Complementary Therapies in Medicine 34 (2017) 66–73

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

The effect of a beeswax, olive oil and Alkanna tinctoria (L.) Tausch mixture MARK
on burn injuries: An experimental study with a control group
⁎
Kenan Gümüşa, , Zeynep Karaman Özlüb
a
Department of Surgical Nursing, Amasya Health School, Amasya University, Amasya, Turkey
b
Department of Surgical Nursing, Faculty of Health Sciences, Atatürk University, Erzurum, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This study was planned to investigate the effect of a mixture of beeswax, olive oil and A. Tinctoria (L.)
A. tinctoria (L.) Tausch Tausch on burn wounds to determine the impact on burn healing, pain during dressing changes and duration of
Beeswax hospital stay.
Burns Methods: The study was conducted between May 2014 and August 2015 in the Burn Unit of Ataturk University
Burn dressing
Research Hospital. The sample of this experimental study consisted of 64 patients (31 experimental group and 33
Olive oil
control group) who met its inclusion criteria. While the specially prepared dressing material was applied to the
Wound care
experimental group, the control group was administered the clinic’s routine dressing. The injuries were pho-
tographed before each dressing. Each picture was uploaded to a computer for measurement with ImageJ soft-
ware. Numbers, percentages, chi square, Independent samples t-test and Mann-Whitney U tests were used to
assess the data.
Results: The patients in the experimental and control groups had similar descriptive characteristics and burn
injury features (p > 0.05). The average age of the patients in the control group was 5.52 ± 0.64 years, and
6.68 ± 1.09 years in the experimental group. The majority of the patients were male (control: 54.5%, ex-
perimental: 58.1%). Boiling liquids were the most common cause of both groups’ burns (control: 93.9%, ex-
periment: 83.9%). The most common first aid practice used was the application of cold water (control: 75.0%,
experimental: 43.6%). The epithelization initiation time average of the experimental group patients
(3.00 ± 0.85 days) was found to be earlier than that of the control group patients (6.90 ± 1.77 days), and this
difference was statistically significant (p < 0.05). The mean pain scores experienced by the patients in the
experimental group during dressing (8.12 ± 1.38) were determined to be lower than those of the control group
(9.39 ± 1.05), and this difference was statistically significant (p < 0.05). It was also found that mean hos-
pitalization durations of the patients in the experimental group (8.22 ± 3.05) were shorter than those of the
control group (14.42 ± 7.79), and this difference was also found to be statistically significant (p < 0.05).
Conclusion: When a beeswax, olive oil and A. tinctoria (L.) Tausch mixture was applied to second degree burns,
this accelerated epithelization, reduced the pain experienced during dressing changes and shortened the hospital
stay durations of the patients.

1. Introduction
Burn injuries are a serious public health problem in Turkey and
developing countries. They are one of the most severe traumas for the
human body and affect people both physically and psychologically.1,2
Tissue injuries caused by burns have high rates of morbidity and mor-
tality and require long-term hospitalization.3 Since they cause severe
pain, significant changes in physical appearance, loss of limbs and de-
formities, burns are among the most serious health problems glob-
ally.4,5
In the USA, 2.5 million people are exposed to burns every year,
more than 2 million people receive medical care for burn injuries, and
half of these are children.6,7 According to 2014 World Health Organi-
zation (WHO) data, 265,000 people died due to burn injuries, and 96%
of these deaths occurred in underdeveloped and developing countries.8
Throughout the centuries, experts have searched for ideal treatment
for burns and burn pain.9,10 While some treatments based on traditional
practices appear as complementary or supportive practices in burn in-
jury treatment, practices that are not based on a scientific foundation
can also be found as well. In the literature, it is observed that olive oil,

⁎
Corresponding author.
E-mail addresses: kenangumus_010@hotmail.com (K. Gümüş), zynp_krmnzl@hotmail.com (Z.K. Özlü).

http://dx.doi.org/10.1016/j.ctim.2017.08.001
Received 15 December 2016; Received in revised form 27 July 2017; Accepted 2 August 2017
Available online 10 August 2017
0965-2299/ © 2017 Elsevier Ltd. All rights reserved.
K. Gümüş, Z.K. Özlü
unpeeled apple, butter, century oil, potato, beeswax, egg yolk, cold
application, toothpaste, mud, lime putty, yogurt, sauce/paste and salt
are the most frequently used treatments for burn injury in folk medi-
cine.11–13 In folk medicine, beeswax, olive oil and A. tinctoria (L.)
Tausch (A. tinctoria) are also frequently used for burn care and treat-
ment.11,14,15A. tinctoria of the genus Alkanna belongs to the Bor-
aginaceae family of the Tubiflorae order.16 The flowers usually have 5
petals. From April to July, the blue-blooming plant grows to between 10
and 30 centimeters.17 A. tinctoria grows widely in Europe, the Medi-
terranean and Western Asia. The wound healing characteristics of A.
tinctoria has also been considered to make it useful for traditional
ointments and pastes for wounds. Its anti-nociceptive and anti-in-
flammatory activities have been used in folk medicine to cure in-
flammatory and pain-related ailments.15
It has been determined that beeswax, olive oil and A. tinctoria are
traditionally used in folk medicine in the treatment of burn injuries;
however, no studies have been conducted in accordance with scientific
norms about their efficacy in the treatment of burn injuries in order to
include them in modern medical practices. It is thought that the results
obtained from this study will make a positive contribution to the
treatment and care of burn injuries, guide future studies in this field and
contribute to the scientific literature.
This study was planned to investigate the effect of a mixture of
beeswax, olive oil and A. Tinctoria (L.) Tausch on burn wounds to de-
termine the impact on burn healing, pain during dressing changes and
duration of hospital stay.
2. Methods
2.1. Type of study
This study was conducted as an experimental study. It could not be
conducted as randomized controlled because the hospital stays of the
patients were not the same, patient rooms in the clinic could not be
separated and the wound dressing room could be seen by all patients.
2.2. Population and sample of the study
It was selected from the specified population using improbable
random sampling (choosing appropriate people in terms of research
criteria as they came into the burn unit and asking them if they wanted
to participate in the study). Five patients in the control group and four
patients in the experimental group were excluded from the study since
they did not meet its inclusion criteria. These patients were excluded
for leaving hospital before the end of treatment or having surgerySince
there was no previous research, power analysis was done at the end of
the study. It found that the significance level was p = 0.05, the con-
fidence interval was 95%, and the representation power of the popu-
lation was 99%. To prevent the possibility of affecting the interventions
to be administered to the patients in the unit, the patients in the control
group were included in the study first, and after that the patients in the
experimental group were included.
2.3. The inclusion criteria of the study
The inclusion criteria of the study were: patients presenting to
Ataturk University hospital, having second-degree burns, being more
than three years old and less than 65 years old, burns not being in-
fected, not having any chronic disease that could negatively affect
healing, voluntary participation, having extremity burn injuries, having
burns other than chemical and electrical burns with certain borders and
not having undergone a surgical procedure that could affect healing.
67
Complementary Therapies in Medicine 34 (2017) 66–73
2.4. Materials used for data collection
2.4.1. Questionnaire
The questionnaire was prepared by reviewing the related litera-
ture.18–22 The questionnaire was used to determine the descriptive
characteristics of the patients and the characteristics and exposure
properties of their burns.
2.4.2. Visual Analogue Scale (VAS)
The Visual Analogue Scale (VAS) was used in order to evaluate the
pain intensity of the patients. The VAS is a 10 centimeter ruler in-
dicating no pain at one end and unbearable pain at the other end.
Patients are asked to evaluate their pain intensity between 0 and 10 (0
means no pain, and 10 means unbearable pain).23 The VAS is a clear,
easy to use scale for patients over five years of age.24
2.4.3. Facial expression scale (FES)
This is facial expression scale which determines the intensity of
pain. Facial expressions at one end of the scale signify no pain, and they
signify very severe pain at the opposite end.23 The FES is recommended
for use with young children who cannot use the VAS because their
language skills and mental capacities are not yet sufficiently devel-
oped.24
2.4.4. Digital camera with interchangeable lens
Since visualization and evaluation are among the most frequently
used objective methods in the evaluation of injuries,23 in this study the
injuries were followed up by taking photos and evaluation was done
with ImageJ software (NIH, Bethesda, MD, USA).
2.4.5. Dressing material used in the experimental group
The material used was a mixture of beeswax, olive oil and A. tinc-
toria.
2.4.5.1. Beeswax. Beeswax is a mixture of saturated and unsaturated
acids with a high molecular weight that includes both alcohol and
esters. The density of beeswax is almost one (0.966). Its melting point is
62–65 °C. When applied to living tissue, it does not produce any allergic
or toxic effects.25 The use of beeswax is very common. In the literature,
it has been stated that beeswax is an antioxidant that has antibacterial
properties, increases cytokine production in skin cells and decreases
exudation in the injury area.11,18,25,16,26
2.4.5.2. Olive oil. In addition to bactericidal activity similar to that of
hydroxytyrosol and oleuropein, olive oil contains at least 30 phenolic
compounds.18,27 It is especially effective against the Klebsiella and
Pseudomonas bacteria species, which are resistant to antibiotics.
Oleuropein has strong antimicrobial properties.14 Moreover, olive oil,
which is rich in flavonoids, is an antioxidant that has anti-
inflammatory, antioxidant and cell protective effects that inhibit the
release of IL6, IL8 and histamine.27,28
2.4.5.3. A. Tinctoria (L.) Tausch. A. tinctoria of the genus Alkanna
belongs to Boraginaceae family of the Tubiflorae order. It contains a red
naphthoquinone pigment produced from cinchonine plant cells.16 It is
used in the pharmaceutical and cosmetics industries and as a dye in
liquors.17 A. tinctoria exhibits antimicrobial properties against
Staphylococcus aureus and Staphylococcus epidermidis. It is said to be
effective for healing injuries. It is non-toxic and has antitumor and
antithrombotic properties.15,29 Alkannin and shikonin are chiral-pair of
naturally occurring isohexenylnaphthazarins. They are found in the
external layer of the roots of at least a 150 species that belong mainly to
the genera Alkanna of the Boraginaceae family.29
K. Gümüş, Z.K. Özlü
Fig. 1. Measurement of Sizes of Photographed Injuries and Their Evaluation with ImageJ.
2.5. Preparation of the dressing material consisting of a mixture of beeswax,
olive oil and A. tinctoria
Before the preparation of the dressing material, expert opinions and
advice were sought from the faculty of the Department of
Pharmacology of Atatürk University. In order to prepare the mixture, A.
tinctoria, natural beeswax and medical olive oil with an acid rate lower
than 0.8% were used. According to expert advice, 1000 ml of medical
olive oil, 30 g of beeswax and 50 g of A. tinctoria were used in order to
obtain a 1080 ml mixture applicable for injuries. The preparation of the
mixture was done in a laboratory environment. The medical olive oil
was heated to its boiling point (200–210 °C). When the olive oil reached
its boiling point, 30 g of beeswax were added and melted. When the
beeswax was melted completely in the olive oil, 50 g of A. tinctoria were
added to the mixture. The mixture was heated and mixed for 5 min to
integrate the extract of the A. tinctoria with the mixture. While the
mixture was hot, it was passed through a very fine mesh filter to se-
parate the plant particles. The liquid mixture was put into 100 cc dis-
posable amber glass bottles. To prevent degeneration of the tops of the
amber glass bottles during sterilization, they were covered with alu-
minum foil. The bottles were placed in the sterilizer under 1.5 atmo-
spheric pressure at 121 °C. Immediately prior to dressing the injuries, a
sterile sponge was saturated with the sterilized and disposable material
along with a compress that could be applied to the injury.
2.6. Application of dressing for the control and experimental groups
The dressing was applied in the usual burn unit routine to the pa-
tients in the control group. In the unit, nitrofurazone is routinely ap-
plied as a topical pomade, and rifamycin in the ampoule form is used.
Since the patients in the burn unit where the study was conducted are
generally from lower socio-cultural levels, they cannot meet general
hygiene standards, and their injuries are open and tend to be infected.
Rifamycin is routinely used in dressings. Nitrofurazone and rifamycin
were mixed on a sterile sponge to form a compress over the burn and
applied to the injury using an aseptic technique under sterile condi-
tions. After opening the injury during dressing, irrigation was made
with 0.09 NaCl and 0.010 Savlon. After cleaning the surface of the
injury, the injuries were photographed by the researcher using a stan-
dard camera under standard lighting conditions. After taking photos
and dressing the wound, the surface of the injury was covered with a
sterile pad. In the burn unit, the dressing is done every two days in
accordance with hospital policy and routine clinical practice.
The dressing made from a mixture of beeswax, olive oil and A.
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Complementary Therapies in Medicine 34 (2017) 66–73
tinctoria was applied to the patients in the experimental group by the
researcher using sterile technique under aseptic conditions in the
dressing room of the burn unit. After opening the injuries of the patients
in the experimental group, the injury was first irrigated and then
cleaned with 0.09 NaCl and 0.010 Savlon. The sterile mixture prepared
by the researcher was applied to the injury to make a compress on the
sterile sponge in proportion to the size of the injury, and it was covered
with the sterile sponge or pad. The material covering the injury was
fixed by the dressing. This dressing material was applied once a day as
traditionally used in folk medicine.
On the third day after the occurrence of the burn incident, a wound
culture was taken from each of the patients of the control and experi-
mental groups. The cultures were sent to the laboratory under appro-
priate conditions. While the dressing and photo taking processes were
carried out, care was taken to protect the privacy of the patients. Except
for the dressing material, all other factors (calories, proteins, carbo-
hydrates, etc. intake per meal, fluid replacement, medical treatment,
ambient temperature, light and moisture) that could affect the healing
of the injuries in either group were kept as constant as possible. When
the size of a patient’s injury in either the experimental or the control
group was less than one millimeter, the treatment was terminated with
the approval of the unit physician, and the patient was discharged.
2.7. Data collection
For each patient who agreed to participate in the study, the ques-
tionnaire for descriptive characteristics was completed, and the first
dressing was made. An interview was conducted with each individual
and lasted an average of 5–9 min. The pain scale (VAS and FES) was
administered in the dressing room to all patients during the first dres-
sing change. Photos were taken by the researcher during the dressing.
Throughout the study, a total of 1254 photos were taken. Photos of each
patient in the control and experimental groups were separately filed
with information such as date, number of dressings, etc. Each photo-
graph was evaluated with ImageJ software, and injury sizes were cal-
culated in millimeters (Fig. 1).
2.8. Variables of the study
The dependent variables of the study were the starting time of
epithelialization, hospitalization duration and mean pain scores of the
patients during dressing changes. The independent variables of the
study were age, gender, marital status, educational level, place of re-
sidence and occupation.
K. Gümüş, Z.K. Özlü Complementary Therapies in Medicine 34 (2017) 66–73

Fig. 2. ImageJ Image Analysis Software.

2.9. Data assessment Table 1

Comparison of Descriptive Characteristics of Patients in Experimental and Control
2.9.1. ImageJ Groups.

ImageJ is a public domain Java image processing program inspired Characteristics Controla (n = 33) Experimentala Test resultsb p value
by NIH Image for Macintosh. It runs, either as an online applet or as a (n = 31)
downloadable application, on any computer with a Java 1.4 or later
virtual machine. It can calculate area and pixel value statistics of user- Gender
2
Female 15 (45.5) 13 (41.9) x = 0.80 0.77
defined selections. It can measure distances and angles.30 ImageJ can
Male 18 (54.5) 18 (58.1)
calculate each identified parameter to determine morphological struc- Average Age (year) 5.52 ± 0.64 6.68 ± 1.09 t = 0.93 0.35
ture and tissue characteristics represented in an image using a com-
Marital Status
mand system. Therefore, it is a suitable program for field measurement Married 2 (6.1) 1 (3.2) x 2
= 0.28 0.59
of tissue (Fig. 2). Single 31 (93.9) 30 (96.8)
The calculations and results made by this program are accepted in Educational Status
international evaluations and can be used in scientific studies.31 Under 28 (53.8) 24 (77.4) x 2
= 6.53 0.08
educational
age
2.9.2. Statisticsal analysis Literate-primary 5 (15.2) 2 (6.5)
Coding and statistical analyses of obtained data were made using school
IBM SPSS for Windows 18.0. For all study data, descriptive statistics Secondary 0 (0) 4 (12.9)
were used. Descriptive statistics for the variables determined by mea- education-
high school
surement were shown as means and standard deviations, whereas de-
Undergraduate- 0 (0) 1 (3.2)
scriptive statistics for the variables determined by calculation were Graduate
shown as numbers and percentages. To determine differences between
Occupation
individual characteristics of the patients in the control and experi- Civil servant 0 (0) 2 (6.5) x 2
= 4.58 0.20
mental groups and the characteristics of their injuries, chi-square (x2) Worker 0 (0) 2 (6.5)
was performed. The level of pain, epithelialization and the length of Housewife 2 (6.1) 2 (6.5)
stay in the hospital were evaluated by Mann Whitney U test in the Under working 31 (93.9) 25 (80.5)
age
experimental and control groups. The threshold for significance was
0.05. Income Status
2
Income less than 19 (57.6) 13 (41.9) x = 1.93 0.38
expense
3. Results Income equals to 10 (30.3) 11 (35.5)
expense
Income more 4 (12.1) 7 (22.6)
The population of the study consisted of patients in the burn unit of
than expense
a university hospital Erzurum, inTurkey between May 2014 and August
Residence Place
2015. The sample of the study consisted of 73 patients (35 patients in 2
City 8 (24.2) 8 (25.8) x = 0.13 0.93
the experimental group and 38 patients in the control group) who met District 11 (33.4) 9 (29.0)
the inclusion criteria. Village 14 (42.4) 14 (45.2)
Comparison of the descriptive characteristics of patients in the ex-
a
perimental and control groups were compared (Table 1) determined All values are expressed as mean ± standard deviation (SD) and number (percent).
b
Analyzed using the Independent samples t-test and chi square.
that the average age of the control group was 5.52 years and 6.68 years
in the experimental group. The majority of the patients in both groups
injuries of the patients in the experimental and control groups. The
were male, single and younger than school or work age. Their incomes
average sizes of the injury measured during the first dressing were
were less than their expenses, and they resided in villages. Comparison
25.76 mm for the control group and 21.04 mm for the experimental
of the descriptive characteristics of the patients in the experimental and
group. It was found that 45.4% of the control group’s injuries were on
control groups found no significant differences between the groups
the arms, and 51.6% of the experimental group’s injuries were on the
(p > 0.05). This indicated that the groups were homogenous.
legs. It was determined that in both groups, most of the injuries were
Table 2 shows the comparison of the characteristics of the burn

69
K. Gümüş, Z.K. Özlü Complementary Therapies in Medicine 34 (2017) 66–73

Table 2
Comparison of Characteristics of the Burn Injuries of Patients in the Experimental and
Control Groups.

Characteristics Controla (n = 33) Experimentala Test resultsb p value

(n = 31)

Burn site
2
Hand 3(9.1) 2(6.5) x = 1.71 0.63
Arm 15(45.4) 10(32.3)
Leg 12(36.4) 16(51.6)
Foot 3(9.1) 3(9.6)

Mean of Injury 25.76 ± 21.06 21.04 ± 20.74 t = 0.90 0.37

Area during
the First
Dressing

Reason of Burn
2
Being boiled 31(93.9) 26(83.9) x = 1.66 0.19
Flash 2(6.1) 5(16.1)

Did you make any application before applying to the hospital? Fig. 3. Means of the Starting Time of Epithelialization for the Patients in the Control and
Yes 16(48.5) 16(51.6) x 2 = 0.06 0.80 Experimental Groups.
No 17(51.5) 15(48.4)

What kind of application did you make*

2
Cold water 12(75.0) 7(43.6) x = 7.45 0.18
Yogurt 3(18.8) 4(25.0)
Salt 1(6.2) 0(0)
application
Toothpaste 0(0) 1(6.3)
Egg yolk 0(0) 1(6.3)
Lemon juice 0(0) 3(18.8)

When did you apply to the hospital after burning?

Within the first 25(75.8) 27(87.1) x 2
= 1.34 0.24
24 h
Within 8(24.2) 4(12.9)
24–48 h

Infection in Burn injury

2
Yes 2(6.1) 0(0) x = 1.93 0.16
No 31(93.9) 31(100)

* Multiple answers were given (n = 16).

a
All values are expressed as mean ± standard deviation (SD) and number (percent).
b
Analyzed using the Independent samples t-test and chi square.
Fig. 4. Mean Pain Scores of the Patients in the Experimental and Control Groups During
Dressing.
caused by boiling liquids, and the patients came to the hospital within
the first 24 h after their injuries. It was found that most patients in the
control and experimental groups had applied cold water to their burns
before coming to the hospital. Cultures taken from the injuries of the
patients in both groups showed that infection occurred in 6.1% of the
patients in the control group, and no infections occurred in the patients
of the experimental group. Comparison of the characteristics of the
injuries of the patients in the control and experimental groups de-
termined that there were no significant differences between them
(p > 0.05).
Comparison of the means of the starting time of epithelialization for
the patients in the control and experimental groups were compared
(Fig. 3) found that epithelialization of the burn injuries of the patients
in the experimental group (3.00 ± 0.85 days) started earlier than that
of the control group (6.90 ± 1.77 days), and this difference was sta-
tistically significant (p > 0.05).
Comparison of the mean pain scores of the patients in the experi-
mental and control groups during dressing (Fig. 4) determined that
mean pain scores of the patients in the experimental group
(8.12 ± 1.38) were lower than those of the control group Fig. 5. Means of Hospitalization Durations of the Patients in the Experimental and
(9.39 ± 1.05), and this difference was statistically significant Control Groups.
(p > 0.05).
Comparison of the means of hospitalization durations of the patients
(p > 0.05).
in the experimental and control groups (Fig. 5) found that the mean
hospitalization duration of the patients in the experimental group
(8.22 ± 3.05 days) was shorter than that of the control group 4. Discussion
(14.42 ± 7.79 days), and this difference was statistically significant
The results obtained by this study investigating the effect of the

70
K. Gümüş, Z.K. Özlü
beeswax, olive oil and A. tinctoria mixture on burn injury were com-
pared to the results of related studies. For the purpose of this study is to
investigate the effectiveness of the mixture of beeswax, olive oil and
alkaline tinctoria on burn injuries.
This study determined that, while infections occurred in 6.1% of the
wound cultures of the control group patients, zero infections occurred
in the wound cultures of the patients in the experimental group. Among
the studies in the literature, it is possible to find numerous publications
stating that A. tinctoria, beeswax and olive oil have antioxidant, anti-
bacterial, and anti-inflammatory properties.16,26,32–37 A retrospective
study of burn dressings conducted by Wang et al.38 stated that one of
the criteria required to specify a dressing material as very good is the
non-occurrence of infection.
It has been reported that second-degree burn injuries can recover by
spontaneous epithelialization within an average of three weeks when
there are no complications.39 This study found that, while the average
starting time of epithelialization for the injuries of patients in the ex-
perimental group was 3.0 ± 0.85 days, it was 6.9 ± 1.77 days for the
control group, and this difference was statistically significant (Fig. 3).
These results imply that the epithelialization of the injuries of the pa-
tients in the experimental group started very quickly. This result cor-
responds to the short hospitalization durations of the experimental
group patients. When the international literature on the subject was
examined, it was found that Karayannopoulou et al.34 determined that,
when ointment obtained from a mixture of the alkannin and shikoninin
A. tinctoria was applied on full-thickness burns in dogs, the epithelia-
lization rates of the injuries were significantly higher than those of the
group irrigated with ringer lactate. In a study conducted by Moustafa
et al.27 on second-degree burn injuries in dogs, the injuries were se-
parated into the following groups: injuries to which a honey, beeswax
and olive oil mixture was applied, injuries to which silver sulfadiazine
was applied, and injuries to which nothing was applied. The healing of
the injuries was then compared. It was found that contraction in in-
juries to which the mixture of honey, beeswax, and olive oil was applied
occurred earliest. Oğurtan et al.40 investigated the therapeutic effect of
a mixture of A. tinctoria and medical olive oil on burn injuries in rabbits
and found that the earliest granulation tissue started to form on the fifth
day after the application. Another study of the wound healing proper-
ties of A. tinctoria found that it increased production of the fibroblasts
that stimulate angiogenesis, which is one of the most important stages
of healing.41Increased fibroblastic activity on the wound and stimulated
angiogenesis will help the wound be epithelialized faster since they
indicate better perfusion of the wound area and accelerated granula-
tion. Such a quick epithelialization of the wound can reduce the hos-
pitalization time, which supports the findings of this study. In a study
conducted by Abdulrahman et al.42 to examine the efficacy of a mixture
of honey, beeswax, olive oil and propolis on the treatment of oral
mucositis induced by chemotherapy, it was determined that the healing
of the injury with this mixture was faster than the healing of individuals
to which benzocaine gel was applied. These findings were presented to
scientifically support the thesis using the literature that the mixture
developed would ensure wound epithelialization. In another study, the
Tephrosia purpurea plant, which is rich in flavonoids like pure olive oil,
was applied to the burn injuries of rats, and it increased wound con-
traction.43 A retrospective study of burn dressings by Wang et al.38
stated that one of the criteria required to specify a dressing material as
very good is fast epithelialization.For wound care, wound dressings can
be used in a variety of forms. However, the best wound dressing has yet
to be identified. Accelerating the epithelialization of the wound bed has
been reported to be a criterion to define the ideal wound dressing. The
researchers placed an emphasis with the support of the literature on the
fact that the presence of olive oil in the mixture they administered had
an epithelializing feature in the wound care, which would make a
significant difference to obtain an ideal medical dressing. For an injured
individual, the burn itself and the treatment of the burn are the most
important causes of pain. Comparison of the patients’ pain levels during
71
Complementary Therapies in Medicine 34 (2017) 66–73
dressing changes found that mean pain score of the experimental group
(8.12 ± 1.38) was significantly lower than that of the control group
(9.39 ± 1.05) (Fig. 4). In the literature, it is stated that narcotic an-
algesics can be administered before dressing because burn dressing
changes can be extremely painful.44 We think that since the use of a
dressing that reduces the pain experienced during dressing also means
reducing dosages of narcotic analgesics, which is very important for
burn injury care. Use of a narcotic analgesic was not a parameter
considered in experimental and control groups. However, significantly
lower level of pain experienced in the experimental group indicated
that the material administered would have high benefits for the clinical
use of analgesics. It has also been stated that the levels of pain felt
during dressing can increase as the depth of the burn injury increases.45
In this study, the low level of pain felt by the patients in the experi-
mental group during dressing could be associated with the olive oil in
the applied dressing material. It may have prevented traumatization
during the uncovering of the dressing material by preventing adherence
to the injury. The literature states that olive oil is used in wound care in
the preparation of medicines, such as ointments, and is also used as a
lubricant during various procedures in addition to the treatment of
wounds and burns.46 And also A. tinctoria also reduces nociceptive pain
(stimulus causing pain and aches).15 In a study conducted by Esfahani
et al.15 to examine whether Alkanna frigida and Alkanna orientalis have
anti-inflammatory and nociceptive pain reduction effects on rats, it was
determined that these plants reduced nociceptive pain, like diclofenac,
and this effect was clinically significant.
This study determined that, while the mean hospitalization duration
of the patients in the control group was 14.42 ± 7.79 days, the mean
hospitalization duration of patients in the experimental group, to which
dressing material containing beeswax, olive oil and A. tinctoria was
applied, was 8.22 ± 3.05 days. This difference was statistically sig-
nificant (Fig. 5). In a study conducted by Moustafa et al.27 on dogs, it
was reported that while the average period of wound healing was
22.9 ± 2.56 days for injuries to which a mixture of honey, beeswax
and olive oil was applied and 25.7 ± 2.31 days for injuries to which
silver sulfadiazine was applied. Karayannopoulou et al.34 determined
that, when ointment obtained from a mixture of alkannin and shikonin
from A. tinctoria was applied on full-thickness burns in dogs, the per-
fusion and the contraction rate of the injury areas were significantly
higher than those of the group irrigated with ringer lactate. High level
of perfusion and contraction reduce the epithelialization time, which
will also reduce the hospitalization time, accordingly. Al et al.47 re-
ported that as hospitalization durations extend, mortality rates increase
as well. Brusselaers et al.48 examined the effect of infections in patients
with severe burn injuries on morbidity and mortality and found a
correlation between long hospitalization durations and infections. Long
periods of hospitalization cause complications such as morbidity and
mortality and negatively affect quality of life.49,50 In the literature, it
has been claimed that the alkannin and shikonin in A. tinctoria have a
strong effect on wound healing.35,51 This difference in hospitalization
durations, occurring in patients who consumed standard diets in a
standard environment, may be associated with the A. tinctoria in the
dressing material applied to the experimental group, which had the
effect of accelerating their healing.
The results of this study can be regarded as evidence indicating that
this dressing is ideal for burn injury care. The reduction of patients’
hospitalization durations, the prevention of wound site infections, rapid
epithelialization and the reduction of pain caused by dressing changes
are all criteria for successful burn care treatment.
4.1. Limitations and generalization of the study
The most significant limitation of the study was the use of im-
probable sampling. The other limitation was different treatment re-
ceived between the control and experimental group regarding dressing.
Its results can be generalized to patients who meet its inclusion criteria.
K. Gümüş, Z.K. Özlü
4.2. Conclusion
This study, which was conducted to evaluate the effects of a mixture
of beeswax, olive oil and A. tinctoria on burn injuries, determined that
the dressing applied to the experimental group patients accelerated the
process of epithelialization, reduced hospitalization durations, reduced
the levels of pain experienced by the patients during dressing and
completely prevented wound site infections in the experimental group.
These results suggest that this mixture may be considered as an
effective burn dressing, researchers may use the scientific contribution
made by this study to develop ideal injury care materials for burn in-
juries, and this dressing may be adopted as a routine clinical treatment
for the care of second-degree burns in burn centers and burn units. It is
recommended to conduct further related studies with larger popula-
tions and different burning types.
Ethical principles of the study
Ethics committee approval was obtained from the Atatürk
University, Medical Faculty, Clinical Trials Ethics Committee. The pa-
tients were given an informed consent form stating the objective and
type of the study, that they were free to participate or not participate in
the study, and that they would be able to withdraw from the study at
any time even if they had volunteered to participate in it. The informed
consent forms were signed by the literate patients. The relatives of
patients who could not read explained the study to the patients before
they signed the consent forms. The nurses and doctors working in the
unit where the study was conducted were informed about the objectives
of the research and the data collection methods. The principles of
privacy and the protection of privacy and non-disclosure of personal
information were explained to the patients and their relatives.
Conflict of interest
The authors have no conflicts of interest to declare. The authors
declared that they have legally equal rights (right ownership of 50%) on
legal documents in the beginning of patenting process of this product;
therefore, the conflict of interest is not expected in the following pro-
cess.
Authors’ contributions
Drs. Gumus and Karaman Ozlu are responsible for conception and
design of the study, analyzed the data. All the authors contributed to
the interpretation of the results of the experiments. All the authors were
involved in drafting the manuscript and its revision. All authors ap-
proved the final version of the manuscript.
Acknowledgements
This manuscript was produced from a doctoral dissertation that was
submitted as oral presentation at the Twentieth National Congress of
Surgery between April 13 and 17, 2016.
A patent application has been made for the dressing material pre-
sented in this study, the preliminary application phase has been com-
pleted, and the patenting process continues. In Turkey, the patenting
process takes an average of 3 years. In this process, the product is re-
gistered nationally and internationally. Following the completion of the
national process, according to the information provided by the patent
office, the international procedure now continues. The process is
planned to be completed in 2018. A patent application acceptance
document has been recieved. The patent number is 2015-GE-387505.
The authors would like to acknowledge Drs. Zekai Halıcı, Ph.D.,
Osman Enver Aydın, Ph.D, all clinical and scientific staff and all the
patients who participated in the study at Atatürk University Medical
Faculty Hospital. We thank all the patients in the Burn Unit, Research
72
Complementary Therapies in Medicine 34 (2017) 66–73
Hospital at Atatürk University, Erzurum, Turkey.
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