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ORIGINAL ARTICLE
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 52-56

To determine the efficacy and safety of acetic acid gel in comparison to silver sulfadiazine cream in patients suffering from second-degree burns


1 Department of Plastic Surgery, KEM Hospital and GSMC, Mumbai, Maharashtra, India
2 Department of Plastic Surgery and Burns, Kasturba Hospital Affiliated to Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India
3 Department of Plastic Surgery, Topiwala National Medical College and B.Y.L. Nair Charitable Hospital, Mumbai, Maharashtra, India

Date of Submission20-May-2021
Date of Acceptance23-Nov-2021
Date of Web Publication08-Jun-2022

Correspondence Address:
Dr. Chandrashekar Chalwade
Department of Plastic Surgery, KEM Hospital and GSMC, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_12_21

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  Abstract 


Acetic acid solution is effective in healing of chronic wounds by its ability to eradicate biofilms. One percent silver sulfadiazine (SSD) cream is the commonly used topical antimicrobial agent in burn wound care. In our study, we compared the efficacy and safety of 1% acetic acid gel with 1% SSD in partial-thickness burn wound with <20% total body surface area.
Context: Bacterial colonization of burn wounds results in delayed wound healing. SSD is commonly used as a topical antibiotic in the second degree and third-degree burn wounds. The acetic acid solution is found to be clinically effective against the eradication of mature or chronic biofilm.[6] We have used 1% acetic acid gel as an anti-microbial dressing for acute burn wounds and compared it with 1% SSD.
Aims: To evaluate the efficacy and safety of acetic acid gel with SSD cream in patients with second-degree burn wounds involving up to 20% of total body surface area. Outcome parameters evaluated were Wound healing (BWAT score and status as on Day 21), Pain (VAS score), Healing quality (VSS score at 1 and 3 months) and adverse effects if any.
Settings and Design: The study was conducted in the burn department affiliated with a tertiary care centre. It is a prospective randomized, investigator-initiated open-label case-control study. Inclusion criteria 1. Males and females between the ages of 18 and 65 years 2. Second-degree burn involving total body surface area up to 20% at 48 h of burn injury. Exclusion criteria1.Patients with pre-existing comorbidities. Uncontrolled diabetes Mellitus. Renal insufficiency.2. Patients with known keloid tendency3.Patients with electrical burn4.Patients with inhalation burn. Patients were included in the study in accordance with mentioned inclusion and exclusion criteria. Informed consent was obtained from all patients. All procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The study group received 1% Acetic acid gel while the control group received 1% SSD cream for antimicrobial dressings. Simple randomization was followed for the allocation of patients. Outcome parameters were assessed, compiled, and were statistically analyzed.
Subjects and Methods: Eighty cases were included in the study, forty in each group. Each group patient underwent dressing with respective allotted topical antimicrobial agent, and outcome parameters were compared. In both groups, Bates-Jensen Wound Assessment Tool (BWAT), Visual Analog Scale (VAS), and Vancouver Scar Scale (VSS) scores were documented. Parameters compared were wound healing, patient acceptability, any adverse events, and quality of the healed scar.
Statistical Analysis Used: The data was compiled and analyzed statistically for Outcome parameters will be analyzed for distribution, central tendency, and variability by calculating Mean, SD and p-value using Microsoft excel software (2007).
Results: At 21 days, the acetic acid group showed complete reepithelialization in 45% of the cases and complete granulation in 7.5% of the cases, whereas the SSD group showed complete reepithelialization in 32.5% of the cases. The remaining cases in both groups healed after 21 days. BWAT scores were reduced in both groups. Mean VAS and mean VSS scores were comparable in both groups. No adverse event was noted in any group due to respective agent.
Conclusions: In our study, we found that 1% acetic acid gel was comparable to 1% SSD in terms of efficacy and is safe to use in partial-thickness burn wounds <20% total body surface area (TBSA) with good clinical outcomes.

Keywords: Acetic acid gel, partial-thickness burn wounds, topical antimicrobial dressing


How to cite this article:
Chalwade C, Pawar MK, Sawant A. To determine the efficacy and safety of acetic acid gel in comparison to silver sulfadiazine cream in patients suffering from second-degree burns. Indian J Burns 2021;29:52-6

How to cite this URL:
Chalwade C, Pawar MK, Sawant A. To determine the efficacy and safety of acetic acid gel in comparison to silver sulfadiazine cream in patients suffering from second-degree burns. Indian J Burns [serial online] 2021 [cited 2022 Jun 25];29:52-6. Available from: https://www.ijburns.com/text.asp?2021/29/1/52/346900




  Introduction Top


Bacterial colonization of burn wound results in delayed wound healing. It may also progress to life-threatening septicemia with systemic complications. Topical antimicrobial agents for burn wound care such as silver sulfadiazine (SSD), mafenide acetate, honey solution, antibiotic ointments, and antiseptic solutions are available for control of wound sepsis. These agents not only reduce the wound microbial load but also they adversely affect wound healing.[1] SSD is commonly used as a topical antibiotic in second-degree and third-degree burn wounds. Silver is effective in controlling the wide range of bacteria and fungi and is lethal to various pathogenic strains[2] in the wound. However, the silver also has a profound effect on tissue healing[3],[4],[5] and the wound polymicrobial flora may develop resistant to it due to which the duration of healing may prolong.

Acetic acid solution is found to be clinically effective against eradication of mature or chronic biofilm.[6] It is used in treating various nonhealing wounds. We have used 1% acetic acid gel as an antimicrobial dressing for acute burn wounds and compared it with 1% SSD. Our study describes the comparison of efficacy and safety of acetic acid gel and SSD cream in patients suffering from second-degree burns.


  Subjects and Methods Top


This study is a prospective randomized, investigator-initiated open-label case–control study comparing the efficacy and safety of acetic acid gel with SSD cream in patients with second-degree burn wound involving up to 20% of total body surface area. The study was conducted in the burn department affiliated to a tertiary care center. Informed consent was obtained from all patients. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guidelines on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Inclusion criteria

  1. Males and females between the ages of 18 and 65 years
  2. Second-degree burn involving total body surface area up to 20% at 48 h of burn injury.


Exclusion criteria

  1. Patients with preexisting comorbidities


    1. Uncontrolled diabetes mellitus
    2. Renal insufficiency.


  2. Patients with known keloid tendency
  3. Patients with electrical burn
  4. Patients with inhalation burn.


Study group

This included cases who received 1% acetic acid gel for antimicrobial dressings.

Control group

This included cases who received 1% SSD cream for antimicrobial dressings.

Both group patients underwent dressings with respective allotted topical antimicrobial agent. At our institute, we follow a protocol of observing and doing daily antimicrobial dressings of second-degree burn wound for 21 days. After 21-day granulated wound is closed by skin grafting procedure, partially reepithelialized wounds are continued with daily moist dressings till they are healed. In our study, wounds were clinically examined daily and comparison between study and control groups was done as follows:

  1. Comparison of wound healing in two groups was done by two methods.


    1. First method by using “Bates-Jensen Wound Assessment Tool score.”[7] It consists of 13 items; each item has a score out of 5. The total (out of 65) is calculated by adding all the individual items to become a range of 13–65. Reduction in total score on serial examination indicates progression of wound healing. Bates-Jensen Wound Assessment Tool (BWAT) score was calculated and recorded on days 0, 3, 7, 14, and 21 for each patient in both groups
    2. Second method by assessing the wound status in each group at the end of 21 day. Wounds were categorized as a healed group which included completely reepithelialized and completely granulated wounds, whereas partially reepithelialized and partially granulated wound was categorized as a nonhealed group. The number of wounds in each group with the abovementioned wound status at the end of 21 days was recorded for comparison.


  2. Evaluation of patient acceptability using “Visual Analog Scale”[8] (VAS, score 0–10) at 1 h and at 24 h after dressing application. VAS score was documented daily
  3. Assessment of quality of healed burn scar using “Vancouver Scar Scale”[9] (VSS score out of 13) at 1 month and 3 months
  4. Any adverse event following the antimicrobial dressing such as allergic reaction to agent, surrounding skin redness, and rashes was noted during each dressing change.


Statistical analysis between the two groups was done. Data were statistically described in terms of mean and standard deviation. Comparison between the two groups was done using unpaired t-test and calculated. P < 0.05 was considered statistically significant.


  Results Top


Total eighty cases were included between January 2018 and April 2019, forty cases in each group. Overall, there was a reduction in mean BWAT scores in both groups from day 0 to day 21 [Table 1] and [Figure 1]. Comparison of mean BWAT scores at day 14 and day 21 showed significant P = 0.04 and 0.01.
Table 1: Mean Bates-Jensen Wound Assessment Tool score in study and control groups

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Figure 1: Line diagram showing the comparison of mean Bates-Jensen Wound Assessment Tool score on days 0, 3, 7, 14, and 21 in study and control groups

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The mean VAS score in the study group was 5.325 and in the control group was 4.625 at the end of 1 h after dressing application. At 24 h, the mean VAS score was reduced to 2.85 in the study group and 2.325 in the control group indicating good patient acceptability of both antimicrobial dressings more so for the control group [Table 2].
Table 2: Mean Visual Analog Scale at 1 h and 24 h in study and control groups

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At the end of 3 weeks, the study group showed complete reepithelialization in 45% of the cases, 7.5% of the cases showed complete granulation which underwent skin grafting for closure, and the remaining 47.5% required more than 3 weeks for complete healing. In the control group, 32.5% showed complete reepithelialization and the remaining 67.5% wounds required more than 3 weeks for complete healing [Table 3] and [Figure 2].
Table 3: Wound status at 21 days in both groups

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Figure 2: Wound status at 21 days

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The quality of healed wound scar in both groups was assessed at the end of 1 and 3 months after complete healing, using VSS. The mean VSS score in both groups is shown in [Table 4]. On comparison of mean VSS score, it showed a significant P value at 1 and 3 months [Table 4].
Table 4: Mean Vancouver Scar Scale at 1 month and 3 months in study and control groups

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There were no adverse events related to treatment during the study period.


  Discussion Top


Burn wound healing is a natural phenomenon. All the factors which may delay wound healing should be optimized. Controlling wound sepsis will lead to wound healing in a natural pace. Furthermore, the fact should be considered that as the wound healing time increases, the number of daily dressings will also increase causing economic burden. It will also lead to a poorly healed scar leading to scar complications in future.[10]

We used 1% acetic acid gel as an antimicrobial dressing for second-degree burn wound with <20% TBSA in our study group and compared it with 1% SSD as a control group [Table 5].
Table 5: Comparison of various parameters studied in study and control groups

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Acetic acid is effective against biofilms. It is a popular agent in wound care for transforming a nonhealing wound into a healing one. Acetic acid has its antibacterial activity by reduction of wound pH as well as by several other mechanisms.[11] Using at a 1% concentration, acetic acid is nontoxic to healing tissues and also it has no effect on reepithelialization.[6] In our study, we found acetic acid gel was comparable to SSD in terms of wound healing rate as the mean BWAT scores were reduced in both groups from day 0 to day 21. At the end of 3 weeks, the acetic acid gel group had more cases with completely healed wound, i.e., complete reepithelialized and granulated as compared to the SSD group. The remaining patients in both groups were healed after 3 weeks.

Acetic acid is a nociceptive solution. The acetic acid group patients experienced more pain, unpleasant stinging sensation than control group patients immediately after dressing application. However, after few hours, the pain experienced was almost same in both groups.

The ultimate result of wound healing is a scar. Scar quality has linear association with total time to heal the wound and also depth of the wound. Any surgical procedure done on wound for its closure like skin grafting surgery will also have an impact on final scar as well. In our study, quality of healed scars in both groups was better as we found lower mean VSS scores in both groups. The mean VSS score in the acetic acid group at 1 and 3 months was 5.45 and 2.525 which was comparable to the SSD group with a mean VSS of 6.025 and 2.825 with significant P value.

Our study was a preliminary study done in small group of patients with encouraging results. We have selected <20% TBSA second-degree burns for our study with no comorbid conditions. Future studies with larger cohorts may give more detail about the use of acetic acid gel in acute burn wound care.


  Conclusions Top


Our study has shown that 1% acetic acid gel is well tolerated as a topical antimicrobial agent in second-degree burn wound with <20% TBSA with good clinical outcome and its efficacy and safety was comparable to the use of 1% SSD cream.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Landis SJ. Chronic wound infection and antimicrobial use. Adv Skin Wound Care. 2008;21:531-40. quiz 541-2. doi: 10.1097/01.ASW.0000323578.87700.a5.  Back to cited text no. 1
    
2.
Lansdown AB, Williams A. How safe is silver in wound care? J Wound Care 2004;13:131-6. doi: 10.12968/jowc.2004.13.4.26596.  Back to cited text no. 2
    
3.
Subrahmanyam M. A prospective randomised clinical and histological study of superficial burn wound healing with honey and silver sulfadiazine. Burns 1998;24:157-61. doi: 10.1016/s0305-4179(97)00113-7.  Back to cited text no. 3
    
4.
Chaby G, Viseux V, Poulain JF, De Cagny B, Denoeux JP, Lok C. Topical silver sulfadiazine-induced acute renal failure. Ann Dermatol Venereol 2005;132:891-3. doi: 10.1016/s0151-9638(05)79509-0.  Back to cited text no. 4
    
5.
Muller MJ, Hollyoak MA, Moaveni Z, Brown TL, Herndon DN, Heggers JP. Retardation of wound healing by silver sulfadiazine is reversed by Aloe vera and nystatin. Burns 2003;29:834-6.  Back to cited text no. 5
    
6.
Bjarnsholt T, Alhede M, Jensen PØ, Nielsen AK, Johansen HK, Homøe P, et al. Antibiofilm properties of acetic acid. Adv Wound Care (New Rochelle) 2015;4:363-72. doi: 10.1089/wound.2014.0554.  Back to cited text no. 6
    
7.
Harris C, Bates-Jensen B, Parslow N, Raizman R, Singh M, Ketchen R. Bates-Jensen wound assessment tool: Pictorial guide validation project. J Wound Ostomy Continence Nurs 2010;37:253-9. doi: 10.1097/WON.0b013e3181d73aab.  Back to cited text no. 7
    
8.
Langley GB, Sheppeard H. The visual analogue scale: Its use in pain measurement. Rheumatol Int 1985;5:145-8.  Back to cited text no. 8
    
9.
Baryza MJ, Baryza GA. The vancouver scar scale: An administration tool and its interrater reliability. J Burn Care Rehabil 1995;16:535-8. doi: 10.1097/00004630-199509000-00013.  Back to cited text no. 9
    
10.
Finlay V, Burrows S, Burmaz M, Yawary H, Lee J, Edgar DW, et al. Increased burn healing time is associated with higher Vancouver Scar Scale score. Scars Burn Heal 2017;3:1-10; doi: 10.1177/2059513117696324.  Back to cited text no. 10
    
11.
Halstead FD, Rauf M, Moiemen NS, Bamford A, Wearn CM, Fraise AP, et al. The antibacterial activity of acetic acid against biofilm-producing pathogens of relevance to burns patients. PLoS One 2015;10:e0136190. doi: 10.1371/journal.pone.0136190.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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