Efetividade do ácido hialurônico na terapia tópica de queimaduras de espessura parcial e/ou espessura parcial profunda: revisão sistemática / Effectiveness of hyaluronic acid in topical treatment of partial thickness burns and/or deep partial thickness: systematic review

Objetivo: Avaliar a efetividade e segurança do ácido hialurônico na cicatrização completa, cicatrização parcial, tempo médio de cicatrização e prevenção de formação de queloides e cicatrizes hipertróficas, em pacientes hospitalizados com queimaduras de espessura parcial e/ou espessura parcial profunda, comparado com outros tratamentos. Método: Revisão sistemática de ensaios clínicos randomizados, recuperados nas bases eletrônicas: (1) Medical Literature Analysis and Retrieval System Online, (2) Excerpta Medica Database, (3) Cumulative Index to Nursing and Health Literature, (4) Literatura Latino Americana e do Caribe em Ciências da Saúde, (5) Cochrane Central Register of Controlled Trials e (6) Web of Science. A busca foi realizada no período de junho e julho de 2015. Foram selecionados estudos que descreviam a aplicação de ácido hialurônico em pacientes hospitalizados, adultos ou crianças, que apresentavam queimaduras de espessura parcial ou parcial profunda, considerando diferentes formulações e associações de produtos. Os desfechos selecionados foram: (1) cicatrização completa, (2) cicatrização parcial ou redução da área da ferida, (3) prevenção de queloides e cicatrizes hipertróficas, (4) efeitos colaterais e efeitos adversos. Para a análise estatística utilizou-se o programa Review Manager 5.3. Dois revisores independentes avaliaram o risco de viés dos ensaios clínicos e determinaram a inclusão dos estudos. As divergências entre avaliadores foram resolvidas pela intervenção de terceiro revisor. A qualidade metodológica dos estudos foi definida com a utilização da Ferramenta de Risco de Viés da Colaboração Cochrane. Resultados: Foram recuperados 69 estudos, dos quais, 20 estavam replicados entre as bases. Quatro estudos foram pré-selecionados e avaliados na íntegra, e dois que associaram ácido hialurônico e sulfadiazina de prata em queimaduras de espessura parcial foram incluídos à revisão. A cicatrização completa, que representou o desfecho principal dos estudos, apresentou significância estatística em favor do grupo intervenção. O teste de inconsistência do programa Review Manager 5.3 da Colaboração Cochrane apontou para uma heterogeneidade de 97%, inviabilizando assim, a realização de metanálise entre os estudos para o desfecho "tempo médio de cicatrização". Como houve cicatrização completa de todas as lesões durante o tempo de segmento não foi possível realizar a análise das variáveis categóricas. Conclusão: Os resultados desta revisão sistemática apontam que são necessários novos ensaios clínicos aleatorizados devido à escassez de estudos identificados e ao número reduzido de pacientes avaliados. No entanto, a ação tópica de creme de ácido hialurônico em associação com sulfadiazina de prata apresentou resposta significativamente favorável no que tange a cicatrização de queimaduras de espessura parcial ou espessura parcial profunda, sugerindo assim, a possibilidade para a utilização clínica do produto.

Objective: This study aims to evaluate the effectiveness and safety of HA in complete healing, partial healing, average time of healing, and prevention of formation of keloid and hypertrophic scars in hospitalized patients with partial thickness burns and/or deep partial thickness burns, compared to other treatments. Methods: This study is based on a systematic review of randomized clinical trials retrieved in electronic databases: (1) Medical Literature Analysis and Retrieval System Online, (2) Excerpta Medica Database, (3) Cumulative Index to Nursing and Health Literature, (4) Latin American and Caribbean Health Sciences, (5) Cochrane Central Register of Controlled Trials, and (6) Web of Science. The search was carried out from June to July 2015. Studies selected reporting the application of hyaluronic acid in hospitalized, adults or children, who had burns of partial thickness or deep partial thickness, considering different formulations and products associations. The selected endpoints were: (1) complete healing; (2) partial healing or reduction of wound area; (3) prevention of keloid and hypertrophic scars; and (4) side effects and adverse effects. For statistical analysis, the Review Manager 5.3 software was used. Two independent reviewers determined the inclusion of studies and evaluated the risk of bias of clinical trials. Disagreements among reviewers were resolved by the intervention of a third reviewer. The methodological quality of the studies was determined by Cochrane Collaboration's tool for assessing risk of bias. Results: Sixty-nine studies were retrieved, from which twenty studies were replicated among the bases. Four studies were pre-selected and evaluated in full, including two which associated hyaluronic acid and silver sulfadiazine in partial thickness burns. Complete healing, which represented the main conclusion of the studies, showed statistically significant in favor of the intervention group. The Review Manager 5.3 inconsistency test of the Cochrane Collaboration indicated heterogeneity of 97%, thus impeding the holding of meta-analysis of studies for the outcome "mean time to healing". There was complete healing of all lesions during the segment time, therefore, analysis of categorical variables couldn't be performed. Conclusion: The results of this systematic review indicate that requires new randomized clinical trials due to scarcity of identified studies and the small number of evaluated patients. However, the topical action of hyaluronic acid cream in combination with silver sulfadiazine showed significantly a favorable response as it pertains the healing of partial-thickness or deep partialthickness burns, thus suggesting the possibility for the clinical use of the product.

Overview of Surgical Scar Prevention and Management

Management of incisional scar is intimately connected to stages of wound healing. The management of an elective surgery patient begins with a thorough informed consent process in which the patient is made aware of personal and clinical circumstances that cannot be modified, such as age, ethnicity, and previous history of hypertrophic scars. In scar prevention, the single most important modifiable factor is wound tension during the proliferative and remodeling phases, and this is determined by the choice of incision design. Traditional incisions most often follow relaxed skin tension lines, but no such lines exist in high surface tension areas. If such incisions are unavoidable, the patient must be informed of this ahead of time. The management of a surgical incision does not end when the sutures are removed. Surgical scar care should be continued for one year. Patient participation is paramount in obtaining the optimal outcome. Postoperative visits should screen for signs of scar hypertrophy and has a dual purpose of continued patient education and reinforcement of proper care. Early intervention is a key to control hyperplastic response. Hypertrophic scars that do not improve by 6 months are keloids and should be managed aggressively with intralesional steroid injections and alternate modalities.

The efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids.

OBJECTIVE: To evaluate the efficacy of 5% imiquimod cream in the prevention of recurrence of excised keloids. MATERIAL AND METHOD: The patients with keloids that had occurred over 1 year and could be excised and primary sutured were enrolled in the study. Imiquimod 5% cream was applied to the scar 7 days after stitches removal. The patients were follow-up for recurrence and drug side effect at 4, 6, 8, 16, and 24 weeks. RESULTS: Forty-five patients enrolled to the study but only 35 patients finished the study. The keloids were at the pinnas in 22 patients, at the backs or shoulders in 7 patients, and at chest walls or necks in 6 patients. Imiquimod 5% cream was applied on the wound area 2 weeks after the operation, at alternate night for 8 weeks. The follow-up period ranged from 6 to 9 months. Ten of the treated keloids recurred (28.6% recurrent rate). The lesion at the pinna had the lowest recurrent rate (2.9% recurrent of the total patients). The highest recurrent rate occurred at the chest wall or neck (83.3% recurrent of the chest wall or neck or 14.3% of the total patients). Side effects were found in thirteen patients (37.1%). These were abrasions of the skin around the wound areas in ten patients and hyperpigmentation of the skin around the wounds in three patients. CONCLUSION: Imiquimod 5% cream could effectively prevent recurrence of the excised keloids, especially in the area that had less tension such as pinna.