Clinical Observation on Burn Skin Regenerative Repair

Document Sample
Clinical Observation on Burn Skin Regenerative Repair Powered By Docstoc
					                         The Chinese Journal of Burns Wounds and Surface Ulcers 2003, (1): 51-54

      Clinical Observation on Burn Skin Regenerative Repair
      Zhao Junxiang, Li Tianyu, Zhao Junfang, Yang Binghou, Wangshuo, Yang Caili
              Nanyang Nanshi Hospital, Nanyang, Henan Province 473065

[Abstract] Objective: To summarize the clinical evolution process of regeneration
and repair of various deep burns. Methods: Through statistics of registration data of
12,500 cases of inpatients and outpatients treated in 1987 to 2002 by our hospital,
combined with phased summarization of data, we elaborate the basic situation of
patients and the healing process of wounds treated with moist exposed burn ointment
(MEBO). Results: The maximal burn surface area was 99.8% of TBSA, the oldest
patients was 88 years old, and the youngest was only two days old; superficial
wounds of deep II-degree burns healed in two weeks after injury, without any scars;
deep-type wounds of deep II-degree burns healed in three weeks, and the scar forming
rate was 15%; superficial III -degree wounds should be treated with skin tension
releasing, ploughing and weeding therapy, and the scar forming rate was 25%; Deep
III-degree burns should be surgically closed, and the chief therapeutic drug of all
wounds was MEBO. Conclusion: Using MEBO to treat deep burns plus the aid of
ploughing and weeding therapy or surgical skills could facilitate the regeneration and
repairing of wounds and reduce scar forming rate.
[Key Words]Burn wounds; Moist exposed burn ointment (MEBO); Regeneration and
   repair of skin, Curative effect
[CLC number] Q785; R75; R644
[Document ID code] A
[Article No.] 1001-0726(2003)01-0051-04

The regeneration and healing of burnt skin has two patterns, especially deep burns,
one is physiological healing and the other is non-physiological healing (pathological
healing). The so-called physiological healing means the burn histiocytes regenerate
to normal morphosis and function, and heal without scars. Non-physiological
healing means the morphosis and function of burn histiocytes fail to regain normal
healing, and heal with scars. In the light of the requirements of skin regenerative
medicine, that burn wounds reach physiological healing is the purpose of burn care,
and the moist exposed burn ointment (MEBO) and physiological moist environment
developed by Xu Rongxiang is the basis for realizing regeneration of skin. Our
hospital has obtained rich clinical experiences since the application of this therapy in
1987. Below is the summary:

1.       Clinical data

1.1      General data

Our hospital used moist exposed burn ointment (MEBO) to treat 64,521 burn patients
in the last 16 years, among them, 12,500 cases were inpatients and 52.021 cases were
outpatients. These data takes inpatients as statistical resources, the maximal burn
surface area was 99.8%, the oldest patient was 88 years old, and the youngest patient
was only two days old. The injuries were caused by flame, hot liquid, electricity,
chemicals, combustion and explosion. The burns extended all over the body, and the
most frequent areas burned were faces, both hands, chest, abdomen, four extremities
and perineum. The depth of burns covered various depths of the three-degree


classification method, but the emphasis of this article was the therapeutic analysis of
deep burns.

1.2    Methods and results

All patients were treated with moist exposed burn ointment, and late hospitalizing
patients or patients receiving conventional therapy before were subject to treatment
with MEBO immediately. Wound healing time and patients’ prognosis were the
major observation indexes. Superficial II-degree wounds generally healed in seven
days, and the longest healing time was not more than nine days, and their healing had
no scars. Superficial wounds of deep II -degree burns mostly healed in 14 days after
injury, and the longest was not more than 18 days, and their healing had no scars.
Deep wounds of deep II -degree burns generally healed in 20 days after injury, and the
longest was not more than 24 days, a few wounds healed with punctuated or little
sluglike scars (accounting for about 15%), but most of them had no impact on
function. Superficial III -degree burns mostly healed in 30~40 days, and the scar
forming rate after healing was 25%, most scars were cord-like, mild dysfunction was
seen in 10%, and moderate dysfunction in 5%. The wounds of deep III -degree
burns generally needed the operations for therapy, the scar forming rate after healing
was 40% and 20% of healing had impact on function.
In the statistical result of 1,025 cases of extensive burn care, we found they accounted
for 8.20% of the overall inpatients. The largest burn surface area was 98%, the
largest burn surface area of III -degree burns was 76%. 839 cases were cured, 150
cases presented moderate response, and 36 cases died, more than half of the cases that
presented moderate response and died abandoned therapy or discharged themselves,
an obvious increase compared with the statistics of domestic and foreign extensive
burn healing rate. No toxic side effect was found among all cases during their
administration, which demonstrated MEBO was safe in application in extensive burn

Through observing the analgesic effect of 840 cases with burns wounds of different
degree after administration in the early period, we found 520 case reached the full
analgesic effect after 5 minutes of administration, and 339 cases achieved basic
analgesic effect, 20 cases obtained the effect of reducing pain, and 1 case still suffered
from pain. The pain in dressing change of wounds was far lighter than that in
conventional therapy. In comparison treatment of both lower extremities of 10 cases
of patients, we used moist exposed therapy with MEBO for one part, one parts was
treated with antibiotic occlusive dressing and one part was treated with silver
sulfadiazine (SD-Ａg) therapy. When treated with MEBO, patients had no algesia,
also presented no fear; while treated with occlusive dressing, patients feared the
dressing, and the heart rate of three patients came to 120times/min when changing
dressing, and the pain lasted up to 30~60 minutes when changing dressing; for dry
therapy, the frequency of dressing change was 6~8 times each day, and the time for
dressing changing was 5′~15′, thus discontinuous pains occurred frequently.

The observation of wound infection degree from the angle of burn skin regenerative
medicine, mainly took the following as judgment indexes: the surrounding of wounds
occurred swelling and thermal pain, there was empyema under crust, and number of
cases with discontinuation of the wound petechia and growth and repair. Totally
1,482 cases were observed, and their burn surface area was 30%~50%, only 14 cases


has the aforesaid circumstances, an incidence rate of 0.95%, according to statistics of
conventional therapy, its wound infection rate was about 40%. The infection rate of
this group was obviously lower than that of conventional therapy.

2.     Clinical observation of repair of wounds

Burn skin regenerative medicine takes the level of damaged skin tissue from the
exterior to the interior to decide the depth of burn, which can be divided into the
cuticular layer burn of the outmost layer (superficial burns are I-degree and deep
burns are superficial II -degree), the dermal layer injury under the epidermis
(superficial burns are those of deep II -degree, and deep burns are those of deep II
-degree), and subcutaneous superficial injury (commonly called III -degree injury)
and muscle and skeletal injury (deep III -degree injury), i.e., the rules of three degrees
and six divisions established by Xu Rongxiang. But pathological results cannot be
used to decide the depth of burn in clinical practice, the combination of macroscopic
observation and physical inspection is adopted to decide the depth of various burn
wounds, and its indexes include color and thickness of dead skin festering, blister size
and cleanness of blister liquid, wound temperature, algesia, elasticity, difference of
swelling degree etc. Wounds treatment must ensure wounds have such core
technologies of burn skin regenerative medicine as a three-dimensional moist
environment, smooth drainage, persistent drug supply and clearance without injury

2.1    Epidermis burns

Superficial layer burns of epidermis (I-degree) can be embrocated with MEBO
immediately after injury in default of swelling and exudation, once every four hours,
and the burn wounds will heal in 2~3 days automatically, though pain is obvious, it
will not cause systematic pathological change, thus superficial layers burns are
usually not included in total burn surface area. Deep burns of epidermis (superficial
II-degree) have exudates and swelling during therapy, blister tapping can be made for
early debridement, and protective dead skin shall be applied with MEBO immediately,
and this generally falls off after three days. Pain in wounds in early period of
therapy is very obvious, and the application of MEBO can alleviate pain immediately.
This type of wounds has no parabiotic tissue (blood stasis region), thus will not
appear liquid (white emulsion will appear on wounds), debridement is unnecessary,
adding drugs to 1mm thickness every four hours is acceptable, epidermic tissues will
completely regenerate and repair after about 6~8 days, and color and form will be

2.2    Dermal-injury (deep II -degree) burns

Their clinical treatment and outcome are comparatively complex, and disputes over its
clinical treatment are great, dermal-injury burns can reach full regeneration and repair
if they are treated according to the theory and methods of burn skin regenerative
medicine, without any scar and dysfunction. There often will be scar formation and
dysfunction if they are treated with conventional burn therapy.

The treatment of superficial layer burn of dermis (superficial burns of deep II-degree
burns) requires protecting parabiotic tissues and making wounds superficial,


embrocating MEBO immediately after injury and keep the wounds at 28℃~32℃,
blisters shall be tapped to retain the blister skin, the dressing shall be changed once
every four hours, and the dressing thickness shall be 1mm, skin fester will fall off
after 3~5 days of administration, the wounds present pale red, i.e., the wounds has be
made superficial to the healing result of superficial II -degree burns. The wounds
liquefaction of this type of burns (white emulsion) is a special pharmacological action
of MEBO, and shall be distinguished from so-called suppurative infection of wounds.
The latter has swelling, thermal pain and dysfunction around its wounds, and exudates
a mixture formed by dead epithelium, inflammatory exudates and bacteria whose
toxicity is reduced due to MEBO after they leave the external layer of MEBO and
cannot stay on the wounds for a long time, generally not more than one hour,
otherwise there will be dipping (excessively moist) infection of wounds, thus prompt
debridement without injury must be continued.

The deep layer injury of dermis impairs the deep layer of dermis and appendages of
skin of subcutaneous tissues and forms a microcirculation stasis region, there is no
blister or a few blisters on wounds with macroscopic observation, which show wax
yellow or wax white, and show red or thick brown spots while passing through the
dead layer. Because most nerve endings are damaged or dead, pain in wounds is not
evident and skin temperature is low. The characteristics of this type of injury is that
stasis tissues form an inflammatory infiltrating region after several hours of injury,
and conventional therapy holds the inflammatory infiltrating region is the cause of
secondary infection, and usually uses SD-Ａg plus hot air drying therapy to make it
dry and form a crust rapidly to reduce the inflammatory reaction, but finally wounds
will deepen. But treatment with MEBT/MEBO will control or reduce the
inflammatory region reaction after several hours of injury.

If extensive ploughing and weeding is conducted with ploughing and weeding knife
before the early administration of MEBO, MEBO will permeate to the stasis tissues
under the dead layer as soon as possible to make blood vessels smooth again and
recover their physiological function, then the active ingredients of MEBO will make
the inflammatory reactants neutralize repeatedly and excrete. Meanwhile MEBO
makes parabiotic tissues regenerate, which effectively reduces and postpones the
occurrence of systemic inflammatory response syndrome. The appearance of
exudates after 24 hours demonstrates that deep microcirculation has recovered, the
failure of appearance of exudates from wounds after 48~72 hours can be taken as the
indicator of full-thickness derma injury and that parabiotic tissues are totally dead.
The normal time for liquefaction to appear is 4~6 days after injury. A piece of pH
test paper can be used to test the wounds to determine whether wounds liquefaction
process is normal and have infection signs, pH value ranging 7.3~7.5 are the most
suitable. If pH is more or less than this range, in addition, if there are swelling and
thermal pain around the wounds, wounds have petechia, body temperature and blood
picture are high etc, all of which suggest that wounds have been infected. The
processing method is to clear the dead tissues and liquefaction in time. When the
dead layer is comparatively thick or has a soft crust, a blade shall be used to cut them
thin, then MEBO shall be applied several times each day, generally normal
liquefaction of wounds will be achieved after 3~4 days and infection will discontinue.
The wounds liquefaction will be totally removed to clean in about 14~15 days,
hereafter wounds will come to wound healing stage, and the wounds at this time shall
be treated with MEBO to keep wounds moist and intact, epidermic cells will fully


regenerate and repair after about 11 days, left and right stratum corneums will form
basically after 30 days, and it is considered that protective treatment in the 30 days is
the essential measure to prevent scars.

2.3         III -degree burns

Burn wounds are leathery, dendritic blood vessel blockage can be seen on them, and
the complete disappearance of algesia is III -degree burn. In order to protect the
appendages of skin surviving in subcutaneous tissues, skin tension releasing,
ploughing and weeding therapy shall be used immediately after injury, with MEBO
applied on the subcutaneous tissues, and MEBO can be used repeatedly after 24 hours
of injury. Its therapeutic actions can be summarized as follows:

      (1)     Relieve dead layer as soon as possible to relieve pressure;

      (2)     Increase skin temperature as soon as possible and accelerate MEBO to
              become liquid to enter tissues;

      (3)      Urge MEBO to exert its drug effect as soon as possible and save parabiotic

The occurrence of white, yellow or green liquefaction on wounds will last about 6~8
days, during this period, there may be fever, but the frequency of fever heat is 1~2
time at most each day, such shall not be considered as infection, wound debridement
without injury still shall be enhanced and moist environment shall be kept, epithelized
regeneration and repairing are generally achieved in 25~32 days. Hereafter the
wounds come to restoration stage, which further makes skin tissues change to
physiological healing, and the duration is about 6 months. The scar lotion for
external use shall be used each day 3~5 times.

Deep III -degree burns always impair muscles and skeleton, and conventional therapy
caused many serious disabilities. In recent years plastic technicians use early
reshaping to solve part of the questions, but there is no ideal therapy for the treatment
of extensive wounds. Our hospital used burn skin regenerative therapy in recent
years. First we used MEBO to protect the wounds, supplied nutrients and ensured
full drainage, all of which not only facilitated the growth of granulation tissues, but
also avoided infection. For skeletal burn patients, the debridement and boring with
skeleton exposed was used, then MEBO was used as nutrient to protect wounds,
generally granulation tissues would grow at the bored region in 15 days and gradually
expand to the surrounding bored region, then cover the exposed skeleton. A date
would be chosen to conduct auto blade-thickness skin grafting or intermediate split
thickness skin grafting to close the wounds. The rehabilitation lasting 6 ~10 months
would be conducted after wounds were closed to decrease scar formation and keep
good function.

[Brief introduction to authors]
Zhao Junxiang (1951—), male (Han nationality), Nanyang, graduated from
Department of Medicine of Guangdong Zhongshan Medical University, Director of
Hospital, Chief Physician
Li Tianyu (1964—), male (Han nationality), Nanyang, graduated from Department of


Medicine of Henan Medical University, Section Direction, Associate Chief Physician
Zhao Junfang (1973—), female (Han nationality), Nanyang, graduated from Nanyang
Health School, Physician
(Received date: 2002-08-10; Returning date after amendment: 2002-10-25)