Indications for the use of dermal substitutes in patients with acute burns and in reconstructive surgery after burns: A systematic review

Deep dermal and full-thickness burns often result in scar sequelae such as contractures, hypertrophy, pain and itching following split-thickness skin grafting. Dermal substitutes are currently employed alongside split-thickness skin grafting to enhance clinical outcomes, though their indications remain a subject of ongoing debate. This systematic review aims to clarify the indications for the application of dermal substitutes in burn patients, in both acute and reconstructive settings. A comprehensive search across various databases was conducted. Studies (n = 190) assessing the indications and outcomes of dermal substitutes in acute burn patients and those requiring reconstructive surgery were included. Data extraction included the applied dermal substitute, age, total body surface area, wound depth, burn aetiology, anatomical site and exclusion criteria. The indications were derived from predetermined indications, i.e. inclusion and exclusion criteria and patient characteristics. The depth of the wound emerged as the primary indication for dermal substitute use. A one-stage approach is recommended for deep dermal to full-thickness wounds larger than 10 cm2, while a two-stage approach is advised for wounds of this depth with limited donor sites or exposed bone or tendon. No definitive age or burn/scar location thresholds were identified, and careful consideration is advised for electrical and chemical burns. Contraindications include wound infections and allergies to matrix components. Limited data exist on use in patients with diabetes mellitus, chronic vascular disease, or immunocompromised status. This is the first review to address the indications for dermal substitutes in burn patients, providing valuable insights for the development of international evidence-based treatment guidelines.