epidermolysis bullosa, treated at Great Ormond. Street Hospital in London (Denyer, 2009). While no overt silver-related pathology has been diagnosed in.
COMMENT
Interim advice on silver dressings in paediatric wound and skin care
T
‘
he use of topical antiseptics should be approached with caution in children, especially neonates (Metry and Hebert, 2005). Consequently, every case should be treated individually, recognizing all of the available evidence and considering the risk to benefit ratio of any treatment. Although silver has been used widely for many years, in the form of silver sulfadiazine cream and in wound dressings, the clinical evidence remains controversial. Perhaps most significantly, the use of topical silver-containing dressings in pre-term infants, and in children up to the age of five has been questioned on safety grounds, amid reports of high levels of silver in the blood of burns patients (Wang et al, 2009) and in those with the skin disorder
Infection is a leading cause of mortality, particularly in serious paediatric burns and skin disease. Pending further research, we recommend that cases be treated individually, with careful risk assessment and close monitoring.
’
epidermolysis bullosa, treated at Great Ormond Street Hospital in London (Denyer, 2009). While no overt silver-related pathology has been diagnosed in these children, persistent blood levels of 10 to 100 times the recommended maximum level of silver give reasonable cause for concern. Potential safety issues relate to the body surface area involved, the patient’s age, body weight, the barrier function of the skin (i.e. its nature according to disease states, age and developmental stage) and the duration of treatment (i.e. exposure to topical treatment). There is currently no way to differentiate silver-containing dressings by silver content or chemical form. Pending further research, we recommend that cases be treated individually, with careful risk assessment and close monitoring. Infection is a leading cause of mortality, particularly in serious paediatric burns and skin disease. The duration of treatment with any topical antimicrobial, including silver, should be limited according to existing guidelines (Best Practice Statement, 2010). Consequently, we suggest that silver dressings be used for no longer than two weeks without sound clinical justification. Failure
xx
to respond to treatment should result in careful re-assessment and, where necessary, a change of topical antimicrobial. If there are concerns regarding the choice of antimicrobial or wound progression, then referral to a tissue viability, burns, or dermatology specialist should be considered. Other topical agents which might be considered include glucose oxidase-lactoperoxidase alginate gel (De Smet et al, 2009), PHMB polyhexanide (Eberlein and Assadian, 2010), honey (Vardi et al, 1998; Bittmann et al, 2010) and iodine compounds (Durani and Leaper, 2008). The latter two have known drawbacks in paediatric use but are not inherently unsafe (Howard, 2001; Palmieri and Greenhalgh, 2002). At present, there are no contraindications for the paediatric use of silver. To avoid inappropriate treatment and potential morbidity, we recommend that best practice guidelines and the above advice be BJN followed, pending more evidence. Best Practice Statement (2010) The use of topical antiseptic/ antimicrobial agents in wound management. Wounds UK, 2010. http://tiny.cc/rx3sm (accessed 2 June 2011) Bittmann S, Luchter E, Thiel M et al (2010) Does honey have a role in paediatric wound management? Br J Nurs 19(15): S19–24 Denyer J (2009) Epidermolysis bullosa and silver absorption in paediatrics. Free paper. Wounds UK Conference, Harrogate, 2009 De Smet K, van den Plas D, Lens D, Sollie P (2009) Pre-clinical evaluation of a new antimicrobial enzyme for the control of wound bioburden. Wounds 21(3): 65–73 Durani P, Leaper D (2008) Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation. Int Wound J 5(3): 376–87 Eberlein T, Assadian O (2010) Clinical use of polihexanide on acute and chronic wounds for antisepsis and decontamination. Skin Pharmacol Physiol 23(Suppl): 45–51 Howard R (2001) The appropriate use of topical antimicrobials and antiseptics in children. Pediatr Ann 30(4): 219–24 Metry DW, Hebert AA (2000) Topical therapies and medications in the pediatric patient. Pediatr Clin North Am 47(4): 867–76 Palmieri TL, Greenhalgh DG (2002) Topical treatment of pediatric patients with burns: a practical guide. Am J Clin Dermatol 3(8): 529–34 Vardi A, Barzilay Z, Linder N et al (1998) Local application of honey for treatment of neonatal postoperative wound infection. Acta Paediatr 87(4): 429–32 Wang XQ, Kempf M, Mott J et al (2009) Silver absorption on burns after the application of Acticoat: data from pediatric patients and a porcine burn model. J Burn Care Res 30(2): 341–8
R.J. White1, S. Fumarola2, J. Denyer3
1. Professor of Tissue Viability, University of Worcester; 2. Senior Clinical Nurse Specialist Tissue Viability, University Hospital of North Staffordshire; 3. Epidermolysis Bullosa Nurse Consultant, Department of Dermatology, Great Ormond Street Hospital
Tissue Viability Supplement, 2011, Vol 20, No 10
