The Role of the Compounding Pharmacy in Treating Partial and Full Thickness Burns
Patients who have suffered large-scale partial and/or full thickness burns can remain in the hospital for months or even years. The early days of treatment are vital to survival, while subsequent therapy often determines long-term outcomes, such as limb retention, scarring, and mobility. Caring for burn patients is an enormous team effort, and a crucial element is the compounding pharmacy. Here is a look at the role of compounded pharmaceuticals in treating severe second-degree and third-degree burns.
Understanding the Environment
The burn patient is a particularly fragile one, and treatment is more complex than perhaps any other specialty. Pharmacists who round on the burn unit have a valuable understanding of how complicated treatment can be, and in looking at the factors that influence burn care, it makes sense that compounded topical medications, such as those made possible using PNA pharmaceutical products, make up the bulk of treatment.
- Burned areas in partial and full thickness burns have poor or no vascularization. There is no route for systemic medications to make their way to areas that need treatment.
- Damage to or complete loss of skin alters the way routine topical drugs can be delivered, and permeability/penetration changes as the healing process continues. Delivery systems and carrying agents may need constant evaluation and changing.
- Infection risk is lethally high.
- Patients’ bodies have a poor ability to balance hydration, with both dehydration and edema being issues.
- Loss of skin equates loss of body temperature control.
- Patients’ entire bodies are out of balance, and all bodily systems are subject to complications. This is even more problematic if a patient has comorbidities, such as diabetes or cardiovascular disease, prior to sustaining the burn injury.
- Long-term pain and concerns about aesthetics, loss of limb, and forced changes in lifestyle after suffering burns can precipitate depression and anxiety, which then also need to be treated.
- Many burn patients are pediatric, which means special attention to dosing and side effects.
- Patients are on numerous long-term medications, and the ability to titrate them precisely, combine multiple drugs, and provide optimum administration routes means safer and more efficacious therapy.
It is now commonly accepted that sepsis is still the most frequent cause of mortality in burn units around the globe. As such, much of the focus in treating burn patients, especially in the early days after injury, is on antimicrobial therapy. This focus may be renewed following surgery for debridement, when fresh tissue is exposed, or after skin grafting procedures, before the graft is integrated into the existing tissue. As burn patients are chronically immunosuppressed, some level of antibiotic and/or antifungal therapy may need to be maintained throughout the length of the healing process.
Antimicrobials are used to both reduce the current microbial load and prevent risk of future infection by new pathogens. Antimicrobial treatment should largely be based on laboratory culture and sensitivity reports, with attention paid to both individual and institutional resistance issues. Patients on long-term therapy may need to have their medications rotated to reduce the risk of resistance.
The eschar that replaces skin after a burn injury is moist, full of protein, and devoid of immune cells, which makes it a ripe environment for microbes. An imbalance of surface pathogens exists due to burning off of normal bacteria in the epidermis and dermis and the presence of remaining bacteria in sweat glands and hair follicles, which migrate to the wound surface. There may also be translocation of gut flora that participates in the infective process.
Permeability of eschar is a major concern with the application of topical antimicrobials. Carrying agents may need to be switched to enhance achievement of therapeutic levels of the most essential medications. Also, wound debridement is a concern, and water soluble gel agents can be rinsed off without carrying away new tissue. Ointments, in addition to being harder to remove during irrigation, can lead to renal toxicity if too much polyethylene glycol is absorbed through the wound. Polyox bandages have become more popular, as they can be compounded with numerous ingredients then puffed into wounds and will adhere even in the presence of exudate.
There are literally hundreds of medications used today to treat burns, but the most common antimicrobials are similar to those used in diabetic wounds and pressure ulcers, as they are treating the same types of pathogens in poorly vascularized settings:
- Mafenide acetate: good for treating Gram-negative bacteria, especially Pseudomonas aeruginosa. Can be applied in a 0.5% cream or a 5% solution saturating gauze dressings. When used without dressings, makes wound inspection easier. Is usually combined with nystatin. Should not be used over wide areas in patients with respiratory acidosis, as it can cause metabolic acidosis.
- Mupirocin: treats Gram-positive pathogens and has gained popularity due to its coverage of MRSA. Standard dose for other indications is 2%, which may need to be up or down titrated.
- Bacitracin: a good alternative to silver sulfadiazine for patients with a sulfa allergy. Can be compounded in a hydrophobic or hydrophilic carrier at 5-8%.
- Nitrofurazone: treats both Gram-positive and Gram-negative bacteria and has maintained good activity with little resistance. Has been impregnated in urinary catheters to reduce risk of catheter-induced urinary tract infections.
- Polymyxin B
- Nystatin: an antifungal used most frequently to treat Candida. Higher concentrations needed to treat species other than albicans.
- Silver: use of silver to treat wounds goes back to the time of Hippocrates. Needs to be ionized for antimicrobial effect. Now applied in numerous combinations with many patents pending for unique delivery systems.
Even with damaged enervation and lack of vascular supply, burned areas can be subject to intense pain. Topical medications are utilized for pain and inflammation indications as well. Often patients do not experience pain until around 7-10 days post-injury. Ketoprofen 2% is often compounded for topical application, as is misoprostol 0.0024%, a prostaglandin analog that reduces inflammation and promotes healing. Lidocaine 2% can offer topical anesthesia; when that is unsuccessful, morphine is sometimes prescribed. One of the more challenging aspects of managing medications for burn patients can be alleviating pain without promoting addiction.
Optimizing Tissue Regrowth
On the forefront of current burn treatment is the attempt to create better methods of tissue regrowth that reduces scarring and improves mobility for patients. Newer skin substitutes (synthetic, biosynthetic, and biological) provide barriers to infection and also improved elasticity in healed tissue with reduced scar contracture.
Phenytoin, an oral anticonvulsant, is well-studied for its side effect of tissue hyperplasia. Because it causes tissue growth, it is now being compounded at 2-5% in burn wound medication. Verapamil, most frequently dosed for cardiac indications, can reduce scarring by regulating fibroblasts as a calcium channel blocker and can also be added to compounded preparations. To improve circulation at the wound margin, nifedipine or pentoxifylline may be added as well.
There are other natural substances that burn specialists have been using for years, such as zinc, vitamin E, and aloe vera, and recently honey has been the subject of new research. Papaya is also being studied for its use as a debriding agent, after decades of anecdotal success in Africa, where burn medications are more difficult to obtain. The good news for burn patients, even those that are currently on the ward, is that new developments are taking place every day.
Pharmaceutica North America is pleased to offer products and expert advice to pharmacies wishing to compound their own burn medications. Helping patients heal from devastating injuries is your goal and ours too. Please contact us to let us know how we can assist you in this gratifying work.