A comparative study of clinico-

biochemical responses during

topical silver sulphadiazine and

honey therapy in burn injury.

Bhagwat V R1 and Subrahmanyam M2

1.Dept of Biochemistry, SBH Govt Medical College, Dhule 424001, 2.Dept of Surgery, Govt Med College & Civil Hospital, Sangli 416416Email: bhagwatvr@yahoo.co.in

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The supra-physiological effects of external factors (like heat, chemicals, electricity, radiations etc) resulting in to biological dysfunction,destruction & / or loss of tissue.

Types of Burns

There are 5 basic types of burns that occur:1. Thermal: Fires or flames, explosions, hot surfaces.

2. Chemical: strong acids or alkalis and chemicals - AgNO3.

3. Electrical: High voltage, HT wires, lightning, electrocution.

4. Radiological: Sunlight (UV), X-rays, microwave radiation or

nuclear emissions.

5. Scald: Friction, contact with hot liquids

& gases. Result in blisters.

Burns are caused by a wide variety of substances and external sources such as exposure to heat, chemicals, friction, electricity, and radiations.

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Classification Of Burns

A. Burns can be classified according tothe body surface area that is involved:

Minor Burns → 10% TBSA or less

Moderate Burns → 11 to 20% of TBSA

Major Burns → 20% to 60% of TBSA

Severe Burns → >60% of TBSA

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Classification Of Burns

Superficial: involves the epithelium; Appear pink, red, painful. Heal in 7-10 days.

Partial thickness: involves the epidermis and some dermis; Appears mottled pink, painful, hairs intact. Heal in 2-3 weeks.

Full thickness: extends through the skin to deeper structures; Appears black or white (eschar), leathery, produces no response to pain, and hairs are absent. Skin grafts are required.

B. Burns are also classified according to the depth of injury:

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Response to / Effects of burn trauma

Thermal injuries trigger an intense local and systemicinflammatory response, with increased capillary permeabilitycausing fluids and proteins to leak from the vascular space.This leakage can lead to oedema and hypovolaemia inextensive burns.

Biochemical changes:↑ Degradn of nucleotidesSigft ↓ PUFA in RBCs↑ Generation of FRs →↑ Lipid peroxidation↑ Serum enzymesLocal tissue ischemia →↑ Uric acid formation.

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Treatment of burn injury

Depends on type , severity and age of patient :

1. First Aid

2. Medications

3. Surgery and Other Procedures

4. Nutrition and Dietary Supplements

5. Mind-Body Medicine (Hypnosis)

6. Massage therapy

7. Acupuncture

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Medications

Antimicrobial ointments (such as silver sulfadiazine,

mafenide, silver nitrate, and povidone-iodine) to reduce risk of infection.

Bacitracin may be used for first degree burns.

Parrafin gauzes - superficial burns silver based dressings for deep burns.

Antibiotics (such as oxacillin, mezlocillin, and gentamicin)

are used to treat infection. Large TBSA size

Pain medications (such as acetaminophen with codeine,

morphine, or meperidine) for severe burns.

Anabolic steroids, such as oxandrolone, may be used for

severe burns to help decrease wound healing time.

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Honey

Honey is derived from nectar gathered and modified by the honeybee, Apis mellifera.

pH acidic (3.2 – 4.5), high viscosity, high osmolarity, Density of about 1.36 kilograms per litre (36% denser than water).

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Composition of HoneyHoney is a mixture of sugars and other compounds, mainly fructose (≈ 38.5%) and glucose (≈ 31.0%) of total carbohydrates.

Nutritional value per 100 g

Energy 1,272 kJ (304 kcal)

Carbohydrates 82.4 g

Dietary fiber 0.2 g

Protein 0.3 g

Water 17.10 g

Vitamins

B2, B3, B5 , B6, B9, C

0.751 mg

Minerals

Ca, Fe, Mg, P, K, Na, Zn

68.64 mg

In addition to the sugars, it also contain traces of several phytochemicals with antioxidant activity e.g. chrysin, pinobanksin, catalase, Pinocembrin, inhibin factor.

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Medical uses of honeyHoney has been used as a medicine since ancient times.

Bacteriostatic (high sugar content).

Antibacterial (H2O2, Methyl glyoxal).

Anti-inflammatory (accelerate wound healing).

Anti-necrotic (prevents fibrosis).

Used as Nutraceutical (Auyrveda).

Use for sore throats and coughs.

Use for diabetic ulcers.

Topical use of honey may reduce odors, swelling,

and scarring when used to treat wounds.

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Material of the studyPATIENTS: 117 patients with burn injuries admitted to DCH Superficial burn injuries – 48 %

Partial thickness burns – 31 % , Deep burns – 21 % 60 patients were on topical SSD ointment, while 47 patients were on honey therapy.Honey was obtained from beekeepers,

sterilized along with bandages.

SAMPLES:Random whole blood samples on admn.Thereafter, every week, up to 3 weeksSamples collected in plain containers.Centrifuged at 6ooo rpm 30-45 mins.Serum used for the biochemical assays.

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Methods used in the study

Serum processed from collected blood samples,was used for the assays of,1. Thio-barbituric acid reactive substances (TBARS)

by modified colorimetric method of Kei Satoh.2. Ascorbic acid by PTA colorimetric method.3. Uric acid by Caraway’s method.4. Ceruloplasmin by colorimetric method.

Statistical analysis : Arithmetic mean & sample std deviation.Data are expressed by graphs.

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RESULTS

Blood serum levels of biochemical

analytes in BURN TRAUMA(Thermal injury with superficial and partial thickness burns)

Days of

follow-up

Ascorbic acid (mg/dL)

On Admission

07th day

14th day

21st day

Values are mean ± SD; n = 117; SSD = Silver sulfadiazine treatment; HT = Honey treatment.

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3

4

5

6

7

Adm 7th day 14th day 21st day

nm

ol/

mL

Serum TBARSSSD HT

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INTERPRETATIONS: Burn injury → complex patho-physiology →

Deleterious effects on various organs. Earlier, “Burn Toxin” → Lipid-Protein polymer.

Now, LPP/TBARS are linked to lipoproteins.TBARS ≡ Free radical activity.* ↓PUFA & ↑TBARS in RBC membrane of thermal

injury (Report).

Fall of TBARS in post-burn period HT > SSDIt reflects HT is more efficient in buffering / controlling FR activity.It may be due to complex antioxidants in honey.

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* Subrahmanyam M, Sahapure AG, Nagane NS, Bhagwat VR, Ganu JV.

Free radical control - the main mechanism of the action of honey in burns,

Annals of Burns and Fire Disasters 2003 Sep; 16(3): 135-7.

0.7

0.8

0.9

1

1.1

1.2

1.3

Adm 7th day 14th day 21st day

mg

/dL

Serum Ascorbate

SSD HT

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INTERPRETATIONS: Ascorbic acid = Common aq phase exhaustible

antioxidant vitamin. Serum levels fall with time in burn trauma. Rate of fall in SSD > HT

This again reflects that honey somehow sparesAscorbate by buffering FR activity.

SSD do not have any effect / action on FR activity.*

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* Bhagwat VR, Subrahmanyam M. Damping of oxidative stress in cutaneous thermal injury by topical honey therapy: A comparison

with topical silver sulphadiazine treatment. SFRR-Ind Bul 2004; 3(2): 7-10.

Days of

follow-upUric acid (mg/dL) Ceruloplasmin (IU/L)

On Admission

07th day

14th day

21st day

Blood serum levels of biochemical

analytes in BURN TRAUMA(Thermal injury with superficial and partial thickness

Values are mean ± SD; n = 117; SSD = Silver sulfadiazine treatment; HT = Honey treatment.

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4

5

6

7

8

9

Adm 7th day 14th day 21st day

mg

/dL

Serum Uric acidSSD HT

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Interpretations :In Exptl burn injury models (rats) , ↑ Plasma histamine, XO activity ↑

→ Parallel ↑ in UALocal changes in post burn phase →

Ischemia-reperfusion → ↑ activation of XO (ADP → UA) → Elevation of serum UA.Honey treatment FR generation.* Hence better than SSD.

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* Bhagwat VR, Subrahmaniyam, Pujari KN. Relationship of ascorbic acid, uric acid, lipid peroxidation and burn size in thermal injury. Ind Med Gaz 2005 May; (CXXXI) 131 (5): 170-3.

170

190

210

230

250

270

Adm 7th day 14th day 21st day

IU/L

Serum CLPSSD HT

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Interpretation of data :

Serum protein with Cu & ferroxidase activity.

Acute phase reactant.

Plays dual role (1) Acute response to inflammation & (2) As antioxidant, limits Fe++ catalyzed FR generation.

Sepsis / Burn injury triggers,

1. macrophage activation → FR generation ↑

2. Release of IL-1 → Proteolysis → stimulate hepatic CLP synthesis.

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Nagane NS, Ganu JV, Bhagwat VR, Subrahmanyam M. Efficacy of topical honey therapy against silver sulphadiazine treatment in burns: A biochemical study. Ind J Clin Biochem 2004; 19(2): 173-6.

The results of this study indicate that topical honey treatment is efficient and better than SSD in controlling FR activity and inflammatory state. The honey treatment results in faster (less time to heal burn wounds)

and better recovery (less or negligible scar formation), free of allergy and cost effective than the conventional silver sulfadiazine treatment for majority of superficial and partial thickness burn injuries.

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