burns 42 (2016) 1377–1386

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/burns

Review

The role of silver sulphadiazine in the conservative

treatment of partial thickness burn wounds:
A systematic review

A. Heyneman *, H. Hoeksema, D. Vandekerckhove, A. Pirayesh, S. Monstrey

Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium

article info abstract

Article history: Background: For more than 40 years, silver sulphadiazine 1% (SSD) is considered as standard
Accepted 31 March 2016 therapy for the conservative treatment of burn wounds. However, in the last 10 years,
substantial disadvantages of SSD have been reported in the literature and probably as a
Keywords: result of this, several new dressings for burn wounds have been developed and put on the
Review market. The objective of this systematic review is to evaluate the available evidence on SSD
Burns in the conservative treatment of burns, specifically in comparison with the newer burn
Conservative treatment dressings that are increasingly being used nowadays.
Silver sulphadiazine Materials and methods: A search filter was composed to select randomized controlled trials
(RCTs) from the MEDLINE database. Only RCTs studying the effect of conservative treatment
on burns were selected. At least one of the two comparative groups was treated with SSD.
Each included article was analysed and relevant data (baseline parameters, interventions,
outcomes and methodological parameters) were registered using Microsoft Office Excel
2007.
Results: Many dressings showed superior healing properties compared to SSD, but no
dressing was able to show a clear benefit over SSD regarding infection. The number of
dressing changes, pain and patient’s satisfaction are more favourable in the newer dres-
sings, especially with solid and biological dressings.
Conclusions: The results of this systematic review clearly demonstrate that a faster wound
healing is obtained with the newly developed burn dressings. Additionally, these new
dressings tend to be more comfortable for the patients and easier to use for care givers.
The minor differences in antibacterial activity between SSD and the new products did not
seem to have any influence on the rate of wound healing.
Since rapid wound closure is essential to obtain an optimal functional and aesthetic
outcome, it can be concluded from the results of this systemic review that the standard use
of SSD in the conservative treatment of burn wounds can no longer be supported.
# 2016 Elsevier Ltd and ISBI. All rights reserved.

* Corresponding author at: Department of Plastic and Reconstructive Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent,
Belgium. Tel.: +32 09 332 28 10.
E-mail address: Alexander.Heyneman@uzgent.be (A. Heyneman).
http://dx.doi.org/10.1016/j.burns.2016.03.029
0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.
1378 burns 42 (2016) 1377–1386

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1378
2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1378
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1379
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1382
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1383
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1384
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1384

intensive, expensive and induce fear and pain, especially in

1. Introduction children [17]. A cytotoxic effect of SSD has also been
demonstrated on epidermal cells with hair follicle death
Burn wounds have been present since the day mankind resulting in a slowing down of the healing rate and increased
discovered fire, or maybe even earlier. These wounds were skin problems after healing [18–20].
initially treated with natural remedies such as plants, oil and Because of these disadvantages of SSD, the quest for the
honey. The widespread use of silver started with the introduc- ideal burn dressing is still ongoing. Improvements in technol-
tion of silver nitrate 0.2% and was first mentioned in the ogy and the expansion of our knowledge regarding wound
‘‘Chirurgische Bibliothek’’ published by Richter between 1771 healing, bacterial burden and drug delivery have led to the
and 1797. Since then, several different concentrations have development of a wide range of new dressing options. Factors
been used, ranging from 0.2% up to 10%. Silver nitrate 0.5% such as fluid absorbing and releasing capacity (cfr ‘moist’
solution, introduced by Moyer in 1965, was found to be the wound healing), number of dressing changes, ease of
minimal concentration with sufficient antibacterial properties application and removal, pain and comfort for the patient,
and the application resulted in shorter hospitalization periods, anti-bacterial properties, drug delivery as well as cost-
less complications and a decreased mortality [1–4]. effectiveness have all become increasingly important in the
Silver sulphadiazine (SSD 1%), as we still know it today, was search of the ideal wound dressing [18,21–23].
introduced by Charles Fox Jr. [5]. The new product had a strong An important factor in burn care research and daily
antibacterial effect, improved the survival rate of severely practice is burn depth assessment. Theoretically, burn
burned patients and was reported to be less caustic in wounds are classified into four categories based on anatomic
comparison to silver nitrate [1,2,6]. The widespread success depth going from superficial burns over superficial partial
of SSD lies in its mode of action. Silver binds with amino-acids, thickness burns to deep partial thickness burns and finally full
bacterial cell walls, DNA and interferes with the respiratory thickness burns [24]. In clinical practice it is more useful to link
chain. These different target sites result in a broad antibacte- the burn depth to the time to healing which determines the
rial effect and low resistance rates [7–9]. Sulphadiazine is a optimal therapeutic approach.
sulphonamide antibiotic that does not really act here as an The purpose of this systematic review was to evaluate the
antibacterial agent, but in SSD has been reported to show a role of SSD in the conservative treatement of burn wounds.
specific synergetic effect in combination with ‘subinhibitory’ This evaluation is based on studies comparing SSD with the
levels of silver [2,10]. many newer dressings available. Outcome parameters such as
A decade after the introduction of SSD, cerium nitrate was wound healing, infection, pain, nurse-related characteristics
added to the product [11]. It is used to improve outcome where and patient’s satisfaction were identified and analyzed.
early excision is not performed. Cerium binds and denatures
the lipid protein complex liberated from burned skin that is
responsible for the profound immunosuppression associated 2. Materials and methods
with major cutaneous burns. The reduction in mortality and
morbidity of severely burned patients is due to its action on A PubMed search was performed combining the MeSH terms
the burn eschar. The application of cerium nitrate SSD renders ‘burns’, ‘silver sulfadiazine’ and ‘randomized controlled trial’.
the eschar firm, impermeable and adherent to the wound bed. The sensitive search filter was additionally limited to human
The hardened eschar is beneficial in nursing terms and studies and papers published in English, French, German or
facilitates later excision [12]. Dutch.
Even after more than 40 years of use, silver sulphadiazine Search filter: (‘‘burns’’ [MeSH Terms] OR ‘‘burns’’ [All
still is frequently referred to as ‘the gold standard’ in the Fields]) OR (‘‘burn units’’ [MeSH Terms]) OR (‘‘burn’’ [All
treatment of partial thickness burns because of its excellent Fields] AND ‘‘units’’ [All Fields]) OR (‘‘burn units’’ [All Fields])
antibacterial properties and its wide availability, especially in AND (‘‘silver sulphadiazine’’ [All Fields] OR ‘‘silver sulfadia-
developed countries. However, in recent years, several reports zine’’ [MeSH Terms] OR (‘‘silver’’ [All Fields] AND ‘‘sulfadia-
have shown that this standard therapy also has a number of zine’’ [All Fields]) OR ‘‘silver sulfadiazine’’ [All Fields] OR
substantial disadvantages [1,2,13–16]. Application of SSD ‘‘silver’’ [MeSH Terms] OR ‘‘silver’’ [All Fields]) AND (‘‘random-
always results in the formation of a pseudoeschar layer on ized controlled trial’’ [Publication Type] OR ‘‘randomized
the burn wound which impairs evaluation of burn depth controlled trials as topic’’ [MeSH Terms] OR ‘‘randomized
and healing status [12]. Daily dressing changes are labour controlled trial’’ [All Fields] OR ‘‘randomized controlled trial’’
 burns 42 (2016) 1377–1386 1379

[All Fields]) AND (‘‘humans’’ [MeSH Terms]) AND (English[lang] Table 1 – Classification of parameters into outcome
OR French[lang] OR German[lang] OR Dutch[lang]). The search groups.
was last updated on 30/04/2015. Only randomized controlled Outcome group Parameters
trials (RCTs) studying the effect of conservative treatment on
Healing Epithelialization rate
burn wounds were eligible for this review and at least one of Time to wound closure
the comparative groups was treated with 1% silver sulpha- Surface reduction after a certain
diazine (SSD). Studies with surgically treated burns were period
excluded. There were no restrictions regarding burn cause, Infection Microbial contamination/
location, depth or %TBSA, nor regarding age, gender, sample colonization
size or publication date. The RCTs obtained after initial search Number of positive cultures
were scanned and obvious irrelevant articles were excluded. Rise in bacterial load
Thereafter, the remaining studies were screened against Pus discharge
Bacteraemia
inclusion and exclusion criteria. Subsequently, each article
Sepsis
was analysed and relevant data were extracted: inclusion &
exclusion criteria, patient parameters (age, sex, population Pain Pain experienced by patient
Number of analgesics
size), burn parameters (depth, %TBSA, region, aspect, pain,
odour and culture), analyses of the baseline parameters, Satisfaction Patients satisfaction
outcome measurement (instruments, precision, variables), Comfort/tolerance/unpleasant
patient flow, intervention (standard care, procedure, products, sensations
Anxiety/sleep quality
frequency of dressing change, criteria of dressing change,
Mobility/daily activity
length of treatment), recommendations and remarks. Compliance
The range of synthetic dressings, now available can be
categorized in many ways. One of the classification systems is
based on the appearance at room temperature: viscous review (Fig. 1). In two studies [26,27] SSD was compared to two
(creams/gels/ointment) or solid (plate/sheets) while the term other dressings. In Table 2, each comparison is reported
biological dressings refers to temporary skin replacements separately but both publications were considered as one single
derived from human or animal tissues, such as amniotic study. The 52 trials compared 30 different dressing types with
membranes or porcine skin. They are usually pretreated SSD (Table 2). The RCTs varied widely regarding population
before application, e.g. by freezing, glycerolization, or another sizes (range: 10–154 patients [28,29]), age (range: 1 day–86 years
processing method. All products discussed in this systematic [30,31]), %TBSA (range: 0.5–85% [32,33]), publication date (1979–
review will therefore be referred to as viscous dressings, solid 2013 [34,35]), intervention protocol and inclusion & exclusion
dressings or biological dressings. criteria. The frequency of dressing changes varied from more
The randomized trials were classified into three groups than once daily up to a single application on inclusion in the
based on the composition of the comparative dressings: study, depending on the dressing used. Most trials studied
viscous dressings, solid dressings and biological dressings. intermediate depth burns (PTB or 2nd degree burns) as
This classification system enabled us to categorize the many reported in the study. Superficial and full-thickness burns
varying dressings in an unambiguous way. were each studied in five trials. Burn depth assessment was
The outcome parameters of the individual studies were reviewed and it was described more into detail in only nine
grouped into outcome groups. The most important outcome studies. In all of them burn depth was clinically assessed by a
groups and the corresponding parameters, defined by the member of the medical staff (mostly burn surgeons). Laser
different studies, are listed in Table 1. Minor outcome Doppler imaging was used next to clinical evaluation in the
parameters are scar quality, adverse events, cost(-effective- study of Kumar et al. [27].
ness) and number of dressing changes. Outcomes were Time to healing was the most investigated outcome
considered significant if P < 0.05 and a trend towards signifi- parameter and reported in 46 of the included comparisons
cance was defined as P = 0.05–0.25 or if described as such by [(Fig._1)TD$IG]
between dressings (Table 2). Significantly improved healing of
the author.
Registered methodological parameters were intention to
Pub Med search filter:
treat & power analysis, method of randomization, blinding 101 results
and analyses of the baseline parameters. A CONSORT
statement was used to evaluate the methodological quality
of RCTs [25].
- 29 studies other than burn wounds
- 10 studies other therapies than SSD
versus comparave dressing
3. Results - 10 studies other than RCTs

The search filter resulted in 101 references. Twenty-nine

publications, not related to the conservative treatment of buns
52 studies included
were excluded. Additionally, 10 reviews or study protocols and
10 studies on dressings other than SSD were removed from
inclusion. Finally, 52 studies were included in this systematic Fig. 1 – Study flow chart.
 1380
Table 2 – Overview of groups, dressings and important baseline-, outcome- and methodological parameters.
Comparative dressing Population Depth Healing Infection Pain Satisfaction Randomization Blinding Sponsoring
Viscous dressing
Helvig et al. [34] Cerium nitrate AgSD 34

0

Vs


Munster et al. [87] Cerium nitrate AgSD 60

0

V


de Gracia [40] Flammacerium 60 PTB, FTB + +
V X

Oen et al. [29] Flammacerium 154
0 0 0 0 Vs X V
Ang et al. [68] MEBO 31 PTB 0


Vs


Ang et al. [71] MEBO 111 PTB

+
Vs


Hirsch et al. [88] MEBO 40 PTB 0 0 +
V
X
Khorasani et al. [14] Aloe vera 30 2nd ++ 0

V V

Shahzad et al. [51] Aloe vera 50 2nd ++ 0 ++ 0 Vs


Hansbrough et al. [49] Collagenase Santyl Ointment 79 PTB ++
+
V


Ostlie et al. [56] Collagenase Ointment 100 PTB 0 0

Vs


Subrahmanyam [36] Honey 50 PTB ++ ++

V


Malik et al. [41] Langnese 150 PTB ++ +

V V

burns 42 (2016) 1377–1386

Koller [67] Lalugen 33 2nd ++ 0 0 0 Vs V

Costagliola et al. [65] Connettivina 111 PTB ++ 0 0 0 Vs V V
Ahuja et al. [44] Soframycin 40

0

Vs V X
Carneiro et al. [37] Topical Phenytoin 64 2nd 0 ++ ++
V


Hauser et al. [66] Repithel 47 PTB ++ 0 0 0 Vs X

Homann et al. [58] Repithel 47 PTB ++
0 0 V X

Aramwit et al. [45] Silk sericin AgSD 29 2nd ++ 0 0 0 Vs V V
Fang et al. [42] Hydron AgSD 27 2nd 0 +
+ V V

Glat et al. [63] Silvasorb gel 24 SB, PTB 0 0 ++ ++ V X

Grippaudo et al. [48] Procutase 80 2nd ++ 0 ++
Vs V

Hansbrough et al. [69] Argidene gel 18 PTB ++


Vs X

Inman et al. [33] Silvazine 121 FTB
0

V
V
Peral et al. [50] Oxoid 80 2nd, 3rd 0


V

Solid dressing
Varas et al. [70] Acticoat 14 PTB
0 ++
Vs


Muangman et al. [55] Acticoat 50 PTB
0 ++
V


Huang et al. [38] Acticoat 98 All ++ ++

V V

Abedini et al. [35] Agicoat 69 PTB ++ ++ ++
Vs


Gerding et al. [32] Biobrane 56 PTB ++ 0 ++ ++ Vs X

Barret et al. [53] Biobrane 20 PTB ++ 0 ++
V


Lal et al. [54] Biobrane 79 SPTB ++ 0

Vs X

Kumar et al. [27] Biobrane 33 PTB ++
++
Vs X V
Caruso et al. [47] Aquacell Ag 82 PTB 0 0 ++ ++ V X V
Muangman et al. [60] Aquacell Ag 70 PTB ++
++
Vs


Yarboro [89] Aquacell Ag 24 PTB 0
++ 0 V


Stair et al. [30] Epi-Lock 40 PTB + + + + Vs


Waffle et al. [72] Op-site 87 PTB 0 0 ++ ++ Vs


Cockington [26] Op-site 39 SB + PTB 0 0 0 0 V
V
Wyatt et al. [62] Duoderm 50 2nd ++ 0 ++ ++ V V V
 burns 42 (2016) 1377–1386 1381

the comparative dressing was reported in 28 studies and was

: significant advantage over comparative

[0,1-10]PTB: partial thickness burn; SPTB: superficial partial thickness burns; DPTB: deep partial thickness burn; FTB: full thickness burn; 2nd: 2nd degree burn; 3rd: 3rd degree burn; ++: significant
seen in the three main groups: viscous dressings (12/21), solid
V

V
V

V
X
dressings (14/23) and biological dressings (2/2). In both viscous

and solid dressings healing was significantly better in more
than half of the studies. A trend towards significance was seen
in three of the 46 studies and 15 of the 46 studies did not find
V any differences between the groups. No trial reported superior
X

X

healing of SSD over comparative dressings. No clear relation-
ship of burn depth to this outcome parameter was found as
most trials investigated the whole group of ‘intermediate’
burns without further differentiating between the more
superficial and the more deep dermal burns.
Vs

Vs

Vs
Vs

Vs

Infection was investigated in 40 trials. In 29 of them, no

V
V
V

V
V
V

V
V

significant difference between the compared dressings was

advantage over SSD (P < 0.05); +: advantage over SSD (P > 0.05); 0: no difference between groups; : advantage over comparative dressing (P > 0.05);

seen. In five studies the comparative dressing was more

antibacterial than SSD: Honey [36], Topical Phenytoin [37],
Acticoat/Agicoat [35,38] and Xenoderm [39]. In one study [26]
SSD was significantly better regarding infection, although it
++

++

was compared to Jelonet with no antibacterial properties. The

0

0

comparative dressings in remaining five studies had better

antibacterial properties compared to SSD, but the results were
not statistically significant [30,40–43].
Pain was investigated in 34 of the included studies. Twenty
++

++

++
++
++
++

++
++
0

0

two showed that there was significantly less pain experienced

in patients treated with the comparative dressing: 4/13 in the
viscous dressing group, 16/19 in the solid dressing group and 2/
++

2 in the biological dressing group. Four trials showed a

+
0
0

0
0

tendency towards significance in favour of the comparative

dressing and eight studies demonstrated no significant
difference. No study reported less pain in patients treated
++
++
++
++

++
++

++

++

with silver sulphadiazine.

+
0

Patient satisfaction was examined in 21 of the 52 studies.

Satisfaction includes outcomes investigated by the trials
which are related to comfort (e.g. movement, flexibility,
SB + PTB
2nd, 3rd

tolerance, daily activity, subjective reactions), anxiety, com-

PTB

PTB
PTB
PTB

PTB
PTB
PTB
PTB

PTB
PTB
2nd

pliance and unpleasant sensations (e.g. itching, burning).

Seven studies showed significantly better results for the
dressing (P < 0.05);V: yes; Vs: yes and specified; X: no;
: no data available.

comparative group. Solid dressings showed a higher satisfac-

tion in 5/10 studies; the viscous and biological dressings
30
76
66
14
33
39
68
65
60
101

10
76
120

showed higher satisfaction rates in 1/9 and 1/1 studies

respectively. Eleven studies did not show any difference.
Other less frequent reported outcome parameters were
adverse events, length of hospital stay, scar quality, costs and
number of dressing changes. Adverse events were reported in
11 studies [35,40,44–52]. None of the 11 studies investigating
Glycerolized allograft

adverse events showed any significant results because of its

low prevalence. Ten studies investigated the length of hospital
Askina Calgitrol

stay [31,35,37,39,40,45,53–56]. A significant shorter length of

Mepilex Ag

Xenoderm
Suprasorb

stay compared to SSD was reported in eight studies

Transcyte
Duoderm

Trancyte

Amnion
Urgotul
Mepitel
Mepitel

Jelonet

[31,35,37,39,40,53–55]. A significant better scar quality was

reported in five out of 11 trials compared to SSD
[26,28,29,42,43,47,50,51,57,58]. This was reported by one of
five trials in the viscous dressing group [58], by three of five
Noordenbos et al. [43]

Muangman et al. [90]

Piatkowski et al. [61]

Silverstein et al. [52]

trials in the solid dressing group and in the only trial of the
Opasanon et al. [64]

Mostaque et al. [31]

Bugmann et al. [46]
Gotschall et al. [59]

Hosseini et al. [39]

biological dressings group. The other six trials could not

Biological dressing
Kumar et al. [27]
Afilalo et al. [57]

Horch et al. [28]

Cockington [26]

demonstrate any difference between the groups regarding

scar quality. Seven studies concluded that the comparative
dressing was significantly cost-effective [47,51,52,59–62]. Cost
analysis ranged from simple calculation of dressing costs to a
more advanced incremental cost-effectiveness ratio [47].
1382 burns 42 (2016) 1377–1386
Apart from Glat et al. [63], all studies which investigated the
number of dressing changes showed that significant less dressing
changes were performed compared to SSD [31,39,46,47,52,57,
60,62,64]. Glat et al. [63] and Ostlie et al. [56] were the only trials
to compare a viscous dressing with SSD.
All studies randomized the patients or burns, but almost
half of them (25) specified the method of randomization. The
reported randomization was or computer generated
[32,45,48,54,56,57,60,61,65–67], or by sealed envelopes [52,68–
71], by lottery [27,31,44], by random numbers table [29,35], by
date [34], by charts [72], by consecutive sampling [51] or by
flipping of a coin [30]. Blinding was reported in 22 studies of
which 11 stated that implementation was impossible. Six
studies mentioned involvement of sponsorship and only three
studies stated that there was no inappropriate relationship
that could influence the work. An intention-to-treat analysis was
executed by six studies [29,47,52,58,61,66] and power analysis by
nine trials [29,44,45,47,50,52,53,69]. Most studies compared
baseline parameters between groups. Details of major method-
ological outcomes are listed in Table 2.
4. Discussion
The main goal of this systematic review was to evaluate the
position of SSD in the conservative treatement of burn
wounds. The search filter of this systematic review of SSD
versus newer burn dressings enabled us to retrieve 52 studies.
Article references and related publications were scanned but
no additional studies could be found. The RCTs had dissimilar
selection criteria, study protocols and compared many
different dressings with SSD. It was impossible to obtain a
more homogeneous group of studies without considerably
reducing the number of trials. We believe that, based on the
incomparability of the studies, performing a meta-analysis on
these data would not be inappropriate.
No studies in this review were excluded based on %TBSA or
burn depth. The surface of the burns in the trials was assessed
and registered by different methods (clinically, by photo-
graphs or by laser Doppler imaging) and measured in %TBSA
or cm2. Clinical evaluation of burn depth has low accuracy and
the registration in the trials was performed using different
classification systems: superficial burn (SB), superficial partial
thickness burn (SPTB), deep partial thickness burn (DPTB) and
full thickness burn (FB) versus 1st, 2nd and 3rd degree burns
[73]. In addition, the wound aspect changes and consequently
the time of evaluation (at admission versus after several days)
influences interpretation. By including only conservatively
treated wounds, we assumed that the most severe burns were
excluded as they are treated surgically. Besides clinical
assessment, an even more important factor in defining burn
depth is the expected time to healing. This parameter is
directly linked to the risk of developing a hypertrophic scar.
Cubison et al. [74] concluded that the risk of developing a
hypertrophic scar is low if the wound healed within 14 days. If
healing takes more than 21 days, the occurrence of a
hypertrophic scar is high. Between 14 and 21 days, prevalence
of hypertrophic scars varies. A wide range of technical devices
is available to determine the healing potential of a burn wound
[21]. Laser Doppler Imaging is a frequently used technique and
although available since 1993 [75], it was used in only one
study in this review [27]. In a clinical study comparing the
effect of two different therapies to treat burns it is important to
compare the results in burn wounds of identical depth.
Therefore, an objective method to assess the burn wounds is
required.
Healing time of burns is one of the most important
parameters as it greatly influences the functional and
aesthetic outcome. It is universally accepted that rapid wound
healing results in less scar tissue formation, less contractures,
a shorter length of hospital stay and less expense [28,74,76,77].
It is therefore valid that healing is the most studied outcome
parameter (44/52 RCTs). SSD slows down the wound healing
process by impairing leukocytes, granulation tissue and
epidermal growth [78–80] and this is the main reason why
many dressings in this review show superior healing proper-
ties compared to SSD. We also know since the discovery of
Winter et al. in 1963 that a moist environment fastens the
wound healing process [23]. Although maintaining a moist
environment, SSD cannot absorb excessive wound exudate
[81]. Several viscous and solid dressings provide a moist
wound environment or have other wound promoting proper-
ties such as better debridement (honey and enzymes) or
stimulation of granulation tissue (hyaluronic acids). Solid
dressings need less replacement and are therefore less
traumatic. In 28 of the 44 studies the comparative dressing
showed significantly better healing properties. None of the
studies showed faster wound healing with SSD.
Silver sulphadiazine has excellent antibacterial properties
due to the different cellular target sites of silver. It is active
against gram-positive and gram-negative bacteria, including
Pseudomonas aeruginosa, and there is no or little resistance [6–
9]. These properties are the key to its success and the
widespread use since several decades. Of the 40 studies
investigating infection parameters, only five were able to
demonstrate a significant benefit over SSD [35–39]. However,
in most of the studies there was little or no difference between
both groups (Table 2). The antibacterial properties of SSD are
confirmed in this review but the dressings to which SSD was
compared, are not less effective.
Pain experienced by patients is highly correlated to the
number of dressing changes, as each manipulation of the
wound stimulates sensitive neurons. This is in accordance
with the results of this review. Viscous dressings need more
dressing changes to provide continuous release of active
components. Frequent dressing changes have the advantage
of adequate wound inspection, but are very labour intensive.
Solid and biological dressings cover the wound for a longer
period of time and the majority of these dressings (16/19)
cause significantly less pain for the patients. The development
of new materials with better wound adherence and mechani-
cal properties is also associated with better patient-related
outcomes resulting in a significantly higher degree of patient’s
satisfaction. Moreover, the RCTs in this review also indicate
that the lower number of dressing changes, apart from the
increased patient’s satisfaction and the reduction of pain,
often correlates with superior rates of wound healing (Table 2).
Still, it should be pointed out that many studies investigating
the dressing frequency of solid dressings do not report the
criteria of dressing changes [46,52,60,62,64] or do not have a
 burns 42 (2016) 1377–1386
uniform frequency of dressing change mentioned in the study
protocol [39,47]. The frequency of dressing changes is also
determined by the specific characteristics of the dressing
itself.
Shorter healing times usually result in a better scar quality
and could also result in a shorter length of hospital stay. A
better scar quality was primarily reported in the solid
dressings (3 out of 4 RCTs) and in one study of the biological
dressing group. Despite the limited number of results
available, there seems be a relation between scar quality
and mean healing time in these studies [28,38,43,62]. The
small number of trials studying scar quality is probably caused
by the lack of long-term follow up. Data collection for long
term outcome is time consuming, difficult to organize and
requires a lot of patients’ compliance.
Although the newer dressings are often more expensive, a
reduction of total cost can still be achieved. This seems only
logical when taking into account the length of hospital stay,
physician’s fees, dressing time and costs, pain medication,
transportation costs, work absence, etc. However only a
surprisingly small number of studies made real economical
calculations [47,51,52,59–62]. In none of the included studies
SSD showed a significant financial benefit over the compara-
tive dressings. Further research should combine an extensive
cost-effectiveness analysis with a long term follow up results
of the treated patients. Important shortcomings in RCTs
studying conservative therapy of burns are apparent in study
design and in reporting.
Based on the results of this review, it is impossible to
formulate clear recommendations regarding the most suitable
dressing for partial thickness burn wounds. The choice of a
dressing is determined by several factors such as anatomical
location, expected dressing change frequency, wound fluid
management, pain relieving capacity, antibacterial needs, etc.
Besides these, the availability of solid and/or viscous dressings
also determines the treatment options. Healthcare resources
are sufficient, but not unlimited, in first world countries
whereby a wide range of dressings is available. Low and
middle-income countries on the other hand have a dire need of
them. Although SSD is not the first choice in the treatment of
partial thickness burn wounds, it can be a worthy alternative in
countries with limited health resources and cost structures
which are different from developed countries. [82,83]
For further research we strongly recommend to report burn
surface in %TBSA (not cm2) and to perform intra-individual
comparisons based on comparable anatomical locations. In
order to increase comparability between the different studies,
burn wounds should be categorized by the most commonly
used classification system (SB, SPTB, DPTB and FB). Ideally,
this classification should be based on an objective assessment
of the burn wound by Laser Doppler Imaging, expressing the
expected time of healing [73]. Also, more details about
interventions, patient flow, definitions and measurements
are needed. Guidelines, such as the CONSORT Statement, help
to improve quality of reporting randomized controlled trials
[25]. These guidelines also emphasize the importance of
reporting the method of randomization. In this systematic
review, randomization was reported in only 25 of the 52
studies. Another shortcoming is the impossibility of blinding
in many studies because of the difference in colour or
1383
consistency of dressings. Moreover, different dressings often
give a different aspects to the wound bed (eschar, slough,
discoloration. . .). As a consequence, only 11 trials were able to
perform true blinding. However, besides blinding of the
dressing also outcome assessors, data analysts or other
caregivers can be blinded during the study. Power analysis,
intention-to-treat analysis and the absence of inappropriate
sponsorship was reported respectively in only 9, 6 and 6 trials.
Based on this review we can conclude there still is room for
improvement in reporting a study according to the CONSORT
guidelines.
SSD is frequently studied in RCTs and reviews. A PubMed
search resulted in five published reviews on SSD and partial
thickness burns in the last five years (2011–2015). Three of the
reviews [84,85,17] only focused on children whereas our
review included studies of both children and adults. Malic
et al. [84] focussed on the comparison between SSD and
nanocrystalline silver. Healing time was equivalent or slightly
better with nanocrystalline silver. In the review of Rashaan
et al. [85] SSD was compared to nonsilver treatment. The latter
resulted in shorter healing time, less dressing changes and
shorter length of stay. There was no difference in wound
infection and skin grafting. Finally, Vloemans et al. [17] found
that membranous dressings performed better than cream
based dressings or tulle gras. The application of membranous
dressings was found to be difficult in some anatomical
locations compared to cream based dressings. The purpose
of the review by Wasiak et al. [18] was ‘to establish which type
of dressing from the many now available is more effective in
promoting healing and minimizing discomfort and infection
for patients with superficial and partial thickness burns’. The
purpose in our review is to describe the overall position of SSD
in the conservative treatment of partial thickness burn
wounds. Compared to the review of Wasiak et al. we used a
more sensitive search strategy. This resulted in 52 studies,
with SSD in at least one of the study arms. Wasiak et al.
included 30 studies comparing different dressings and
concluded that the use of SSD was consistently associated
with poorer healing outcomes than biosynthetic dressings,
silver containing dressings and silicon coated dressings. Miller
et al. [86] questioned if the use of topical SSD compared with
non-antibiotic dressings improves mortality, wound healing,
re-epithelialization, or infection rates. No studies on humans
could be included, only 7 animal studies met the inclusion
criteria. In our review all included studies focus on humans.
5. Conclusion
Despite the large differences in study design and limited
methodological registration of randomized controlled trials, it
seems that most viscous, solid and biological dressings have
better healing properties, cause less pain and increase patient
satisfaction compared to silver sulphadiazine. In particular,
solid dressings such as Acticoat1/Agicoat1, Aquacell1, Mepi-
tel1, Biobrane1 and Trancyte1 provide excellent outcomes.
Infection parameters of SSD and the comparative dressings
were comparable.
Burn depth assessment or the determination of the
expected time to healing of a burn wound is important in
1384 burns 42 (2016) 1377–1386
choosing the optimal treatment. Wounds with the potential to
heal spontaneously are preferably covered with a comfortable
dressing providing fast wound healing in order to obtain a
good functional and aesthetic outcome. SSD is not longer the
first choice in this category but it is a worthy alternative if
treatment with the newer developed dressings is not an
option.
Conflict of interest
None of the authors has to disclose any financial and personal
relationships with other people or organizations that could
inappropriately influence (bias) this work.
Acknowledgements
There was no role of study sponsors in the study design, in the
collection, analysis and interpretation of data; in the writing of
the manuscript, and in the decision to submit the manuscript
for publication.
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