The effects of silver dressings on
chronic and burns wound healing
Abstract
Silver (Ag) has been thought to improve wound healing and
reduce instances of associated infections for many years. There
are centuries‑old records of silver being used in wound treatment,
but the past two decades in particular have seen an increasing
clinical application of silver-impregnated wound dressings and as
such, have seen the number of research articles similarly increase.
The majority of these articles focus on the positives and potential
negatives (e.g. the toxicity of silver as a heavy metal) of using
silver‑impregnated dressings in the clinical management of wounds.
This article examines the potential advantages and disadvantages
of using silver in the management of chronic and burn wounds,
and provides a physiological understanding of the body’s response
to silver absorption. The author also attempts to critically appraise
the opposing literature related to the clinical relevance of microbial
kill‑time and the volume of silver contained in dressings, while
investigating the efficacy of silver‑impregnated dressings in the
management of burns and chronic wounds. In order to collect
literature relevant to this review, the author searched CINAHL,
Medline, BMJ, Medscape, Journal of Advanced Nursing, the Electronic
Medicines Compendium (EMC), and the Cochrane Library, using the
terms silver, silver sulfadiazine, impregnated, wound, burn, dressing, review,
quantative, efficacy, in vitro, in vivo, nanocrystalline, toxicity, infection,
microbial kill-time, and comparison.
Key words: Silver n Dressings n Chronic wounds n Burns n Healing
A
significant rise in the use of silver-impregnated
wound dressings has been witnessed over the
last decade. The majority of these dressings
contain quantities of silver sulfadiazine, a
sulfa derivative topical antibacterial widely used in the
management of infections arising from burn injury, as
well as most other forms of wound.The current trend appears
to be the application of the silver sulfadiazine‑containing
dressings to long-term wounds. Owing to the ongoing
use of these dressings in long‑term and chronic wound
management, the potential toxic effects must be taken into
Chris Elliott is Registered Adult Nurse (Non-Commissioned) in
general surgery, Queen Alexandra’s Royal Army Nursing Corps
Accepted for publication: July 2010
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Chris Elliott
account, especially with regard to the quantity of silver
applied to chronic wounds over prolonged periods.
This article aims to provide an analysis of the potential
advantages and disadvantages of using silver in wound
management, while providing a comprehensive physiological
understanding of the processes involved in the absorption
of silver. The author also examines the available research
into the clinical relevance of microbial kill-time, and the
quantity of silver and silver compounds contained within
dressings. Most importantly, the article examines the
efficacy of silver derivatives and compounds to establish the
overall efficacy of silver dressings.
How silver enters the body and the risk
of toxicity
By virtue of its use in wound dressings, silver is coming into
contact with damaged and broken skin on an increasingly
regular basis. Fung and Bowen (1996) identified that as the
use of silver increases, it is necessary that health professionals
are aware of the potential negative effects, such as contact
dermatitis and toxicity. Poon and Burd (2004) go further in
highlighting the need to appreciate that there are multiple
complexities and quantities of silver being used in dressings,
and provide quantitive data in support of their suggestion
that only excessive doses of silver sulfadiazine lead to local
or systemic toxicity.
A review of the published research carried out by
White and Cutting (2006) indicates that there are three
main factors which influence the capacity for silver to
produce toxic effects:
■■ The degree of absorption
■■ The capacity of the compound to bind to biological sites
■■ The degree to which the silver compound ions
are absorbed, metabolized and ultimately excreted from
the body.
There are many compounds and forms in which silver
can be applied to wounds. These possibilities range from
inorganic salts (e.g. silver nitrate) to organic compounds
(e.g. silver sulfadiazine). White and Cooper (2005) indicate
that there is not sufficient conclusive evidence to clarify
whether the chemical nature of silver being absorbed into
the body affects its distribution and the rate at which it
is metabolized. While much of the literature used in a
systematic review conducted by White and Cooper (2005)
makes no conclusion on this matter, research carried out by
Wan et al (1991) and Coombs et al (1992) concludes that
the nature of the compound does affect its metabolism.
Similarly, a double-blind study carried out by Fung and
British Journal of Nursing, 2010 (Tissue Viability Supplement), Vol 19, No 15

Bowen (1996) produced results indicating that organic
compounds are better absorbed by the body and present
a slightly heightened risk of toxicity. Owing to the robust
scientific method used by Fung and Bowen (1996) and the
concurrence with the findings of Coombs et al (1992) and
Wan et al (1991), the author accepts that there is a likelihood
that organic silver, particularly silver sulfadiazine, may have
faster metabolic rates. However, because of the small sample
size and that Fung and Bowen’s (1996) study included
only participants with burn wounds, it is the position of
the present article that their findings are not generalizable,
but do present a need for further research into the area of
silver toxicity.
Having established that silver penetrates the body via
absorption, the next area to consider is whether or not
the quantity of silver absorbed increases background levels
and as such, increases the likelihood of local or even systemic
toxicity.
It is physiologically accepted that background levels
of silver are very low within the human body. Guy’s and
St Thomas’ NHS Foundation Trust quotes background
levels of silver under normal conditions to be less than
3 nanomols/litre (nmol/L) in blood and less than 8 nmol/L
in urine. Studies carried out by Boosalis et al (1987) and
Chaby et al (2005) concluded that those participants treated
with topical silver sulfadiazine often showed plasma/blood
silver concentrations of 900 nmol/L over a 6-hour period
post-application, and a urine/silver concentration of up to
4000 nmol/L over a 24-hour period. Chaby et al (2005)
reported a statistical significance (when viewing P as 0.05)
showing that silver sulfadiazine increases renal background
silver concentration by 4000% over an 8-day period. This
value was the mean value of the results returned from a
sample of 30 participants, as the mean is accepted as the
most accurate measure of central tendency. The present
article accepts the value of 4000% to be an acceptable figure
in the reported findings.
A randomized controlled study carried out by Lansdowne
and Williams (2004) reported findings which suggested
that continued application of silver sulfadiazine increases
background levels of silver, but that the increase is not
significant enough to present any risk of toxicity. These
findings are lacking in that the sample group only included
those specifically presenting with chronic leg ulcers, and
while the present article acknowledges the findings of
Lansdowne and Williams (2004), it must be understood that
it would be inappropriate to generalize these findings to
the wider population owing to the specific nature of
the sample group (those with long-standing leg ulcers).
Consideration must be given to the fact that both sets
of research used similar doses of silver sulfadiazine and
while both reported increased background levels of silver,
the levels at which each research project reported were
significantly different.
It can only be assumed that the statistical data of the two
studies varied as a result of three possibilities. Firstly, the
methods in which the data were analysed may have varied,
yet neither study shows suggestion of this. Secondly, the
rate at which silver was absorbed may vary because of the
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literature review
type of wound, as supported by White and Cooper (2006)
and Poon and Burd (2004). Finally, there may have been
erroneous recordings in one of the studies, which could
have significantly skewed the statistics as both studies used
small sample sizes (25–30 in both studies). Unfortunately,
this assumption could not be substantiated as confidence
intervals were not available for either study. The efficacy
and toxicity of silver dressings will be affected by the type
of wound, duration of application, size of wound, and
mechanism of delivery. Individual wounds may respond
differently to silver preparations and some patients may be
more vulnerable to toxicity. The manner in which silver
compounds are contained within the dressing can affect
the rate and delivery of the compound, and therefore
alter the potential for background levels of silver (Chaby et
al, 2005).
Owing to a lack of relevant research into toxicity and
modern silver dressings, and because both Chaby et al (2005)
and Lansdowne and Williams (2004) reported that increased
levels of background silver associated with the application of
topical silver sulfadiazine subsided and eventually returned to
normal following cessation of treatment, it can be suggested
that modern silver dressings are safe for use in chronic
wound management until definitive research is produced.
It can also be assumed that because background silver levels
returned to normal, the risk of toxicity is minimal; of course,
the author accepts the need for further research.
Antimicrobial properties, microbial kill-time
and the efficacy of silver-impregnated dressing
Antimicrobial properties, as defined by Harvard Medical
School (2008), are the abilities of a chemical substance
to inhibit or destroy bacteria, yeast and mould. Similarly,
microbial kill-time is defined as the time in which an
antimicrobial agent takes to bring about the denaturing of
a bacterium. This article has so far suggested that silver does
not present a significant toxic threat to the human body, but
has stopped short of suggesting whether it poses any threat
to microbes and/or bacterium.
In reviewing the available literature, a number of texts
suggested that silver is an antimicrobial agent. Vermeulen
et al (2007) in particular, examined the findings of
three randomized controlled trials designed to assess the
antimicrobial properties and rate at which organic silver
destroyed infection (microbial kill-time). Vermeulen et
al’s, (2007) review reported that there was insufficient
research to decisively conclude whether the antimicrobial
kill-time held any relevance to the effectiveness of organic
silver in wound healing. The review did, however, suggest
that it could be safely assumed that wound leakage was
considerably less in those treated with organic silver over a
4-week period than those treated with ‘normal’ dressings.
The authors suggest that infection rates were approximately
17% lower among the groups treated with organic silver,
supporting the argument that using silver reduces wound
infection. Unfortunately, the manner in which this figure
was derived is not fully explained. It is therefore unclear
whether this is a mean of the findings of all three
randomized controlled trials or the findings of only one.
S33
 The findings of Gibbins (2003), Pyrek (2004), and
Gibbins and Warner (2005) support the view that infections
rates are lower among participants treated with silver
and in all instances provide good rationale and statistics
to support their arguments. Gibbins (2003) and Gibbins
and Warner, (2005) demonstrate that positively-charged
silver ions (Ag+) systematically attack cell wall synthesis
and nucleic acid production and transport, effectively
denaturing the bacteria. Gibbins (2003) concludes by
categorically clarifying his position that positively-charged
silver ions are highly toxic to microorganisms, but relatively
harmless to human tissue. The views of Gibbins (2003)
and Pyrek (2004) are not shared by those who argue that
there is insufficient evidence to uphold the claim that silver
is an antimicrobial agent. One example of disagreement
lies in the findings of Huckfeldt et al (2007), who carried
out a randomized controlled trial involving the passing
of continuous anodal current through silver dressings.
The test comprised a control group treated with dressings
impregnated with positively-charged silver ions, and a test
group treated with the same dressing but with a continuous
anodal current being passed through them.
Huckfeldt et al (2007) reported a 36% reduction in
the time to wound closure in the test group. This was a
statistically significant result at a P value of <0.05. The study
did not, however, report the same significance in infection
rates, suggesting that those treated with electrically-charged
ions stood the same likelihood of infection as those in
the control group. Furthermore, the infection rates were
reported to be on par with persons treated with regular
silver-free dressings. While this article accepts the work
of Huckfeldt et al (2007) to be scientifically sound in
its methodology, it must be remembered that the main
purpose of the study was not to measure infection rates,
and therefore appropriate measures to prevent infection
among participants may not have been taken. As a result,
the opinions expressed by Vermeulen et al (2007) should
be considered accurate, especially considering the support
provided to this line of argument by Gibbins (2003), Pyrek
(2004), and Gibbins and Warner (2005).
Antimicrobial effects
Owing to the lack of concrete evidence produced by in vivo
studies it is deemed appropriate to examine the findings
produced as a result of studies carried out in vitro. An
example of one such study is that of Ip et al (2006), who
aimed to compare the antimicrobial activities of different
silver‑impregnated dressings. The results decisively proved
that silver-impregnated dressings do have an antimicrobial
effect on gram-negative bacteria; these results are supported
by the findings of Thomas and McCubbin (2003) and
Fong et al (2004). The most effective of the dressings
compared was Acticoat (Smith & Nephew), which contains
nanocrystalline silver. In Ip et al’s (2006) study, Acticoat
dressings denatured all gram-negative bacteria within
24 hours. Among other dressings, such as Actisorb Silver 220
(Johnson & Johnson), there was significant re-growth of
Acinetobacter baumanii, one of the most well-known bacteria
implicated in healthcare‑associated infections (Health
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Protection Agency, 2008). It can be accepted that the work
of Ip et al (2006) produced statistically significant findings
and used appropriate sample sizes, as demonstrated in their
methodology and power calculations.
A contrasting opinion is given by Napoli et al (2005),
who proposed that the benefits of silver in wound treatment
are far outweighed by the negatives; most importantly
that bacteria often re-cultivate at a rapid rate, even in the
presence of silver compounds. This is a stance also adopted
by Fox (1968) who carried out a comparative in vivo study,
which concluded that the use of topical creams containing
silver resulted in the moistening of wound edges and as
such, the promotion of bacterial colonization. Klassen
(2001) reinforces the arguments of Napoli et al (2005) and
Fox (1968), concluding that silver sulfadiazine does not offer
sufficient protection against the regrowth of gram-negative
bacteria in those with burn coverage of more than 50%.
While there is clear evidence to suggest that silver does
possess a potent antimicrobial capability, there is also
evidence supporting the argument that there is a high
possibility of re-colonization of bacteria on sedation of
treatment with silver.There is an increasing body of evidence
to suggest that silver-impregnated dressings produced before
1990 present a higher risk of re-colonization than the newer
style nanocrystalline silver dressings, such as Acticoat and
Silverdin (Deva) (Ulkur et al, 2005; Edwards-Jones, 2006).
An article by Dunn and Edwards-Jones (2004) proposes
that nanocrystalline dressings are an effective way of
managing burns and other wounds because of their long-
lasting bactericidal properties and antimicrobial qualities.
It is further suggested that one of the greatest benefits of
nanocrystalline dressings is the longer period of time they
can be left in situ, reducing the amount of trauma and pain
experienced by the patient (Dunn and Edwards-Jones, 2004;
Strohal et al, 2005) and reducing the potential for cross-
infection (Bradbury et al, 2007).
Risks versus benefits
The argument in support of nanocrystalline silver dressings
is one with a plethora of supporting evidence. Some of
the most compelling research in this area is the work of
Ulkur et al (2005) who found that dressings containing
nanocrystalline silver produced a faster microbial kill-time,
while allowing a far less re-colonization of bacteria. The
findings of Ulkur et al (2005) are mirrored by those of
Yin et al (1999) and Bradbury et al (2007), who support
the opinion that nanocrystalline silver dressings (i.e. Acticoat)
are the most effective and appropriate antimicrobial
dressings for use in the management of burns and long-
term wounds. While there is overwhelming support for the
use of nanocrystalline silver, it is important to remember
that other preparations are available and valid in the
treatment of chronic and burns wounds. Caruso et al (2006)
compared different preparations of silver and reported the
validity of these preparations in the management of partial
thickness burns.
With mounting evidence in support of this type of
dressing, it has been difficult for the author to find
substantiated claims against the use of nanocrystalline silver
British Journal of Nursing, 2010 (Tissue Viability Supplement), Vol 19, No 15

in wound management. One such claim is made by Thomas
and McCubbin (2003), who proposed that over-exposure to
nanocrystalline silver may actually delay the healing process.
Similarly, they suggest that under-exposure may increase
the likelihood of infection if enough time is not available
for the antimicrobial action of the dressing to take effect.
While Thomas and McCubbin (2003) present cautionary
statements on the use of these dressings, they conclude that
the benefits outweigh the risks and recommend Acticoat
and Contreet-H (Coloplast) as the most effective silver-
impregnated dressings.
Consideration must also be given to the work of Trop
et al (2006) who reported silver toxicity in a 17-year-old
male with 30% partial thickness burns. This is an important
disclosure, but it is limited in its wider application given that
there is only one reported case. Trop et al (2006) provide a
view opposed to general consensus; however, owing to the
lack of reported cases, the authors of the study accept the
opinion that in the majority of instances silver dressings are
a safe and effective option in the management of burns and
chronic wounds.
Aucken et al (2002) and Edwards-Jones (2006) add to
the growing support for nanocrystalline silver dressings
by producing research findings which suggest that the
antimicrobial effects of silver sulfadiazine and nanocrytalline
silver are effective against meticillin resistant Staphylococcus
aureus (MRSA). The research of Edwards-Jones (2006)
recommends Acticoat to be the most effective dressing in
reducing the numbers of MRSA bacteria. It should be
noted that this research was partly funded by Smith &
Nephew who manufactures these dressings. However, this
was declared by Edwards-Jones (2006) and in light of the
stringent scientific methods used, the author deems the
findings and recommendations of Edwards-Jones (2006) to
be substantiated.
Further evidence in support of nanocrystalline silver
dressings as an effective anti-MRSA barrier is provided by
Hiratmatsu et al (1997), Yin et al (1999), and Strohal et al
(2005), all of whom show that this type of dressing is not
only an effective antimicrobial, but is also effective against
strains of S. aureus, including the strain resistant to meticillin.
This review has been unsuccessful in finding a contrasting
opinion on the efficacy of silver against MRSA, and
therefore suggests that it is reasonable to assume that
nanocrystalline silver dressings are an effective barrier
against MRSA. The author also accepts that there is
multitude of evidence to suggest that Acticoat is the most
effective of silver‑impregnated dressing in the management
of burns and long-term wounds.
Conclusions
This article has reviewed the results and findings of a
number of research projects and associated literature, and
has been unable to ascertain a definitive answer to the
question ‘what is an appropriate use of silver in wound
management?’ It is evident from the literature that it can
be safely assumed that silver does possess antimicrobial
properties; however, there is no definitive answer on the
subjects of ‘how much silver is too much?’ and whether the
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literature review
data and findings collated from isolated in vitro studies can
be effectively applied to the clinical setting. Many of those
who have carried out in vitro research suggest that their
findings are transposable and therefore assume the results
to be true to the clinical application of silver. However, a
recurrent theme throughout the available literature is the
recommendation that further research be carried out in vivo
in order to establish the accuracy of this assumption. As a
result of extensively reviewing the opinions and findings of
the published works, this text makes the recommendation
that further clinical research is required into the clinical
efficacy of silver compounds, as well as into the most
appropriate dose.
Unfortunately, this review has been unsuccessful in
establishing whether excessively high or low doses have an
effect on the body’s resistance to silver or silver-carrying
products. This is the result of a lack of research on living
participants. The literature does, however, strongly suggest
that there is a link between low doses and heightened
resistance within a number of isolated cells and organisms,
and that although background silver levels do increase when
silver dressings are applied, these levels return to normal
on cessation of treatment. In respect of these findings, it is
the recommendation of the author that further research be
carried out into the resistance of human tissue to silver and
silver derivatives used in wound dressings.
With regard to the relevance of microbial kill-time to
the efficacy of silver-impregnated dressings, the author finds
that while there appears to be a link between higher doses
of organic silver and faster microbial kill-time, there is a
lack of clear, definitive and clinical evidence to suggest that
this is an appropriate measure. To this extent, the findings
of this review are that there is an evident need for further
clinical trials which should endeavour to measure the rate
at which wounds respond to higher or lower doses of both
organic and inorganic silver compounds/derivatives. It is
suggested that a case-control study in which a control group
would receive no silver and two further groups—one of
which receive high doses and the other low doses—would
be the most appropriate method to carry out this research.
It would also be good scientific practice to attempt to
conduct this study as a triple-blinded study and to choose a
suitable representative sample to include both chronic and
acute wounds. Two control groups would be necessary to
ensure scientific robustness. One control would receive no
application of silver to infected wounds, the other receiving
no silver application to non-infected wounds. Ethically, this
could be deemed acceptable as much current practice in
wound care offers no topical application of silver, provided
a suitable wound dressing or covering was applied to the
control group. Considering the lack of research, the author
concludes that there is no definite link between microbial
kill-time and the efficacy of a dressing.
Following an extensive review of the available literature,
the author can conclude that the most popular
silver‑impregnated dressings are those which use
nanocrystalline silver and can be left in place for extended
periods of time. It is evident from the literature that this
type of dressing not only effectively kills bacteria (including
S35

Key Points
n Silver has long been thought to have antimicrobial properties and has been
used in wound healing for many years
n In recent years much research has gone into establishing the efficacy and
safety of silver in wound healing
n The general consensus appears to be in support of using silver in the
management of chronic and burn wounds, despite the occasional concern
with regard to toxicity and background levels of free radicals
n It is evident that further research should be carried out until a definitive
answer can be provided as to the safety of and most appropriate use of silver
in wound healing
MRSA), but that it also reduces the trauma and pain
associated with regular replacement of dressings. BJN
Conflict of interest: The author is unbiased towards any particular
dressing or manufacturer; however, it must be noted that research and
evidence used in this text was sourced from Johnston and Johnston
and Smith and Nephew. This review acknowledges the copyrights
and trademarks of all brand names contained within the text
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