A 24-year-old man had been diagnosed with rapidly progressing limited systemic sclerosis at the age of 19 years. He was under the care of a quaternary centre and was awaiting stem cell transplantation for systemic sclerosis. He suffered with spontaneous ulceration of digits and feet and had several small areas of ulceration at the time of injury. He also had reduced exercise tolerance and gastroesophageal reflux, but no other manifestations of systemic sclerosis. At the time of presentation, his regular medication included: omeprazole; mycophenelate mofetil; sildenafil; and nifedipine.
The patient suffered approximately 6%TBSA mixed depth flame burns to the right leg, following ignition of petrol used as an accelerant for a bonfire. This included areas of deep partial-thickness burn, totalling approximately 2%TBSA. Immediate first aid was applied with cool water for up to 1 h, before ambulance transfer to a local emergency department. Following analgesia, cleaning of burns and temporary dressing with sterile cling film, he was transferred to a UK regional burns unit. On assessment, the patient reported a pain score of 8/10 and it was observed that the burn involved areas of previous lower limb ulceration (Figure 1).
Treatment options were discussed with the patient. He expressed a desire to have enzymatic debridement. At approximately 12 h after the burn, the pre-treatment soak was commenced, following a local treatment protocol. At approximately 16 h after the burn, the patient underwent spinal anaesthesia. A total of 7 g of Nexobrid  was reconstituted and applied to the burn wound in the operating theatre. Clear film dressings were applied with rolled paraffin gauze at the edges (Figure 2) and the patient was returned to the ward. Pain scores were in the range of 4-6 out of 10 following Nexobrid  application, with patient-controlled analgesia in addition to the spinal anaesthetic. Four hours later, the patient was returned to theatre where, under mild sedation, the Nexobrid  was removed and immediate burn reassessment was undertaken (Figure 3). Sterile saline-soaked gauze was applied with continuous saline irrigation via Foley catheter directly into the gauze dressings used for the following 12 h. During this time, pain scores were in the range of 3-6 out of 10.
Following liaison with Rheumatology, mycophenelate mofetil was discontinued. In addition, a course of iloprost infusions over five days were commenced. Dressings consisted of non-adherent silicone-based primary layers and sterile gauze. The patient was discharged from hospital at day 9 after the burn. Outpatient clinical review at day 25 revealed very small areas of over-granulation which were treated with topical steroid cream. Topical aqueous cream was applied to healed areas. At day 31 after the burn, all burned areas were fully healed (Figure 4). Scarring was minimal, the skin was soft and full, and pain-free range of movement was maintained.