Introduction: The evaluation of burn depth is essential in the  therapeutic management of  patients suffering from burns. Traditionally, burn surgeons divide burns into superficial which heal by spontaneous re-epithelialization and deep burns requiring surgical treatment. The most common technique used to determine burn depth is clinical assessment by experienced burn surgeon although this has been shown to be accurate in only 60-75% of the cases. In December 2012, a new Bromelain Based Debridement agent (BBD) was approved for the European market. The results based on previous animal and human burn studies suggested that BBD is an effective, fast and selective diagnostic and therapeutic tool for burn wound management. We present a retrospective analysis of burn depth based on the post-BBD diagnosis compared to clinical evaluation and final treatment.
Methods: Between May 2015 and July 2017 we collected the data regards burn depth of  patients aged between 18-79 years with TBSA no more than 20% suffering from partial and full thickness thermal burns  and  treated with a new  Bromelain Based Debridement agent (BBD). 
Burn depth was assessed by senior burn specialists using standard clinical characteristics (color, capillary refill, skin pliability, sensation, presence of blisters, presence of thrombosed vessels) before BBD treatment and after BBD treatment. 
The experienced burn surgeons were asked if the burns required graft or no.
In case of full thickness burn the wounds were covered with split thickness skin grafts. Deep dermal or partial thickness burns were treated with conservative dressings until spontaneous healing.
The post-BBD diagnosis was than compared with  the clinical evaluation the and final treatment (graft or spontaneous healing). 
Results: Between May 2015 and July 2017, a total of 69 patients were studied (41 men, 28 women) aged 19-76. The mean TBSA treated  was 7,3% (range 3-20%).
Etiologies were flame (81,7%), scald (15,3%) and contact (3%).
22 wounds were covered with split thickness skin grafts  while 47 wounds were treated with conservative dressings and healed spontaneously in 3 weeks.
Clinical assessment by experienced burn surgeons rated: 47 patients (68,1%)  had deep lesions requiring a skin graft; 22 patients (31,9%) had superficial lesions requiring no surgery. The clinical evaluation was equivalent to final treatment in 63,7% of the cases (44/69 patients). In 36,3% of the cases (25/69 patients) the clinical evaluation was different from final treatment. Post-BBD diagnosis by experienced burn surgeons rated: 19 patients (27,5%) had deep lesions requiring a skin graft; 50 patients (72,5%) had superficial lesions requiring no surgery. The post-BBD evaluation was equivalent to final treatment in 95,6 % of the cases (3/69 patients). In 4,4% of the cases (3/69 patients) the post-BBD diagnosis was different from final treatment.
Conclusions: In our study, the clinical assessment of burn depth was exact in 63,7% of the cases which is very close to the rate in the literature. Based on clinical evaluation, the main evaluation errors were more often due to overestimation of the depth, that have heavier consequences since they lead to unnecessary surgery. The use of BBD as diagnostic tool of burn depth based on direct visualization of dermal vital tissue demonstrated to be more accurate in burn depth diagnosis and at the same time proved to be  an effective, fast  safe and selective therapeutic toll for burn treatment

The accuracy of burn depth diagnosis: a comparison between clinical evaluation and diagnosis by direct visualisation after enzymatic debridement