Burns 29 (2003) 487–492

Evaluation of banana leaf dressing for partial thickness burn wounds

Madhuri A. Gore∗ , Deepika Akolekar
Department of Surgery, LTMG Hospital and LTM Medical College, Sion (W), Mumbai 400022, India

Accepted 29 January 2003

Abstract
An important factor in the healing of superficial and moderate partial thickness burn is early and effective coverage with a dressing that
protects the wound from trauma and dessication and is non-adherent. In our country cost is also a very important factor. Disturbed by the
pain and anxiety experienced by the patients during and after dressing changes, search for a new dressing material was begun for partial
thickness burn wounds and the banana leaf dressing (BLD) was subsequently developed and optimised by June 1996.
An open controlled study was carried out to compare banana leaf dressing and boiled potato peel bandage (BPPB), the dressing being
used in our Burn Unit since 1994. Thirty patients all less than 40 years of age, with burn size less than 50% TBSA, involving comparable
body areas with partial thickness burn, were included in the study.
BLD along with a topical agent was applied over the right sided extremity while BPPB was applied with the same topical agent on the
left sided extremity. Dressing was changed every day.
The pain during dressing change, feeling of comfort and ease of handling dressing was assessed by awarding scores by the patients and
care givers for each type of dressing. Analysis of the scores revealed that both BLD and BPPB caused easily tolerable, minimal pain during
dressing change in majority of the patients.
The days taken for epithelialisation, eschar formation and the need for skin grafting over deep partial thickness burns, did not reveal any
significant difference between the areas treated by BLD and those by BPPB. So both the dressings were observed to have equal efficacy
in protecting the wounds and aiding healing.
Thus, the efficacy of BLD and BPPB was parallel in all respects. But BLD is 11 times cheaper than BPPB. Banana plants can be easily
grown, the leaves are easily available throughout the year. The leaves of banana are large thus offering larger surface area and the surface is
non-adherent, waxy and cool. The dressing can be prepared very easily with little training. It is also the cheapest dressing available today.
We strongly recommend the use of banana leaf dressing for all partial thickness burn wounds in our environment.
© 2003 Elsevier Ltd and ISBI. All rights reserved.

1. Introduction It is now universally accepted that for early healing of

Every year about 7–8 million people suffer from burn
injury in India and approximately 0.2 million die [1]. At the
Burns Unit at LTMG Hospital, Mumbai, we treat about 800
patients with burns every year and this accounts for 1.5%
of total hospital admissions. Our own data shows that the
average per capita monthly income of the patients admitted
in our unit is less than Rs. 200. This is true for the majority of
burns victims in India. Burn management entails significant
duration of hospital stay, expensive medications, multiple
operative procedures and prolonged period of rehabilitation.
This makes burn care an expensive proposition and every
effort in cost reduction is welcome.
∗ Corresponding author. Present address: ‘Shreyas’ 20, Udayagiri, V.N.
Purav Marg, Deonar, Mumbai 400088, India.
E-mail address: gores@vsnl.com (M.A. Gore).
partial thickness burn wound it needs to be protected from
repeated tissue trauma and dessication. Occlusive dressings
using non-adherent material are best suited for this purpose.
Petroleum jelly impregnated gauze is a popularly used dress-
ing for these wounds in our country. At our Burns Unit, we
found that this dressing was not completely non-adherent
and the pain and anxiety experienced by the patients during
the dressing change was significant. Keeping this in mind,
we started the use of boiled potato peel bandage (BPPB)
routinely from 1994. This dressing was better accepted
by the patients as compared to the Vaseline gauze dress-
ing and the pain during dressing change was considerably
reduced.
But a significant number of patients experienced pricking
sensation and discomfort under the boiled potato peel dress-
ing, due to the tough and hard edges of the peel. Though
the cost of BPPB was Rs. 50 (US$ 1 = Rs. 52) for a roll of
15 cm width and 3 m length, many of our patients could not

0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved.

doi:10.1016/S0305-4179(03)00050-0
488 M.A. Gore, D. Akolekar / Burns 29 (2003) 487–492
Fig. 1. Banana leaf dressing (top) and boiled potato peel bandage (bottom).
afford even these expenses. Preparation of BPPB was found
to be time consuming and difficult to teach and learn.
With these problems in mind, we at the Burns Unit of
LTMG Hospital, Mumbai, in 1995 started the search for a
dressing that would be non-adhesive, pain-free, cheap and
easily available. The new dressing had to be atleast as effec-
tive as boiled potato peel dressing. It also had to be cheaper,
easier to prepare and readily available throughout the year.
Leaves of banana plants caught our attention as the leaves
are large, cheap, easily available thoroughout the year and
the surface of the leaves is waxy, smooth and non-adherent.
After various modifications and trials the banana leaf dress-
ing (BLD) was optimised.
As we were using BPPB prior to this development, it was
decided to evaluate the efficacy of banana leaf dressing by
comparing it with BPPB. Fig. 1 shows boiled potato peel
bandage (BPPB) and banana leaf dressing.
2. Materials and methods
An open controlled trial was conducted on 30 patients. All
study protocols were approved by the Ethical and Scientific
Committee of LTM Medical College and Hospital, prior to
the commencement of the study. Written consent of all pa-
tients or guardians was taken after giving them appropriate
information about the study.
Comparable body areas with partial thickness burn wound
in the same patient were used as study and control areas.
This avoided the influence of multiple other variable factors
such as anaemia, nutritional status, immunosupression, etc.
which are all known to influence burn wound healing.
Patient inclusion criteria:
• Patients of age upto 40 years.
• Patients of either sex.
• Patients with burns upto 50% TBSA.
• Patients with partial thickness burn wound over compa-
rable areas, e.g. both upper extremities or both lower ex-
tremities.
Patient exclusion criteria:
• Age above 40 years.
• Patients with diabetes, hypertension or known renal or
hepatic dysfunction.
• Pregnant females.
• Burn area more than 50% TBSA.
Banana leaf dressing preparation:
Banana leaf dressing was prepared by cutting the midrib of
the leaf and then pasting the leaf on a piece of bandage cloth
with thin paste made by cooking fine flour. These leaves
were then hung on a clothes stand for 24 h to allow the paste
to dry. Then each banana leaf dressing with average size
15 cm × 60 cm was rolled and six of such rolls were placed
in a brown paper bag and autoclaved for use for individual
patient.
Trial protocol:
BLD along with topical agent—povidone iodine ointment
was applied over right sided extremity, BPPB with same
topical agent was applied over left side extremities.
The application of dressing was started on day 1 and the
dressings were changed every day.
Clinical photographs were taken on admission, once in
first week and after complete epithelialisation of the wound.
The following observations were noted:
1. Day of complete epithelialisation.
2. Day of eschar formation, if any.
3. The areas requiring skin grafting.
The following scores were evaluated:
1. Pain during the change of dressing score:
This score was awarded by adult patients separately for
each type of dressing. The patients were asked to award
the score atleast three times during the trial period and
an average score was worked out. In children, who could
not express their evaluation, mother of the child and an
observer staff nurse was asked to award the score.
The score systems used were as follows:
• Tolerable pain, no screaming—Score 1.
• Pain difficult to tolerate, moderate screaming—Score
2.
• Pain impossible to tolerate, severe screaming and
thrashing—Score 3.
2. Comfort score:
Patients were also asked to award comfort score for
the individual dressings while the dressings were on the
wounds.
The scoring systems devised were as follows:
• Comfortable feeling—Score 1.
• Minor discomfort—Score 2.
• Extreme discomfort—Score 3.
The patients were asked to award these scores thrice
during the trial period and average was worked out.
 M.A. Gore, D. Akolekar / Burns 29 (2003) 487–492 489

Mother of a small child was interrogated for her impres- Table 3

sion about the comfort in paediatric patients. Duration needed for epithelialisation
Dressing BLD BPPB
3. Dressing handling score:
The health care professionals (resident doctors or Areas (nos.) 22 23
trained nurses) carrying out the dressing procedures Range (days) 7–14 7–15
Mode (days) 10 10
were asked to award a score for the handling quality of
each dressing material at the completion of protocol for
each patient.
In four patients both upper and lower extremities were
The score systems followed were as follows:
included in the trial.
• Easy handling—Score 1. The areas where complete epithelialisation was observed
• Difficult handling—Score 2. in each dressing group and the range and mode of days
needed for epithelialisation have been detailed in Table 3.
After approval of the trial protocol by the hospital eth-
It was observed that 22 out of 34 extremities being treated
ical committee and scientific committee, this study was
with BLD and 23 out of 34 extremities treated with BPPB
initiated in year 1996 and was completed in 1997. On the
healed completely, without the need for skin grafting. The
completion of the study in 30 patients, the data collected
healing was complete in maximum number of patients in
was analysed. The statistical significance of relevant ob-
both the groups by the 10th post-burn day. Figs. 2 and 3 show
servations was evaluated using χ2 -test.
the status of right lower extremity dressed by banana leaf
dressing on the 2nd and 13th days. Figs. 4 and 5 show the
3. Observations and results left lower extremity dressed by boiled potato peel bandage
on 2nd and 13th days.
A total of 30 patients with burn size less than 50% TBSA
involving comparable areas of partial thickness burns, were
included in this study.
The age range of these patients was from 11 months to
38 years and the extent of burns varied from 7% TBSA to
48% TBSA. The age and burn extent of these patients has
been depicted in Table 1.
There were 8 males and 22 females in this study. Maxi-
mum number of patients 17 (56.66%) were in 12–30 years
age group.
The body areas under trial in these 30 patients are depicted
in Table 2.

Table 1
Age of patients and extent of burns Fig. 2. Right lower extremity (banana leaf dressing) on second post-burn
Age (years) Extent (%) day.

10 20 30 40 50 Total

3 – 6 2 1 – 9
12 2 1 – – – 3
20 – 4 3 – 1 8
30 – 1 3 3 2 9
40 – – – 1 – 1
Total 2 12 8 5 3 30

Table 2
Body areas under trial
Area BLD BPPB

Upper extremity 23 23
Lower extremity 11 11
Total 34 34
Fig. 3. Right lower extremity (banana leaf dressing) on 13th post-burn
BLD: banana leaf dressing; BPPB: boiled potato peel bandage. day.
490 M.A. Gore, D. Akolekar / Burns 29 (2003) 487–492

Table 5
Scores awarded during dressing change
Score No. of patients BLD BPPB

1 2 3 1 2 3

Dressing change pain 30 28 1 1 27 2 1

Comfort score 21 20 1 0 17 4 0
Dressing handling score 30 30 0 0 30 0 0

Out of 11 extremities with eschar formation in BPPB

group, 3 healed without skin grafting and 8 extremities re-
quired grafting over variable areas.
So, 27 out of the 34 (79.4%) extremities in BLD group
and 26 out of 34 (76.47%) extremities in BPPB group healed
Fig. 4. Left lower extremity (boiled potato peel bandage) on second
post-burn day.
without the need for grafting and 7 of 34 (20.5%) extremities
in BLD group and 8 of 34 (23.5%)extremities in BPPB group
needed skin grafting. The difference in these observations
was found to be statistically insignificant.
The scores awarded for feeling of comfort, ease of han-
dling and pain during dressing change are shown in Table 5.
One patient complained of intolerable pain during change
for both dressing types. 21 patients above the ages of 3 years
could award comfort score. Four out of 21 (19%) patients
experienced pricking sensation and discomfort under BPPB
dressing.
One patient out of 21 (4.7%) expressed some burning
sensation under BLD, this lasted for about 30 min after the
dressing was applied. This difference observed in the com-
fort scores was not statistically significant (P > 0.05).

4. Discussion
Fig. 5. Left lower extremity (boiled potato peel bandage) on 13th post-burn
day.
The ideal dressing for burn wound should be painless
when applied, non-adherent, non-antigenic, non-allergic,
In 12 out of 34 extremities in BLD group and 11 out non-toxic, cheap and easily available.
of 34 extremities in BPPB group, variable extent of eschar Living skin autografts are the best but homografts are a
formation was observed, indicating presence of deep partial good substitute as temporary dressing [2], xenografts are the
thickness burn wound over some portions of the area under next choice. In our country, homografts as well as xenografts
study. are very sparingly available. Burnt patients are numerous
Range and mode of days of first detection of eschar for- and the need for a cheap and easily available dressing for
mation and the number of areas requiring skin grafting are their partial thickness wounds is real and acute.
tabulated in Table 4. Boiled potato peel bandage developed by Keswani and
Out of 12 extremities with eschar formation from BLD co-workers [3–6] was well accepted by most of our pa-
group, 5 eventually healed without the need for skin grafting tients and the wound healing was satisfactory. Discomfort
and 7 extremities needed skin grafting over areas of variable was however experienced by some patients, and the cost of
extent. dressing and the time consuming method of preparation of
the potato peel bandages [7],1 stimulated the search for a
Table 4 cheaper alternative that is easier to prepare. This lead to the
Eschar formation and areas needing skin grafting development of banana leaf dressing in June 1996.
Dressing BLD BPPB In India, banana leaves are universally used as plates for
serving meals. The leaves are also used as lining for cook-
Areas (nos.) 12 11
ing vessels as they have a waxy surface and are impervious
Range (days) 3–5 3–6
Mode (days) 3 4 1 Boiled potato peel bandages are manufactured commercially at Reha-
Skingrafting areas (nos.) 7 8
bilitation Centre, Chembur, Mumbai.
 M.A. Gore, D. Akolekar / Burns 29 (2003) 487–492 491

to water. Patients with smallpox were asked to lie on ba- thickness wounds of all our patients. The main reason for
nana leaves because of their coolness and non-adherence to this choice was the low cost and the ease of preparation
wounds. of BLD. Since the completion of study in 1997, more than
After the thought of using banana leaves as dressing was 2000 patients have been treated successfully in our unit with
conceived, developed and tested on patients, the review of banana leaf dressing.
literature revealed a single reference about the use of banana This is the only reported study of its kind and hence our
leaves on burns wounds from Thailand by Chongchet [8] observations cannot be compared with those from any other
but no objective assessment has been provided. study.
This open controlled trial was carried out by applying Banana leaves are easily available in most parts of India,
BLD and BPPB on comparable body areas with partial thick- in cities, towns and villages. It is not difficult to have a patch
ness burns in the same patient and using the same topical of land with banana plantation within the hospital premises
microbial agent (povidone iodine ointment). Both dressing with a busy Burn Unit. The preparation of BLD is very
materials were sterilised by autoclaving before use and were simple and can be easily learnt by previously treated patients,
changed every day till healing (superficial partial thickness) relatives of patients and literate or illiterate individuals.
by natural process or by skin grafting (deep partial thick-
ness) was achieved. 4.1. Banana leaf dressing: problems and solutions
The age of patients ranged from 11 months to 38 years
and the extent of burns from 7 to 48% TBSA.
The days taken for epithelialisation, eschar formation and 1. Banana leaf dressing being totally non-adherent, tends to
the need for skin grafting over deep partial thickness burns, slip. It thus needs careful, firm bandaging.
did not reveal any significant difference between the areas 2. Prepared banana leaf dressing cannot be stored for more
treated by BLD and those by BPPB. The average number than 7–10 days. Fungal growth is seen on the leaves on
of days needed for epithelialisation could be compared well prolonged storage and they need to be discarded. Our
to the observations by Keswani and co-workers [3–5] using policy is to prepare dressings enough to last for 3–4 days
BPPB and with Chongchet [8] using sterile steamed banana only. Sterilisation by ␥-irradiation was observed to in-
leaves. Subramanyam [9] observed that in majority of the crease the shelf life of BLD upto 2–3 months.
patients, the wounds dressed with BPPB healed between 3. If paucity of personnel or time does not permit prepa-
11 and 15 days. Ramakrishnan and Jayaraman [10] have ration of BLD by the above-described method, the ba-
reported healing of superficial partial thickness burns by 10th nana leaves can be autoclaved and used just after cutting
day using amniotic membrane. So, both the dressing were the thick midrib without the bandage cloth backing. The
observed to have equal efficacy in protecting the wounds backing makes the banana leaf dressing more convenient
and in aiding epithelialisation. to handle.
Various clinical trials using synthetic dressings for partial
thickness burn wounds have shown the healing time needed 4.2. Cost comparison
to be 9.8 days (range 6–10 days) using Biobrane [11] and
12 days for both Granuflex E [12] and Bactigras.
Table 6 shows comparison between the cost of different
Thus banana leaf compared favourably with the other
commonly used dressings for partial thickness burn wounds.
available dressing materials in terms of healing time.
The cost of banana leaf dressing of 15 cm × 60 cm size is
Microbiological study also did not show any difference
89.2 paise.
in the incidence of colonisation, colony counts or the types
So, banana leaf dressing is 11 times cheaper than boiled
of microbes grown over the areas being treated by these two
potato peel bandage, 160 times cheaper than Sofratulle
dressings.
(Soframycin impregnated gauze), 1750 times cheaper than
Analysis of the scores awarded revealed that both BLD
Kollagen (collagen sheet), and 5200 times cheaper than
and BPPB caused easily tolerable, minimal pain during
Skintemp (biosynthetic dressing).
dressing change in majority of the patients. Though 4 out
of 21 patients expressed some discomfort with BPPB, the
difference was not statistically significant. The remaining Table 6
nine patients (younger than 3 years of age) were observed Cost comparison between various dressings
to be comfortable with the dressings. They continued their
Dressing Size Price Unit price
routine activities like running, playing, etc. without any (cm × cm) (Rs.) (paise/cm2 )
evidence of pain or distress. The health care professionals Sofratulle 10 × 10 16.00 16
carrying out the dressing procedures, evaluated both BLD Kollagen 10 × 10 175.00 175
and BPPB as equally simple and easy to handle. Skintemp 10 × 7.5 390.00 520
Thus the efficacy of BLD and BPPB was parallel in all (biosynthetic dressing)
respects. These observations resulted in the decision to stop BPPB 15 × 300 50.00 1.11
BLD 15 × 60 00.892 0.1
the use of BPPB at our unit and to use BLD over partial
492 M.A. Gore, D. Akolekar / Burns 29 (2003) 487–492
5. Conclusion
1. Banana leaf dressing is a suitable and effective dressing
for partial thickness burn wounds.
2. The efficacy of banana leaf dressing for partial thickness
burn wounds is comparable to that of boiled potato peel
bandage.
3. Banana leaf dressing is the cheapest of the available
dressings for partial thickness burn wound cover.
4. The preparation method is very simple and can be eas-
ily taught and learnt. This can provide an opportunity to
achieve economic independence and successful rehabili-
tation of burn victims.
Thus BLD is non-adherent, non-toxic, non-antigenic,
cheap, simple to prepare and easily available, effective and
acceptable alternative for management of partial thickness
burn wounds.
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