225

ORIGINAL ARTICLE
Effectiveness of Aloe Vera Gel compared with 1% silver sulphadiazine cream as
burn wound dressing in second degree burns
Muhammad Naveed Shahzad, Naheed Ahmed

Abstract
Objective: To assess the efficacy of Aloe Vera gel compared with 1% silver sulfadiazine cream as a burn dressing for
the treatment of superficial and partial thickness burns.
Methods: This Interventional Comparative study was carried out at the Burn unit and Plastic surgery department,
Nishtar Hospital Multan , Pakistan from July 2008 to December 2010. A total of 50 patients with superficial and
partial thickness burns were divided into two equal groups randomly by consecutive sampling method, one group
was dressed with Aloe Vera gel while the other was treated with 1% silversulphadiazine cream, and the results
regarding duration of wound epithelialization, pain relief and cost of treatment were compared.
Results: In patients treated with Aloe Vera gel, healing of burn wounds were remarkably early than those patients
treated with 1% silver sulfadiazine. All the patients of Aloe Vera group were relieved of pain earlier than those
patients who were treated with SSD.
Conclusion: Thermal burns patients dressed with Aloe Vera gel showed advantage compared to those dressed with
SSD regarding early wound epithelialization, earlier pain relief and cost-effectiveness.
Keywords: Aloe Vera gel, Second degree burns, Aloe Vera gel vs. 1% Silver sulphadiazine cream. (JPMA 63: 225; 2013)

Introduction several studies confirmed that this topical cream should

Burn injuries are among the most devastating of all not be used for long periods on extensive wounds.11,12
injuries and a major global public health crisis.1,2 Burns are Aloe Vera (family: Liliaceae) has a long association with
the fourth most common type of trauma worldwide, herbal medicine.13,14 Aloe Vera gel, obtained by breaking
following traffic accidents, falls, and interpersonal or slicing a leaf, contains nutrients, vitamins, antioxidants
violence.3 Approximately 90 percent of burns occur in low and has wound healing and immunomodulating
to middle income countries, regions that generally lack effects.15-19 Although burn wound healing is one of major
the necessary infrastructure to reduce the incidence and indications of Aloe Vera gel use in several animal and
severity of burns.4 Despite recent advances in clinical studies, few studies have compared the efficacy of
antimicrobial chemotherapy and wound management, this gel with SSD in the treatment of burns.16
infection continues to be an important problem in the
treatment of burns. One of the most effective means to The purpose of the present study was to compare the
achieve a microbial balance in a colonized or infected efficacy of SSD and Aloe Vera dressing for treatment of
wound is the proper use of prophylactic topical agents. partial thickness burn wounds.
Maintaining wounds at low colonization levels diminishes
the frequency and duration of septic episodes caused by
Patients and Methods
In our study we used Aloe Vera gel (AloeTone JelR). This
wound flora.5 The introduction of topical antimicrobial
product consists of the 98 % of unrefined gel from inner
agents has resulted in a significant reduction in burn
leaf of the plant.
mortality to date.6,7 Recent studies have demonstrated
that some agents used in the past are no longer effective This international comparative study was conducted in
in inhibiting bacterial growth in vitro.8 the burn unit/plastic surgery department, Nishtar
Hospital Multan during the period from July, 2008 to
The most common topical antimicrobial agent used is 1%
December, 2010.
silver sulfadiazine (SSD) cream.9 Its side effects are
delayed wound healing,10 resistance to 1% silver After approval of the study protocol from the Institutional
sulfadiazine (SSD) cream, renal toxicity, and leukopenia: Ethical Committee, 50 patients who had second degree
burns were enrolled. Patients with second degree burns
Department of Plastic Surgery, Nishtar Hospital, Multan. who presented within 24 hours and had total burn surface
Correspondence: Muhammad Naveed Shahzad. area (TBSA) < 25 % involved were included. Patients who
Email: drmuhammaad@gmail.com had corrosive, electrical and chemical burns and history of

J Pak Med Assoc

226 Effectiveness of Aloe Vera Gel compared with 1% silver sulphadiazine cream as burn wound dressing in second degree burns

diabetes, hypertension, epilepsy, kidney disease or SSDe cream.

pregnancy were excluded.
Tape method was used to measure length and width of the
All burn patients were received in A & E department of wound and then these measurements were multiplied i.e.
Nishtar Hospital Multan where the fluid resuscitation was Area (in centimetre square) = length x width.
done and every effort was made to eliminate shock. After
The wound progression was measured by calculating
that patients were admitted in the burns unit. Wounds
percentage rate of change by a simple statistical
were cleaned with pyodine scrub and normal saline and
calculation by using the following formula:
the topical agent either aloe vera gel or 1% SSD cream
was applied to the wound. Treatment with topical agents Wound area an admission day — Area on 2nd time x 100%
was continued until the burns were fully healed and re-
epithelialized. Empirically, 3rd generation cephalosporins Baseline wound area an admission day.
were started in all patients. Wound swab cultures from Pain relief was noted by visual analogue scoring system
three different sites from all patients were taken, at the (1-10). Pain was considered as severe for score 6-10,
time of admission and then at every seventh day and then moderate 3-5, and mild less than 3. Pain was considered
antibiotics were initiated according to the results of relieved if patient scored 0-1.
bacteriological examination.
Final outcome was measured after 2 months of follow-up,
Relevant data of patients regarding their registration, in terms of complete and incomplete recovery. Complete
history, site of burn, TBSA affected degree of burn, depth of recovery included complete healing without scar or
burn, presence or absence of slough in the wound, medical contracture. Formation of soft scar, hypertrophic scar
report, operative notes, pre- and postoperative and/or contracture was taken as incomplete recovery.
photographs, duration of hospital stay and outcome were
filed individually. During their stay in the ward, strict Statistical analysis was done using SPSS 11 software. Two-
monitoring of intake/ output was done. Where indicated, Tailed Unpaired Student T-Test was used to analyse
patients were supported with blood products. In all the predictors between two groups. P value of less than 0.05
patients, great care was given to nutrition. Almost all the was considered to indicate statistical significance.
patients were given oral feed with occasional intravenous
support in the form of amino acid infusion in a few patients. Results
Demographic characteristics and other parameters of the
Fifty patients with second degree burns were randomized patients are summarized in Table-1. All patients in the
(consecutive sampling method) into 2 groups and were present study survived.
given burn wound treatment with SSD (25 patients) or
aloe vera (25 patients). Both groups were compared with The authors found no significant differences in age, total
regard to patient demographics including age, sex, type body surface area, type of burn injury, time elapsed after
of burn, TBSA burn (%), time elapsed after burns to reach burns to reach the hospital. Of fifty patients, 26 were male
the hospital. Patients were also reviewed for and 24 were female (age range 15-65 years). In Aloe
documentation of efficacy of treatment including time group, epithelialization begun at 5th day, and in all
required for healing (epithelialization), pain scores, type of patients healing was complete by 40th day (Mean= 11
cultured organisms, wound colonization and infection, 4.18), whereas in SSD group healing was prolonged
cost of treatment and mortality between both groups. (Mean= 24.24 11.16).

Wound dressing was done twice a day until healing was Thirty eight patients (76%) developed wound
complete. Before dressing we washed wounds with colonization, sixteen (64%) in the Aloe group and twenty-
pyodine scrub and then either aloe vera soaked gauzes or two (88%) in the 1% SSD group. There were no differences
1% Silver sulphadiazine dressing was done. At the time of in wound infection between both groups (seven patients
change of dressing details regarding the condition of the developed wound infection; three in the Aloe group and
wound such as signs of wound infection, condition of four in the 1% SSD group, p > 0.0). All of the patients who
developed wound infection responded well to targeted
surrounding unburned tissues, discharge, smell, necrotic
topical and systemic antibiotic treatment.
tissue and state of epithelialisation was noted by on every
3rd day. Subjective factors such as pain and local irritation In Aloe group, 9 patients (36%) had complete relief of pain
were recorded regularly. Allergies or other side effects by 5th day; another 9 patients (36%) were relieved by 12th
were noted in both groups. The patients and attendants day. Pain relief was slow in SSD group and it took 26 days
were given information regarding the Aloe Vera gel and for all patients to be pain free in SSD group.

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M. N. Shahzad, N. Ahmed 227
Table: Demographics of patients in both groups & Comparison of results in both groups.

Patient Characteristics Aloe group SSD group

No of cases(n=25) %age No of cases(n=25) %age

Gender of patient Male 17 68% 09 36%

Female 8 32% 16 64%
Type of burn injury in both group Flame 16 64% 11 44%
Scald 9 36% 14 56%
Age of patient 11-20 4 16% 5 20%
21-30 16 64% 10 40%
31-40 4 16% 6 24%
41-50 3 12% 3 12%
>50 YEARS 2 8% 1 4%
Minimum age =15 years. Maximum age =65 years
Mean = 30.18±12.06
P value = 0.6691 [ not statistically significant]
Total body surface area 5 - 10% 2 8% 3 12%
11-15% 17 68% 15 40%
16-20% 4 16% 4 16%
21-25% 2 8% 3 12%
Minimum (TBSA)=6%. Maximum(TBSA)=25%
Mean = 13.64±4.68
P value = 0.1323[not statistically significant]
Time elapsed after burns to reach the hospital <1 hour 3 12% 4 16%
1-8 hours 12 48% 14 56%
9-16 hours 6 24% 3 12%
17-24 hours 4 16% 4 16%
Time required for healing (epithelialization)
5 - 10 days 14 56% 3 12%
11 - 15 days 6 24% 2 8%
16 - 20 days 3 12% 7 28%
21 - 30 days 1 4% 8 32%
31 - 40 days 1 4.0% 3 12%
41 - 50 days 0 0% 1 4%
51 - 60 days 0 0% 1 4%
Aloe group

Minimum days for epithelialization =5 days

Maximum days for epithelialization =20 days

Mean =11±4.18

Silversulphadiazine Group

Minimum days for epithelialization =9 days

Maximum days for epithelialization =56 days

Mean = 24.24±11.16

P value = < 0.0001[extremely statistically significant].

Type of cultured wound organisms between 2 treatment groups MRSA 6 24% 7 28%
Pseudomonas spp. 8 32% 9 36%
Acinetobactor spp 4 16% 2 8%
Enterobactor 4 16% 2 8%
Staph.
Coagulase ne 2 8% 3 12%
E coli 1 4% 2 8%
Time taken for pain relief (days) Up to 5 9 (36.0%) 1 4.0%
6 - 12 9 36% 11 44%
13 - 21 7 28% 11 44%
22 - 26 0 0% 2 8%
Silversulphadiazine Group

Time taken for Complete pain relief = 26 days

Aloe group

Time taken for Complete pain relief = 21 days

p-value = 0.01 between the two groups is statistically significant

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228 Effectiveness of Aloe Vera Gel compared with 1% silver sulphadiazine cream as burn wound dressing in second degree burns

Figure-2: A male patient 42 year of age had a flame burn treated with Aloe Vera
Dressing. Wound showing epithelisation at the time of discharge at 14th day post burn.

Discussion
Aloe Vera has been used for medicinal purposes in several
cultures for millennia: Greece, Egypt, India, Mexico, Japan
and China.18 Egyptian queens Nefertiti and Cleopatra
used it as part of their regular beauty regimes. Alexander
the Great, and Christopher Columbus used it to treat
soldiers' wounds. The first reference to Aloe vera in English
was a translation by John Goodyew in A.D. 1655 of
Dioscorides' Medical treatise De Materia Medica.19 By the
early 1800s, Aloe Vera was in use as a laxative in the
United States, but in the mid-1930s, a turning point
occurred when it was successfully used to treat chronic
and severe radiation dermatitis.20
Aloe Vera contains 75 potentially active constituents:
vitamins (vitamins A ,C and E, vitamin B12, folic acid, and
Figure-1: A young patient of 22 years had a flame burn (TBSA = 20%), Aloe Vera choline), enzymes (alkaline phosphatase, amylase,
dressing was done. (a)= Second degree burn after wound wash at the time of
bradykinase, carboxypeptidase, catalase, cellulase, lipase,
admission. (b)= At 5th day epithelisation started and was complete at 11th day.
and peroxidise), minerals (calcium, chromium, copper,
selenium, magnesium, manganese, potassium, sodium
The price of 1000ml of Aloe gel was Rs.480, whereas the and zinc), sugars (monosaccharides and polysaccharides),
price of 250gm of Silver sulphadiazine was Rs.617. The lignin, saponins, salicylic acids and amino acids.21-23
cost of Dressing per percent body surface burnt per Salicylic acid in Aloe Vera gel possesses anti-inflammatory
dressing of silver sulfadiazine was Rs.4.92 for 2grams of properties. Lignin, enhances penetrative effect of the
ointment and Rs.2.40 for 5ml of Aloe gel. other ingredients into the skin. Saponins that are the
soapy substances form about 3% of the gel and have
Among 25 patients treated with Aloe dressing, 24 patients cleansing and antiseptic properties.
had complete recovery while 1 had incomplete. In the
SSD group, out of 25 patients, 19 patients had complete The normal wound repair process is coordinated and
recovery and 6 had hypertrophic scar formation or the predictable series of cellular and biochemical events.
Glucomannan, a mannose-rich polysaccharide, and
development of contractures. These differences were
gibberellin, a growth hormone, interacts with growth
statistically significant.
factor receptors on the fibroblast, thereby stimulating its
Figure-1 and 2 show the results of aloe vera dressing. activity and proliferation, which in turn significantly

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M. N. Shahzad, N. Ahmed 229
increases collagen synthesis after topical and oral Aloe healing time in the conventional care group (53 days)
Vera.24 Aloe gel not only increased collagen content of the was significantly shorter (P<0.003) than in the aloe vera
wound but also changed collagen composition (more gel group (83 days).
type III) and increased the degree of collagen cross
In our study time taken for partial thickness burns to heal
linking. Due to this, it accelerated wound contraction and
was significantly shorterd with aloe than in those treated
increased the breaking strength of resulting scar tissue.25
with SSD (11 4.18 days vs. 24.24 11.16 days). One study,34
An increased synthesis of hyaluronic acid and dermatan
has demonstrated antimicrobial effect of aloe vera, but in
sulfate in the granulation tissue of a healing wound
our There were no differences in wound infection
following oral or topical treatment has been reported.26
between both groups.
Aloe Vera contains 6 antiseptic agents: Lupeol, salicylic
acid, urea nitrogen, cinnamonic acid, phenols and sulfur. In Aloe group, patients were rendered pain free early,
They all have inhibitory action on fungi, bacteria and mean pain relief was by 12th day, while with the SSD
viruses. Aloe vera inhibits the cyclooxygenase pathway dressing mean pain relief was in 16.8 days. Cost of
and reduces prostaglandin E2 production from treatment with Aloe came out to be significantly less
arachidonic acid. Recently, the novel anti-inflammatory than that with Silver sulphadiazine. No allergic reaction
compound called C-glucosyl chromone was isolated from or side effect was noted in any of our patients dressed
gel extracts.27 with Aloe or SSD. Only irritation, itching, discomfort, and
minimal transient pain were reported. However, these
The antimicrobial effect of silver sulfadiazine is the only
events were common signs and symptoms in burns, and
mechanism justifying its continued use in burn injury.
they were present in both the aloe and the control
However, resistance has been demonstrated. Hepatic
groups.28-30
or renal toxicity and leukopenia may be caused by the
topical application of SSD. In fact, these side effects Conclusion
have been observed in the treatment of large In conclusion, aloe vera gel promoted wound healing in
wounds.10-12 second degree burn patients better than SSD cream. The
The findings of this clinical study showed that aloe vera mechanism of the remarkable efficacy of aloe cream in
gel promoted burn wound healing more effectively than the healing of burn injuries may be explained by its cell
proliferation, and anti-inflammatory effects. It also
SSD. Existing evidence demonstrates that aloe vera used
relieves pain better than SSD and is cost effective.
in a variety of forms might be effective in shortening the
duration of wound healing in first to second degree Recommendations
burns, and it tended to increase rate of success to Well-designed trials with sufficient details of the contents
healing and rate of epithelialization. Aloe gel have been of aloe vera products should be carried out for
found to be effective for burn wound healing in animal determining the effectiveness of aloe vera for burn
models32,33 and humans.28,31-34 Thamlikitkul et al.28 used wound healing. As existing evidence lack such trails.
Aloe fresh mucilage in 38 patients and found accelerated
healing. Visuthikosol et al.29 reported a study on 27 References
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