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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 24
| Issue : 1 | Page : 24-28 |
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Papaya pulp for enzymatic wound debridement in burns
Rajshree C Jayarajan, Puthucode V Narayanan, Hirji S Adenwalla
Department of Plastic, Reconstructive Surgery and Burns, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
| Date of Web Publication | 12-Dec-2016 |
Correspondence Address:
Rajshree C Jayarajan
Department of Plastic Surgery, Leicester Royal Infirmary, LE1 5WW, United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-653X.195533
Context: Early surgical debridement in burns has its disadvantages like extensive blood loss and long anaesthesia time and risks. Enzymatic wound debridement as an alternative to surgical debridement has been assessed for its effectiveness, safety and patient compliance. Aims: To assess the effectiveness and safety of papaya pulp as an enzymatic wound debriding agent in burns. Setting and Design: The study was conducted including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. Materials and Methods: A prospective study including 50 patients with second degree and third degree burns, age ranging from 15 to 60 years was carried out from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India. There were 38 female and 12 male patients in the study group. Areas of burns ranging from 10% to 60% TBSA were included in the study. Daily dressings were done using autoclaved unripe papaya pulp smeared on potato peel dressing. The progress was assessed daily and application stopped when adequate debridement has been achieved or a maximum of 1 week. Statistical Analysis Used: None. Results: All 50 patients included initially completed the study. There were 38 females and 12 males. Papaya pulp was found to be a very effective debriding agent in all cases. Deep dermal wounds cleared up in 5 to 6 days and eschar in full thickness burns became loose by this period so that it needed minimal surgical debridement. The granulation tissue found following debridement with papaya pulp was pink and healthy. In patients who had to be taken up for grafting, a mild scraping was sufficient before placement of a graft. This has helped on reducing blood transfusions and has considerably reduced anaesthesia time. Conclusions: The use of papaya pulp results in 1. Early and complete non-invasive debridement, 2. Healthy granulation tissue, 3. Decreased blood loss and hence decreased number of blood transfusions in cases which have to be grafted, as excision is avoided. 4. Less operating time and hence less anaesthesia time. Keywords: Burns, Enzymatic wound debridement, Papaya
How to cite this article:
Jayarajan RC, Narayanan PV, Adenwalla HS. Papaya pulp for enzymatic wound debridement in burns. Indian J Burns 2016;24:24-8 |
| Introduction | |  |
The management of deep dermal and full thickness burns involves excision and grafting. The devitalized soft tissue (eschar) has to be removed for wound closure to take place.
Early burn wound debridement by surgical excision as introduced by Janzekovic in 1970 is the method of treatment employed currently. Although, tangential excision is rapid and effective, intraoperative hemorrhage is considerable. Patients with extensive burns will need to have repeated procedures associated with surgical as well as anesthetic risks.
It has been proposed that enzymatic debridement can substitute for surgical escharectomy.
We, in our study, have been using the pulp of unripe papaya as a debriding agent. The objective of the study was to determine the efficacy and safety of papaya pulp for enzymatic wound debridement.
| Materials and Methods | | |
Patient demography
A prospective study including 50 patients with second-degree and third-degree burns, age from 15 years to 60 years, was carried out from January 2004 to December 2004 at the Burns Centre, Department of Plastic, Reconstructive and Burns Surgery, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India.
Informed consent was obtained from all patients.
The study was conducted based on ethical principles on medical research on human subjects.
There were 38 female and 12 male patients in the study group.
Areas of burns ranging from 10% to 60% total body surface area (TBSA) were included in the study.
Application of papaya pulp was started from 48 h after burn.
Procedure
Pulp of unripe papaya was autoclaved at 120° for 10 min. This pulp was then smeared on boiled potato peel dressing [Figure 1]. Potato peel dressing helps to retain moisture, is totally nonadherent and, hence, painless on removal. This was the dressing routinely used in our center for burns dressing with silver sulfadiazine smeared on it. In this study, instead of silver sulfadiazine, autoclaved papaya pulp was used. We recommend the use of any moisture-retaining dressing for the purpose, as dry dressing would make the pulp dry out and ineffective. Dressing was applied on the area of burns and secured with gauze and bandage. The dressing was removed after 24 h, a bath given and wound assessed for the effect. This procedure of daily washing and fresh application of the debriding agent was repeated for a maximum period of 1 week. Application, once daily, was sufficient for all wounds. | Figure 1: Autoclaved papaya pulp on potato peel dressing ready to be applied
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Patients were monitored for systemic symptoms as for all cases of burns and investigations as routine in the department for burns patients carried out.
Pain was assessed as a verbal response and it was noticed that if the papaya pulp was on an area that is raw and has no eschar, it resulted in slight burning pain being experienced by the patient. Hence, as soon as the wound cleared up, the application of the debriding agent was discontinued. None of the patients had to be withdrawn from the study due to pain, as this problem presented only after the eschar cleared. The granulation tissue on clearance of the nonviable tissue was always found to be very healthy when compared with that following the dressing with silver sulfadiazine, with no clinical or wound culture evidence of invasive infection. If the wound showed signs of healing, as in superficial second-degree burns, nonadhesive (paraffin and antibiotic based) dressing was continued till complete healing. Otherwise, the patient was taken up for grafting.
| Results | | |
All 50 patients included initially, completed the study.
Papaya pulp was found to be a very effective debriding agent in all cases. Deep dermal wounds cleared up in 5 to 6 days [Figure 2] and [Figure 3] and eschar in full thickness burns became loose by this period, [Figure 4] so that it could be removed with just scraping of the wound. The progress of the wound in terms of clearance of dead tissues was assessed on a daily basis [Figure 5]. The granulation tissue found, following debridement with papaya pulp, was pink and healthy. In patients who had to be taken up for grafting, a mild scraping was sufficient before the placement of a graft. This has helped on reducing blood transfusions and considerably reduced anesthesia time. | Figure 2: (a) Burn wound before application of papaya pulp dressing (b) Wound, 4 days after papaya pulp dressing
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 | Figure 3: (a) Wound, before application (b) Wound, 5 days after papaya pulp dressing
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 | Figure 4: (a) Areas of mixed partial-and full-thickness burns — before papaya pulp dressing (b) Partial thickness areas completely clear of slough and full thickness areas showing slough amenable to removal by scraping before grafting by day 5
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 | Figure 5: (a) Areas of mixed partial- and full-thickness burns before papaya pulp application (b) Moth-eaten appearance of slough after 2 days of papaya pulp dressing (c) Wound on day 6 after the application of papaya pulp dressing
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| Discussion | | |
Burns are a cause of major morbidity and mortality. For healing to take place in deep burns, the dead tissue has to separate or be removed and then the clean raw area has to be managed appropriately. Dead tissue predisposes the patient to severe infection that carries a high mortality rate.
Surgical debridement of deep burns poses the problem of extensive blood loss when done early, and chances of infection setting in, if delayed. Deep dermal burns could either be overassessed or underassessed. The tendency to overdiagnose deep partial thickness burns in the early injury phase and very early surgical therapy would be expected to sacrifice some considerable burn area that would otherwise heal. Underassessment results in late healing with deformities.
Enzymatic wound debridement is an alternative that can be highly beneficial. This has been attempted with proteases elaborated by Bacillus subtilis, but has not gained wide acceptance as bacteremia is associated with its use.
Enzymatic debridement can be achieved using various plant products. The proteolytic enzyme bromelain extracted from the pineapple plant [1] available as Debrase,[2] has been found to be effective in burns. Other enzymatic agents that have been studied in burn wound debridement are collagenase clostridiopeptidase [3] A (CCA) and Actinidia deliciosa (kiwifruit).[4]
Concept of papaya pulp
The concept of using papaya as a debriding agent came from observing the use of papaya latex as a debriding agent in Ayurvedic practice by local Ayurvedic physicians. This was based on Bhavaprakasham Nighantu, an Ayurvedic classic written in the sixteenth century by Bhava Mishra. It describes the characteristics and the use of various plants and minerals in medicine. Wound cleansing effect of papaya is mentioned in this.
Carica papaya has a long history of being a very effective medicinal plant.[5] It is considered to have significant wound healing properties.[6] It contains the proteolytic enzymes,[7] papain, and chymopapain in various levels in the fruit, latex, leaves, stems, and roots. Its proteolytic action is marked in acid, alkaline, and neutral solutions and has a digestive power at a wide range of temperatures and pH. Studies at the University of Nigeria, Nigeria have revealed that extracts of papaya fruits are active against gram-positive bacteria and strong doses effective against gram-negative bacteria. Very significant antibacterial activity was found on Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa etc.[8] The activity of papain is higher in extracts from the younger fruit than the older fruit.
Vitamin C in papaya converts proline to hydroxyproline, which is an indicator of collagen content of granulation tissues.[9]
Papain from Carica papaya has been used since ancient times in Ayurvedic medicine in India. The latex has been used to treat bronchitis, urinary tract infections, skin conditions, parasitic manifestations etc.
Papain and chymopapain are the proteolytic enzymes in Carica papaya. As enzymes themselves are proteins, their potency can be affected by variations in temperature and pH. The proteolytic activity of papaya pulp was found to be maintained even after autoclaving.
The antioxidant property of papain prevents the risk of oxidative damage to tissues.[10]
The Paediatric Unit of Royal Victoria Hospital, Gambia has been using mashed papaya fruit for dressing of full thickness and infected burns.[11]
The use of unripe papaya pulp as an enzymatic debriding agent results in early separation of the dead tissue and, hence, obviates the need to transfuse large quantities of blood and saves operation time and thus, anesthesia time. Unnecessary excision of indeterminate areas of the burn wound is avoided; and only the deeper areas are prepared and grafted. Cultures of the papaya pulp after autoclaving, as described, were sterile. The proteolytic action of the enzyme is preserved even after autoclaving as the enzyme is heat resistant.
| Conclusions | | |
To summarize, the use of papaya pulp results in:
- Early and complete noninvasive debridement.
- Healthy granulation tissue.
- Decreased blood loss and, hence, decreased number of blood transfusions in cases that have to be grafted, as excision is avoided.
- Less operating time and, hence, less anesthesia time.
It is easily available and cheap and can be used for removing slough from all kinds of wounds.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Koller J, Bukovcan P, Orság M, Kvalténi R, Gräffinger I. Enzymatic necrolysis of acute deep burns-report of preliminary results with 22 patients. Acta Chir Plast 2008;50:109-14.  |
| 2. | Singer AJ, Taira BR, Anderson R, McClain SA, Rosenberg L. The effects of rapid enzymatic debridement of deep partial-thickness burns with debrase on wound reepithelialization in swine. J Burn Care Res 2010;31:795-802. |
| 3. | Ozcan C, Ergün O, Celik A, Cördük N, Ozok G. Enzymatic debridement of burn wound with collagenase in children with partial-thickness burns. Burns 2002;28:791-4. |
| 4. | Hafezi F, Rad HE, Naghibzadeh B, Nouhi A, Naghibzadeh G. Actinidia deliciosa (kiwifruit), a new drug for enzymatic debridement of acute burn wounds. Burns 2010;36:352-5. |
| 5. | Reddy GA, Priyanka B, Saranya S, Kumar CK. Wound healing potential of indian medicinal plants. IJPRR 2012;2:75-87. |
| 6. | Alam G, Singh MP, Singh A. Wound healing potential of some medicinal plants. Int J Pharm Sci Rev Res 2011;136-45. |
| 7. | Frankel EM. Factors influencing the proteolytic activity of Papain. J Biol Chem 1917;31:201-15. |
| 8. | Emeruwa AC. Antibacterial substance from Carica papaya fruit extract. J Nat Prod 1982;45:123-7. |
| 9. | Murthy MB, Murthy BK, Bhave S. Comparison of safety and efficacy of papaya dressing with hydrogen peroxide solution on wound bed preparation in patients with wound gape. Indian J Pharmacol 2012;44:784-7. [ PUBMED]  |
| 10. | Biswas TK. A review of Indian medicinal plants for wound management. In: Mani R, Teot L, editors. The Basic Needs to Achieve Wound Healing. 1 st ed. India: Jaypee Brothers Medical Publishers (P) Ltd; 2011. p. 135. |
| 11. | Starley IF, Mohammed P, Schneider G, Bickler SW. The treatment of paediatric burns using topical papaya. Burns 1999;25:636-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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