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.

Abstract

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. 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. 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. 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.