THE EFFECTS OF POVIDONE-IODINE IN T H E T R E A T M E N T

OF BURNS AND TRAUMATIC LOSSES OF SKIN

By D. WYNN-WILLIAMS,M.S., F.R.C.S., and G. MONBALLIU,M.D.

Nottingham City Hospital

THE range of bactericidal and bacteriostatic antibiotics available for topical and
systemic use during the last few years has been increasing. With their use,
however, the resistance of micro-organisms has increased in ratio and so amplified
that the maintenance of sterilisation of burns and large traumatic skin losses is
still an incompletely solved problem. The number of new antibiotics shows how
difficult it is to keep pace with the growing resistance and maintain a protective
cover against bacterial invasion. The use of antibiotics is also connected with a
recrudescence in the degree and severity of infections. As pointed out by Clarkson
(1963), four out of every five deaths from burns can still be ascribed to generalised
infection or septicmmia. Tumbusch et al. (1962) found that in sixty-three
hospitalised cases of burns, there was a 5o per cent. mortality due to Staphylococcus
aureus septicmmia and IOO per cent. mortality within forty-eight hours due to
pseudomonas septicmmia. Every extensive infected burn can therefore be
considered as being an open door allowing infection to penetrate into the deeper
layers.

Clinical Properties.--Our previous experience in the treatment of burns was

associated with the use of topical neomycin, bacitracin, colomycin or polymyxin
spray combined with systemic use of the common antibiotics. This treatment
has been generally successful in reducing infection to a large extent, but it was
felt that the initial effect was declining and that more and more cases were failing
to respond after a short period of time. Their use is also restricted by the high
toxicity of neomycin and bacitracin when used in extensive burns, due to the danger
of absorption and consequently possible damage to the kidneys and acoustic nerve.
Other investigators have been concerned with the same problem and have had to
re-assess the antiseptic technique.
Following reports in current literature, povidon-iodine (Betadine) was thought
to be the most effective germicidal agent for destroying bacteria, viruses, fungi,
and protozoa (Cantor and Shelanski, 1952 ; Joress, 1961 ; Lowbury et al., 1963).
The low toxicity was noticed by Shelanski (I956), Bogash (I956), and others.
This was not completely unexpected, as povidone was used extensively as a blood
plasma volume expander (Periston) in the treatment of shock during and after
the last war (Schulz, 1941 ; Hecht and Weese, 1943 ; Weese, 1948 ; Cordice et al.,
I953).
Further studies showed it to be a detoxifying agent, a drug vehicle, and a
suspending agent (Duttmann, 1941 ; Shelanski and Shelanski, 1956). Its capacity
for absorbing other substances gives it an additional advantage, as by liberating
the bound iodine slowly, the germicidal action is prolonged. There is an extremely
low incidence of sensitivity reactions with minimal symptoms (Bogash, 1956 ;
Lowbury et al., 1963).
146
 POVIDONE-IODINE IN TREATMENT OF BURNS AND TRAUMATIC LOSSES OF SKIN 147
One of our patients with a mild degree of lagophthalmia showed, however
considerable irritation of the left eye after daily spraying of the face with povidone-
iodine. These symptoms disappeared five days after discontinuation of treatment.
One of our staff known to be iodine-sensitive and one patient with a known previous
idiosyncrasy to iodine did not, however, have any reaction after a spray of povidone-
iodine. One child (Case x8) treated with povidone-iodine and systemic tetracycline
developed a rash and hyperthermia on the fifth day of treatment. Sensitivity to
povidone-iodine was tested for nine days later but no reaction was noted.
Treatment was resumed but on the fourth day an eczematous reaction over a large
area of the body appeared. Treatment was then definitely abandoned.

B u r n s . ~ I t is frequently difficult at the time of injury to assess the depth

of a burn, and a definite estimation may not be possible for some days. Infection
will alter not only the original estimation, but will certainly delay healing. A
superficial burn once infected may progress to a full-thickness skin loss. The
epithelial islands, which survived the initial thermal trauma, are very sensitive to
any accessory form of injury such as infection or intoxication, and if no special
care is taken these islands will necrose. Re-epithelialisation in the presence of
infection will almost certainly be by outgrowths from the skin margins alone.
Delay in healing will also increase the risk of subcutaneous fibrosis, hypertrophic
scarring and keloid formation with consequent impairment of functional activity
and cosmetic appearance. On the other hand, when the slough separates from
the living tissues, time will have elapsed during which the wound will have become
infected many times. It is obvious that by sealing off the wound with a germicidal
substance which is non-toxic to living cells, an obvious benefit in treatment will
have been achieved. As already emphasised by other investigators (Games et al.,
I959 ; Georgiade et aL, I962), a dry sterile film covers the wound a few hours
after the application of povidone-iodine sway. A similar result was seen in our
cases. In superficial or partial-thickness burns the crust started to peel off after
a few days, and this peeling off is progressive from the periphery to the centre of
maximum injury, exposing underneath a healed surface. When the crust adheres
to the deeper layers, usually full-thickness burns are involved, and these areas
have to be removed in the operating theatre with all aseptic precautions. In most
of the cases described later, the burn surfaces have been treated by exposure, as
bacterial growth is lowered by this method. Darkness, moisture, and heat are
very favourable conditions for bacterial proliferation. Where, as a result of
circumferential skin loss and concomitant lesions, exposure could not be undertaken,
dressings were applied.
When large areas of the body had been burned, a plaster bed was made which
allowed patients to lie at rest in a relatively comfortable position, avoiding flexor
contracture of the involved limbs. As a result of this, the grafted areas were not
subjected to the strain of movement, which is one of the reasons why skin grafts
do not take. Nursing of the patient and treatment of the burns are more easily
carried out without the stress of frequent painful changes of position. This method
of treatment is useful in adults, and essential in children, as immobilisation
following grafting is compulsory when using the exposure method. Cross-
infection is also reduced since handling of the patient is reduced to a minimum.
Special care should be taken in facial burns of the eyelids, eyes, ears, oral and
nasal orifices, as they involve specific areas of cosmetic and functional importance.
 BRITISH JOURNAL OF P L A S T I C SURGERY

Fortunately, because of the excellence of the blood supply, facial burns do not
usually result in full-thickness destruction of the skin. Conservative management
of the burned area is therefore often successful. The povidone-iodine spray was
found to be of great help in obtaining a marked decrease in the picture of mixed
bacterial flora, and in the rate of infection, thus enabling wounds to heal quickly
and with as little impairment as possible.

Skin Grafting.--Skin grafts are taken after consideration of the area burned,
or the part of it planned to be desloughed. The defects are covered by means of
big sheets in one or more pieces or by strip grafting. The former method is more
easily done when the defect is small and there is adequate skin available, and the
results are more likely to be cosmetically acceptable. The latter procedure,
however, is the only way when dealing with large areas of skin loss, or where there
is any doubt about infection of the area to be grafted. The amount of skin grafts
saved in this way is considerable as it covers a much larger surface, and also limits
infection or necrosis to definite parts, and allows one to alternate homografts with
autografts. Immediate skin grafting of the desloughed area is sometimes impossible
because oozing from the wound would result in the development of seromata and
possible loss of the grafts. Delayed skin grafting can easily be performed in the
ward by specially trained staff and with the necessary precautions for asepsis.
Superficial infection was effectively controlled by the use of povidone-iodine spray
on the grafted area. It also did not interfere with the viability of skin grafts or
delay healing, thus confirming the opinion of others (Georgiade et al., I958 ;
Games et al., I959).

Traumatic Skin Loss.--Traumatic injuries with avulsion of the skin of

either upper or lower limbs present a similar problem. They also result in large
areas of necrotic tissue ingrained with dirt and septic material, and complicated
by an impaired blood supply. Degloving of the limbs, and circumferential
lacerations frequently interfere with function so that the reconstructive problem
is not only one of resurfacing large defects, but also one of restoring function in
the shortest possible time without serious sequelm. After debridement of the
sloughed tissues, the wounds are sprayed with povidone-iodine. Daily dressings
are applied till normal red granulation tissue appears, and this is then covered with
split-thickness skin grafts. Bacteriological cultures and sensitivity to common
antibiotics were taken at regular intervals. Povidone-iodine aerosol spray controlled
infection to a very large extent. The mixed growth of various bacteria was in
most cases reduced in number to a resident group of coagulase-positive staphy-
lococci. Resistance to the usual antibiotic sprays appeared after a short period
of use.
Povidone-iodine was also tried out on varicose ulcers and various reconstructive
cases with the same effects.

MateriaL--Investigations as to the bacterial sensitivity to common antibiotics

and the clinical appearance of surgical wounds following treatment with a germicidal
agent were carried out in thirty-three patients, nineteen of whom had superficial
or deep burns, the remaining fourteen suffering traumatic skin loss. Amongst
the burn cases, ten were admitted having had prior treatment with bacitracin,
neomycin, and colomycin spray. Repeated swabs for culture and sensitivity in
 POVIDONE-IODINE IN TREATMENT OF BURNS AND TRAUMATIC LOSSES OF SKIN 149

seven patients revealed a progressive resistance to these, and most of the common
antibiotics. Nine patients were treated on admission with povidone-iodine, and
six of these, although they had never had treatment with an antibiotic spray,
developed resistance against these antibiotics. This is of particular interest for
it shows the apparent existence of resistant groups of bacteria in normal hospital
conditions.
Within twenty-four hours following the use of povidone-iodine spray, a change
was noticed in the appearance of the wound; a dry film covered the burn when
treated initially with povidone-iodine spray, sealing it off from surrounding tissues.
In infected burns pus secretion was inhibited and normal red granulation tissues
,developed within a few days. Direct examination showed a reduced number of
pus cells accompanied by a lower count of micro-organisms. In some cases the
profuse mixed growth consisted of coagulase-positive staphylococci, Pseudomonas
pyocyaneae, proteus and hmmolytic streptococci, and this was reduced to one group
of coagulase-positive staphylococci after the use of povidone-iodine. These
coagulase-positive staphylococci were the most common infective organisms, and
although considerably reduced in number by povidone-iodine, could always be
traced in infected areas. Their presence, however, did not interfere with the
"taking " of skin grafts, and this was in accordance with the p H of the defects.
The surgical cases showed a greater variety in the type of micro-organisms,
and the extensive lacerations developed a mixed profuse growth of Staphylococcus
aureus, Pyocyaneus, Bacillus coli, Proteus, and hmmolytic streptococci.
Case 21, a pregnant woman who was involved in an accident and sustained
complete degloving of the leg from knee to foot, with concomitant fractures of the
pelvis, spine, and ribs, is a typical example of mixed growth and of the effect of
povidone-iodine on it. Culture grew Staphylococcus aureus and Pyocyaneus on
28th April 1963. Although the wound was sprayed twice daily with neomycin,
bacitracin, and colomycin, culture on 6th May 1963 revealed infection with
Bacillus coli, Staphylococcus aureus, and Pyocyaneus. Starting on 9th May 1963,
povidone-iodine was sprayed on the infected area, and culture on I3th May 1963
showed that all the micro-organisms were eliminated with the exception of
Staphylococcus aureus. This culture was repeated on 25th May 1963 and showed
Staphylococcus aureus resistant to neomycin and bacitracin, but the appearance of
the wound had improved so much that it was possible to graft the defects successfully
after a few days.
Initial treatment with a topical antibiotic spray was carried out in seven
patients until resistance appeared. Treatment was therefore discontinued and
povidone-iodine substituted and the healing period was considerably shortened.
Seven patients were treated from the outset with povidone-iodine spray and
healing was uneventful ; five of these were contaminated by antibiotic-resistant
bacteria, one of which did not show any infection clinically, and there was no
bacterial growth in another.

CONCLUSIONS

The cases presented here are small in number but the results suggest that the
new non-toxic germicidal agent Betadine (povidone-iodine) is able to control
infection and protect epithelial growth when used in the treatment of burns and
traumatic skin losses. It has the advantage over antibiotic skin sprays in that it
2C
150 BRITISH JOURNAL OF PLASTIC SURGERY

is not subject to potential resistances and is effective even when the antibiotic
sprays have become ineffective.

SUMMARY
The management of burns and skin trauma with topical antibiotics is proving
to be progressively less satisfactory. Cultures and sensitivity tests revealed in
most patients a growing resistance to locally applied antibiotics. Resistant groups
of micro-organisms were found in patients who had not previously been treated
with common antibiotic sprays. Cross-infection under normal hospital conditions
emphasises the need for a germicidal agent which is itself not subject to potential
resistance. Povidone-iodine aerosol spray was used as a microbiocidal agent in
an attempt to lower the incidence of infection. This treatment reduced infection
to a minimum, and the range of micro-organisms was lowered to one group of"
Staphylococcus aureus.
Treatment was found to be most effective when povidone-iodine was used
immediately after injury. Crust formation following topical spray provided a
protective cover against infection, and allowed the injured epithelium to heal in
an ideal environment. Povidone-iodine aerosol spray and antiseptic solution are
now used routinely for every plastic surgical procedure.

We wouM like to express our thanks to Mr F. H. Choppin, Managing Director, and

Dr A. R. Ellerker of the Clinical Trials Department of Berk Pharmaceuticals Ltd., 8 Baker
Street, London, W. I, for a generous supply of Betadine aerosol spray and antiseptic solutiom

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