Journal of Plastic Surgery and Hand Surgery

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The use of moist exposed burn ointment (MEBO)

for the treatment of burn wounds: a systematic
review

Nigel Tapiwa Mabvuure , Christopher Felix Brewer , Kevin Gervin & Siobhan
Duffy

To cite this article: Nigel Tapiwa Mabvuure , Christopher Felix Brewer , Kevin Gervin &
Siobhan Duffy (2020): The use of moist exposed burn ointment (MEBO) for the treatment
of burn wounds: a systematic review, Journal of Plastic Surgery and Hand Surgery, DOI:
10.1080/2000656X.2020.1813148

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JOURNAL OF PLASTIC SURGERY AND HAND SURGERY
https://doi.org/10.1080/2000656X.2020.1813148

REVIEW ARTICLE

The use of moist exposed burn ointment (MEBO) for the treatment of burn
wounds: a systematic review
Nigel Tapiwa Mabvuurea, Christopher Felix Brewera, Kevin Gervinb and Siobhan Duffyc
a
St. Andrews Centre for Plastic Surgery, Broomfield Hospital, Broomfield, UK; bBelfast Health and Social Care Trust, Belfast City Hospital, Belfast,
UK; cGreater Glasgow and Clyde NHS Health Board, Glasgow, UK

ABSTRACT ARTICLE HISTORY

Moist exposed burn ointment (MEBO) is an oil-based herbal paste, purported to be efficacious in manag- Received 1 April 2020
ing burn wounds and more commonly used in Asia and the Middle East. A PRISMA-compliant systematic Revised 21 July 2020
review was performed to analyse the evidence for the use of MEBO on burn wounds. Wound healing Accepted 17 August 2020
rate was the primary outcome of interest. PubMed-listed randomised controlled trials (RCTs) comparing
KEYWORDS
the efficacy of MEBO with placebo, standard care or other therapies in the treatment of partial thickness MEBO; MEBT; burn; moist
burns in adults and children were eligible for inclusion (November 2019). Six RCTs were eligible. The exposed burn ointment;
majority of trials comparing wound healing between MEBO and SSD favoured MEBO (two of three). There moist exposed burn
may be improved healing in MEBO-treated wounds vs. those treated with povidone-iodine þ bepanthenol therapy; review
cream. There was no difference between MEBO and Acquacel Ag, but Helix Aspersa had faster healing
rates than MEBO. However, all evidence was from moderately to poorly reported trials with a high risk of
bias, thereby limiting the strength of this evidence. In conclusion, the evidence for MEBO in English-lan-
guage literature was poor and inconsistent with respect to wound healing rate and analgesis compared
to 1% SSD, Acquacel Ag, Helix aspersa cream and povidone-iodine þ bepanthenol cream. Blinded RCTs
comparing MEBO to both placebo and other common topical treatments may further improve the confi-
dence in concluding their analysis. There is some evidence that MEBO is as safe as its comparators as
shown by the low complication rate.

Introduction wound types. Several more reports have been published in

Chinese literature with authors supporting the use of MEBO for
There are several nonsurgical treatment options for superficial
treating a wide range of ailments [15]. Ang et al. noted that some
and partial thickness burns. They include inorganic and biosyn-
thetic dressings, topical treatments such as silver sulfadiazine hospitals in China have reported survival rates reaching 90% in
(SSD) and alternative/complementary therapies such as honey. patients receiving MEBO following burn injuries covering 40–80%
The evidence for many of these treatments, however, remains of their total body surface area (TBSA) [16]. These claims, includ-
weak. A 2013 Cochrane review by Wasiak et al., assessing the effi- ing those that MEBO prevents shock in burned patients [17] if
cacy of a range of dressings for treating burn wounds could not confirmed would make this herbal paste an important addition to
draw firm conclusions due to a lack of adequately powered high- burn management algorithms.
quality comparactive trials [1]. Similarly, the 2013 Cochrane review Despite these claims, it has been noted there is a paucity of
by Hoogewerf et al. also failed to draw conclusions on topical scientifically rigorous studies assessing MEBO’s efficacy for treating
treatments for facial burns owing to a paucity of high-quality evi- burn wounds [16]. The Cochrane review by Wasiak et al. [1] did
dence [2]. The optimal treatment options for superficial and par- not include an assessment of the efficacy of MEBO although one
tial thickness burns remains controversial and subject to active nonrandomised comparative study of MEBO vs. Aquacel Ag by
investigation. Mabrouk et al. [18] was listed as awaiting assessment. Hoogewerf
Moist exposed burn ointment (MEBO) or moist exposed burn et al.’s Cochrane review included one study comparing MEBO
treatment/therapy (MEBT), an oil-based herbal paste, was devel- with silver sulfadiazine (SSD) for routine care of facial burns [19],
oped in 1989 in Beijing. It remains a popular topical treatment for however noting the small sample size and absence of intention to
burn wound treatment especially in Asia and the Middle East. The treat analysis as barriers to forming evidence-based conclusions
main ingredient in MEBO is beta-sitosterol, a plant-derived sterol [2]. Similarly, the Cochrane review by Norman et al. [20] con-
with reportedly anti-inflammatory and antipyretic properties [3–5]. cluded there was only low/very low-grade evidence relating to
The oily component of MEBO is thought to improve wound mois- the effect of MEBO on the incidence of infection and wound heal-
ture retention. Given the recognised importance of moisture in ing time due to study imprecision and reporting inconsistency in
wound healing [6–8], the hypothesis that MEBO positively affects the included trials [21,22]. No systematic reviews of studies assess-
wound healing appears intuitive. Numerous anecdotal reports ing MEBO have been published to date.
[9,10], animal studies [11,12] and non-comparative reports [13,14], For these reasons, this systematic review was performed to col-
concluded that MEBO was efficacious in treating burns and other late and analyse the evidence for the use of MEBO from English-

CONTACT Nigel Tapiwa Mabvuure [email protected] St. Andrews Centre for Plastic Surgery, Broomfield Hospital, Broomfield CM1 7ET, UK
ß 2020 Acta Chirurgica Scandinavica Society
2 N. T. MABVUURE ET AL.

Outcome measures
The primary outcome of interest was the effect of MEBO on
wound healing. Therefore, time to wound healing, wound healing
rate, transepidermal water loss (TEWL) and reduction in wound
surface area were considered primary outcome measures.
Secondary outcomes of interest were post-dressing pain reduc-
tion, complications and wound infections.

Search strategy
The EMBASE and MEDLINE databases were searched from incep-
tion to November 2019 using the term: (MEBO OR MEBT OR
‘moist exposed burn therapy’ OR ‘moist exposed burn treatment’
OR ‘moist exposed burn ointment’).ti,ab. The search was dupli-
cate-filtered and limited to human studies reported in English.

Study selection
Two authors independently assessed titles and abstracts for rele-
vance and verified by a third.

Data extraction
Data extraction was performed by one author and independently
verified by two others. Data extracted from each study included
bibliometric indices (authorship, year of publication, the country
in which study was conducted and type of study), anatomical
area, TBSA, population characteristics and outcomes.

Assessment of the risk of bias in included studies

The risk of selection, performance, detection, attrition, reporting
Figure 1. PRISMA flow chart. and other biases in each study was assessed using the Cochrane
Collaboration’s risk of bias assessment tool (RevMan version
language literature. The clinical question, with reference to PICOS, 5.2.11, Cochrane Collaboration) [23].
was as follows: Descriptive statistics were used to synthesise data.
 Participants: Patients with burn wounds,
 Intervention: Treatment of burn wounds with MEBO,
Results
 Comparisons: Comparison to either standard of care
or placebo, Search results
 Outcomes: Effect on wound healing measures.
The search results are summarised in Figure 1. Eight articles
 Study design: Comparative studies.
remained after applying the exclusion criteria [16,17,19,22,24–27].
However, since three of these articles all reported data from a sin-
gle RCT by Ang et al. [16,19,27], their data were pooled and were
treated as one article. A similar approach was taken by Dat et al.
Methods in a Cochrane review of studies of Aloe vera for treating acute
and chronic wounds [28]. Therefore, the eight eligible articles rep-
A systematic review was performed following PRISMA guidelines. resent data from six RCTs.
The review protocol was not published or registered prospectively
on a registry.
Characteristics of included studies
All studies provided level 3 evidence on the Oxford scale. The
included RCTs (578 patients) were undertaken in Greece [22,26],
Inclusion and exclusion criteria Germany [17], Singapore [16,19,27] and Egypt [24,25] between
2002 and 2011 (Table 1). Tsoutsos [26], Hindy [24] and their
Randomised controlled trials (RCTs) comparing the efficacy of respective teams included only patients with facial burns whilst
MEBO with placebo, standard wound care or other therapies in Allam et al. [25] included only patients with hand burns. The
treating superficial and partial-thickness burn wounds in adults remaining studies did not specify the affected anatomical region
and children were eligible. Non-comparative studies, retrospective [16,17,19,22,27]. Only two trials included patients with non-ther-
studies, reviews, animal studies, expert opinion articles and pre- mal burns although the aetiology remains unclear [17,25].
liminary reports were excluded. Economic analyses were only The depths of burns in the patients included in the trials were
included if they also investigated clinical outcomes. deep partial thickness (DPT) [26], superficial partial thickness (SPT)
Table 1. Summary of eligible studies.
Number of
participants Result
First author, year (Male:Female) Anatomical Mean age in Study
(Country of origin) (Extent of burn) Burn thickness Burn aetiology region years (range) design Comparison(s) Outcome (measure) MEBO Comparison
Hirsh, 40 adults (M25:F15) Partial thickness Thermal Not specified 41.15 (20–65) RCT MEBO vs. 1% SSD Day 12 Wound healing (mean TEWL): 11 7
2008 (Germany) (<20% TBSA) (n ¼ 20 each) Day 0 Inflammation (WCC and CRP): NR NR
Day 8 inflammation (WCC and CRP): NR NR
Pain (mean VAS score D1): 5 5
Pain (mean VAS score D12): 3.8 3.5
Adverse effects: 0 0
Hindy, 2009 (Egypt) 60 patients (<25% Superficial Thermal Facial NR RCT Aquacel Ag (I) vs. MEBO Mean time to complete healing (II vs I 10.35 ± 2.8 10.05 ± 2.3,
TBSA in >12- partial thickness (II) vs. saline (III) vs III): 12.05 ± 2.4¥
years-old, <15% (n ¼ 20 each) Pain (mean VAS score D1 & D2): 3.1 ± 1.9 NR
TBSA in <12- Itching (proportion itch-free) (%): 65 25, 10¥
years-old) Adverse effects: NR NR
Ang, 115 patients Partial thickness Thermal Not specified 22 RCT MEBO (n ¼ 57) vs. 1% Wound healing rate (days to 17 20
2002 (Singapore) (<40% TBSA) SSD (n ¼ 58). 75% healing):
Pain (mean week 1 post-dressing 2.9 3.5
verbal numerical rating scale):
MRSA infection rate (%): 37.4 38.5
Adverse effects NR NR
Allam, 2007 (Egypt) 106 patients Partial thickness Thermal Hand NR RCT MEBO vs. 1% SSD cream Mean days to healing (superficial 10.48 ± 2.66 14.53 ± 3.83
(<25% TBSA) and a polyethylene partial thickness)
bags (n ¼ 53 each) Mean days to healing (deep 30.50 ± 5.10 36.60 ± 5.08
partial thickness)
Pain Score 0 (%): 35.85 33.96
Pain Score 1 (%): 47.17 41.51
Pain Score 2 (%): 16.98 24.53
Pain Score 3 (%) 0 0
Adverse effects NR NR
Carayanni, 211 adults Partial thickness Thermal Not specified 42.68 (18–75) RCT MEBO (n ¼ 104:50 deep Time to wound healing (days to 50% 8.7 10.75
2011 (Greece) (<15% TBSA) partial and 54 reduction in TEWL for superficial
superficial partial) vs. partial thickness burns)
Povidone Reduction in admission for deep 3.02 2.79
iodine þ bepanthenol partial thickness burns (days)
cream (n ¼ 107: 52 Pain (mean morning VAS on day 2) 3 4.2
deep partial and 55
superficial partial) Pain (mean evening VAS on day 2) 3.8 4.7
Adverse effects (allergic reactions, (%) 10.6 7.5
Wound infection rate (%) 5.8 7.5
Tsoutsos, 46 adults (extent Deep partial Not specified Facial (20–70) RCT Helix aspersa extract Days to full epithelialisation 15 ± 3 11 ± 2
2009 (Greece) not reported) thickness (Elicina cream) (27) vs. (photographic assessment)
MEBO (n ¼ 16) Days to eschar detachment 11 ± 2 9 ± 2
D4 pre-intervention pain score (VAS) 6.50 ± 0.89 6.22 ± 1.25
D4 30 mins post-intervention pain 4.50 ± 0.52 3.52 ± 0.80
score (VAS)
Adverse effects (allergic reactions) 0 0
Abbreviations. CRP: C-reactive protein; MEBO: moist exposed burn ointment; SSD: silver sulfadiazine; TBSA: total body surface area; TEWL: transepidermal water loss ;VAS: visual analog scale; WCC: white cell count.
4 N. T. MABVUURE ET AL.

Figure 3. Risk of bias graph: review authors’ judgements about each risk of bias
item presented as percentages across all included studies.

Three trials had a low risk of selection bias owing to detailed

random sequence generation [16,19,22,26,27]. Although the
remaining three trials all randomised patients into study arms,
their procedures were unclear [17,24,25]. Only Ang et al.
[16,19,27] detailed allocation concealment making it unclear
whether the remaining five trials [17,22,24–26] adequately con-
cealed allocation. Across most trials, the risk of selection bias is
unclear (Figure 3).
None of the trials had a low risk of performance bias although
there was insufficient information in three of the trials [24–26] to
allow an assessment. The remaining three trials were at high risk
of performance bias due to the non-blinding of patients and
some study personnel [16,17,19,22,27].
Three trials [16,19,22,26,27] were at low at risk of detection
bias because outcome-assessors were either blinded or non-blind-
ing was unlikely to have affected outcome measurement. Two tri-
als [24,25] had an unclear risk of bias whilst one had a high risk
of detection bias [17].
Four trials had low risk [17,22,24,26], one was at high risk
[16,19,27] and the remaining trial had an unclear risk of attrition
bias [25].
Only two trials had a low risk of reporting bias [16,19,22,27].
Figure 2. Risk of bias summary: review authors’ judgements about each risk of Three trials had a high risk of reporting bias [17,24,25] and the
bias item for each included study. risk in the remaining trial was unclear [26].

[24] and two studies included patients with both SPT and DPT Effects of interventions
burns [22,25]. Two trials included patients with partial-thickness
burns but did not specify whether these were SPT or DPT Meta-analysis was precluded by the heterogeneous reporting of
outcomes; poor definition of the study population (i.e. not sepa-
[16,17,19,27]. Only Ang et al. [16,19,27] detailed the method used
rating SPT and DPT burns); missing data and poor reporting
to determine burn depth.
(Table 1). A narrative synthesis was performed.
Three studies compared MEBO with 1% SSD cream
[16,17,19,25,27]. Others compared with sodium carboxymethylcel-
Measures of wound healing (primary outcome)
lulose silver (Aquacel Ag) [24], povidene iodine plus bepanthenol
Both Ang [16,19,27], Allam [25] et al. observed faster healing in
cream [22] and Helix aspersa extract (Elicina cream) [26]. Only
patients treated with MEBO compared to SSD. The mean number
Hindy [24] included a negative control group (saline-soaked
of days to 75% wound healing recorded by Ang et al. for the
gauze dressing).
MEBO and SSD groups were 17 and 20 respectively [16,19,27]. In
Allam et al’s study [25], patients with SPT burns healed faster
Characteristics of studies excluded after reading full-texts compared to when treated with MEBO compared to SSD
(10.5 ± 2.7 versus 4.5 ± 3.8 days) (p < 0.05). Similarly, patients with
Two studies were excluded after reading full-texts: an economic DPT burns treated with MEBO healed faster (30.5 ± 5.1 vs.
analysis that did not assess efficacy [29] and a nonrandomised 36.6 ± 5.1 days) (p < 0.05). Hirsch et al. measured day 12 TEWL and
study [18]. markers of inflammation such as CRP and leukocyte count as
markers of wound healing [17] comparing MEBO with SSD. The
Risk of bias in included studies finding that patients treated with MEBO had greater loss of water
Figures 2 and 3 summarise and illustrate the authors’ risk of bias transepidermally (11 vs. 7) suggests that these wounds healed
assessment. The trials by Hirsch [17], Hindy [24], Allam [25] and slower than those treated with SSD. However, the levels of other
their respective colleagues had the highest or unknown risk of markers were not reported.
bias across all domains (Figure 2). The studies by Ang [16,19,27] Patients treated with Helix aspersa cream by Tsoutsos et al.
and Tsoutsos’ [26] teams had a lower risk of bias whilst Carayanni healed significantly faster compared to MEBO, as assessed on
et al. [22] was judged least likely to be biased. photographs by blinded assessors (11 ± 2 vs. 15.3 days) [26]. This
 JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 5

planimetric finding was corroborated by another from the same respective rates of adverse effects of MEBO and Aquacel Ag were
study showing that eschar detachment was faster in patients not reported in the sole trial comparing the two [24]
treated with Helix aspersa cream [26]. Only two trials reported the incidence of wound infections
Hindy found no difference in the healing times of MEBO and [16,19,22,27]. There was no difference in the incidence of methicil-
Aquacel Ag (10.35 ± 2.8 vs. 10.05 ± 2.3 days) [24]. Compared to lin-resistant Staphylococcus aureus infections between the MEBO
povidone-iodine þ bepanthenol cream, patients treated with and SSD groups in one trial (37.4 vs. 38.5%, respectively)
MEBO healed faster as shown by faster 50% TEWL reduction (8.7 [16,19,27]. Similarly, no statistically significant difference was seen
vs. 10.75 days) [22]. in the incidence of Staphylococcus and Pseudomonas infections
In summary, more trials comparing wound healing between in groups receiving either MEBO or povidone-iodi-
MEBO and SSD favoured MEBO. There may be improved healing ne þ bepanthenol creams (5.8 vs. 7.5%, respectively) [22].
in MEBO-treated wounds vs. those treated with povidone-iodi- In summary, the incidences of adverse reactions and wound
ne þ bepanthenol cream. There was no difference between MEBO infections were low and no statistically significant differences
and Acquacel Ag, but Helix Aspersa had faster healing rates were noted between MEBO and any of the comparators.
than MEBO.
Discussion
Pain and itch
There has been a suggestion that there are “double standards” in
Two studies found no difference in the analgesic effects of MEBO assessing complementary and alternative therapies in medicine
and SSD. Hirsch et al. found no statistically significant difference [30]. It is therefore crucial that these treatments are subjected to
in mean visual analogue scale (VAS) scores between the MEBO the same scientifically rigorous analysis as used for ‘traditional’
and SSD groups on both days 1 and 12 (both mean 5 on day 1 treatments. As such, this systematic review was performed with
then 3.8 and 3.5, respectively on day 12) [17]. Similarly, Allam the aim of pooling data relating to the efficacy of MEBO for the
et al. found no statistically significant difference in pain scores treatment of burn wounds. Such a synthesis for the first time
between MEBO and SSD [25]. One study found a statistically sig- allows both surgeons and patients to appraise collated and syn-
nificant difference in pain profiles between MEBO and SSD thesised evidence of MEBO and several comparators and is there-
[16,19,27]. MEBO patients rated their pain as less than that of the fore crucial to cost-effectiveness calculations by these groups.
SSD group after one week (2.9 vs 3.5 mean post-dressing verbal Data from six RCTs, all level 3 evidence, mostly poorly reported,
numerical pain rating (VNPR) score). However, the MEBO group were eligible for inclusion. The heterogeneity of study methods,
had a higher mean VNPR on admission (5.09 vs. 4.72) (p-value comparators and outcome measures precluded meta-analysis.
unreported) which may partially explain the pain score differences. Even the three studies comparing MEBO to 1% SSD were suffi-
Furthermore, by the third week, there were no longer any differ- ciently heterogeneous to preclude meta-analysis of only
ences in analgesic effect. these studies.
In Hindy’s study, the MEBO group rated their pain as signifi- The results of this review should be interpreted with the fol-
cantly less than that of the Aquacel Ag and saline control groups lowing caveats in mind. There were varying anatomical locations
during the first 48 h [24]. However, although the mean VAS score and not all papers specified. The appropriateness of 1% SSD as a
for the MEBO group was 3.1 ± 1.9, those of the Aquacel Ag and comparator or standard treatment is debatable since SSD has
saline control groups were not reported. MEBO also had a greater been shown to be consistently associated with poorer healing
ichthyotic effect than Acquacel Ag as shown greater proportions outcomes compared to treatments such as skin substitutes, silver-
itch-free patients in the MEBO group compared to the Aquacel containing dressings and silicon-coated dressings [1]. Other fac-
Ag and saline control groups (65 vs. 25% and 10%, respect- tors precluding meta-analysis included variability in outcome
ively) [24] measurement. Surrogates included time to complete wound heal-
There was no difference in the analgesic properties of MEBO ing [24–26], TEWL [17], time to 75% healing [16,19,27] and 50%
and povidone-iodine þ bepanthenol cream (mean morning VAS reduction in TEWL [26].
scores: 3.0 vs. 4.2, respectively, mean evening VAS scores: 3.8 vs.
4.7 respectively) [22].
MEBO effect on wound healing
Tsoutsos et al. found that pain scores were significantly
improved with Helix Aspersa compared to MEBO (4.50 ± 0.52 vs. The results do not consistently favour MEBO or any of its compa-
3.52 ± 0.80) [26]. In this trial, mean VAS scores were similar rators. Of the three studies comparing the wound healing proper-
between the MEBO and Helix aspersa groups before dressings ties of SSD with MEBO, two favoured MEBO [16,25] whilst one
were applied (6.50 ± 0.89 vs. 6.22 ± 1.25). favoured SSD [17]. One of the favourable studies was poorly
In summary, there was no difference in the analgesic effects of reported, exposing it to significant biases [25]. The small improve-
MEBO and SSD. It is unclear whether MEBO has superior anal- ment in the other favourable study was not statistically significant
gesic effects to Acquacel Ag, Helix Aspersa and povidone-iodine þ [16,19,27]. This small and statistically insignificant benefit should
bepanthenol cream. be interpreted in the context of moderate risk of bias due to
issues with blinding and failure to analyse on an intention to treat
Incidence of adverse effects basis.
The incidence of adverse effects was very low in all studies and Wound healing was also reportedly improved in MEBO com-
for all interventions. One MEBO vs. SSD RCT reported no adverse pared to Acquacel Ag [24] and povidone-iodine þ bepanthenol
outcomes for either intervention but the other two RCTs did not cream groups [22]. The results in the Acquacel Ag trial were at
report their incidence of adverse effects [16,19,25,27]. There was risk of bias due to poor reporting [24]. The highest quality study
no difference in allergy rates between MEBO and either Helix used an indirect surrogate measure, that is, reduction in TEWL to
aspersa [26] or povidone-iodine þ bepanthenol creams [22]. The suggest faster healing in SPT but not DPT burns [22]. This trial by
6 N. T. MABVUURE ET AL.

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Conclusions
[16] Ang ES, Lee ST, Gan CS, et al. Evaluating the role of alter-
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Disclosure statement
dressing (AquacelV Ag) versus moist open dressing
R

(MEBOV) in the management of partial-thickness facial

R
No potential conflict of interest was reported by the author(s).
 JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 7

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