What topical agents should be applied to a split‑thickness skin graft (SSG) with low uptake or failure?

Management of Split-Thickness Skin Graft (SSG) with Low Uptake or Failure

Apply topical antimicrobial agents to sloughy or infected areas only, with silver-containing products or chlorhexidine being first-line choices, while maintaining greasy emollients (50% white soft paraffin with 50% liquid paraffin) over all other areas to prevent desiccation. 1

Immediate Assessment and Wound Preparation

When a split-thickness skin graft demonstrates low uptake or failure, first identify the underlying cause:

• Remove necrotic or loose infected epidermis and clean wounds using topical antimicrobial agents such as betadine or chlorhexidine under appropriate conditions 1
• Regularly cleanse wounds and intact skin by irrigating gently using warmed sterile water or saline or an antimicrobial such as chlorhexidine (1/5000) 1
• Avoid preparations containing sensitizers or irritants that could further compromise graft viability 1

Topical Antimicrobial Selection

The choice of topical agent should be guided by wound characteristics and local microbiology:

For Sloughy or Infected Areas:

• Silver-containing products/dressings are recommended as first-line antimicrobials, though use should be limited if extensive areas are being treated due to absorption risk 1
• Chlorhexidine solutions (1/5000 dilution) provide effective antimicrobial coverage for irrigation and cleansing 1
• Betadine (povidone-iodine) can be used for wound cleaning, particularly when preparing for debridement 1

Experimental Evidence for Specific Combinations:

While not standard clinical practice, research has identified that nitrofurazone, 1% silver sulfadiazine, and povidone-iodine do not negatively affect graft healing and take in noncontaminated burn wounds, with nitrofurazone showing significantly earlier epithelialization 2. However, these findings apply to prophylactic use rather than salvage of failing grafts.

Dressing Strategy

Primary Layer:

• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over the whole epidermis, including denuded areas 1
• Consider aerosolized formulations to minimize shearing forces associated with topical applications 1
• Apply nonadherent dressings to denuded dermis (suitable options include Mepitel™ or Telfa™) 1

Secondary Layer:

• Use a secondary foam or burn dressing to collect exudate (suitable dressings include Exu-Dry™) 1
• For heavily contaminated wounds, Omiderm (hydrophilic polyurethane film) can serve as a transparent, permeable interface that allows topical treatment without disturbing the graft 3

Dressing Change Frequency:

• Change external dressing with topical antimicrobial agent 8-24 hours postoperatively and then at regular intervals when using interface dressings 3
• For standard dressings with Xeroform and dry gauze, leaving intact until day 5 has shown excellent results (98.54% take), though this applies to successful grafts rather than failing ones 4

Critical Management Principles

What to Apply:

1. Topical antimicrobials ONLY to sloughy areas - not to healthy graft tissue 1
2. Greasy emollients everywhere else to prevent desiccation 1
3. The choice of topical antibiotic should be guided by local microbiological advice 1

What to Avoid:

• Do not apply antimicrobials to healthy graft tissue, as this is unnecessary and may cause irritation 1
• Avoid aggressive fluid application that could disrupt fragile graft adherence 1
• Do not use preparations with sensitizers or irritants 1

When to Escalate Care

Consider transfer to a burn center in patients with evidence of:

• Clinical deterioration 1
• Extension of epidermal detachment 1
• Subepidermal pus 1
• Local sepsis 1
• Wound conversion and/or delayed healing 1

In specialized centers, conservative measures may be supplemented with surgical debridement using Versajet™ and physiological closure with Biobrane, allograft, or xenograft skin for noninfected large confluent areas 1

Common Pitfalls to Avoid

• Delaying antimicrobial treatment when infection is present - early intervention is crucial for salvaging infected grafts 5
• Over-applying topical antimicrobials to healthy tissue - restrict use to problem areas only 1
• Using adherent dressings that will traumatize the graft upon removal 1
• Ignoring signs of infection such as purulent drainage, foul odor, or increasing pain beyond days 3-4 5