Naheed Ahmed et al
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
Original Article
Effectiveness of 0.025% Dakin’s
Solution Versus
1% Silver
Sulphadiazine for Treatment of
Partial Thickness Burns
Objective: To evaluate effectiveness of 0.085% Dakin’s solution verses 1% Silver
Suplhadiazine in the treatment of partial thickness burns
Study Design: Quasi Experimental Study
Place and Duration of the Study: The Study was conducted in the burn unit/plastic
surgery department, Nishtar Hospital Multan during a period from July, 2008 to December,
2010.
Materials and Methods: 30 patients were enrolled with second degree burns at two
sites on different parts of the body. Each patient had one burn treated with 0.025% Dakin’s
Solution and one treated with 1 % Silver sulphadiazine.
Results: The rate wound healing was significantly faster in the site treated with 0.025%
Dakin’s Solution than in the site treated with 1 % Silver sulphadiazine. The mean times for
healing were 18.73 ± 2.65 and 15.9 ± 2 days for 1 % Silver sulphadiazine and 0.025 %
Dakin’s Solution, respectively, being significantly shorter for 0.025 % Dakin’s Solution (P <
0.0001).
Conclusion: 0.025% Dakin’s Solution demonstrated the greater efficacy and effectiveness
for treating partial thickness burns.
Key words: 0.025% Dakin’s Solution, 1 % Silver sulphadiazine , partial thickness burns
Introduction
1,2
Burns and scalds form 5-12 % of all traumas.
3
The exact incidence of burns in Pakistan is not known
due to non availability or incompleteness of death
registration and disease reporting. However, in United
4
States almost two million people burns annually. Burn
injury not only damages the normal skin barrier but also
impairs host immunological defenses. Because the
eschar may be several centimeters or more distant from
patent microvasculature, systemically administered
antimicrobial agents may not achieve therapeutic levels
by diffusion to the wound surface, where microbial
numbers are usually greatest. Topically applied
antimicrobials provide high concentrations of drug at the
wound surface; they penetrate eschar variably, a
5
property that should be considered in their selection.
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
Naheed Ahmed*
Muhammad Naveed Shahzad **
Khalid hussain qureshi***
Muhammad Bilal Saeed
Faisal Waheed
Ahmad Ali
FCPS (PLAST)Assistant Professor of
Plastic Surgery & Head of Plastic
Surgery Department, Nishtar
Hospital, Multan
**MCPS,FCPS(General surgery)
Post Graduate Resident of Plastic
Surgery, Nishtar Hospital, Multan
***FCPS(G.surgery)FCPS(URO)
Associate Professor of Surgery
,Nishtar Hospital, Multan
Address for Correspondence
Dr. Naheed Ahmed. Burn Unit
Nishtar Medical College & Hospital,
Multan
Email: naheedahmed1@yahoo.com
The goal of prophylactic topical therapy is initially to
6
delay and later to minimize wound colonization.
1% silver sulfadiazine (SSD) cream is the most common
topical agent used in the treatment of burns because of
7
its antimicrobial efficacy , but there is the problem of
8
delayed wound healing associated with SSD cream.
Currently the most effective topical antibacterial for
9
cleansing a wound is sodium hypochlorite (NaOCl).
While povidone-iodine is bactericidal at 1% and 0.5%
concentrations, it is toxic to fibroblasts; acetic acid at a
0.25% concentration is not bactericidal but is toxic to
fibroblasts; and hydrogen peroxide at 3% and 0.3%
concentrations is toxic to fibroblasts but only the 3%
10
concentration is bactericidal. Reducing bacteria counts
and supporting the immune response of the host without
compromising the activities of proliferative cells would
constitute optimal antisepsis. Dilute concentrations of
Dakin’s solution from 0.025% to 0.005% have been
demonstrated the effective antimicrobial activity without
127
Naheed Ahmed et al
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
any effect on fibroblast activity. In addition, it is
extremely inexpensive to produce, and maintains its
bactericidal capacity for several days when stored in an
11
opaque, closed container.
Realizing the antimicrobial effect of 0.025% Dakin’s
solution in burn wound, we designed a comparative
study to evaluate the effect of Dakin’s Solution dressing
and 1% silver sulfadiazine dressing in second degree
burns. By doing this we would be able to find the better
modality which will be further helpful in treatment of
partial thickness burns.
Materials and Methods
In our study we used 0.025% Dakin’s Solution. This
solution was prepared in the Department of
Biochemistry Nishtar Hospital Multan by the joint
venture of an experienced biochemist and a pharmacist.
This solution was made under the guidelines of US
12
Pharmacopea:
• Sodium hypochlorite Solution
0.5 mL
• Monobasic sodium phosphate monohydrate 1.02g
• Dibasic Sodium Phosphate anhydrous
17.61g
• Purified water to 1000mL
Study Protocol: This study was a randomized,
comparative clinical trial conducted in the burn
unit/plastic surgery department, Nishtar Hospital Multan
during a period from July, 2008 to December, 2010.
After approval of the study protocol from the Institutional
Ethical Committee, 30 patients who were willing to
participate in the study were enrolled. The inclusion
criteria for this trail were as follows: history of the burn
within 24 hours of the initiation of treatment; burns
affecting two same sites e.g. on the feet or hands;
second degree burns with respect to depth; and burns
with <40% total burn surface area (TBSA). Patients who
had diabetes, hypertension, epilepsy, kidney disease or
pregnancy were excluded. Similarly patients with
corrosive, electrical and chemical burns were also not
included in the study.
All burn patients were received in A & E
department of Nishtar Hospital Multan where the fluid
resuscitation was done and patients were admitted in
the burn unit. Wounds were cleaned with pyodine scrub
and normal saline and the topical agent either 0.025%
Dakin’s solution or 1% SSD cream was applied to the
wound. The dressing was changed twice daily.
Treatment with topical agents was continued until the
burns were fully healed and re-epithelialized.
rd
generation cephalosporin and BEmpirically, 3
penicillin were started in all patients. Wound swab
cultures from three different sites from all patients were
taken, at the time of admission and then at every
seventh day and then antibiotics were initiated according
to the results of bacteriological examination.
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
Relevant data of patients regarding their
registration, history, site of the burn, TBSA affected
degree of burn, depth of burn, presence or absence of
slough in the wound, medical report, operative notes,
pre- and postoperative photographs, duration of hospital
stay and outcome were filed individually.
During their stay in ward, Strict monitoring of
intake/ output was done. Where indicated, we supported
our patients with blood products. In all the patients,
great care was given to nutrition. Almost all the patients
were given oral nutrition with occasional intravenous
support in the form of amino acid infusion in few
patients. At the time of change of dressing details
regarding the condition of the wound such as signs of
wound infection, condition of surrounding unburned
tissues, discharge, smell, necrotic tissue and state of
epithelialisation was noted by our consultant burn
rd
surgeon on every 3 day. Subjective factors such as
pain and local irritation were recorded regularly.
Allergies or other side effects were noted in both groups.
The patients and attendants were given
information regarding the Dakin’s Solution and 1%silver
sulphadiazine cream.
All the data were analyzed using SPSS 11
software. The Student t-test and analysis of variance
test were used to compare the study groups, wound
size, and healing time. Significance level was
determined as less than 0.05.
In this study, the “B” part of the body was
treated with 1 % Silver Sulfadiazine and the “A” part was
treated with 0.025% Dakin’s Solution.
Patients and nursing staff were blinded to the
28
procedure. We followed the method of Flanagan M. for
measuring Wound Length, Width, and Area. We
measured the longest length and width, regardless of
head-to-toe orientation and multiplied the 2
measurements to obtain the area in squared
2
centimetres (cm ), i.e.
Area (in centimetre square) = length x width
29
We measured the wound progression by calculating
percentage rate of change by a simple statistical
calculation that uses the following formula:
1. Baseline (week 0) wound size (OA or overall OA
size) measurement as the original size.
2. Subtract the next wound size OA or overall OA size
measurement (interim) taken from the baseline.
3. Divide by baseline wound measurement and multiply
by 100 %.
Formula for Healing percentage in burn wound.
nd
Wound area an admission day - Area on 2 time x 100%
Baseline wound area an admission day
Results
The effectiveness of 0.025 % Dakin’s Solution
was compared with 1% silver sulfadiazine in this trial.
128
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
There was no mortality recorded in our study. To
minimize the confounding variables, only those patients
who had partial thickness burns of the hands or feet with
similar extent and the size of the burn at both sites were
selected. With this randomization, one site was treated
with SSD cream and the other site was treated with
0.025% modified Dakin’s Solution.
Out of 30 patients, 18 patients reported within 916 hours of burn, 5 patients came to the hospital within
1-8 hours of burn, 3 patients in < 1hour, while 4 patients
came within 17-24 hours of burn. Other demographic
characteristics of our patients with Burns are
summarized in Table I.
Table I :Demographic Characteristics
Gender
No
of Percentage
cases
25
56.81%
5
43.19 %
Male
female
Age of Patients
14-20 years
6
13.63%
21-30 years
20
45.45%
31-40 years
6
13.63%
41-50 years
3
9.09%
51-60 years
6
13.63%
> 60 years
3
9.09%
Minimum age of the patient included in our
study=15 years
Maximum age of the patient included in our
study=65 years
Mean age + =33.59 + 15
TBSA
10 -20 %
14
31.8%
21 -30 %
22
50%
31 -40 %
8
18.2 %
Mean + SD TBSA 19.8+ 7.9
Time of Admission
<1 hour
3
6.81%
1-8 hours
5
11.36%
9-16 hours
26
59.1%
17-24 hours
10
22.7%
Site of burns
Right and left hand
26
(87%)
Right and left foot
2
(7%)
Right or left hand or 2
(7%)
arm / right and left
foot or leg
Naheed Ahmed et al
Table II: Time of healing after treatment with
0.025 % Dakin’s Solution versus silver
sulfadiazine (SSD)
Time for complete
healing
<10 days
<13 days
<16 days
<19 days
Mean healing period
± SD (days)
P value
No. of patients
SSD group
0.025% Dakin’s
(n = 30)
Solution group (n
= 30)
1
2
2
5
7
25
24
30
18.73 ± 2.65
15.9 ± 2
<0.0001
Table III: Comparison of wound burn sizes
in the silver sulfadiazine and 0.025 %
Dakin’s Solution groups. The wound size
was defined as 100% on day 4 and then
calculated and compared with day 4
thereafter
Days Comparison of wound burn sizes In
After percentage
Burns 0.025 % Dakin’s SSD group
Solution group (n = (n = 30)
30)
Day
Wound size 100 % Wound size 100 % as
4
as on day 1
on day 1
No change /healing
No change /healing
Day
Wound size 100 % Wound size 100 % as
7
as on day 1
on day 1
Healing started but Healing started but
wound size is not wound size is not
changed
changed
Day
Wound size started Wound size 100 % as
10
to decrease
on day 1
80-100 % as on day 1 Healing started but
wound size is not
changed
Day
Wound size 50-80 % Wound size started to
13
as on day 1
decrease
90-100 % as on day 1
Day
Wound size 10-50 % Wound size 80 % or
16
as on day 1
more as on day 1
Day
Complete healing
Wound size 50 % or
19
more as on day 1
Day
Wound size 30 % or
21
more as on day 1
Day
Wound size 10-30 %
21
as on day 1
Complete healing = day
32
The mean times for healing were 18.73 ± 2.65
and 15.9 ± 2 days for SSD and 0.025 % Dakin’s
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
129
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
Table IV: Comparison of the effectiveness
of daily dressings with 0.025 % Dakin’s
Solution and with 1% silver sulfadiazine
Criteria for
cure
Time taken
for 0.025 %
Dakin’s
Solution
to show
100%cure
Time taken for SSD to
show 100%cure
Wound
Healing
(mean ± SD;
days)
Negative
bacterial
culture
18.73 ± 2.65
15.9 ± 2
1 week
Less than 3 weeks
Solution, respectively, being significantly shorter
for 0.025 % Dakin’s Solution (P < 0.0001; Table II). The
sites treated with 0.025 % Dakin’s Solution healed
approximately 3 days sooner than the sites treated with
SSD in all the patients. In fact, wound healing took less
than 16 days in 83% of the sites treated with 0.025 %
Dakin’s Solution, but more than 19 days in the sites
treated with SSD. The average wound size at 4, 7, 10,
13, 16, 19, 21, and 24 days after burn injury were
measured. With this trend, the percentage of each
wound size was calculated by reducing the fraction of
the second to the first wound size (cm2). There was a
significant difference between the 0.025 % Dakin’s
Solution group and the SSD group 10, 13, and 16 days
after treatment (P < 0.01). (Table III)
The mean times for healing were 18.73 ± 2.65
and 15.9 ± 2 days for SSD and 0.025 % Dakin’s
Solution, respectively, being significantly shorter for
0.025 % Dakin’s Solution (P < 0.0001; Table 2). The
sites treated with 0.025 % Dakin’s Solution healed
approximately 3 days sooner than the sites treated with
SSD in all the patients. In fact, wound healing took less
than 16 days in 83% of the sites treated with 0.025 %
Dakin’s Solution, but more than 19 days in the sites
treated with SSD. The average wound size at 4, 7, 10,
13, 16, 19, 21, and 24 days after burn injury were
measured. With this trend, the percentage of each
wound size was calculated by reducing the fraction of
the second to the first wound size (cm2). There was a
significant difference between the 0.025 % Dakin’s
Solution group and the SSD group 10, 13, and 16 days
after treatment (P < 0.01). (Table III)
The surfaces of both sites were swabbed to test
for microbial contamination on days 3, 7, and 13, and
was found to be negative in 0.025 % Dakin’s Solution
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
Naheed Ahmed et al
group after 7th day while The swabs were positive for
bacterial growth in 80% of the patients at 7th day and 30
% on 13th day and after 21 days wound became sterile
in SSD group. (Table IV)
There was significant difference of cost of
treatment. The cost of treatment per percent body
surface burnt per dressing of 1% silver sulfadiazine was
Rs. 60 for 1 grams of ointment. As against of this, cost
of 0.025% Dakin’s Solution dressing was amazingly low
costing only RS.50 / gallon.
Figure I: A young male of 34 having burns
of feet ,ankle and leg area .Side treated with
silver sulphadiazine show wounds while
better healing can be seen on the side
where 0.025 % Dakin’s Solution dressing
was done
Figure II: A lady of 45 years showing better
healing on the dorsum of the right hand
which was treated with 0.025 % Dakin’s
Solution dressing
130
Naheed Ahmed et al
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
Discussion
The normal wound repair process is coordinated
and predictable series of cellular and biochemical
events. However certain pathophysiological conditions
alter this pre-programmed course of events so that
wound healing can be enhanced or impeded. Presence
of necrotic tissue not only inhibits wound healing but it
deepens wounds through extensive inflammatory
response. So removal of necrotic tissue is extremely
13-16
and
essential to prevent and diminish wound sepsis
enhance wound healing.
The antimicrobial effect of silver sulfadiazine is
the only mechanism justifying its continued use in burn
17
injury. How ever resistance has been demonstrated.
Hepatic or renal toxicity and leukopenia may be caused
by the topical application of SSD. In fact, these side
effects have been observed in the treatment of large
13
wounds.
Dakin and Carrel developed sodium hypochlorite
18-20
solution; Bunyan used it in the treatment of burns.
The use of sodium hypochlorite solution in treatment of
burns diminished with the availability of antibiotics
21
mafenide acetate and silver sulfadiazine. However,
some burn centres continue to use dilute NaOCl in
22
hydrotherapy.
Sodium hypochlorite as a dilute solution is attractive as
a topical agent for a variety of reasons.
• It is cheap than any of the currently available topical
agents used in burn therapy
• It is easy to prepare
• At dilute concentrations (0.025 %) NaOCl kill
virtually all of the microorganisms known to infect
burn patients, and there has been no evidence that
microorganisms can develop resistance to its action.
Although the precise microbicidal action of NaOCl
has not been fully established, it is currently
believed that the oxidation of sulfhydryl groups on
essential enzymes by chlorine is responsible for cell
23
death. Since this is a multitarget system, the
chances of resistant mutants arising are quite
remote.
• NaOCl is known to reduce oedema and
inflammation, and it does not appear to affect
granulation tissue or reepithelialisation of the burn
18-19
wound.
• The proteolytic action of NaOCl causes rapid
24
breakdown of dead tissue.
Sodium hypochlorite (0.5% or 0.25% NaOCl)
solution is considered a general bactericidal (e.g.,
Staphylococci and Streptococci), fungicidal, and
veridical agent. Concentrations as low as 0.025% has
also demonstrated bactericidal effects. The bactericidal
effects are the suggested rationale for aiding wound
healing. Sodium hypochlorite at 0.25%, however, has
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
25-28
26,29
and keratinocytes
displayed toxicity to fibroblasts
in culture. Polymorphonuclear leukocyte viability is also
30
inhibited by this topical agent. Sodium hypochlorite
solutions of 0.5% would be expected to demonstrate at
least these same levels of toxicity. Tissue toxicity was
25
not observed at concentrations of 0.025%. In 1991
Herndon DN, noted that sodium hypochlorite solution as
31
low as 0.025 % had Bactericidal effects. Burn patients
have a higher morbidity than mortality because burn
wound, due to the presence of necrotic tissue, has great
chances of infection and thus require long periods of
32
dressings, leading to deformities and contracture.
Delayed reporting has been found to be an important
factor that causes an increase in wound infection and
33
thus morbidity. This is a major problem in the third
world countries like Pakistan, owing to poor transport
condition, illiteracy and relative inaccessibility of tertiary
health-care centres.
Conclusion
0.025% Dakin’s Solution demonstrated the
greater efficacy and effectiveness for treating partial
thickness burns.
References
1.
Olaitan PB, Olaitan JO. Burns and Scalds-epidemiology and
prevention in a developing country. Niger J Med 2005;14(1):9-16.
2. Gudaviciene D, Rimdeika R, Adamonis K. Nutrition of burned patients.
Medicina (Kaunas) 2004;40(1):1-8.
3. Jamil H, Khalil F, Saeed M. Etiology and Outcome of burn victims in a
tertiary care facility. J Sur (PIMS) 2002;(25):1.
4. Garner WL, Magee W. Acute burn injury. Clin Plast Surg
2005;32(2):187-93.
5. Bessey PQ .Wound care In:Herndon DN, editor. Total Burn Care.3rd
edition. China: Saunders Elsevier Inc; 2007.p. 131.
6. Monafo WW, West MA. Current treatment recommendations for topical
burn therapy. Drugs 1990; 40(3):364–373.
7. Vloemans AFPM, Soesman AM, Suijker M,et al. A randomized clinical
trial comparing a hydrocolloid-derived dressing and glycerol preserved
allograft skin in the management of partial thickness burn. Burns
2003;29:702–10
8. Gallagher JJ, Williams-Bouyer N, Villarreal C, Heggers JP, Herndon
DN. Treatment of infection in burns.In:Herndon DN,editor. Total Burn
Care.3rd edition. China: Saunders Elsevier Inc; 2007.p. 170
9. Lindberg RB, Moncrief JA, Mason AD Jr. Control of experimental and
clinical burn wound sepsis by topical application of sulfamylon
compounds. Am NY Acad Sci 1968; 150:950.
10. Heggers JP, Robson MC eds. Quantitative bacteriology: its role in the
armamentarium of the surgeon. 1st edn. Boca Raton, FL,
CRC;1991:139
11. McKenna, P., Lehr, G., Leist, P., Welling, R. (1991) Antiseptic
Effectiveness with Fibroblasts Preservation. Annals of Plastic Surgery,
27 265-268.
12. Allen LV.Allen's compounded formulations: the complete U.S.
pharmacist collection. American Pharmaceutical Association,
2003.p.167.
131
Effectiveness of 0.025% Dakin`s Solution Versus 1% Silver Sulphadiazine…
13. Murphy JT, Duffy S, Prudue GF et al. Thermal injury altersendothlielial
vasoconstrictor and vasodilator response to endotoxin.J Truama
1999;47(3):492.
14. Lu S, Xiang L, Quing C ,et al. Effect of necrotic tissue on progressive
injury in deep partial thickness burn wounds. Chin Med J
2002;115(3):323-5.
15. Reynolds N, Cawrse N, Burge T et al. Debridement of a mixed partial
and full thickness burn with an erbium:YAG laser.Burns
2002;29(2):183-8.
16. Epstein AM. The outcomes movement—will it get us where we want to
go? N Engl J Med 1990;323:266–70.
17. Lansdown AB. Silver. I: Its antibacterial properties and mechanism of
action. J Wound Care 2002;
18. Bunyan, J. 1941. The treatment of burns and wounds by the envelope
method. Br. Med. J. 2:1-7.
19. Bunyan, J. 1960. Use of hypochlorite for the control of bleeding.Oral
Surg. Oral. Med. Oral Pathol. 13:1026-1031.
20. Flanagan M. Wound Management. Churchill Livingstone: Edinburgh;
1997.
21. Moncrief, J. A. 1974. Topical antibacterial therapy of the burn wound.
Clin. Plastic Surg. 1:563-576.
22. Rodeheaver, G., W. Bellamy, M. Kody, G. Spatafra, L. Fitton, K.
Leyden, and R. Edlich. 1982. Bactericidal activity and toxicity of iodinecontaining solutions in wounds. Arch. Surg.117:181-186.
23. Knox, W. E., P. K. Stumpf, D. E. Green, and V. H. Auerbach. 1948.
The inhibition of sulfhydryl enzymes as the basis of the bactericidal
action of chlorine. J. Bacteriol. 55:451-458.
24. Morgan, O., F. Saner, and E. Schlesinger. 1917. Some aspects of the
treatment of the infected war wounds. Br. J. Surg.5:425-461.
Ann. Pak. Inst. Med. Sci. 2011; 7(3): 127-132
Naheed Ahmed et al
25. Heggers JP, Sazy JA, Stenberg BD, et al. Bactericidal and woundhealing properties of sodium hypochlorite solutions: the 1991 Lindberg
Award. J Burn Care Rehabil. 1991;12: 420-424.
26. Kozol RA, Gillies C, Elgebaly SA. Effects of sodium hypochlorite
(Dakin's solution) on cells of the wound module. Arch Surg. 1988;
123:420-427.
27. Lineaweaver W, McMorris S, Soucy D, Howard R. Cellular and
bacterial toxicities of topical antimicrobials. Plast Reconstr Surg.
1985;75:394-396.
28. Smoot EC, Kucan JO, Roth A, et al. In vitro toxicity testing for
antibacterials against human keratinocytes. Plast Reconstr Surg. 1991;
87:917-924.
29. Cooper ML, Boyce ST,. Hansbrough JF, et al. Cytotoxicity to cultured
human keratinocytes of topical antimicrobial agents. J Surg Res.
1990;48:190-195.
30. Hansbrough JF, Zapata-Sirvent RL, Cooper ML. Effects of topical
antimicrobial agents on the human neutrophil respiratory burst. Arch
Surg. 1991;126:603-608.
31. Herndon DN. Robson MC. Bactericidal and wound-healing properties
of sodium hypochlorite. Journal of Burn Care & Rehabilitation.1991;
12(5):420-4.
32. Subrahmanyam M. Honey dressing versus boiled potato peel in the
treatment of burns: A prospective randomized study. Burns
1996;22:491-3.
33. Ozbek S, Ozgenel Y, Etoz A, Akin S, Kahveci R, Heper Y, et al. The
effect of delayed admission in burn centers on wound contamination
and infection rates. Ulus Travma Acil Cerrahi Derg 2005;11:230-7.
132