Evaluation of the Effect of Topical Heparin on the Treatment of Facial Burn

INTRODUCTION

Heparin has been used for improving tissues perfusion¹. Heparin has been reported to be beneficial for burn-related treatment since the 1950s. Green et al indicated that burn patients treated with heparin in the acute stage of illness were observed to have clearer mental status, better urinary output, less morbidity and earlier healing².

Heparin is a multifaceted compound with anti‑inflammatory, anti‑allergenic, anti‑histaminic, anti‑serotonin and anti‑proteolytic enzyme properties. It has been used in both parenteral and topical forms in the management of thermal injuries to prevent burn extension, limit cutaneous tissue loss, promote faster healing with fewer contractures, relieve of pain, reduce tissue edema and weeping, prevent infection, and to promote revascularization, granulation and re-epithelialization of deeply burned tissue ³.

Burns of face and neck have been treated with open topical ointments. Burns of face and neck need special care because of possible damage to air way, ear cartilage and eye. A number of studies suggest that heparin reduce the healing time of burn leading to better quality scaring ⁴.

Heparin has been reported to be of value. The routes of heparin administration described are topical, intravenous, subcutaneous, inhalation, and in membranes. The largest and longest use of heparin was by topical application¹.

In this thesis we evaluate the effect of topical heparin on the treatment of facial burn in comparison with traditional treatment.

PATIENTS AND METHODS

This is a prospective controlled random study, done at the burn unit and clinic of the department of plastic and Burn surgery at Al-Azhar University Hospitals and El Salalm Specialized Hospital. The burn unit for in patients and the clinic for out patients and follow up visits after hospital discharge.

Forty consecutive patients -either males or females-, ranging from 15-60 years old, with acute thermal burn up to 20% body surface area burn including the face, either it was superficial partial, deep partial or full thickness were selected and followed up at the period from April 2019 to September 2019, The forty patients were divided into two similar twenty patients groups; Heparin group was treated with diluted topical heparin drip and Control group which treated with topical antimicrobial creams.

Patients with contraindication to the use of heparin like liver disease, renal disorders, blood coagulating diathesis, an allergy to heparin, active peptic ulcer, thrombocytopenia, electrical and chemical burns, active or potential bleeding due to trauma and extensive, fatal or old burns were excluded.

Results of both groups were compared with various variables to know the effectiveness of topical heparin dressing on acute facial burn regarding pain relief, antibiotic requirements and healing time. All patients were subjected to full history taking, general and local examination and laboratory investigations.

All patients of both groups were followed up weekly in the first month, one month, two months and three months later. Either they were inpatients or out patients. Daily dressing of wounds was done, medical photography for each follow up visit.

The need for analgesiaandvisual analog pain scale (VAS) were calculated for all patients to evaluate the analgesic effect of topical heparin and to adjust the analgesic dose to each group; Clinicalhealing timewas evaluated to patients all through time of hospital stay and upon discharge by clinical assessment and time of wound healing at each follow up visit. Also, routine laboratory investigations (CBC, SGOT, SGPT, etc) and coagulation profile (PT, PTT, INR) were done to the admitted cases to assess patients and monitor heparin effect, wound culture swabs were taken to follow up the rate of infection and treat it according to culture results.

Burn blisters, were ruptured, and the burn wound was cleansed with normal saline, The total day one topical heparin dose is about 100,000 IU /15% TBSA in two or three divided doses, more initially and less lately. As the face accounts for about 4.5% BSA, we placed 2 to 8 milliliters of the 5000 IU/ml heparin according to burned surface area, in a 20ml syringe with 28 gauge needle attached, the calculated dose of topical heparin was diluted 1:1 or 1:2 with normal saline and dripped on to the burn surface.  Approximately, 50% or more of day one dose was initially dripped on to the burn surfaces repeatedly in the first 10-15 min of heparin treatment, until the patient report that the burn pain has been relieved, and the initial burn erythema has blanched and the burn surface was dressed with normal saline in between to keep it moist. Day two and beyond, Topical use of heparin on healing burn surfaces was repeated four times daily using diminishing dose and duration until only a few drops are used in the final healing phase.

The patients were informed of the study and after this signed a consent term of their participation, after explanation of possible complications, ethical and legal implications.

To compare the effect of each dressing method on the clinical outcome these criteria and signs were observed and documented during follow up. Data collected, revised, coded and entered to the Statistical Package for Social Science (IBM SPSS) version 23. The quantitative data were presented as mean, standard deviations and ranges when their distribution found parametric and median with inter-quartile range (IQR) when their distribution found non parametric.

RESULTS

The patients in Heparin group reported less pain scores which means more satisfaction and comfortableness and less requirements of analgesics (Doses & Numbers) with topical heparin dressing than patients in Control group.

Also, Healing time which is the time that burn injury take to get rid of dead tissues and make neo-epithelilization, was calculated per week for all patients on each group. The number of healed cases per week in Heparin group was more than those in Control group. Figures (2- 9) show the comparison between the pre and post results of the two group’s patients.

     Figure 1: Pain scale and percentage of healed                          patients in each group per week.

Fig. 2: 28 year's old pt. with deep

Partial thickness burn

Fig.3: After two weeks of topical                                                                                 heparin dressing.

Fig. 4: 28 year's old pt. with deep

Partial thickness burn

Fig.5: After two weeks of topical                                                                                 antimicrobial creams.

Fig.6: 19 years old pt with superficial and partial thickness burn

Fig.7: After one week of topical                                                                                   heparin dressing.

Fig.8: 21 years old pt. with superficial

Partial thickness

Fig.9: After one week of topical                                                                                                                           antimicrobial creams.