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Ziegler et al. Plast Aesthet Res 2018;5:33 Plastic and
DOI: 10.20517/2347-9264.2018.46 Aesthetic Research

Review Open Access

State of the art in enzymatic debridement

Benjamin Ziegler, Gabriel Hundeshagen, Tomke Cordts, Ulrich Kneser, Christoph Hirche
Department of Hand, Plastic and Reconstructive Surgery, Microsurgery - Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and
Plastic Surgery, University Heidelberg, Ludwigshafen D-67071, Germany.
Correspondence to: Dr. Christoph Hirche, Research group “Trauma meets Burns”, Department of Hand, Plastic and Reconstructive
Surgery, Microsurgery - Burn Center, BG Trauma Center Ludwigshafen/Rhine, Hand and Plastic Surgery, University Heidelberg, Ludwig-
Guttmann-Str. 13, Ludwigshafen D-67071, Germany. E-mail: christoph.hirche@bgu-ludwigshafen.de

How to cite this article: Ziegler B, Hundeshagen G, Cordts T, Kneser U, Hirche C. State of the art in enzymatic debridement. Plast
Aesthet Res 2018;5:33. http://dx.doi.org/10.20517/2347-9264.2018.46

Received: 11 Jun 2018 First Decision: 30 Jul 2018 Revised: 8 Aug 2018 Accepted: 13 Aug 2018 Published: 29 Aug 2018
Science Editor: Raymund Engelbert Horch Copy Editor: Cai-Hong Wang Production Editor: Huan-Liang Wu

Abstract

Surgical treatment of deep partial thickness to full thickness burn wounds by knife has been the undisputed standard
of care and was one key point in surgical burn medicine for decades. Recently, it gets more and more challenged by
Bromelain-based enzymatic burn wound debridement (ED) as technique for non-surgical, selective eschar removal.
Although the literature on ED is increasing constantly it cannot comprise the rapid progress that is made in clinical
application of ED. To outline the current state of art in ED, recent literature as well as clinical experience is summarized
and the main steps in clinical application including indications, wound preparation, application of the enzyme, wound
bed assessment and further treatment after ED are discussed. Initial indications and limitations in application of ED
could be gradually extended to increase versatility of ED as tool in burn surgery. Several randomized controlled trials
compared ED to standard of care (SOC). They could show significant shorter time to complete burn wound debridement
and wound closure, reduced need for surgery, reduced blood loss, reduced area of burns that needed surgical excision
and need for autograft as well as an improved scar quality. Further research is necessary to justify an extensive use of
ED as tool for burn eschar removal. Especially a robust comparison to surgical burn wound excision by knife as SOC is
required to facilitate evidence-based burn surgery.

Keywords: State of the art, enzymatic debridement, Nexobrid, eschar removal, burns

INTRODUCTION
Effective removal of necrotic burned tissue is a key step in the treatment of all deep partial thickness and full
thickness burn wounds. It aims to promote wound healing, reduce bacterial colonization and infection, is the

© The Author(s) 2018. Open Access This article is licensed under a Creative Commons Attribution 4.0
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