham, Stan Monstrey, Henk Hoeksema, Jeremy Goverman, William Hickerson, Ilaria Mataro, Adam J. Singer

    Research output: Contribution to journalReview articlepeer-review

    Abstract

    Deep burns are characterized by the presence of a necrotic eschar that delays healing and results in a local and systemic inflammatory response and following healing by secondary intention: heavy scarring. Early surgical debridement followed by grafting was a major advance in deep burn care and is now the standard of care, reducing mortality and hypertrophic scarring. Eschars have alternatively been managed by non-surgical, autolytic debridement, which often results in infection-inflammation, slow epithelialization, granulation tissue formation and subsequent scarring. Studies based on these traditional approaches have demonstrated an association between delayed wound closure (beyond 21 days) and scarring. Early enzymatic debridement with NexoBrid (NXB) followed by appropriate wound care is a novel minimally invasive modality that challenges the well-accepted dictum of a high risk of hypertrophic scarring associated with wound closure that extends beyond 21 days. This is not surprising since early and selective removal of only the necrotic eschar often leaves enough viable dermis and skin appendages to allow healing by epithelialization over the dermis. In the absence of necrotic tissue, healing is similar to epithelialization of clean dermal wounds (like many donor sites) and not healing by the secondary intention that is based on granulation tissue formation and subsequent scarring. If and when granulation islands start to appear on the epithelializing dermis, they and the inflammatory response generally can be controlled by short courses (1-3 days) of topically applied low strength corticosteroid ointments minimizing the risk of hypertrophic scarring, albeit with wound closure delayed beyond the magic number of 21 days. Results from multiple studies and field experience confirm that while deep burns managed with early enzymatic debridement often require more than 21 days to reepithelialize, long-term cosmetic results are at least as good as with excision and grafting.

    Original languageEnglish
    Pages (from-to)66-77
    Number of pages12
    JournalOpen Dermatology Journal
    Volume15
    Issue number1
    DOIs
    StatePublished - 1 Jan 2021

    Keywords

    • Burns
    • DGD
    • Debridase
    • Debriding gel dressing
    • Enzymatic débridement
    • Enzymatic escharotomy
    • Enzymatic surgery
    • Minimal invasive modality for burn care
    • NexoBrid
    • Scarring
    • Time to wound closure

    ASJC Scopus subject areas

    • Dermatology

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