practice
Clinical experiences of using a
cellulose dressing on burns and
donor site wounds
These preliminary results suggest this temporary skin substitute reduces pain
and achieves comparable healing rates to other dressings. Furthermore, its
transparency enables regular inspection of the wound bed for signs of infection
burns; cellulose dressing; partial-thickness wounds
B
urns are common injuries and can be
difficult to treat. Occlusive dressings
are generally used for the management
of second-degree burns.1,2 These dress-
ings create a moist wound environment
that promotes epithelialisation, protects against
bacteria and is associated with good pain control.3
In recent years, bioengineered skin substitutes
have been developed to stimulate orderly and effi-
cient restoration of the skin tissue’s architecture.
One such product is Veloderm, an occlusive, tempo-
rary skin substitute that is indicated for moderately
exuding burns, donor sites and abrasions. It is man-
ufactured in Italy by BTC and distributed in Brazil
by Cristalia Ltda.
The dressing is produced from bacterial cellulose,
which is derived from the Gram-negative bacterium,
Acetobacter xylinum and two yeasts, Saccharomyces
cervisiae and Schizosaccharomyces pombe. During its
manufacture, a metabolic reaction produces a bio-
mass of bacteria, over which a cellulose layer
appears. After washing, drying and sterilisation, this
layer turns into a thin, translucent membrane,
resembling baking paper. It is this membrane that
comprises the cellulose dressing (Veloderm).4,5
The membrane can absorb up to five times its
own weight of liquid. When hydrated with normal
saline, it swells slightly and becomes soft and flexi-
ble, with a texture similar to human skin. Its absorb-
ency is lost once it is hydrated.4 The dressing is
transparent once applied.
According to one of the cellulose dressing’s Euro-
pean distributors, only one application is required
and it ‘removes itself’ when healing is complete.6
The distributor states that, when wet, the dressing
coheres with the damaged skin only (ie, not the sur-
rounding intact skin), so a secondary dressing is not
required. However, there are anecdotal and pub-
lished accounts of the use of permeable secondary
dressings. As the wound heals, parts of the cellulose
dressing that had been attached to wound bed
J O U R N A L O F WO U N D C A R E V O L 1 8 , N O 1 , J A N U A RY 2 0 0 9
become loose as the skin heals and then fall off. H.R.N. Alves, MD, Chief
The cellulose dressing is permeable to gas and Resident, Division of
Plastic Surgery;
moisture vapour, but not bacteria, thereby enabling
P.C. Cavalcante de
exudate to evaporate. In addition, it is biocompati- Almeida, MD, Staff
ble and therefore non-allergenic.4 In vitro trials indi- Surgeon, Burn Service,
cate that fibroblasts are unable to adhere strongly to Division of Plastic
the membrane or penetrate it,4,5 in turn avoiding Surgery;
V.A.T. Grillo, MD, Fellow
pain and trauma when it falls off. Surgeon, Division of
Unfortunately, the published research evidence Plastic Surgery;
on the cellulose dressing comprises low-level, open, P. Smaniotto, MD,
non-randomised, uncontrolled trials with small Resident, Division of
General Surgery,;
sample sizes. In particular, there is little evidence on
D.V. Santos, MD,
its use on burns and skin grafts. The largest studies Resident, Division of
published to date are summarised below. Dermatology;
Tucci et al.7 used the cellulose dressing in an open, M.C. Ferreira, PhD,
uncontrolled trial of 25 patients with minor trauma Chairman, Division of
Plastic Surgery;
injuries, principally to the hand or leg (n=10), first- all at Faculty of Medicine,
or second-degree burns (n=10) and with donor-site University of São Paulo,
wounds (n=5). (One patient with a burn injury did Brazil.
not complete the study.) All of the trauma and burn Email: heliomed85@
yahoo.com
wounds healed within two weeks, with no differ-
ence between the two types in healing times (aver-
age 11.1 ± 2.4 days versus 11.3 ± 2.2 days respec-
tively). All five donor site wounds healed
uneventfully. The Veloderm dressing needed to be
replaced in three patients: in two burns patients
because of excessive exudate and in one trauma
patient because it got damaged. None of the burn
injuries became infected. The wounds were assessed
every 4–5 days, precluding an accurate assessment
of healing time.
In another open uncontrolled study, Cardoni et
al.8 treated 26 patients with either first- or second-
degree burns of less than 10% of the total body area
(n=10), or traumatic injuries (n=6), principally fin-
gertip amputations, with Veloderm. All of the burns
healed, with an average healing time of 18.4 ± 3.6
days (range 11–24). The dressing needed replacing
in two cases because of exudate leakage. All of the
trauma injuries healed, with an average healing
▲
time of 18.3 ± 8.1 days (range 8–25). The dressing
27
 practice
Table 1. Pain scale
0 = no pain
1–3 = mild pain
4–6 = moderate pain
7–9 = severe pain
10 = intolerable pain
needed replacing once because of excessive bleed-
ing. The investigators also reported that the dressing
was well tolerated by the patients, and none of the
wound became infected. However, they did not
define how they evaluated tolerance or healing.
The only structured comparative study yet pub-
lished on the cellulose dressing is a multicentre,
open, within-patient controlled study by Melandri
et al.9 Twenty-three adult patients with burns that
required grafting were included. Each patient had
donor sites that were divided into three sections, to
which the following three dressings were applied:
● The cellulose dressing (Veloderm)
● An alginate (Algisite M, Smith & Nephew)
● Jaloskin, a film derived from hyaluronic acid
(ConvaTec and Fidia Advanced Biopolymers).
A higher proportion of Veloderm-treated donor
site areas healed completely in 10–13 days: 47.6%
Veloderm, 26.3% for Algisite M and 10% for Jeloskin
(p<0.03).
We have been using Veloderm for partial-thick-
ness wounds, mainly burns and minor trauma inju-
ries, since March 2003, with adequate healing times
and patient tolerability.
Given the paucity of published evidence on the
dressing, we undertook a preliminary non-control-
led prospective study to report healing times, pain
levels and the need for dressing re-applications
when using it on partial-thickness or second-degree
burns and donor site wounds.
Method
Consecutive patients attending the department of
plastic surgery at the University of São Paulo, Brazil,
between November 2006 to June 2007 for the treat-
ment of partial-thickness or second-degree burns
and donor site management were recruited into the
study. Patients with more than 10% total body sur-
face burns and heavily exuding wounds were
excluded, as were those aged under 10 (for practical
reasons) or over 60 (as healing times tend to be
slower in this age group).
Ethics committee approval was granted for the
study and all of the patients gave written, informed
consent.
28
Treatment protocol
● Burns Before applying the test dressing to
patients with second-degree burns, the blisters were
removed and the wound was cleansed with saline
and 2% chlorhexidine. The burn was then dried and
covered with the cellulose dressing. No secondary
dressing was used.
Patients were allowed to bathe 48 hours after the
dressing was first applied, but were advised not to
submerge the dressing into the water or scrub the
surrounding skin.
The cellulose dressing was left in place for the 14-
day study period or until it fell off. If the wound had
not healed by 14 days, a new cellulose dressing was
used to cover the wound until the complete healing
occurred.
● Donor sites The grafts were harvested from the
anterior thigh using an electric dermatome. The site
was infiltrated with epinephrine before harvest.
After graft removal, the site was covered with rayon
soaked in a vasoconstrictor solution and compressed
with a crêpe bandage. The compressive bandage and
the rayon were removed at the end of the surgery,
and the cellulose dressing was applied, again without
a secondary dressing.
Assessment
Evaluation criteria comprised:
● Time to complete healing (visual evaluation of
epithelialisation)
● Time taken for all of the dressing to fall off.
● Level of persistent/ongoing pain while the cellu-
lose dressing was in place. Patients self-reported this
using a visual analogue scale (0–10) (Table 1) every
three days, from the first postoperative day until the
wound had healed completely or the entire dressing
had fallen off. Patients were given oral analgesics as
required.
Statistical analysis
The Student’s t-test was used to identify any statisti-
cally significant reductions in average pain scores
for each of the three-day assessment periods
described above.
Results
Ten patients (two females and eight males) were
recruited into the study. The average age was 39
years (range 22–58). Five patients had second degree
burns: four had 2% TBA burns and one had 3% TBA.
The remaining five patients had donor site wounds
ranging from 80cm2 to 184cm2 in size.
Healing times
The average healing times were:
● 12 days (range 9–15) for the second-degree burns
● 12.4 days (range 10–14) for the donor site
wounds.
J O U R N A L O F WO U N D C A R E V O L 1 8 , N O 1 , J A N U A RY 2 0 0 9
 practice

Time to dressing removal References

Three of the 10 patients (30%) required a new dress- 1 James, J.H., Watson, A.C.
The use of Opsite, a vapour
ing application: permeable dressing, on skin
● In one patient (no. 6) with a donor site wound the graft donor sites. Br J Plast
original cellulose dressing tore on first day of use Surg 1975; 28: 2, 107-110.
2 Lobe, T.E., Anderson, G.F.,
and had to be replaced. The initial cellulose dressing
King, D.R., Boles, E.T. Jr An
comprised one large sheet (12x18cm), and became improved method of
taut and tore as the patient moved around in bed. wound management for
pediatric patients. J Pediatr
We therefore replaced it with two smaller sheets Surg 1980; 15: 6, 886-889.
(6x9cm) to prevent tearing. No further dressing 3 Uhlig, C., Rapp, M.,
applications were needed after this. Hartmann, B. et al.
● Two patients (9 and 10) with second-degree burns
Suprathel: an innovative,
resorbable skin substitute
developed heavy exudate levels, which caused the for the treatment of burn
dressing to become loose (Fig 1). As most of the cel- victims. Burns 2007; 33: 2,
221-229.
lulose dressing still remained on the wound bed, we Fig 2. A large sheet of the cellulose dressing ruptured,
4 Thomas, S. A review of
decided not to withdraw these patients from the exposing the wound area the physical, biological and
study, despite the presence of heavy exudate. Addi- clinical properties of a
bacterial cellulose wound
tional cellulose dressings were applied to both Adverse events dressing. J Wound Care.
patients on days 3 and 5, but there was still no No dressing-related side-effects were reported by the 2008; 17: 8, 349-352.
marked reduction in exudate levels. After this, mois- patients or investigator. Two patients with second- 5 Sanchavanakit, N.,
Sangrungraungroj, W.,
ture and vapour permeable secondary dressings ary degree burns developed cellulitis during the Kaomongkolgit, R. et al.
(rayon and gauze) were applied on a daily basis to study and were treated with systemic antibiotics Growth of human
absorb the exudate, as is regular practice in our unit. (Table 2). keratinocytes and
fibroblasts on bacterial
None of the other patients required a secondary cellulose film. Biotechnol
dressing. Discussion Prog 2006; 22: 4,
The cellulose dressing also tore but remained in The treatment of burn injuries can be stressful for 1194-1199.
continued on page 30
place on the first postoperative day in three patients patients as dressing changes can be slow and painful.
(5, 7 and 8) with donor site wounds. The exposed Additionally, most occlusive dressings for burn inju-
areas were covered with a new cellulose dressing (Fig ries are opaque, making it impossible to assess the
2). None of these patients required any further dress- wound bed on a daily basis, including for early signs
ing applications after this. of local infection. In our opinion, an ideal dressing
All of cellulose dressings in the remaining patients would be effective, safe, easy to use, comfortable and
stayed in place until full healing occurred. permit regular inspection of the wound bed.
In our study, the average healing time for second-
Pain scores degree burns and donor-site wounds was 12.2 days,
The average daily decrease in pain scores was statis- which is similar to that reported for other dressings
tically significant until day seven (Table 2). On day indicated for these wounds.
1, nine patients classified their pain as severe, where- Malpass et al. reported an average healing time of
as on day 5 six complained of just itching or local 10.4 ± 2.6 days with Xeroform (Kendall Healthcare),
discomfort. Scores reported for all patients through- a petrolatum gauze available in the US and Canada,
out the study are given in Table 2. and 10.6 ± 2.8 days with Jelonet when treating 19
graft donor skin sites.10
When assessing 67 patients with second-degree
burns (50–90% total body surface area) treated with
a porcine acellular dermal matrix, Feng et al. report-
ed an average healing time of 12.2 ± 2.6 days.11
In a non-comparative study by Carsin et al., 24
out of 41 patients with partial-thickness burns
(mean baseline surface area 192.7cm2 ± 151.1) treat-
ed with Urgotul SSD healed without requiring a skin
graft in an average of 10.8 days.12
Despite the small sample size, there was a statisti-
cally significant reduction in pain levels between
days 1 and 7. Nine patients reported their pain as
severe on day 1 compared with only one on day 3,
and none after that.
Fig 1.The cellulose dressing on a heavily exuding Although the cellulose dressing is regarded as
▲

wound requiring a single application only, like other inves-

J O U R N A L O F WO U N D C A R E V O L 1 8 , N O 1 , J A N U A RY 2 0 0 9 29
 practice

Declaration of
interest Table 2. Results: pain scores and complications
Cristalia, São Paulo, Brazil,
donated the dressing Patient Wound Pain scores Complications
materials for this
preliminary study but did
no. characteristics Day 1 Day 3 Day 5 Day 7 Day 9 Day 12 Day 14
not provide any other
commercial sponsorship 1 Burn (2% TBA) 6 4 2 0 0 None

We would like thank all 2 Burn (3% TBA 8 2 2 2 0 None

the staff of burns unit of
Hospital das Clinicas da 3 Burn (2% TBA) 7 4 2 2 0 None
Universidade de Sao
2
Paulo for their 4 DSW (105cm ) 8 6 5 3 3 3 0 None
cooperation. We are
grateful for Cristalia ltda, 5 DSW (154cm2) 7 4 3 3 1 1 0 Dressing tore
Sao Paulo, Brasil for
Veloderm supply 6 DSW (184cm2) 8 4 2 1 1 1 0 Dressing tore

7 DSW (80cm2) 9 4 1 1 1 0 None

8 DSW (140cm2) 9 6 5 4 1 1 0 Dressing tore

9 Burn (2% TBA) 9 8 5 4 2 2 2 Heavy exudate and cellulitis

10 Burn (2% TBA) 8 6 6 0 0 0 Heavy exudate and cellulitis

Mean 7.9 4.8 3.3 2 0.9 0.7 0.2

SD 0.99 1.68 1.76 1.49 0.99 1.05 0.63

p values for the differences in pain scores were: p<0.0001 (day 1 versus day 3); p<0.001 (day 3 versus day 5); p<0.05 (day
5 versus day 7); p<0.01 (day 7 versus day 9); p=0.16 (day 9 versus day 12); p=0.13 (day 12 versus day 14)

DSW = donor site wound; TBA = total body area

All burns were second degree

tigators we reported high rates of dressing re-appli- these results are not generalisable to clinical prac-
cations. Cardoni et al.8 and Tucci et al.7 replaced tice, and larger studies are needed to provide more
Veloderm in 11.5% and 20% of cases respectively robust evidence, including comparative data with
due to excessive exudate levels. Melandri et al. advanced wound dressings.
reported that 52% of patients needed a new dress- Nevertheless, in our experience the cellulose
ing, but did not specified the reasons for this.9 dressing was easy to use and adhered well to the
In the present study, the cellulose dressing became wound bed. Furthermore, its transparency enabled
extremely loose in two patients with high exudate us to inspect the wound bed on a regular basis and
levels. Clearly, Veloderm is not absorbent, and we so rapidly identify signs of infection.
consider that it is best not used on heavily exudat-
ing wounds as re-application or a secondary dress- Conclusion
ing will be required. Indeed, further investigation is Initial reports indicate that Veloderm may be a
needed on the use of the cellulose dressing with a promising treatment for burn injuries and donor
permeable secondary modern wound dressing on site wounds, and this was borne out by our experi-
highly exuding wounds. ence. Larger clinical comparative studies are needed
Clearly, given that this is a preliminary non-ran- before the dressing can be incorporated into routine
domised study with a sample of only 10 patients, clinical practice. ■
6 www.nordic pharmagroup.com/ for the treatment of cutaneous Tron,V. Comparison of donor-site 44: 7, 467-470.
art-4-4-16-veloderm.html losses (in Italian).Vasc Dis Ther healing under Xeroform and 12 Carsin, H., Wassermann, D.,
7 Tucci, M.G., Cataldi, I., Cardoni, 2000; 1: 14-17. Jelonet dressings: unexpected Pannier, M. et al. A silver
G. et al. Safety and efficacy 9 Melandri, D., De Angelis, A., findings. Plast. Reconstr Surg sulphadiazine-impregnated
evaluation of a new biomaterial Orioli R. et al. Use of a new 2003; 112: 2, 430-439. lipidocolloid wound dressing to
for the treatment of cutaneous hemicellulose dressing 11 Feng, X.S., Pan,Y.G., Tan, J.J. et treat second-degree burns. J
losses (in Italian). Chronica (Veloderm) for the treatment of al. Treatment of deep partial Wound Care 2004; 1: 4, 145-148.
Dermatologica 1996; 4. split-thickness skin graft donor thickness burns by a single
8 Cardoni, G., Bruni, C., Pellegrini, sites: a within-patient controlled dressing of porcine acellular
P. et al. Safety and efficacy study Burns 2006; 32: 8, 964-972. dermal matrix (in Chinese).
evaluation of a new biomaterial 10 Malpass, K.G., Snelling, C.F., Zhonghua Wai Ke Za Zhi 2006;

30 J O U R N A L O F WO U N D C A R E V O L 1 8 , N O 1 , J A N U A RY 2 0 0 9