| 7( 1):19-20 MAtAwl MEDJOURNAL; June2005
AKfICLE ORIGINAI
Thedseof tanninsin the localtreatmentof burn wounds-a pilotstudy L Chokotho,Evan Hasselt Departmentof Surgery,Collegeof MedicineUniversityof Malawi
Tiventy patients aged 3 years and above with fresh partial thickness burns of less than 207o total body surface area were randomly assigned to local treatment of the burn wound either with a solution containing tannins (tannin group), or one of the other commonly used topical agents, such as honey and ghee, silver sulfadiazine, etc (the other group). The effects on serum transaminase and alkaline phosphatase, the incidence and type of wound infection, the quality of the eschar, the formation of scar tissue, adverse effects, the alleviation of pain and possible adverse reactions were studied in both treatment groups. Surprisingly initial assessmentof the burn wound depth proved more difficult than anticipated even in the hands of the more experienced
Abstract health worker. Liver function testswere elevatedin both the tannin (6 patients) and the other group (7 patients). Bacterial colonizationof the woundswasequallydistributed in both groups, although Staphylococcusaureus was found more often in the other group (9 versus1). The quality of the escharwas better in the tannin group (6 patientshad a supple escharyersus3 in the other group). The most important observationswere that no adversereactionswere encountered and that in the tannin group only one patient developeda hypertrophic scar comparedto 5 patientsin the other group.It proveddifficult to quantify alleviationof pain especially in the children.
sue formation 3 months post burn and adversereactions. Burn patients were recruited who met the following criteria: presentaA burn injury is a distressing and challenging condition which tion on the day of the burn; 3 years of age or older; total body is common in Malawi. A whole array of remedieshas servedin the local treatmentof burns through the ages1. The use of dress- surface area (TBSA) burnt of less than 20Vo wing Lund and Browder chart; and partial thickness burns. ings with antibacterial topical agents in the local treatment of Informed consent was obtained from the patient or guardian. burn wounds is the current standard.It is a time consuming and often painful method. A number of the topical agents used are The patients were.randomly assignedto treatment with either a either expensiveor difficult to acquire. fresh solution of tannins twice daily or one of the commonly burn wounds with tannins on in1925 started to treat Davidson2 used topical agents such as honey and ghee, silver sulfadiazine, reaction due to the the assumptionthat it reduced the systemic silver nitrate, Eusol and paraffin and Zinc oxide. The tannin absorption of toxic substancesfrom the burned skin. Tannins solution was preparedby mixing l0 grams of ground tea stalks are widely distributed in plants and are divided in two types, with 100cc of boiling water and left for 5 minutes. The solution hydrolysable and condensedtannins. The latter are found in tea was then filtered and allowed to cool down and subsequently plants3. More recent research has found that tannin has the used. The strength of tannin obtained this way proved to be the property to form complexes with several biomolecules and correct one after being tested in a laboratory in Utrecht. therefore might be efficacious in precipitating poisonous mateBlood for liver function tests (LFT's) and wound swabs were rials in burned tissuel. Tannin also leads to improved wound taken at weekly intervals. Pain charts were used, (visual onesfor healing and reduced scar tissue formation by inhibition of the children). Pictures with a digital camera were made to record formation and removal of reactive oxygen substances. wound appearancesat weekly intervals, at discharge and 3 Additional advantagesof tannins include: relief of pain, limitamonths post burn. A separateform to report adversedrug effects tion of secondary infection, prevention of loss of plasma and was included in the studv file. promotion of prolific epithelialisation4,5. The use of tannin in the treatment of burn wounds was abanBesults doned in the mid forties due to the availability of topical Ninety percent of the patients were less than lOyears old. Hot antibacterial agents and the associated hepatotoxic effects water was the commonest causeof burn wounds. Most patients observed in both patients and experimental animals4,5. sustainedpartial thickness burn wounds (table 1). LFT's were However critical evaluation of early literature and experimental elevated in both groups. Almost all wounds were colonised by observationhas shown that the hepatotoxic effects are not relatbacteria with staphylococcusas the most common bacteria culed to tannin but are due to the burn syndrome itself 6. In additured (table 2). Supple escharformed mostly in the tannin group tion use of tannin results in formation of supple eschar.The use and only one patient in the tannin group developed a hyperof tannin as adjuvant therapy for burn wounds therefore has trophic scar (table 3). regained interest. Becauseofthe availability oftea and its by-products and its low Discussion cost we conducteda pilot study in the use of tannins in the topHot water was the commonest causeof burn wounds. This is as ical treatment of the burn wound and comparedthe outcome of expectedin societieswhere cooking takes place at ground level this treatment with the currently used agents. and children are allowed near it unguardedor being looked after by a young sibling. The initial assessmentof depth was more difMethods ficult than anticipated since somepatients who were recruited as The following parameters were studied: effect on serum partial thickness ended up being full thickness.Intensive laboratransaminaseand alkaline phosphatase,incidence and type of tory testing was too difficult within the existing staffing wound infection, alleviation of pain, quality of eschar,scar tis-
lntroduction
Malawi Medical Journal
Theuseoftanninsin the localtreamentofburn wounds 20 levels. Ele\Tationof LFT's in both groups suggeststhat this was due to the burn syndrome itself. Quantification of the level of pain was difficult in children as all pointed towards "hurts terri-
btv".
Table3: Comparisonof escharquality and outcomeof scar
Supple Hard N/A
This study was not blinded. However, results of this pilot study ESCHAR suggestthat the use of tannins may provide benefit by reducing colonisation of S. aureuswith better quality of healing and at the same time not increasing toxicity. There was only one case of yes hyperlrophic scar formation in the tannin group. No adverse HYPERTROPHY No reactionswere encounteredin either treatmentgroup. The use of N/A tannin in the treatmentof partial thicknessburn wounds could be advantageousand cheap in places where tea and its by-products are easily available. A larger study population is required to see whether thesepotential benefits are clinically significant. References i. Health Management Publications, Inc. Wounds l3(4): 144158, 2001. http;//www.medscape.com 2. Davidson EC. Tannic acid in the treatment of burns. Surg Gynecol Obstet 1925; 4I:202-21 3. Haslam E. Practical Polyphenolics: From Structure to Molecular Recognition and Physiological Action.Cambridge, UK: CambridgeUniversity Press,1998:10-83 4. Halkes SB A et al, The use tannic acid in the local treatment of burn wounds: intriguing old and new perspectives.Wounds 13(4):144-158,2001 5. Hupkens P et al, Tannic acid as a topical agent in burns: historical considerations and implications for new developments.Bums 2l(1) 51-61,1995 6. Kreis RW et al, Tannin Ointment. Clinical pilot trial reporl. Burns researchinstitute 1992
Thble 1: Fatient Demography, Cause and Depth of the Burn Wound
Male Female
TANNIN 86 24
OTHER
Sex
Age
Range
AKfICLE ORIGINAI
Thedseof tanninsin the localtreatmentof burn wounds-a pilotstudy L Chokotho,Evan Hasselt Departmentof Surgery,Collegeof MedicineUniversityof Malawi
Tiventy patients aged 3 years and above with fresh partial thickness burns of less than 207o total body surface area were randomly assigned to local treatment of the burn wound either with a solution containing tannins (tannin group), or one of the other commonly used topical agents, such as honey and ghee, silver sulfadiazine, etc (the other group). The effects on serum transaminase and alkaline phosphatase, the incidence and type of wound infection, the quality of the eschar, the formation of scar tissue, adverse effects, the alleviation of pain and possible adverse reactions were studied in both treatment groups. Surprisingly initial assessmentof the burn wound depth proved more difficult than anticipated even in the hands of the more experienced
Abstract health worker. Liver function testswere elevatedin both the tannin (6 patients) and the other group (7 patients). Bacterial colonizationof the woundswasequallydistributed in both groups, although Staphylococcusaureus was found more often in the other group (9 versus1). The quality of the escharwas better in the tannin group (6 patientshad a supple escharyersus3 in the other group). The most important observationswere that no adversereactionswere encountered and that in the tannin group only one patient developeda hypertrophic scar comparedto 5 patientsin the other group.It proveddifficult to quantify alleviationof pain especially in the children.
sue formation 3 months post burn and adversereactions. Burn patients were recruited who met the following criteria: presentaA burn injury is a distressing and challenging condition which tion on the day of the burn; 3 years of age or older; total body is common in Malawi. A whole array of remedieshas servedin the local treatmentof burns through the ages1. The use of dress- surface area (TBSA) burnt of less than 20Vo wing Lund and Browder chart; and partial thickness burns. ings with antibacterial topical agents in the local treatment of Informed consent was obtained from the patient or guardian. burn wounds is the current standard.It is a time consuming and often painful method. A number of the topical agents used are The patients were.randomly assignedto treatment with either a either expensiveor difficult to acquire. fresh solution of tannins twice daily or one of the commonly burn wounds with tannins on in1925 started to treat Davidson2 used topical agents such as honey and ghee, silver sulfadiazine, reaction due to the the assumptionthat it reduced the systemic silver nitrate, Eusol and paraffin and Zinc oxide. The tannin absorption of toxic substancesfrom the burned skin. Tannins solution was preparedby mixing l0 grams of ground tea stalks are widely distributed in plants and are divided in two types, with 100cc of boiling water and left for 5 minutes. The solution hydrolysable and condensedtannins. The latter are found in tea was then filtered and allowed to cool down and subsequently plants3. More recent research has found that tannin has the used. The strength of tannin obtained this way proved to be the property to form complexes with several biomolecules and correct one after being tested in a laboratory in Utrecht. therefore might be efficacious in precipitating poisonous mateBlood for liver function tests (LFT's) and wound swabs were rials in burned tissuel. Tannin also leads to improved wound taken at weekly intervals. Pain charts were used, (visual onesfor healing and reduced scar tissue formation by inhibition of the children). Pictures with a digital camera were made to record formation and removal of reactive oxygen substances. wound appearancesat weekly intervals, at discharge and 3 Additional advantagesof tannins include: relief of pain, limitamonths post burn. A separateform to report adversedrug effects tion of secondary infection, prevention of loss of plasma and was included in the studv file. promotion of prolific epithelialisation4,5. The use of tannin in the treatment of burn wounds was abanBesults doned in the mid forties due to the availability of topical Ninety percent of the patients were less than lOyears old. Hot antibacterial agents and the associated hepatotoxic effects water was the commonest causeof burn wounds. Most patients observed in both patients and experimental animals4,5. sustainedpartial thickness burn wounds (table 1). LFT's were However critical evaluation of early literature and experimental elevated in both groups. Almost all wounds were colonised by observationhas shown that the hepatotoxic effects are not relatbacteria with staphylococcusas the most common bacteria culed to tannin but are due to the burn syndrome itself 6. In additured (table 2). Supple escharformed mostly in the tannin group tion use of tannin results in formation of supple eschar.The use and only one patient in the tannin group developed a hyperof tannin as adjuvant therapy for burn wounds therefore has trophic scar (table 3). regained interest. Becauseofthe availability oftea and its by-products and its low Discussion cost we conducteda pilot study in the use of tannins in the topHot water was the commonest causeof burn wounds. This is as ical treatment of the burn wound and comparedthe outcome of expectedin societieswhere cooking takes place at ground level this treatment with the currently used agents. and children are allowed near it unguardedor being looked after by a young sibling. The initial assessmentof depth was more difMethods ficult than anticipated since somepatients who were recruited as The following parameters were studied: effect on serum partial thickness ended up being full thickness.Intensive laboratransaminaseand alkaline phosphatase,incidence and type of tory testing was too difficult within the existing staffing wound infection, alleviation of pain, quality of eschar,scar tis-
lntroduction
Malawi Medical Journal
Theuseoftanninsin the localtreamentofburn wounds 20 levels. Ele\Tationof LFT's in both groups suggeststhat this was due to the burn syndrome itself. Quantification of the level of pain was difficult in children as all pointed towards "hurts terri-
btv".
Table3: Comparisonof escharquality and outcomeof scar
Supple Hard N/A
This study was not blinded. However, results of this pilot study ESCHAR suggestthat the use of tannins may provide benefit by reducing colonisation of S. aureuswith better quality of healing and at the same time not increasing toxicity. There was only one case of yes hyperlrophic scar formation in the tannin group. No adverse HYPERTROPHY No reactionswere encounteredin either treatmentgroup. The use of N/A tannin in the treatmentof partial thicknessburn wounds could be advantageousand cheap in places where tea and its by-products are easily available. A larger study population is required to see whether thesepotential benefits are clinically significant. References i. Health Management Publications, Inc. Wounds l3(4): 144158, 2001. http;//www.medscape.com 2. Davidson EC. Tannic acid in the treatment of burns. Surg Gynecol Obstet 1925; 4I:202-21 3. Haslam E. Practical Polyphenolics: From Structure to Molecular Recognition and Physiological Action.Cambridge, UK: CambridgeUniversity Press,1998:10-83 4. Halkes SB A et al, The use tannic acid in the local treatment of burn wounds: intriguing old and new perspectives.Wounds 13(4):144-158,2001 5. Hupkens P et al, Tannic acid as a topical agent in burns: historical considerations and implications for new developments.Bums 2l(1) 51-61,1995 6. Kreis RW et al, Tannin Ointment. Clinical pilot trial reporl. Burns researchinstitute 1992
Thble 1: Fatient Demography, Cause and Depth of the Burn Wound
Male Female
TANNIN 86 24
OTHER
Sex
Age
Range
