Topical Therapies for Pediatric Burns

The management of pediatric thermal burns always seems to be a hot topic, whether we are caring for a little future chef who splashed a scalding microwaved noodle cup on himself, or a toddling youngster who pulled a pot of boiling water on herself.  Or maybe you have the adventurous adolescent who was a little too aggressive with the lighter fluid before igniting the campfire. Once you’ve assessed that they are medically stable and have treated their pain, the next important step in the management is selecting a topical therapy for those burns.  We have previously touched on assessment of burn severity/depth and debridement, so now let’s review what kind of wound care and dressings are best for ideal burn healing.  Let’s take a moment to review Topical Therapies for Pediatric Burns:

(Side note: remember that electrical burns are a different beast. This tasty morsel applies only to scald and thermal burns.) 

Topical Therapies for Pediatric Burns: The options? 

• First degree (superficial) burns that only involve the epidermis do not need antimicrobial treatment. 
  • Skin barrier is maintained 
  • Pain control, moisturization, and oral hydration are key 
• Partial and full thickness burns that involve the dermis and beyond require more- debridement, antimicrobial dressings, and possible grafting if not healed after 2 weeks. 
• Debridement is often recommended by burn surgeons for faster healing overall.  
  • Leave small blisters and those on palms and soles intact 
  • Open large, blistered areas and cleanse with soap and water, remove only devitalized tissue 
• Choosing your antimicrobial agent depends on the wound depth, size, and location. [Palmieri 2002] 

• Ointments and Creams and Gauzes, Oh My!   
  • There are many topical burn dressing options on the market. 
  • Nitrofurazone, silver sulfadiazine, mupirocin, bacitracin, and mafenide acetate have all been tested in vitro as antimicrobials [Rodgers 1997] but no one product stands out as the best in clinical applications 
    • Nitrofurazone has the broadest activity 
    • Mupirocin was best against MSSA 
    • Silver sulfadiazine was effective against gram positives 
    • Bacitracin had activity against Staph aureus and Strep pyogenes 
    • Mafenide acetate had the highest minimum inhibitory concentrations (MIC) for all isolates 

Topical Therapies for Pediatric Burns: Ointments 

• Ointments are more common than creams [Palmieri 2002] 
  • Tolerated better, more soothing 
  • Apply thick layer then cover with non-adherent dressing or bismuth impregnated gauze (like Xeroform), then bulky dry gauze. 
  • Ointment has shorter half-life, so should be cleansed and changed every 12 hours. 
  • Bacitracin and neomycin are most commonly used 
• Bacitracin by far is the most commonly used antimicrobial ointment [Palmieri 2002] 
  • Soothing and well tolerated 
  • Low rates of developing resistance 
  • Systemic hypersensitivity and toxicity very rare 
  • Easily available 
  • Effective against Gram positive cocci and bacilli 
  • Encourages PMN and lymphocyte activity 
  • Inhibits bacterial cell wall synthesis 
  • May promote fungal growth after wound is epithelialized, so stop using once wound has epithelial layer  

Topical Therapies for Pediatric Burns: Creams 

• Creams like silver sulfadiazine and mafenide usually used for full thickness burns [Palmieri 2002] 
  • Apply very thick then apply bulky dressing 
  • Change every 12 to 24 hours 
• Silver sulfadiazine most common in full thickness, deep wounds [Palmieri 2022, Walker 2023] 
  • Contraindicated with a sulfa allergy 
  • Effective against Gram positive and Gram negative bacteria 
  • May impede wound healing because of toxicity to keratinocytes and fibroblasts 
  • Rare complications– leukopenia and cutaneous hypersensitivity reactions 
  • May cause ocular injury when used on the face 
  • Risk of kernicterus – not recommended for premature infants, infants < 2m old, and in pregnancy 
• Mafenide acetate penetrates eschars better [Palmieri 2002, Walker 2023] 
  • Bacteriostatic against many Gram negative and Gram positive bacteria 
  • No action against fungi 
  • Inhibits keratinocytes and fibroblasts and may delay burn healing 
  • Impairs PMN and lymphocyte activity 
  • May cause cutaneous rash, metabolic acidosis from carbonic anhydrase inhibition, and pain 
  • Usually used on small full thickness burns or auricular burns because excellent penetration of cartilage 

Topical Therapies for Pediatric Burns: Rate and quality of burn healing  

• Debridement of devitalized tissue and topical antibiotic ointment epithelializes and heals faster than just applying petrolatum gauze. [Liu 2024]  
• A silver-based dressing has been shown to have longer healing times as compared to antibiotic ointment when compared head-to-head. [Palmieri 2002, Choi 2018, Raymond 2018] 
• A systematic review with moderate quality evidence found no difference in the rate of wound healing or epithelialization with silver sulfadiazine compared to silver impregnated foam dressing. [Chaganti 2019] 
• A small study found faster epithelialization with Aquacel Ag Hydrofiber versus petrolatum gauze [Saba 2009] 
• Xeroform stick down dressing had similar rates of epithelialization to silver sulfadiazine at one burn center [Grauberger 2024] 

Topical Therapies for Pediatric Burns: Infection risk 

• Initial management should include cleansing the wound with mild soap (containing chlorhexidine if possible) and warm water. [Palmieri 2002] 
• Wash and dry wounds one to two times per day before re-applying antimicrobial ointment. [Palmieri 2002] 
• A systematic review of 3 RCTs compared silver sulfadiazine to silver impregnated foam dressing, and found no statistical difference in infection risk between the groups, though the data was favoring the foam dressing. [Chaganti 2019] 
• Other studies have not shown a difference in infection rates between silver-containing creams and antimicrobial ointments. 

Topical Therapies for Pediatric Burns: Pain and comfort with dressing changes 

• A systematic review that compared silver sulfadiazine to silver impregnated foam dressing found that patients favored the foam dressing at the first dressing change at 7 days, but ultimately there was no difference in pain scores by 1 month. [Chaganti 2019] 
• Xeroform stick down dressing technique required fewer dressing changes and therefore caused less pain than silver sulfadiazine in a burn center [Grauberger 2024] 
• Aquacel Ag Hydrofiber required fewer dressing changes and therefore caused less pain than petrolatum gauze dressing [Saba 2009, Lau 2016] 

Topical Therapies for Pediatric Burns: Cost 

• Although time in hospital may be slightly shorter after debridement of devitalized tissue after a burn versus just applying petrolatum gauze, the cost difference between these two methods may not be significantly different. [Liu 2024] 
• One small study showed a significantly decreased time in hospital (and thereby cost) for partial thickness burns treated with Aquacel Ag Hydrofiber compared to petrolatum gauze (median 2 days vs 9 days) [Saba 2009] 
  • Direct cost of Aquacel Ag Hydrofiber was $61 per 6×6 sheet and petrolatum was $3 per 5×9 sheet 
  • But many fewer dressing changes, fewer narcotics given, shorter hospital stay, indicated overall cost likely lower with Aquacel Ag Hydrofiber 

Topical Therapies for Pediatric Burns: Additional reminder 

• Although we do not see much tetanus in the US thanks to higher vaccination rates compared to less developed countries, don’t forget to still update the tetanus vaccine after burns. 
• Tetanus toxoid and tetanus vaccines may be crucial when practicing international medicine and managing patients with burns that are showing complications. 
• This case report from the Ivory Coast reported on an undervaccinated child whose burns were treated with cassava leaves, and ultimately died from tetanus within 24 hours of presentation with symptoms. [Irie 2018] 

Moral of the Morsel 

• Burns are Bad! But debridement of devitalized tissue, cleansing of wounds, and application of topical antimicrobials can help burns heal faster. 
• Get the Goop!  Antibacterial ointments, like bacitracin, tend to be well tolerated and promote faster wound healing than silver sulfadiazine and other creams in partial thickness wounds. 
• Halt the Hurt!  Topical agents that reduce the number of dressing changes required are associated with less pain and fewer narcotic doses. 
• Phone a friend. Always consult your friendly neighborhood burn surgeon for their preferred management of partial and full thickness burns, as treatment agents can vary based on your hospital system standard of care. 

References: 

• Palmieri TL, Greenhalgh DG. Topical treatment of pediatric patients with burns: a practical guide. Am J Clin Dermatol. 2002;3(8):529-534. doi:10.2165/00128071-200203080-00003  
• Rodgers GL, Mortensen JE, Fisher MC, Long SS. In vitro susceptibility testing of topical antimicrobial agents used in pediatric burn patients: comparison of two methods. J Burn Care Rehabil. 1997;18(5):406-410. doi:10.1097/00004630-199709000-00006  
• Walker NJ, King KC. Acute and Chronic Thermal Burn Evaluation and Management. [Updated 2023 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430730/  
• Liu H, Li D, Yuan H, et al.. Improved Short-Term Prognosis of Pediatric Partial-Thickness Burns. Pediatric Emergency Care. 2024; 40 (5): 390-394. doi: 10.1097/PEC.0000000000003098.  
• Choi YM, Campbell K, Levek C, Recicar J, Moulton S. Antibiotic ointment versus a silver-based dressing for children with extremity burns: A randomized controlled study. J Pediatr Surg. 2019;54(7):1391-1396. doi:10.1016/j.jpedsurg.2018.06.011 
• Raymond SL, Zecevic A, Larson SD, Ruzic A, Islam S. Delayed Healing Associated with Silver Sulfadiazine Use for Partial Thickness Scald Burns in Children. Am Surg. 2018;84(6):836-840.  
• Chaganti P, Gordon I, Chao JH, Zehtabchi S. A systematic review of foam dressings for partial thickness burns. Am J Emerg Med. 2019;37(6):1184-1190. doi:10.1016/j.ajem.2019.04.014 
• Saba SC, Tsai R, Glat P. Clinical evaluation comparing the efficacy of aquacel ag hydrofiber dressing versus petrolatum gauze with antibiotic ointment in partial-thickness burns in a pediatric burn center. J Burn Care Res. 2009;30(3):380-385. doi:10.1097/BCR.0b013e3181a2898f 
• Grauberger JN, Joshi N, Joo A, Phelan AL, Lalikos JF. Xeroform Stick-Down Dressing: A Novel Treatment for Pediatric Partial-Thickness Burns. Ann Plast Surg. 2024;92(4S Suppl 2):S123-S128. doi:10.1097/SAP.0000000000003795  
• Lau CT, Wong KK, Tam P. Silver containing hydrofiber dressing promotes wound healing in paediatric patients with partial thickness burns. Pediatr Surg Int. 2016;32(6):577-581. doi:10.1007/s00383-016-3895-0 
• Irie BGS, Asse KV, Kadiane NJ, et al. Tetanus after application of traditional topical treatment to a severe burn. Tétanos après application de topique traditionnel sur une brûlure grave. Med Sante Trop. 2018;28(4):446-447. doi:10.1684/mst.2018.0803l