Healing of burn wounds by topical treatment: A randomized controlled comparison between silver sulfadiazine and nano-crystalline silver


Adhya, A.; Bain, J.; Ray, O.; Hazra, A.; Adhikari, S.; Dutta, G.; Ray, S.; Majumdar, B.Kumar.

Journal of Basic and Clinical Pharmacy 6(1): 29-34

2014


Silver sulfadiazine (SSD) has been the standard topical antimicrobial for burn wounds for decades. Recently, nanometer-sized silver particles are available which have high surface to volume ratio and remain effective even at a very low concentration and minimizes the chance for tissue toxicity due to silver. Hence, we conducted a randomized controlled trial to compare the effectiveness of topical SSD and nano-crystalline silver (AgNP) hydrogel in burn wounds management. Study was conducted in the Burn Unit of IPGME&R & SSKM Hospital Calcutta, from January 2011 to August 2012. Patients with 2° burn injury were randomly allocated to SSD and AgNP treatment group. Clinical assessments of burn wound were done on every week till 4(th) week and on completion of treatment. Data for evaluation were obtained for 54 patients on SSD (2° deep-dermal cases 27) and 52 (2° deep-dermal cases 31) on AgNP treatment. Healing status of 2° deep-dermal burns was more satisfactory for AgNP group than SSD treatment at 4 weeks. Among patients receiving AgNP, 80.6% showed at least 50% healing of 2° deep-dermal wounds compared to 48.1% on SSD at 4 weeks (P = 0.001). The figures for complete healing at 4 weeks were, respectively, 4% and 0% (P = 0.116). AgNP can be an effective and superior alternative to SSD for burn wounds, particularly 2° deep-dermal burns. Healing can be expected, in general, in 6 to 8 weeks time, depending upon the extent of body surface involvement.

Original
Article
Healing
of
burn
wounds
by
topical
treatment:
A
randomized
controlled
comparison
between
silver
sulfadiazine
and
nano-crystalline
silver
Abstract
Background:
Silver
sulfadiazine
(SSD)
has
been
the
standard
topical
antimicrobial
for
burn
wounds
for
decades.
Recently,
nanometer-sized
silver
particles
are
available
which
have
high
surface
to
volume
ratio
and
remain
effective
even
at
a
very
low
concentration
and
minimizes
the
chance
for
tissue
toxicity
due
to
silver.
Hence,
we
conducted
a
randomized
controlled
trial
to
compare
the
effectiveness
of
topical
SSD
and
nano-crystalline
silver
(AgNP)
hydrogel
in
burn
wounds
management.
Materials
and
Methods:
Study
was
conducted
in
the
Burn
Unit
of
IPGME&R;
&
SSKM
Hospital
Calcutta,
from
January
2011
to
August
2012.
Patients
with
burn
injury
were
randomly
allocated
to
SSD
and
AgNP
treatment
group.
Clinical
assessments
of
burn
wound
were
done
on
every
week
till
4th
week
and
on
completion
of
treatment.
Results:
Data
for
evaluation
were
obtained
for
54
patients
on
SSD
(2°
deep-dermal
cases
27)
and
52
(2°
deep-dermal
cases
31)
on
AgNP
treatment.
Healing
status
of
deep-dermal
burns
was
more
satisfactory
for
AgNP
group
than
SSD
treatment
at
4
weeks.
Among
patients
receiving
AgNP,
80.6%
showed
at
least
50%
healing
of
deep-dermal
wounds
compared
to
48.1%
on
SSD
at
4
weeks
(P
=
0.001).
The
figures
for
complete
healing
at
4
weeks
were,
respectively,
4%
and
0%
(P
=
0.116).
Conclusions:
AgNP
can
be
an
effective
and
superior
alternative
to
SSD
for
burn
wounds,
particularly
deep-dermal
burns.
Healing
can
be
expected,
in
general,
in
6
to
8
weeks
time,
depending
upon
the
extent
of
body
surface
involvement.
Key
words:
Burn
wound
assessment,
nano-crystalline
silver,
silver
sulfadiazine
Introduction
Burn
is
a
common
medico-surgical
problem
all
over
the
world.
It
is
probably
the
most
devastating
of
all
wounds,
and,
it
imposes
a
serious
burden
on
physical,
mental,
and
socioeconomic
conditions
of
the
victim.
It
is
estimated
that,
annually,
about
ii
million
people
over
the
world
and
1
million
people
in
India
suffer
from
burn
injuries.E
13
According
to
a
recent
Indian
study,
mortality
as
high
as
40.3%
among
2499
burn
patients
was
reported.E
23
Infection
is
a
major
problem
for
burn
injuries
as
it
delays
the
normal
process
of
wound
healing
by
prolonging
the
inflammatory
phase
of
the
immune
response.
Accumulation
Access
this
article
online
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DOI:
10.4103/0976-0105.145776
El
agl
.
of
dead
tissue
on
the
wound
bed
serves
as
rich
nutrient
source
for
bacteria,
which,
coupled
with
immunosuppression
and
exhaustion
of
body's
protein
reserve
enhances
the
chance
of
bacterial
infection.
Silver
sulfadiazine
(SSD)
has
been
the
standard
topical
antimicrobial
for
burn
wounds;
however,
it
has
some
adverse
effects
such
as
argyria,
leucopenia,
hepatic,
and
renal
toxicity.E
3-63
Thus
it
demands
a
new
therapy
options
for
better
burn
wound
management.
Metallic
silver
holds
a
unique
position
as
a
strong
antimicrobial
agent
to
which
resistance
is
not
encountered.
The
AbhishekAdhya,
Jayanta
Bain,
Oindri
Ray
2
,Avijit
Hazra',
Souvik
Adhikari,
Gouranga
Dutta,
Sudhin
Ray,
Bijay
Kumar
Majumdar
Department
of
Plastic
Surgery,
Institute
of
Post
Graduate
Medical
Education
and
Research,
'Department
of
Pharmacology,
Department
of
Plastic
Surgery,
Institute
of
Post
Graduate
Medical
Education
and
Research,
2
Meghnad
Saha
Institute
ofTechnology,
Kolkata,West
Bengal,
India
Address
for
correspondence:
AbhishekAdhya,
Shanti
Kunja
Joraghat,
Chinsurah
,
Hooghly
-
712
10
1
,West
Bengal,
India.
E-mail:
abhishek0817@yahoo.co.in
Vol.
6
I
Issue
1
I
December-February
2015
29
>
Journal
of
Basic
and
Clinical
Pharmacy
Adhya,
et
al.:
Healing
of
burn
wounds
by
nano-silver
advent
of
nanotechnology
has
permitted
conversion
of
metallic
silver
into
its
fine
nanoparticle
form.
These
nano-sized
silver
particles
are
more
effective
than
its
pure
form
against
microbial
organisms
and
holds
the
promise
of
malting
topical
silver
therapy
more
effective
and
better
tolerated.m
Hence,
we
have
conducted
this
study
to
compare
the
clinical
efficacy
of
compound
silver
(SSD)
and
nano-sized
metallic
silver
(nano-crystalline:
AgNP)
among
burn
wounds
management.
Materials
and
Methods
Our
study
population
comprised
burn
victims
who
were
treated
in
a
Burn
Unit
of
a
Tertiary
Care
Hospital
at
Kolkata,
India.
Period
of
study
was
from
January
2011
to
August
2012.
The
study
was
approved
by
the
Institutional
Ethics
Committee,
and
informed
consent
was
obtained
from
all
patients during
the
study.
For
the
purpose
of
sample
size
calculation,
the
difference
in
duration
of
treatment
for
complete
wound
healing
was
considered
as
primary
outcome
measure.
It
was
calculated
that
64
subjects
would
be
required
per
group
in
order
to
detect
a
difference
of
5
days
in
this
parameter
with
8o%
power
and
5%
probability
of
type
I
error.
This
calculation
assumed
a
standard
deviation
of
10
days
for
the
complete
wound
healing
parameter.
From
our
earlier
experience,
20%
of
subjects
admitted
to
our
burn
unit
are
expected
not
to
survive.
Therefore,
adjusting
for
dropouts,
the
recruitment
target
was
kept
at
8o
subjects
per
group.
During
this
period,
106
patients
aged
between
5
and
6o
years
with
burn
injury
and
20-60%
total
body
surface
area
(TBSA)
involvement
were
recruited
from
among
244
screened.
Patients
with
superficial
(1°)
or
full-thickness
(3°)
burn
injury,
pregnancy,
and
significant
co-morbidities
such
as
preexisting
cardiac
disease,
renal
disease
or
diabetes
were
excluded.
The
study
was
designed
as
an
open-label,
prospective,
parallel
group,
randomized
controlled
trial.
Simple
randomization
sequence
was
generated
by
computer
software.
After
allocation
of
patients
in
two
different
groups,
SSD
and
AgNP
gel
were
administered
topically
on
every
alternate
day
in
respective
group.
Totally,
163
subjects
were
randomized
of
whom
data
were
analyzed
for
54
patients
treated
with
1%
SSD
cream
and
52
patients
treated
with
AgNP
gel.
The
assessment
period
was
4
weeks
for
each
type
of
treatment.
However,
time
taken
for
complete
wound
healing
was
also
recorded.
Since
the
time
required
for
complete
wound
healing
is
directly
proportional
to
the
extent
of
TBSA
and
depth
of
tissue
injury
involved,
all
patients
in
both
treatment
groups
were
divided
into
two
groups
that
is,
(i).
20-40%
TBSA,
(ii).
41-60%
TBSA
involvement
groups;
each
of
which
were
further
sub-divided
according
to
the
depth
of
tissue
injury
as
superficial
and
deep-dermal
burns.
Of
52
patients,
31
(59.62%)
deep-dermal
cases
from
AgNP
group
and
27
(50%)
deep-dermal
cases
out
of
54
on
SSD
were
studied
for
the
assessment
of
wound
healing.
Condition
of
all
ulcers/wounds
was
assessed
at
weekly
intervals
by
examining:
"(i)
Edge
of
the
ulcer/wound;
(ii)
Type
of
necrotic
tissue
present
inside
the
ulcer/wound;
(iii)
Amount
of
necrotic
tissue
present
inside
the
ulcer/wound;
(iv)
Color
of
skin
surrounding
the
ulcer/wound;
(v)
Type
of
granulation
tissue
and
its
amount
present
inside
the
ulcer/wound;
(vi)
Amount
of
wound
healing
by
means
of
epithelization
of
the
ulcer/wound"
following
photographic
wound assessment
tool
(PWAT).
[8
'
9
'
Besides
various
parameters
in
PWAT,
(vii)
Type
of
exudate
inside
the
ulcer/wound;
(viii)
Amount
of
exudate
inside
the
ulcer/wound;
were
also
taken
as
determinants
of
burn
wound
healing,
because,
exudate
increases
the
wound
bio-burden
and
increases
the
need
for
dressing
change,
which,
in
turn,
may
delay
wound
healing.E
1
°
3
These
were,
therefore,
taken
into
account
as
well.
The
eight
determinants
of
wound
healing
are
depicted
in
Table
1.
Assessors
assigned
a
score
between
"0"
and
"4"
for
each
determinant;
the
total
score
for
each
wound
was
calculated
by
summing
up
the
scores
assigned
to
the
various
determinants.
Lesser
score
implied
better
wound
condition.
Percentage
of
improvement
was
calculated
by
applying
the
following
formula:
(initial
score
final
score)/initial
score
x
100.
The
outcome
of
treatment
was
categorized
on
the
basis
of
percentage
improvement
as
poor
(0-25%),
moderate
(26-50%),
good
(51-75%),
or
excellent
(76-100%).
Table
1:
Determinants
of
burn
wound
assessment
Score
Edge
Necrotic Necrotic
Exudate
Exudate
Skin
color
Granulation
tissue
type
Epithelization
tissue
type
tissue
amount
%
type
amount
surrounding
wound
and
amount
%
0
Clearly
visible
None
0
None
Dry
Pink/normal
Intact
skin
and
100
covered
100
1
Distinct
but
attached
White/
nonadherent
>
25
Serous/clear
Just
moist
Bright
red
Beefy
red
and
75-
<
100
covered
75-
<
100
2
Not
attached
Yellow
slough
25-
<
50
Pale
red
Small
White/
hypo-pigmented
Beefy
red
and
50-
<
75
covered
50-
<
75
3
Rolled
under
Adherent
50-
<
75
Bloody
Moderate
Dark
red/purple
Pink/husky
red
and
25-
25-
<
50
<
50
covered
4
Fibrotic/
scarred
Black
escher
75-100
Purulent
Large
Black/
hyper-pigmented
None
<
25
Individual
items
were
summed
up
to
obtain
the
burn
wound
score
at
a
particular
time
point
1
Journal
of
Basic
and
Clinical
Pharmacy
30
>
Vol.
6
I
Issue
1
I
December-February
2015
I
Adhya,
et
al.:
Healing
of
burn
wounds
by
nano-silver
Silver
sulfadiazine
1%
cream
was
purchased
under
the
trade
name
of
DISILVA
Cream
Diamond
Drugs
Pvt.
Ltd
(37,
S.G
Mullick
Lane
Kolkata-12.
AgNP
containing
hydrogel
Carbopol
934
polymer
was
purchased
from
Loba
Chemie
Pvt.
Ltd.,
India
and
the
0.5%
w/v
gel
was
prepared
by
dispersing
specified
amount
of
carbopol
934
powder
into
de-ionized
water,
mixing
well
and
then
leaving
overnight
to
ensure
complete
swelling
of
the
polymerElli
AgNP
suspension,
which
was
prepared
by
chemical
reduction
method
using
silver
nitrate as
precursor
element,
[12]
was
added
to
the
material
to
a
final
concentration
of
5o
ppm.
Finally,
the
gelling
was
done
by
drop-wise
addition
of
triethanolamine
in
sufficient
quantity
till
neutralization.
The
complete
procedure
was
carried
out
aseptically;
the
product
was
packed
in
a
sterile
container
and
further
subjected
to
UV
sterilization.
Statistical
analysis
Data
have
been
summarized
as
mean
±
standard
deviation
for
numerical
variables
and
counts
and
percentages
for
categorical
variables.
Numerical
parameters
have
been
compared
between
groups
by
Student's
independent
samples
t-test
if
normally
distributed,
or
by
Mann—Whitney
U-test
if
otherwise.
The
Chi-square
test
for
trend
was
used
to
compare
the
outcome
of
treatment
between
the
study
arms
while
the
Fisher's
exact
test
was
employed
to
compare
proportions
healed.
Time
trend
toward
5o%
and
complete
healing
have
been
studied
by
constructing
Kaplan—Meier
plots,
which
have
been
compared
between
the
groups
by
log-rank
test.
Analysis
was
two-tailed,
and
P
<
0.05
was
considered
statistically
significant.
Statistica
version
6
(StatSoft
Inc.,
2001,
Tulsa,
Oklahoma,
USA)
and
MedCalc
version
11.6
(MedCalc
Software
2011,
Mariakerke,
Belgium)
software
were
used
for
analysis.
Results
The
flow
of
study
participants
is
depicted
in
Figure
1.
Of
the
52
patients
recruited
into
AgNP
group
25
were
males,
and
among
54
patients
in
SSD
group
29
were
males.
Patients
in
the
former
group
ranged
between
7
and
6o
years
in
age,
with
mean
and
SD
of
27.4
±
11.34
years.
Age
range
in
the
latter
group
was
12-55
years
with
mean
and
SD
of
31.8
±
10.66.
As
shown
in
Table
2,
there
was
no
statistically
significant
difference
between
groups
in
age
and
gender
distribution.
The
extent
of
body
surface
area
burnt
was
also
comparable
between
the
groups.
Data
in
Table
3
depict
the
average
time
required
for
complete
wound
healing
among
various
categories
of
burn
wounds.
The
differences
between
groups
were
statistically
significant
for
deep-dermal
wounds
only,
with
patients
in
the
AgNP
arm
recovering
on
average
10
days
earlier
than
in
their
SSD
counterparts
when
body
surface
area
involved
was
between
20%
and
4o%
and
13
days
earlier
when
involvement
was
>40-60%.
As
shown
in
Table
4,
considering
deep-dermal
burn
wounds
only,
the
differences
in
treatment
outcome
at
4
weeks
was
statistically
highly
significant
(P
=
0.003)
in
favor
of
AgNP
treatment.
However,
at
4
weeks,
only
4
cases
in
AgNP
arm
had
achieved
complete
wound
healing
compared
to
none
in
the
SSD
arm,
and
this
was
not
a
statistically
significant
difference
[Table
5].
However,
25
had
achieved
5o%
wound
healing
compared
to
13
on
SSD,
and
this
was
statistically
significant
(P
=
o.00i).
The
probability
of
achieving
5o%
wound
healing
by
4
weeks
have
been
depicted
in
the
Kaplan—Meier
plots
in
Figure
2.
The
log-rank
test
also
indicates
significantly
faster
achievement
of
this
endpoint
in
the
AgNP
group
compared
to
the
SSD
group
(P
=
o.00i).
Photograph
of
a
clinical
case,
who
was
treated
with
nano
silver
(AgNP),
is
shown
here
as
an
example
to
describe
how
we
have
clinically
scored
the
burn
ulcer
and
what
was
the
response
of
the
therapy.
Figure
3a
shows
a
35-year-old
male
patient
admitted
with
43%
TBSA
flame
burn,
with
an
ulcer
in
right
lower
limb,
the
ulcer
had
fibrotic
edge
(score:
4),
Table
2:
Demographics
and
clinical
data
of
burn
patients
in
both
treatment
groups
Parameter
Silver
sulfadiazine
(n=52)
(%)
Nano-silver
(n=54)
(%)
P
Age
31.8±10.66
27.4±11.34
0.064
Sex
Male
29
(53.70)
25
(48.08)
0.697
Female
25
(46.30)
27
(51.92)
Total
body
surface
area
burnt
(%)
20-40
(2°
superficial)
12
(31.48)
15
(28.85)
0.992
20-40
(2°
deep-dermal)
13
(24.07)
17
(32.69)
>
40-60(2°
superficial)
10
(18.52)
6
(11.54)
>
40-60(2°
deep-dermal)
14
(25.92)
14
(26.92)
P
value
in
the
last
column
is
from
Independent
samples
t-test
for
age,
Fisher's
exact
test
for
gender
and
Chi-square
test
for
body
surface
area
involvement
Table
3:
Duration
of
treatment
for
complete
wound
healing
(days)
by
wound
type
Group
Total
body
surface
area
burnt
20.40%
>
40.60%
superficial
deep-dermal
Silver
sulfadiazine
(n=52)
20.5
±
8.75
(n=17)
48.4±14.11
(n=13)
Nano-silver
(n=54)
15.7±4.14
(n=15)
38.6±
11.26
(n=17)
P
0.206
0.022
P
value
is
from
between
group
comparison
by
Mann-Whitney
U-test
superficial
deep-dermal
28.1±12.76
(n=
10)
58.9±18.18
(n=14)
26.0±6.22
(n=
6)
45.4±
11.35
(n=14)
0.739
0.007
1
Vol.
6
I
Issue
1
I
December-February
2015
31
>
Journal
of
Basic
and
Clinical
Pharmacy
.
Enrollment
.,
Assessed
for
eligibility
(n=
244)
Excluded
(n=
81)
Not
meeting
inclusion
criteria
(n=
60
)
Declined
to
participate
(n=0
)
Other
reasons
(n=
21
didn't
survive
72
hours
)
Randomized
(n=
163)
Allocated
to
intervention
(n=79)
Received
allocated
intervention
(n=
79
)
Did
not
receive
allocated
intervention
(n=0
i
Allocated
to
intervention
(n=
84)
Received
allocated
intervention
(n=
84
)
Did
not
receive
allocated
intervention
(n=
0
)
Allocation
Fallow-Up
ir
Lost
to
follow-up
(give
reasons)
(n=
27)
Discontinued
intervention
(n=0)
Lost
to
follow-up
(give
reasons)
(n=30)
Discontinued
intervention
(n=0)
Analysis
Analysed
(n=54)
Excluded
from
analysis
(n=0)
Analysed
(n=52)
Excluded
from
analysis
(n=0)
Adhya,
et
al.:
Healing
of
burn
wounds
by
nano-silver
Figure
1:
Diagram
showing
flow
of
study
participants
Table
4:
Comparison
of
healing
status
of
deep-
dermal
burn
wounds
after
4
weeks
treatment
Group
Poor
Moderate
Fast
Excellent
P
(0.25%)
(26.50%) (51.75%)
(76.100%)
Silver
sulfadiazine
6
8
13
0
0.003
(n=27)
Nano-silver
(n=31)
2
4
20
5
P
value
is
from
between
group
comparison
by
Chi
-
square
test
for
trend
with
<5o%
(score:
2),
adherent
necrotic
(score:
3)
tissue,
with
moderate
(score:
3)
bloody
(score:
3)
exudate,
with
surrounded
hypo-pigmented
(score:
2)
skin,
with
husky
red
(score:
3)
<25%
granulation,
with
<25%
(score:
4)
epithelization,
with
a
total
score
24/40.
The
patient
was
treated
in
a
district
hospital
for
2
weeks,
but
the
wound
was
not
improving
and
transferred
to
our
burn
unit.
After
admission
in
our
center,
we
started
dressing
with
nano-silver
(AgNP).
Within
zo
days
the
patient
shows
significant
clinical
improvement
[Figure
3b]
and
within
23
days,
patient
had
complete
wound
healing
[Figure
3c].
Both
the
topical
treatments
were
well-tolerated
and
apart
from
mild
irritation
during
the
application
in
a
few
subjects;
no
other
adverse
event
was
noticed.
There
were
no
instances
of
argyria
as
well.
Discussion
Effective
healing
of
skin
wounds
implies
the
regeneration
of
normal
skin
by
resurfacing
with
new
epithelium.
In
the
case
1
Journal
of
Basic
and
Clinical
Pharmacy
32
>
Vol.
6
I
Issue
1
I
December-February
2015
I
Group
1
100
Pro
ba
bi
lity
o
f
50
0
/o
hea
ling
by
4
w
60
40
20
r
i
-r
10
20
30
40
50
60
70
80
Time
(days)
0
Figure
2:
Kaplan—Meier
plots
depicting
the
time
trend
toward
achieving
50%
wound
healing
in
the
two
study
arms
(Group
1
=
Nano-silver,
Group
2
=
Silver
sulfadiazine)
Adhya,
et
al.:
Healing
of
burn
wounds
by
nano-silver
of
superficial
burns,
when
epidermis
is
destroyed
leaving
dermis
and
its
elements
intact,
the
skin
virtually
restores
its
epidermal
cover
within
7-14
days
without
any
complication.
However,
in
burn,
only
a
part
of
dermis
remains
viable,
and
wounds
take
several
weeks
to
heal.
The
healing
process
may
be
retarded
by
disintegrative
necrosis
of
the
upper
dermis
which
is
susceptible
to
bacterial
infection.
As
a
deep-dermal
burn
heals
slowly,
the
chance
for
infection
is
more
prolonged
than
superficial
burns.
In
the
addition,
formation
of
necrotic
slough
provides
a
rich
source
of
nutrition
that
enhances
bacterial
growth.m
A
number
of
silver
compounds
with
antimicrobials
activity
are
used
prophylactically
to
prevent
infective
complications
in
burn
wounds.
Among
them,
mafenide
acetate
11.2%
cream
(e.g.,
sulfamylon)
is
one
of
the
oldest
effective
topical
antimicrobial
agents;
it
has
broad
spectrum
of
antimicrobial
activity,
with
some
antifungal
properties
and
has
good
penetration
through
the
eschar.
But,
mafenide
cream
is
toxic
to
epithelial
cells
and
fibroblasts
and
it
can
cause
an
allergic
skin
rash
and
being
a
carbonic
anhydrase
inhibitor,
it
can
also
cause
metabolic
acidosis,
so
it
is
not
preferred
as
a
first-line
antimicrobials
ointment
for
burn
wounds.
Unlike
mafenide
or
silver
nitrate,
SSD
does
not
hinder
epithelialization,
although
it
does
hamper
contraction
of
fibroblasts.
Furthermore,
SSD
is
painless
on
application,
has
high
patient
acceptance,
and
is
easy
to
use
with
or
without
dressing.
[14]
Thus,
SSD
is
widely
used
and
has
been
considered
as
the
"gold
standard"
topical
treatment
for
burn
wounds
and,
therefore,
it
was
selected
as
the
active
comparator
in
our
study.
However,
it
is
not
the
ideal
topical
antimicrobial,
because
deep-dermal
wounds
usually
heal
slowly
and
there
is
suspicion
that
SSD
may
delay
the
process
further,
[4,15,16]
and
bacterial
resistance
to
SSD
has
also
been
reported.
[4,17]
The
sticky
nature
of
the
preparation
can
make
the
periodic
dressing
change
process
painful.
Leukopenia,
hepatic,
and
renal
toxicity
have
also
been
documented
following
prolonged
application
of
SSD.
[4,5]
Thus
there
is
a
need
to
continue
the
search
for
a
superior
antimicrobial
with
desirable
effects
on
burn
wound
healing.
In
recent
years,
with
the
advent
of
nanotechnology,
pure
form
of
silver
can
now
be
utilized
as
a
topical
treatment
for
burn
wounds.
The
nanometer-sized
particles
are
metastable
in
nature
and
thus
more
reactive
than
bulk
form.
[18,191
The
high
surface
to
volume
ratio
of
the
nanoparticles
is
another
advantage
as
it
allows
the
particles
to
remain
effective
even
at
a
very
low
concentration.
Thus
minimizes
the
chance
for
tissue
toxicity,
if
any.
Several
studies
have
reported
a
broad
spectrum
antibacterial
as
well
as
antifungal
properties
of
Table
5:
Status
of
wound
healing
(50%
healing
or
complete
healing)
by
4
weeks
Group
50%
healing
by
Complete
healing
4
weeks
(%)
by
4
weeks
(%)
Yes
No
Yes
No
Silver
sulfadiazine
(n=27)
13
(48.14)
14
(51.85)
0(0)
27
(100)
Nano-silver
(n=31)
25
(80.64)
6
(19.35)
4
(12.9)
27
(87.09)
P
0.001
0.116
P
value
is
from
between
group
comparison
by
Fisher's
exact
test
a
b
Figure
3:
(a)
Two
weeks
old
burn
ulcer
presented
for
nano-crystalline
silver
treatment.
(b)
Ulcer
after
10
days
and
3
times
dressing
with
nano-crystalline
silver
gel.
(c)
Complete
wound
healing
achieved
within
23
days
with
nano-crystalline
silver
gel
Vol.
6
I
Issue
1
I
December-February
2015
33
>
Journal
of
Basic
and
Clinical
Pharmacy
Adhya,
et
al.:
Healing
of
burn
wounds
by
nano-silver
nano-crystalline
silver.
[17,20,21]
The
mechanism
may
involve
disruption
of
bacterial
cell
wall,
blocking
of
DNA
replication
and
deactivation
of
vital
enzymes
of
bacterial
respiratory
system.
Thus,
nano-crystalline
silver
can
be
an
effective
barrier
against
microbial
invasion
and
significantly
decrease
the
risk
of
infection.
In
addition
to
the
superior
antimicrobial
action,
AgNP
has
potential
antiinflammatory
effects,
less
tissue
toxicity,
analgesic
property
and
faster
wound
healing
by
achieving
moist
condition
under
a
scab
and
there
is
already
evidence
to
suggest
that
AgNP
formulations
can
achieve
better
wound
outcome
than
conventional
silver
preparations,
and
this
may
be
in
ways
beyond
just
excellent
antimicrobial
action.
[17,22-27]
Our
results
suggest
that
significantly
faster
and
improved
wound
healing
can
be
achieved
by
topical
application
of
nano-crystalline
silver
(AgNP)
as
compared
to
conventional
SSD.
This
is
particularly
true
of
deep-dermal
wounds.
However,
complete
wound
healing
time
extends
beyond
4
weeks
and
generally
requires
6-8
weeks
or
even
more.
This
is
in
agreement
with
earlier
studies.tl•
31
No
adverse
effects
were
encountered,
and
there
was
no
instance
of
argyria.
To
conclude,
nano-crystalline
silver
(AgNP)
can
be
an
effective
and
superior
alternative
to
SSD
in
the
management
of
burn
wounds,
particularly
deep-dermal
burns.
Healing
can
be
expected,
in
general,
in
6-8
weeks
time,
depending
upon
the
extent
of
body
surface
involvement.
Confirmation
of
these
results
in
larger
trials,
with
exploration
of
pharmacoeconomic
aspects,
will
be
worthy
areas
for
future
study.
Acknowledgement
We
are
grateful
to
Department
of
Science
&
Technology
West
Bengal
for
providing
financial
resources
and
also
to
the
Medical
Superintendent
cum
Vice-Principal,
IPGME&R;
SSICM
Hospital
&
The
West
Bengal
University
of
Health
Sciences
for
academic
support.
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How
to
cite
this
article:
Adhya
A,
Bain
J,
Ray
0,
Hazra
A,
Adhikari
S,
Dutta
G,
et
al.
Healing
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Source
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Support:
DST
West
Bengal,
Conflict
of
Interest:
None
declared.
Journal
of
Basic
and
Clinical
Pharmacy
34
>
Vol.
6
I
Issue
1
I
December-February
2015
I