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Page 4 of 7 Ziegler et al. Plast Aesthet Res 2018;5:33 I http://dx.doi.org/10.20517/2347-9264.2018.46

A B

C D

Figure 1. The case of a 27-year-old male patient suffering a deep partial thickness burn due to flame burn at his right hand is shown. A:
After admission to hospital right after trauma; B: two days after ED; C: two weeks after ED; D: one year after ED

[14]
[7]
ring , while other authors prefer conventional antiadhesive wound dressings with polyhexanide gel . If
wound bed assessment indicates a deep dermal wound with expected prolonged healing time or instable
scarring, early surgical coverage - eventually accompanied by additional debridement - by split-thickness
skin grafting (STSG) should be considered. As in every burn wound, development of hypergraulation tissue
prevents primary wound healing and can lead to hypertrophic scarring. Topical administration of potent ste-
roids (e.g., clobetasol) can be recommended to treat occurring hypergranulation tissue in the wound man-
[15]
agement phase . If spontaneous healing is absent 21 days after ED or a sticky layer, called pseudo-eschar,
[10]
which does not peel off after 14 days, surgical intervention and STSG should also be taken into account .

DISCUSSION
Bromelain-based ED is more than a new technique, it includes a new concept of selective eschar removal
without the necessity to schedule OR for this initial step. Due to encouraging results, the technique and its
concept behind has been implemented in the leading burn centers in Europe since 2013. With experience of
treating many hundreds of burn victims with ED, results could even be improved and are stable enough to
[10]
use ED in routine patient treatment . Despite the growing experience, the literature offers seven publica-
tions on studies with a high level of evidence proving ED’s advantages with certain issues over standard of
[16]
care (SOC), which is remarkable for literature in burns. Loo et al. investigated literature on ED from 1986
to 2017 and reported seven prospective studies including four randomized controlled trials in a recent re-
[5]
view. The largest available randomized-control trial by Rosenberg et al. compared 74 cases of ED with 81
cases treated by SOC and could show a significant shorter time to complete eschar removal, a lower number
of wounds requiring surgical excision and STSG as well as a significant lower blood loss in in the ED group.
No significant difference could be shown in time to wound closure and scar quality. While these results
[6,7]
could be confirmed by other authors one group even reported a reduced time to wound closure and an
[8,9]
improved scar quality in comparison to historical control groups . Further encouraging results could be