Decreased Incidence of Hypertrophic Burn Scar Formation with the Use of Collagenase, an Enzymatic Debriding Agent
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Scar control is a major concern in burn wound management. When scarring occurs, the outcome may be associated with a loss of function or an undesirable cosmetic result. The functional problems may be severe enough to result in the inability to perform one’s usual work tasks. An unacceptable cosmetic result may lead to psychosocial concerns.
Early wound closure results in less hypertrophic scarring. Early excision and grafting of deeper injuries expedites wound closure. A significant challenge remains in how to avoid hypertrophic scar formation in partial-thickness wounds that are allowed to heal spontaneously.
In 1994, the authors’ institution began using an enzymatic debriding agent, collagenase, in the treatment of superficial burn wounds. Collagenase is a metalloproteinase derived from the fermentation of Clostridium histolyticum. Collagenase has been shown to expedite wound debridement.1,2 Furthermore, with earlier debridement to a clean dermis, re-epithelization occurs faster.1,2 The authors believe that a decrease in hypertrophic scar formation also occurs.
The purpose of this study was to compare the incidence of hypertrophic scar formation in patients with partial-thickness burns not treated with collagenase to those treated with collagenase. The authors’ intent was to report an observation that needs further investigation. The hypothesis for this study was that the use of collagenase in the partial-thickness burn wound decreased the incidence of hypertrophic scar formation.
This was a retrospective review of patients treated for partial-thickness burn injuries at the University of South Alabama Burn Center. Only patients who received their entire care and follow-up care at the University of South Alabama were included in this study.
Burn wound management from 1989 to 1993 consisted of first placing a silver sulfadiazine dressing on the wound. The dressing was changed daily for 3 days and then changed to a daily wet-to-dry dressing. The wet-to-dry dressing part of this routine was changed in 1993 to a collagenase enzymatic debriding dressing. Daily wound care then continued until a barrier dressing could be applied or until the wound spontaneously re-epithelized.
The criteria for inclusion in the study consisted of patient age between 8 and 70 years and no need for excision and grafting. Patients treated for a burn injury in 1993 were excluded from the review, because this was a transition year when the burn care management shifted from a normal saline dressing to the collagenase dressing. Data was not available as to which patients were treated with a wet-to-dry dressing and which patients were treated with collagenase.
The patients treated between 1989 and 1992 for acute partial-thickness burns were classified as the Saline Wet-to-Dry group. Those patients treated between 1994 and 1997 were labeled the Collagenase group.
An outpatient chart review was performed for patients meeting the stated criteria. The number of months a patient was followed as an outpatient depended on the level of concern regarding possible scar formation. Care was taken to record whether or not scarring had been an issue in the patient’s care. The criteria for considering scarring as an issue included a description of the scar as “moderate” or “severe” in intensity, the need for use of pressure garments, or the use of silicone gel sheets. Patients were not placed into garments unless scar concerns existed. Age, race, sex, percent total body surface burn, and the mechanism of the burn were also recorded.
For the years 1989 to 1992, the Saline Wet-to-Dry group comprised 225 patients. For the years 1994 to 1997, the Collagenase group comprised 207 patients. The mean age for both groups was 32 years.