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Use of Silver-Containing Hydrofiber and Chlorhexidine-Impregnated Tulle Gras Dressings for Second-Degree Burns

Pamuk Cebeci, Sevil PhD; Acaroğlu, Rengin Prof Dr

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Advances in Skin & Wound Care: July 2019 - Volume 32 - Issue 7 - p 1-5
doi: 10.1097/01.ASW.0000553598.12820.e7
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Burns are a common physical and psychological trauma accompanied by significant morbidity and mortality.1–7 Prompt and effective treatment at burn centers can reduce mortality and disability,8,9 especially in patients with deep and/or large burn injuries requiring specialized care.9–11 Patients with burns have to cope with a host of stress factors, including separation from their friends and family during treatment and fear of disfiguration, scar tissue, pain during treatment and dressing changes, and death.9,12–15

A range of treatments are applied for second-degree burns, the most common of which are conventional occlusive dressings. At the study authors’ facilities, chlorhexidine-impregnated tulle gras dressings (Bactigras; Smith & Nephew, Fort Worth, Texas) are the standard treatment because they are cost-effective. However, this product often does not fully adhere to the wound and slips, resulting in the need for frequent dressing changes and associated pain.

A number of wound care products have been developed to maintain adequate moisture in the wound area, provide protection against infection, prevent maceration, and obviate frequent dressing changes.16–19 One of these products is a silver-containing hydrofiber dressing (Aquacel Ag; Convatec, Berkshire, United Kingdom).15,20,21 This dressing contains sodium carboxymethyl cellulose combined with hydrofiber with a high absorptive capacity and 1.2% silver. When the hydrofiber, composed of sodium carboxymethyl cellulose, interacts with wound exudate, it turns into a gel and creates a moist environment, absorbing the exudate in the wound. It also releases silver to protect against infection.20,22–27

This study sought to evaluate the respective effects of silver-containing hydrofiber dressings and chlorhexidine-impregnated tulle gras dressings on wound healing in the management of patients with second-degree burns.


The study was performed at the burn unit of a state hospital affiliated with the Eskisehir Province General Secretariat of Public Hospitals between January 2014 and March 2015. The trial recruited 60 participants of all ages admitted to the burn unit who volunteered to take part in the study. Informed written consent was obtained from all of the patients. Forms stated that registered information would be kept confidential and wound photographs would only be used for publication following this research. The Eskisehir Osmangazi University Medicine Faculty Drug Clinical Trials Ethics Committee approved the study (80558721/271-05).

The exclusion criteria were as follows: diabetes mellitus, vascular diseases, deep vein thrombosis, blood clotting disorder, anemia, dermatitis, cancer, immune system diseases, and infection in wound area. The patients who met the study criteria were randomized either to the experiment group (n = 30) or to the control group (n = 30) with the use of the Urn method.

Study data were collected with a Patient Identification Form and Wound Assessment Form (both created by the researchers), the visual analog scale (adult patients), and the Wong–Baker Faces Pain Rating Scale (pediatric patients). The silver-containing hydrofiber wound dressing was applied to the experiment group and the chlorhexidine-impregnated tulle gras dressing to the control group; both groups also received standard care. The patients were followed up until full epithelialization occurred in the wound.

The data were analyzed using SPSS version 17.0 (IBM, Armonk, New York), and descriptive (average, SD, minimum-maximum, percentage) and comparative statistical methods (Mann-Whitney U, χ2, Fisher exact, Student t, Friedman, and Wilcoxon signed rank tests) were used.


The Patient Identification Form was filled in within the first 24 hours of the patient’s admission to the hospital. The form includes sociodemographic characteristics such as age, gender, and education level, as well as clinical characteristics such as the total body surface area (TBSA) burned, burn location, and burn type based on cause. The severity of pain was rated before dressing was applied using the appropriate pain assessment scale. Based on this score, analgesia was administered in accordance with physician recommendation.

If a patient already had a dressing (conventional methods applied at home or at the emergency room/medical center), it was removed carefully. The injury was assessed by the attending physician at the burn unit and by the researcher, and the TBSA was calculated. The wound was washed with water and surgical soap, and the periwound skin was cleaned. The researcher, if present, removed large blisters (bullae) and dead tissue. Next, the burn area (cm2) was calculated using a sterile paper ruler over the largest part of the wound. Next, the Wound Assessment Form was filled out, recording the presence of exudate, debridement, and necessity of analgesics before dressing. Pictures of the burn injury were also taken. Finally, silver-containing hydrofiber dressing or chlorhexidine-impregnated tulle gras dressings were applied to the wound, overlapping the surrounding skin by at least 3 cm. A sterile gauze bandage and pads were placed on the dressing and fixed with sterile bandage and elastic net to prevent slipping and deformation of dressings.

After 24 hours, the dressings were checked to ascertain whether they had adhered to the wound properly. If not, the dressings were reapplied and fixed. The wound was assessed on days 7, 15, and 22; these follow-up assessments also were recorded on the Wound Assessment Form. New dressings were applied until complete epithelialization occurred (Figures 1-4).

Figure 1.
Figure 1.:
Figure 2.
Figure 2.:
Figure 3.
Figure 3.:
Figure 4.
Figure 4.:


The mean age of participants was 16.1 ± 14.7 years, 55% were females, 33.3% were married, 46.7% had graduated from primary school, 88.3% had social security, 83.3% were referred from the emergency room, and 50.0% were of normal weight. No statistically significant differences were found between the experiment and control groups in terms of demographic characteristics (P > .05).

The lower extremities accounted for 38.3% of burn locations. Hot liquid was the most frequently encountered burn cause (60.0%), and 71.6% were superficial partial-thickness burns. No statistically significant differences between the experiment and control groups in burn cause, depth, size, and TBSA were noted (P > .05, Table 1).

Table 1.
Table 1.:

There were, however, statistically significant differences in favor of the experimental group in terms of the exudate (P = .0001), debridement (P = .0001), pain level (P = .0001), and necessity of analgesics before dressing change (P = .0001).

Researchers found that the average burn surface area reduced quickly in the experimental group, and all burn wounds had healed completely by day 22. In some subjects in the control group, their wound had not healed by the day 22, which represented a highly significant difference (U = 315.0, P < .05, Table 2). The average pain score decreased significantly in the experimental group compared with the control group from the seventh day onward (U = 20.5, P < .05, Table 2).

Table 2.
Table 2.:

Full epithelialization occurred in 11.2 ± 3.7 days in the experiment group and 16.2 ± 4.2 days in the control group, which is highly significant (t = −4.83, P < .05, Table 3).

Table 3.
Table 3.:


At baseline, no statistically significant differences existed between the groups in terms of variables affecting wound healing after burn injury, such as burn location, agent, depth, area, and TBSA (P > .05). Both groups were observed to have similar burn characteristics (Table 1), which is common in the literature.2,21

The choice of dressing plays a central role in the managing wound exudate, regulating the wound environment, avoiding maceration, and preventing infection.22–24,28,29 The hydrofiber dressing has sodium carboxymethyl cellulose fibers that absorb and transform into gel on contact with exudate, create a moist wound environment, and continue releasing silver into wound up to 14 days (which helps prevent infection).21,23–25,29,30 Although no statistically significant difference was found between the groups in terms of presence of exudate and debridement at the baseline assessment (P > .05), authors found considerably less exudate, and less debridement was required in the experimental group compared with the control group (P < .05). The experimental group was followed up weekly, with no need for daily dressing changes. In contrast, in the control group, frequent wound dressing changes debrided recently epithelialized areas on the wound surface, traumatizing these areas and delaying healing.

No statistically significant differences were found between the groups in terms of burn area on the first and seventh day (P > .05, Table 2). However, the average burn area decreased significantly in the experimental group compared with the control group on the assessments on the 15th day and the following days (P < .05, Table 2), which is consistent with the literature.21,23,24,31

Second-degree burns are among the most painful because nerve endings remain intact. Some studies assert that the most significant problem encountered in the care of patients with second-degree burns is the need for frequent dressing changes and the associated pain felt during the procedure.30,32 In Turkey, no clear protocol has been developed for the treatment of second-degree burns. Chlorhexidine-impregnated tulle gras dressings, which are routinely applied in the department where this study was conducted, require frequent dressing changes, resulting in severe pain. When the average pain scores were compared between groups, no statistically significant difference was found on the first day (P > .05, Table 2), but on the seventh day and all following days, the average pain scores decreased significantly in the experimental group compared with the control group, and no pain was reported in the last two assessments of the experimental group (P < .05, Table 2). Caruso et al24 found analgesia use and number of dressing changes were lower with hydrofiber dressings. Giray21 found that the number of days patients needed analgesia from the first day to complete healing was lower with hydrofiber dressings; further, Saba et al33 reported that the number of dressing changes was fewer, and pain was lower in their silver-containing hydrofiber dressing group.

The average number of days needed for complete epithelialization of wound area was 11.2 ± 3.7 days in the experiment group. The average number of days needed for complete epithelialization of the wound area was 16.2 ± 4.2 days in the control group. A statistically significant difference was found between these groups (P < .05, Table 3). These results are in line with the literature; Mabrouk et al26 found that the average number of days needed for complete wound epithelialization was 10.5 days in a group treated with silver-containing hydrofiber dressings, lower than the comparison group; in other studies of dressings with silver, Eski et al29 reported that epithelialization occurred in only 10 days (7–12 days); the duration of epithelialization was 9.87 ± 0.86 days in a study by Giray;21 and epithelialization occurred in 15.6 days in a study by Duteille and Jeffery.34


The results of this study suggest that exudate control was better in patients with second-degree burns treated with silver-containing hydrofiber dressings. These patients needed less debridement and fewer analgesics because of infrequent dressing changes. Lower pain scores were reported, the size of the burn area reduced more quickly, and faster epithelialization and wound healing were achieved.

The silver-containing hydrofiber dressing costs more than the chlorhexidine-impregnated tulle gras dressings; however, patients treated with the hydrofiber dressings had shorter hospital stays, and the daily workload of dressing changes was significantly reduced because the hydrofiber dressings adhered to the wound surface more effectively, requiring fewer reapplications, thus lowering costs. Study authors posit that the silver-containing hydrofiber dressing is an effective burn dressing that improves wound healing. Future studies comparing other wound care materials will improve the quality of care for patients with burns.


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chlorhexidine; chlorhexidine-impregnated tulle gras dressings; hydrofiber; second-degree burn; silver-containing hydrofiber dressing; wound care; wound dressings

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