Bromelain-based enzymatic debridement versus standard of care in deep partial- and full-thickness burns: A systematic review and meta-analysis of randomized controlled trials

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Abstract

BACKGROUND: Management of debridement-eligible thermal burns requires accurate removal of devitalized tissue. Tangential excision remains limited by imprecise depth assessment beneath opaque eschar, risking unintended dermal sacrifice. Bromelain-based enzymatic debridement (BBD) has emerged as an alternative; however, its impact on patient-level surgical outcomes has not been rigorously quantified in randomized trials. METHODS: A systematic review and meta-analysis of randomized trials compared BBD with standard of care (SOC) in acute deep thermal burns. The primary outcome was the proportion requiring surgical excision. Random-effects models pooled effects. A prespecified sensitivity analysis evaluated a wound-level trial. Risk of bias was assessed using the Cochrane RoB 2 tool. RESULTS: Five randomized trials met criteria. Four reporting per-patient outcomes contributed to the primary meta-analysis (n = 336). BBD reduced surgical excision versus SOC (RR, 0.11; 95% CI, 0.06-0.23; I² = 0%), corresponding to an absolute risk reduction of 65% and a number needed to treat of 1.5. BBD was also associated with reduced autograft use, shorter time to debridement, and comparable or improved blinded scar assessments at 12 months. Open-label design was the principal source of potential bias. Sensitivity analysis including the wound-level trial preserved effect direction with increased heterogeneity. CONCLUSIONS: Randomized evidence demonstrates that, in early-treated debridement-eligible burns with limited total body surface area burned (TBSA), BBD reduces operative and graft burden without compromising wound closure or long-term remodeling. Future trials incorporating blinded operative endpoint adjudication, objective assessment of dermal preservation and broader clinical outcomes will further clarify treatment effect and optimize patient selection.

Abstract as published, via PubMed.