Topical Antimicrobials in Burn Wound Care: A Recent History
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“It is nearly 100 years since antisepsis came to dominate the treatment of burns. All that has been accomplished, as far as we can see from the data available, has been to offset the good that sound physiological and surgical principles and modern aseptic technique should have afforded.”1
—Carl A. Moyer, MD, 1954
The topical therapy of burn wounds dates back to the beginnings of civilization. Throughout history, a number of famous philosophers, physicians, and scientists have contributed to the knowledge of burn wound management, including such notables as Hippocrates, Celsus, Pliny the Elder, Galen, Aristotle, Rhases, Clowes, Paré, Hildanus, Marjolin, Dupuytren, and Syme.2 A diverse variety of substances have been advocated as effective topical burn treatments including various plants, gums, milks (goat milk, and milk from “a women who has given birth to a son”), tea leaves, roasted angle worms, oak bark extract, honey, cork, bear fat, bran, ashes, vinegar, wine, fat from “very old wild hogs,” calcium chloride soaks, moss “from the skull of a person hung,” red sandalwood, cold water, saline baths, lemon strips soaked in oily dressings, soot, spider webs, linseed oil mixed with lime water, picric acid, medicated paraffin, carbolic acid, cod liver oil, and “portions of a genuine mummy.”2–4 Such ancient history, while fascinating, has little utility in contemporary practice with the possible exception of providing entertainment on teaching rounds. This article will concentrate instead on the more recent history of topical agents utilized in burn care.
Over the years, the goals of topical burn treatment have changed. At the beginning of the 20th century, it was understood that the systemic derangements seen in burn patients resulted from a release of “toxins” from the burn wound, and the goal of topical therapy was to bind or leach toxins before they could be absorbed.4 A secondary goal was to dry out the burn wound or to create a hard coagulum to minimize exudate, drainage, or fluid loss. A number of “escharotics” have been employed, alone or in combination, including 5% or 10% silver nitrate solution, gentian violet,2,5 “triple” dyes, trinitrophenol, and tannic acid. Davidson at the Henry Ford Hospital first described the use of tannic acid spray in 1925,2,6 and believed that this modality reduced pain and produced a cleaner wound bed.2 In 1935, Bettman added 10% silver nitrate to a 2.5% tannic acid solution, which allowed wound tanning to occur in seconds.4 Reports of liver necrosis in patients treated with tannic acid began to appear in the 1930s, although the liver necrosis was often ascribed to the burn injury itself. Additionally, pus tended to accumulate under the coagulum formed by tannic acid application. McClure, also from Henry Ford Hospital, reported in 1944 that tannic acid was a hepatotoxin and the use of this agent was discontinued.2
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exquisitely researched, very well written & a very interesting topic.
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