The use of moist exposed burn ointment (MEBO) for the treatment of burn wounds: a systematic review

Abstract

Moist exposed burn ointment (MEBO) is an oil-based herbal paste, purported to be efficacious in managing burn wounds and more commonly used in Asia and North Africa. A PRISMA-compliant systematic
review was performed to analyse the evidence for the use of MEBO on burn wounds. The wound healing
rate was the primary outcome of interest. PubMed-listed randomised controlled trials (RCTs) comparing
the efficacy of MEBO with placebo, standard care or other therapies in the treatment of partial thickness
burns in adults and children were eligible for inclusion (November 2019). Six RCTs were eligible. The
majority of trials comparing wound healing between MEBO and SSD favoured MEBO (two of three). There
may be improved healing in MEBO-treated wounds vs. those treated with povidone-iodineþ bepanthenol
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. In conclusion, the evidence for MEBO in English-language 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 confidence in concluding their analysis.

Full text

IPHS#1813148, VOL 0, ISS 0
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, and Siobhan Duffy
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REVIEW ARTICLE
The use of moist exposed burn ointment (MEBO) for the treatment of burn
wounds: a systematic review
Nigel Tapiwa Mabvuure
a
, Christopher Felix Brewer
a
, Kevin Gervin
b
and Siobhan Duffy
c
a
St. Andrews Centre for Plastic Surgery, Broomfield Hospital, Broomfield, UK;
b
Belfast Health and Social Care Trust, Belfast City Hospital, Belfast,
UK;
c
Greater Glasgow and Clyde NHS Health Board, Glasgow, UK
Q2
ABSTRACT
Moist exposed burn ointment (MEBO) is an oil-based herbal paste, purported to be efficacious in manag-
ing burn wounds and more commonly used in Asia and North Africa. A PRISMA-compliant systematic
review was performed to analyse the evidence for the use of MEBO on burn wounds. The wound healing
rate was the primary outcome of interest. PubMed-listed randomised controlled trials (RCTs) comparing
the efficacy of MEBO with placebo, standard care or other therapies in the treatment of partial thickness
burns in adults and children were eligible for inclusion (November 2019). Six RCTs were eligible. The
majority of trials comparing wound healing between MEBO and SSD favoured MEBO (two of three). There
may be improved healing in MEBO-treated wounds vs. those treated with povidone-iodineþbepanthenol
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. In conclusion, the evidence for MEBO in English-language 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 þbepanthenol cream. Blinded RCTs comparing MEBO to both placebo and other com-
mon topical treatments may further improve the confidence in concluding their analysis. There is good
evidence that MEBO is as safe as its comparators as shown by the low complication rate.
ARTICLE HISTORY
Received 1 April 2020
Revised 21 July 2020
Accepted 17 August 2020
KEYWORDS
MEBO; MEBT; burn; moist
exposed burn ointment;
moist exposed burn
therapy; review
Q4
Introduction
There are several nonsurgical treatment options for superficial
and partial thickness burns. They include inorganic and biosyn-
thetic dressings, topical treatments such as silver sulfadiazine
(SSD) and alternative/complementary therapies such as honey.
The evidence for many of these treatments, however, remains
weak. A 2013 Cochrane review by Wasiak et al. assessed the effi-
cacy of a range of dressings for treating burn wounds could not
draw firm conclusions due to the lack of adequately powered
high-quality trials [1]. Similarly, the 2013 Cochrane review by
Hoogewerf et al. also failed to draw conclusions on topical treat-
ments for facial burns owing to a paucity of high-quality evidence
[2]. The optimal treatment options for superficial and partial thick-
ness burns remain controversial and subject to an active
investigation.
Moist exposed burn ointment (MEBO), an oil-based herbal
paste, was developed in 1989 in Beijing. It remains a popular top-
ical treatment for burn wound treatment especially in Asia and
the Middle East. The main ingredient in MEBO is beta-sitosterol, a
plant-derived sterol with reportedly anti-inflammatory and anti-
pyretic properties [3–5]. The oily component of MEBO is thought
to improve wound moisture retention. Given the recognised
importance of moisture in wound healing [6–8], the hypothesis
that MEBO positively affects wound healing appears intuitive.
Numerous anecdotal reports [9,10], animal studies [11,12] and
non-comparative reports [13,14], concluded that MEBO was effica-
cious in treating burns and other wound types. Several more
reports have been published in Chinese literature with authors
supporting the use of MEBO for treating a wide range of ailments
[15]. Ang et al. noted that some hospitals in China have reported
survival rates reaching 90% in patients receiving MEBO following
burn injuries covering 40–80% of their total body surface area
(TBSA) [16]. These claims, including those that MEBO prevents
shock in burned patients [17] if confirmed would make this herbal
paste an important addition to burn management algorithms.
Despite these claims, it has been noted there is a paucity of
scientifically rigorous studies assessing MEBO’s efficacy for treating
burn wounds [16]. The Cochrane review by Wasiak et al. [1] did
not include an assessment of the efficacy of MEBO although one
nonrandomised comparative study of MEBO vs. Aquacel Ag by
Mabrouk et al. [18] was listed as awaiting assessment. Hoogewerf
et al.’s Cochrane review included one study comparing MEBO
with SSD for routine care of facial burns [19], however noting the
small sample size and absence of intention to treat analysis as
barriers to forming evidence-based conclusions [2]. Similarly, the
Cochrane review by Norman et al. [20] concluded there was only
low/very low-grade evidence relating to the effect of MEBO on
the incidence of infection and wound healing time due to study
imprecision and reporting inconsistency in the included trials
[21,22]. No systematic reviews of studies assessing MEBO have
been published to date.
For these reasons, this systematic review was performed to col-
late and analyse the evidence for the use of MEBO from English-
language literature. The clinical question, with reference to PICOS,
was as follows:
Participants: Patients with burn wounds,
Intervention: Treatment of burn wounds with MEBO,
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CONTACT Nigel Tapiwa Mabvuure n.mabvuure@doctors.org.uk St. Andrews Centre for Plastic Surgery, Broomfield Hospital, Broomfield CM1 7ET, UK
Q3
ß2020 Acta Chirurgica Scandinavica Society
JOURNAL OF PLASTIC SURGERY AND HAND SURGERY
https://doi.org/10.1080/2000656X.2020.1813148

Comparisons: Comparison to either standard of care
or placebo,
Outcomes: Effect on wound healing measures.
Study design: Comparative studies.
Methods
A systematic review was performed following PRISMA guidelines.
The review protocol was not published or registered prospectively
on a registry.
Inclusion and exclusion criteria
Randomised controlled trials (RCTs) comparing the efficacy of
MEBO with placebo, standard wound care or other therapies in
treating superficial and partial-thickness burn wounds in adults
and children were eligible. Non-comparative studies, retrospective
studies, reviews, animal studies, expert opinion articles and pre-
liminary reports were excluded. Economic analyses were only
included if they also investigated clinical outcomes.
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, the extent of burn injury (TBSA), population characteristics
and outcomes.
Assessment of the risk of bias in included studies
The risk of selection, performance, detection, attrition, reporting
and other biases in each study was assessed using the Cochrane
Collaboration’s risk of bias (RoB) assessment tool (RevMan version
5.2.11, Cochrane Collaboration) [23].
Descriptive statistics were used to synthesise data.
Results
Search results
The search results are summarised in Figure 1. Eight articles
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.
in a Cochrane review of studies of Aloe vera for treating acute
and chronic wounds [28]. Therefore, the eight eligible articles rep-
resent data from six RCTs.
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],
Germany [17], Singapore [16,19,27] and Egypt [24,25] between
2002 and 2011 (Table 1). Tsoutsos [26], Hindy [24] and their
respective teams included only patients with facial burns whilst
Allam et al. [25] included only patients with hand burns. The
remaining studies did not specify the affected anatomical region
[16,17,19,22,27]. Only two trials included patients with non-ther-
mal burns although the aetiology remains unclear [17,25].
The depths of burns in the patients included in the trials were
deep partial thickness (DPT) [26], superficial partial thickness (SPT)
[24] and two studies included patients with both SPT and DPT
burns [22,25]. Two trials included patients with partial-thickness
burns but did not specify whether these were SPT or DPT
[16,17,19,27]. Only Ang et al. [16,19,27] detailed the method used
to determine burn depth.
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Figure 1. PRISMA flow chart.
2 N. T. MABVUURE ET AL.

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Table 1. Summary of eligible studies.
First author, year
(Country of origin)
Number of
participants
(Male:Female)
Burn thickness Burn aetiology
Anatomical
region
Mean age in
years (range)
Study
design Comparison(s) Outcome (measure)
Result
(Extent of burn) MEBO Comparison
Hirsh,
2008 (Germany)
40 adults (M25:F15)
(<20% TBSA)
Partial thickness Thermal Not specified 41.15 (20–65) RCT MEBO vs. 1% SSD
(n¼20 each)
Day 12 Wound healing (mean TEWL): 11 7
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%
TBSA in >12-
years-old, <15%
TBSA in <12-
years-old)
Superficial
partial thickness
Thermal Facial NR RCT Aquacel Ag (I) vs. MEBO
(II) vs. saline (III)
(n¼20 each)
Mean time to complete healing (II vs I
vs III):
10.35 ± 2.8 10.05 ± 2.3,
12.05 ± 2.4¥
Pain (mean VAS score D1 & D2): 3.1 ± 1.9 NR
Itching (proportion itch-free) (%): 65 25, 10¥
Adverse effects: NR NR
Ang,
2002 (Singapore)
115 patients
(<40% TBSA)
Partial thickness Thermal Not specified 22 RCT MEBO (n¼57) vs. 1%
SSD (n¼58).
Wound healing rate (days to
75% healing):
17 20
Pain (mean week 1 post-dressing
verbal numerical rating scale):
2.9 3.5
MRSA infection rate (%): 37.4 38.5
Adverse effects NR NR
Allam, 2007 (Egypt) 106 patients
(<25% TBSA)
Partial thickness Thermal Hand NR RCT MEBO vs. 1% SSD cream
and a polyethylene
bags (n¼53 each)
Mean days to healing (superficial
partial thickness)
10.48 ± 2.66 14.53 ± 3.83
Mean days to healing (deep
partial thickness)
30.50 ± 5.10 36.60 ± 5.08
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,
2011 (Greece)
211 adults
(<15% TBSA)
Partial thickness Thermal Not specified 42.68 (18–75) RCT MEBO (n¼104:50 deep
partial and 54
superficial partial) vs.
Povidone
iodine þbepanthenol
cream (n¼107: 52
deep partial and 55
superficial partial)
Time to wound healing (days to 50%
reduction in TEWL for superficial
partial thickness burns)
8.7 10.75
Reduction in admission for deep
partial thickness burns (days)
3.02 2.79
Pain (mean morning VAS on day 2) 3 4.2
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,
2009 (Greece)
46 adults (extent
not reported)
Deep partial
thickness
Not specified Facial (20–70) RCT Helix aspersa extract
(Elicina cream) (27) vs.
MEBO (n¼16)
Days to full epithelialisation
(photographic assessment)
15 ± 3 11 ± 2
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
score (VAS)
4.50 ± 0.52 3.52 ± 0.80
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.

Three studies compared MEBO with 1% SSD cream
[16,17,19,25,27]. Others compared with sodium carboxymethylcel-
lulose silver (Aquacel Ag) [24], povidene iodine plus bepanthenol
cream [22] and Helix aspersa extract (Elicina cream) [26]. Only
Hindy [24] included a negative control group (saline-soaked
gauze dressing).
Characteristics of studies excluded after reading full-texts
Two studies were excluded after reading full-texts: an economic
analysis that did not assess efficacy [29] and a nonrandomised
study [18].
Risk of bias in included studies
Figures 2 and 3summarise and illustrate the authors’risk of bias
assessment. The trials by Hirsch [17], Hindy [24], Allam [25] and
their respective colleagues had the highest or unknown risk of
bias across all domains (Figure 2). The studies by Ang [16,19,27]
and Tsoutsos’[26] teams had a lower risk of bias whilst Carayanni
et al. [22] was judged least likely to be biased.
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
concealed 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].
Three trials had a high risk of reporting bias [17,24,25] and the
risk in the remaining trial was unclear [26].
Effects of interventions
Meta-analysis was precluded by the heterogeneous reporting of
outcomes; poor definition of the study population (i.e. not sepa-
rating SPT and DPT burns); missing data and poor reporting
(Table 1). A narrative synthesis was performed.
Measures of wound healing (primary outcome)
Both Ang [16,19,27], Allam [25] et al. observed faster healing in
patients treated with MEBO compared to SSD. The mean number
of days to 75% wound healing recorded by Ang et al. for the
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
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
DPT burns treated with MEBO healed faster (30.5 ± 5.1 vs.
36.6 ± 5.1 days) (p<0.05). Hirsch et al. measured day 12 TEWL and
markers of inflammation such as CRP and leukocyte count as
markers of wound healing [17] comparing MEBO with SSD. The
finding that patients treated with MEBO had greater loss of water
transepidermally (11 vs. 7) suggests that these wounds healed
slower than those treated with SSD. However, the levels of other
markers were not reported.
Patients treated with Helix aspersa cream by Tsoutsos et al.
healed significantly faster compared to MEBO, as assessed on
photographs by blinded assessors (11 ± 2 vs. 15.3 days) [26]. This
planimetric finding was corroborated by another that the eschar
detachment was faster in patients treated with Helix aspersa
cream [26].
Hindy found no difference in the healing times of MEBO and
Aquacel Ag (10.35 ± 2.8 vs. 10.05 ± 2.3 days) [24]. Compared to
povidone-iodine þbepanthenol cream, patients treated with
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Figure 2. Risk of bias summary: review authors’judgements about each risk of
bias item for each included study.
Figure 3. Risk of bias graph: review authors’judgements about each risk of bias
item presented as percentages across all included studies.
4 N. T. MABVUURE ET AL.

MEBO healed faster as shown by faster 50% TEWL reduction (8.7
vs. 10.75 days) [22].
In summary, more trials comparing wound healing between
MEBO and SSD favoured MEBO. There may be improved healing
in MEBO-treated wounds vs. those treated with povidone-iodi-
ne þbepanthenol cream. There was no difference between MEBO
and Acquacel Ag, but Helix Aspersa had faster healing rates
than MEBO.
Pain and itch
Two studies found no difference in the analgesic effects of MEBO
and SSD. Hirsch et al. found no statistically significant difference
in mean VAS scores between the MEBO and SSD groups on both
days 1 and 12 (both mean 5 on day 1 then 3.8 and 3.5, respect-
ively on day 12) [17]. Similarly, Allam et al. found no statistically
significant difference in pain scores between MEBO and SSD [25].
One study found a statistically significant difference in pain pro-
files between MEBO and SSD [16,19,27]. MEBO patients rated their
pain as less than that of the SSD group after one week (2.9 vs 3.5
mean post-dressing verbal numerical pain rating (VNPR) score).
However, the MEBO group had a higher mean VNPR on admission
(5.09 vs. 4.72) (p-value unreported) which may partially explain the
pain score differences. Furthermore, by the third week, there were
no longer any differences in analgesic effect.
In Hindy’s study, the MEBO group rated their pain as signifi-
cantly less than that of the Aquacel Ag and saline control groups
during the first 48 h [24]. However, although the mean VAS score
for the MEBO group was 3.1 ± 1.9, those of the Aquacel Ag and
saline control groups were not reported. MEBO also had a greater
ichthyotic effect than Acquacel Ag as shown greater proportions
itch-free patients in the MEBO group compared to the Aquacel
Ag and saline control groups (65 vs. 25% and 10%, respect-
ively) [24]
There was no difference in the analgesic properties of MEBO
and povidone-iodine þbepanthenol cream (mean morning VAS
scores: 3.0 vs. 4.2, respectively, mean evening VAS scores: 3.8 vs.
4.7 respectively) [22].
Tsoutsos et al. found that pain scores were significantly
improved with Helix Aspersa compared to MEBO (4.50 ± 0.52 vs.
3.52 ± 0.80) [26]. In this trial, mean VAS scores were similar
between the MEBO and Helix aspersa groups before dressings
were applied (6.50 ± 0.89 vs. 6.22 ± 1.25).
In summary, the majority of trials comparing wound healing
between MEBO and SSD favoured MEBO. There may be improved
healing in MEBO-treated wounds vs. those treated with povidone-
iodine þbepanthenol cream. There was no difference between
MEBO and Acquacel Ag, but Helix Aspersa had faster healing rates
than MEBO.
Incidence of adverse effects
The incidence of adverse effects was very low in all studies and
for all interventions. One MEBO vs. SSD RCT reported no adverse
outcomes for either intervention but the other two RCTs did not
report their incidence of adverse effects [16,19,25,27]. There was
no difference in allergy rates between MEBO and either Helix
aspersa [26] or povidone-iodine þbepanthenol creams [22]. The
respective rates of adverse effects of MEBO and Aquacel Ag were
not reported in the sole trial comparing the two [24]
Only two trials reported the incidence of wound infections
[16,19,22,27]. There was no difference in the incidence of methicil-
lin-resistant Staphylococcus aureus infections between the MEBO
and SSD groups in one trial (37.4 vs. 38.5%, respectively)
[16,19,27]. Similarly, no statistically significant difference was seen
in the incidence of Staphylococcus and Pseudomonas infections
in groups receiving either MEBO or povidone-iodi-
ne þbepanthenol creams (5.8 vs. 7.5%, respectively) [22].
In summary, the incidences of adverse reactions and wound
infections were low and no statistically significant differences
were noted between MEBO and any of the comparators.
Discussion
There has been a suggestion that there are “double standards”in
assessing complementary and alternative therapies in medicine
[30]. It is therefore crucial that these treatments are subjected to
the same scientifically rigorous analysis as used for ‘traditional’
treatments. As such, this systematic review was performed with
the aim of pooling data relating to the efficacy of MEBO for the
treatment of burn wounds. Such a synthesis for the first time
allows both surgeons and patients to appraise collated and syn-
thesised evidence of MEBO and several comparators and is there-
fore crucial to cost-effectiveness calculations by these groups.
Data from six RCTs, all level 3 evidence, mostly poorly reported,
were eligible for inclusion. The heterogeneity of study methods,
comparators and outcome measures precluded meta-analysis.
Even the three studies comparing MEBO to 1% SSD were suffi-
ciently heterogeneous to preclude meta-analysis of only
these studies.
The results of this review should be interpreted with the fol-
lowing caveats in mind. There were varying anatomical locations
and not all papers specified. The appropriateness of 1% SSD as a
comparator or standard treatment is debatable since SSD has
been shown to be consistently associated with poorer healing
outcomes compared to treatments such as skin substitutes, silver-
containing dressings and silicon-coated dressings [1]. Other fac-
tors precluding meta-analysis included variability in outcome
measurement. Surrogates included time to complete wound heal-
ing [24–26], TEWL [17], time to 75% healing [16,19,27] and 50%
reduction in TEWL [26].
MEBO effect on wound healing
The results do not consistently favour MEBO or any of its compa-
rators. Of the three studies comparing the wound healing proper-
ties of SSD with MEBO, two favoured MEBO [16,25] whilst one
favoured SSD [17]. One of the favourable studies was poorly
reported, exposing it to significant biases [25]. The small improve-
ment in the other favourable study was not statistically significant
[16,19,27]. This small and statistically insignificant benefit should
be interpreted in the context of moderate risk of bias due to
issues with blinding and failure to analyse on an intention to treat
basis.
Wound healing was also reportedly improved in MEBO com-
pared to Acquacel Ag [24] and povidone-iodine þbepanthenol
cream groups [22]. The results in the Acquacel Ag trial were at
risk of bias due to poor reporting [24]. The highest quality study
used an indirect surrogate measure, that is, reduction in TEWL to
suggest faster healing in SPT but not DPT burns [22]. This trial by
Carayanni et al. was at risk of intrinsic bias as it was funded by a
manufacturer of MEBO [31].
Patients receiving Helix aspersa cream healed faster than those
receiving MEBO [26]. This study by Tsoutsos et al. [26] was at
moderate risk of bias and also compared MEBO to a treatment
that is not standard of care. Due to these quality issues, these
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JOURNAL OF PLASTIC SURGERY AND HAND SURGERY 5

results should, therefore, be interpreted with caution. At present,
poor evidence shows no difference in wound healing properties.
MEBO effect on secondary outcomes
Similar caution should be exercised in interpreting the effects of
the interventions on secondary outcomes. In summary, there was
no difference in pain profiles in two [17,25] of three trials compar-
ing MEBO with SSD and in one trial comparing MEBO with povi-
done-iodine þbepanthenol cream [22]. One 3-week trial found
that MEBO had better analgesis than SSD but only in the first
week [16,19,27]. Helix aspersa cream had a greater analgesic effect
than MEBO [26].
The claim that MEBO was more analgesic than Acquacel Ag
could not be verified since pre-treatment VAS scores were not
reported [24]. Furthermore, the Acquacel Ag trial was either inad-
equately randomised, poorly reported or both. The identity of
outcome assessors and blinding protocols were also not specified.
Wound infection and adverse effects rates were similarly low
in both MEBO and comparator groups in all studies. However,
none of the studies reported adverse events according to item 19
of the CONSORT scale which advises recording adverse events
with reference to standardised criteria.
Limitations
This systematic review was conducted following PRISMA guide-
lines. However, some limitations remain. The methodological flaws
of the eligible studies and their effect on this review’s conclusions
have been extensively described above. This abundance of pre-
clinical evidence of efficacy would suggest a likely positive clinical
efficacy. However, the evidence was not high quality enough to
definitively answer this question. Furthermore, there was a selec-
tion bias towards trials indexed on MEDLINE and EMBASE, argu-
ably the two preeminent general healthcare databases. Several
case reports written in unscientific formats and listed on the man-
ufacturer’s website were excluded as they were largely anecdotal
[15]. Papers were limited to English-language publications.
Attempts were made to contact all authors for clarification of
missing data required but only one author responded.
Conclusions
The evidence for MEBO in English-language literature was poor
and inconsistent with respect to wound healing rate and analge-
sis compared to 1% SSD, Acquacel Ag, Helix aspersa cream and
povidone-iodine þbepanthenol cream. Blinded RCTs comparing
MEBO to both placebo and other common topical treatments
such as paraffin wax, which may also provide a moist and
exposed environment, may further improve the confidence in
concluding their analysis. There is good evidence that MEBO is as
safe as its comparators as shown by the low complication rate.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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