Beyond Early Excision and Grafting: A Perspective on Tissue-Preserving and Regenerative Topical Burn Wound Care

Whilst early debridement and autologous skin grafting remain the cornerstones of treatment for deep burns, there has been a shift towards a more selective and regenerative medicine-oriented approach in the topical management of burn wounds. The most critical issue is whether the wound can achieve epithelialization within approximately 2 to 3 weeks. This timeframe is of clinical significance due to the strong association between delayed epithelialization and hypertrophic scarring, which can result in contractures and functional impairment. However, given that the likelihood of epithelialization is influenced by factors such as the mechanism of injury, anatomical location and skin thickness at that site, age, and blood flow, its prediction remains incomplete and relies heavily on experience. The second challenge is to remove necrotic tissue while preserving as much healthy tissue as possible, thereby creating a wound bed with an adequately controlled microbial burden. Excessive excision should be avoided. The cytotoxic effects of several topical antimicrobial agents can inhibit the migration of keratinocytes, fibroblasts and other cells, as well as damaging the extracellular matrix. In order to address these issues, a range of methods are employed, including enzymatic debridement. The third challenge pertains to the reconstruction of the dermis in full-thickness burns, and the role of dermal and matrix-based materials is expanding. In addition to conventional artificial dermis, acellular fish skin matrices, synthetic biodegradable temporary matrices, and recombinant biomaterials are now being used. These materials can be regarded not solely as wound dressings, but also as instruments for preserving or re-establishing a biologically functional dermal matrix prior to epithelialization. Once these conditions are achieved, autologous skin cell suspension or cultured epidermal autografting may become appropriate options in selected wounds. This Perspective proposes a framework for precision-oriented local burn wound care structured around four sequential but iterative objectives.