Letters to the Editor

REFERENCES
1. Greaves M. Chronic urticaria. J Allergy Clin Immunol 2000;105:664-72. 2. Godse KV. Autologous serum skin test in chronic idiopathic urticaria. Indian J Dermatol Venereol Leprol 2004;70:283-4. 3. Grattan CE, Sabroe RA, Greaves MW. Chronic urticaria. J Am Acad Dermatol 2002;46:645-57. 4. Greaves MW. Chronic idiopathic urticaria. Curr Opin Allergy Clin Immunol 2003;3:363-8. 5. Hyry H, Elg P, Ranki A. A commercial histamine release test and autologous serum skin test in the diagnosis of autoimmune urticaria. Allergy 2006;61:1147-8.

Moist exposed burn ointment: Role of alternative therapy in the management of partial-thickness burns
Figure 1: After Charcoal Burns

Sir, Burn injury is a global problem that equally concerns under-developed, developing and developed countries. Even after so many advances in burns care the selection of the most appropriate dressing material for burns is still elusive. The use of silver sulphadiazine for treating burns has remained the standard treatment of partial-thickness burn wounds for more than four decades. The adverse effects include painful dressing changes, local skin reaction, hypersensitivity reactions and occasionally selflimiting leucopenia. An alternative therapy for treating the burn was developed at the China National Science and Technology Center in Beijing in 1989 in the form of a herbal remedy, moist exposed burn ointment (MEBO), and was claimed to be an ideal burn wound dressing option for burns.[1,2] Subsequently, many studies proposed MEBO as a good alternative for treating burns [Figures 1 and 2]. MEBO is claimed to shorten wound healing time, reduce bacterial colonization, reduce the need for analgesics, antibiotics and results in aesthetically superior wound healing. MEBO is an oil-based ointment containing sesame oil, beta-sitosterol, berberine, and other small quantities of plant ingredients.[1,2] In addition, MEBO includes in its formula 18 amino acids, four major fatty acids, vitamins, and polysaccharides. The betasitosterol, main ingredient of MEBO has shown antiIndian J Dermatol Venereol Leprol | July-August 2010 | Vol 76 | Issue 4

Figure 2: After 1 month

inflammatory effects, another ingredient berberine has demonstrated antimicrobial effects. Many studies substantiated the claim that it promotes epithelial repair, inhibits bacterial growth, has analgesic effects, leads to reduction of water evaporation from burn wound surface, and provides the optimum physiological environment for healing and results in improved scar formation.[3-12]
415

Letters to the Editor

A study comparing the efficacy of MEBO to silver sulphadiazine in partial-thickness facial burns found comparable rate of wound healing but the ease of dressing and healing progression assessment was more in patients treated by MEBO.[3] MEBO, because of hyperosmolar medium has also been claimed to prevent bacterial growth. It seems to change the biological behavior of bacteria, decreases the bacterial toxicity and invasive capacity, increases the bacterial sensitivity to antibiotics and enhances both the local and systemic immunity.[4] A retrospective pilot study by Numairy et al., using MEBO for open wounds in wide variety of surgical conditions including burns, sunburn, pressure sore, diabetic ulcers, skin graft donor site, surgical traumatic wounds including laser and chemical peels, found MEBO to be a cost-effective, simple and safe modality producing consistently good functional and aesthetic results.[5] A study by Ang et al., in 2001, evaluating the role of alternative therapy in burn wound management found MEBO to be as effective as conventional management. MEBO imparted a greater analgesic effect in the first five days of therapy, eased the management of face and neck burns, facilitated early institution of occupational therapy in hand burns and reduced hospital costs by 8%.[6] A multicenter pilot study by Atiyeh et al., in 2002 on the efficacy MEBO in the management of cutaneous wounds and ulcers found rapid reduction in ulcer size along with maintaining the wound in a relatively clean and socially acceptable condition without leading to the emergence of resistant bacterial strains.[7] A study comparing benefitcost analysis of MEBO with other topical preparations utilized for local burn wound treatment found reduction in hospital stay, decrease in average time spent by the treating physicians, requirement of less analgesics and significant decrease in treatment cost with MEBO.[8] A randomized, controlled study comparing pain control in MEBO versus conventional methods in patients with partial-thickness burns found greater pain relief during the first week after burns with MEBO.[9] In three consecutively conducted clinical studies, Atiyeh et al., found that the MEBO exhibited a beneficial prophylactic effect on primary and secondary wound healing with scar quality superior in wounds treated with MEBO.[10] In a prospective comparative study comparing healing of MEBO with conventional occlusive dressings, the biologic healing with MEBO, as determined by trans epidermal water loss (TEWL) measurements occurred at an extremely significant
416

earlier stage and was associated with better scar quality.[11] A randomized mono-center German study comparing the efficacy of MEBO with conventional therapy in partial-thickness burns < 20% total body surface area (TBSA) found MEBO an attractive alternative for the topical treatment of limited partialthickness thermal burns.[12] With the use of MEBO, four major difficulties in burn treatment are claimed to be overcome: the control of pain and infection, the decrease of scar formation and the prevention of progressive necrosis of burn tissues. However, more controlled clinical trials are still needed to explore the full action of MEBO and investigate its role at the cellular level of wound healing.

Sanjay Saraf
Department of Plastic Surgery, NMC Specialty Hospital, Dubai, UAE Address for correspondence: Dr. Sanjay Saraf, Department of Plastic Surgery, NMC Specialty Hospital, Dubai, U.A.E. E-mail: drsaraf@hotmail.com
DOI: 10.4103/0378-6323.66589 - PMID: *****

REFERENCES
1. 2. Xu RX. A great historical turn in the burn medical science. Chinese J Burns Wounds Surf Ulcers 1989;1:62. Xu RX. Moist exposed burn therapy (MEBT). Textbook for technological training. Beijing Guangming Chinese Medicine Institute for Burns. Beijing: Wounds and Ulcers; 1989a. p. 160-8. Ang ES, Lee ST, Gan CS, See P, Chan YH, Ng LH, et al. The role of alternative therapy in the management of partial thickness burns of the face--experience with the use of moist exposed burn ointment (MEBO) compared with silver sulphadiazine. Ann Acad Med Singapore 2000;29:7-10. Iovanovich J, Tsati E, Tsoutsos D, Frangia K, Papalois A. Moist exposed burn therapy: Evaluation of the epithelial repair process (an experimental model). Ann Burns Fire Disast 2000;13:3-9. Ali Al-Numairy. Clinical use of MEBO in wounds management in U.A.E. Int J Cosm Surg Aesthet Dermatol 2000;2:27-33. Ang ES, Lee ST, Gan CS, See PG, Chan YH, Ng LH, et al. Evaluating the role of alternative therapy in burn wound management: Randomized trial comparing moist exposed burn ointment with conventional methods in the management of patients with second-degree burns. MedGenMed 2001;3:3. Atiyeh BS, Ioannovich J, Magliacani G, Masellis M, Costagliola M, Dham R, et al. Efficacy of moist exposed burn ointment in the management of cutaneous wounds and ulcers: A multicenter pilot study. Ann Plast Surg 2002;48:226-7. Atiyeh BS, Dham R, Kadry M, Abdallah AF, Al-Oteify M, Fathi O, et al. Benefitcost analysis of moist exposed burn ointment. Burns 2002;28:659-63. Ang E, Lee ST, Gan CS, Chan YH, Cheung YB, Machin D. Pain control in a randomized, controlled, clinical trial comparing moist exposed burn ointment and conventional methods in Patients with partial-thickness burns. J Burn Care Rehabil 2003;24:289-96.

3.

4.

5. 6.

7.

8.

9.

Indian J Dermatol Venereol Leprol | July-August 2010 | Vol 76 | Issue 4

Letters to the Editor

10. Atiyeh BS, Amm CA, El Musa KA. Improved scar quality following primary and secondary healing of cutaneous wounds. Aesthetic Plast Surg 2003;27:411-7. 11. Atiyeh BS, El-Musa KA, Dham R. Scar quality and physiologic barrier function restoration after moist and moist-exposed dressings of partial-thickness wounds. Dermatol Surg 2003;29:14-20. 12. Hirsch T, Ashkar W, Schumacher O, Steinstraesser L, Ingianni G, Cedidi CC. Moist Exposed Burn Ointment (MEBO) in partial thickness burns - a randomized, comparative open monocenter study on the efficacy of dermaheal (MEBO) ointment on thermal 2nd degree burns compared to conventional therapy. Eur J Med Res 2008;13:505-10.

than 85% and average of particle size was estimated to be 1.6 m. Leishmania major parasites (MRHO/IR/75/ER) were provided by Iranian Pasteur Institute, grown in Roswell Park Memorial Institute (RPMI) 1640 medium supplemented with 10% heat-inactivated fetal bovine serum, pH 7.4, and antibiotic agents in a 25C incubator.[2,3] Then the stationary-phase promastigotes underwent pre-planned in vitro treatments.[3] First, the parasite suspension was divided into four groups and incubated at the liposomal ZnPc concentrations (0,1,5,10 M) for 3 hours at 25C.[4] After parasite washing in phosphate buffer solution (PBS), it was suspended again in a complete culture medium and spread in the wells of two 24-well sterile plates. One of them underwent illumination, and the other was maintained in dark. An incoherent light source, such as LUMACARE, equipped with fiber-optic and filter of 670 20 nm was utilized for illumination at intensity and fluence of 45 mW/cm2 and 100 J/cm2, respectively. Twenty-four hours post-treatment, the parasite survival was determined by3-(4,5-Dimethylthiazol2yl)-2.5-diphenyltetrazolium bromide (MTT) assay. The treated samples were incubated in a 96-well plate with the MTT reagent (10 mg/mL) for 40 minutes at 24C, and optical density of the formazan crystals was measured at 545 nm using a 96-well microplate reader (AWARENESS, Model 3200). The experiments were repeated SPSS 16 using Kolmogorov-Smirnov normality test, ANOVA and Tukey test and analyzed three times. As shown in Figure 1, among the groups which received complete PDT, minimum survival rate was obtained at 10 M (12.4%), which was significant in comparison with the other concentrations (P< 0.005), while no significant reduction was confirmed between the 1-(Micromolar) M group and control group. Without illumination, at 1 M, reduction of parasite survival was significant in comparison with the control group, while it was not significant between 5 and 10 M. On the basis of an exponential trend line fitted on the PDT data (R2= 0.97), ED50 and ED90 of liposomal ZnPc after 100 J/cm2 illumination were obtained to be about 3.5 and 11.5 M, respectively. Regarding our data, liposomal ZnPc showed toxicity on the Leishmania parasite in darkness, but the
417

Liposomal zinc phthalocyanine as a potential agent for photodynamic therapy of leishmaniasis

Sir, Developing a new therapeutic method for leishmaniasis, besides obtaining a prompt treatment response that prevents lesions' progression and scarring, is significant success in the treatment of the disease. Regarding the superficiality of the leishmaniasis lesions, there is anticipation that photodynamic therapy (PDT) could be beneficial in treating or at least preventing the lesions' progression. Pharmacokinetic characteristics of zinc phthalocyanine (ZnPc) make this molecule a promising secondgeneration photosensitizer. ZnPc is not water-soluble, and aggregation of the molecules decreases its photosensitizing effect. In this paper, efficacy of PDT with liposomal ZnPc was assessed on Leishmania parasite. ZnPc was purchased from Sigma-Aldrich (97% dye content). In order to formulate the photosensitizer in liposomal form, 300 mg of egg lecithin, 100 mg of cholesterol, 400 mg of glucose and a precise amount of zinc phthalocyanine were dissolved in 10 mL of pyridine. The solution was frozen using particular processes by dry ice and subsequently dried via freezedryer (Labco Co., USA) during two consecutive stages of 40C and 25C temperature designed for 24 hours.[1] Eventually, to prepare the final stable solution, 2 mL of distilled water was added. Based on the spectroscopic results from the liposomal suspension supernatant, the encapsulation rate of ZnPc was determined to be more
Indian J Dermatol Venereol Leprol | July-August 2010 | Vol 76 | Issue 4

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.