# Histopathological Changes Following Bromelain-Based Enzymatic Debridement (NexoBrid®): A Comprehensive Systematic Review of Preclinical and Clinical Evidence

## TL;DR

This review examines how bromelain-based debridement affects tissue in burn treatment, showing promise in preclinical studies but highlighting a lack of clinical histological data.

## Contribution

The study systematically reviews preclinical and clinical histological evidence of bromelain-based debridement, revealing a significant translational gap.

## Key findings

- Bromelain-based debridement selectively removes eschar while preserving dermal layers in preclinical models.
- Clinical studies show limited histological data, with findings like upper dermal homogenization and pseudoeschar formation.
- Preclinical evidence suggests accelerated re-epithelialization and protection of the zone of stasis.

## Abstract

Background: NexoBrid® (NXB; MediWound Ltd., Yavne, Israel) (anacaulase-bcdb) is a bromelain-based enzymatic debriding agent approved for eschar removal in burn care. Despite widespread clinical use, histological evidence of tissue-level changes after enzymatic debridement remains limited. This systematic review aimed to evaluate preclinical and clinical studies describing histological findings following bromelain-based enzymatic debridement of thermal burns. Methods: Following PRISMA 2020 guidelines, we performed parallel systematic searches of preclinical (animal) and clinical (human) studies across PubMed, Embase, CENTRAL, Web of Science, and Scopus. Included studies reported thermal burns treated with bromelain-based enzymatic debridement and tissue biopsies with histological analysis. Quality was assessed using the SYRCLE Risk of Bias Tool (preclinical) and JBI Critical Appraisal Checklists (clinical). Results: Six preclinical studies (five porcine, one rat) met inclusion criteria. Findings included: selective eschar removal with dermal preservation; protection of the zone of stasis (67% partial- vs. 100% full-thickness necrosis; p = 0.05); viable dermal thickness of 1.1 ± 0.7 mm; and accelerated re-epithelialization (7.4 ± 0.8 vs. 9.1 ± 2.1 days; p < 0.05). Only two clinical studies (n = 9 patients) met the inclusion criteria: one case series (n = 8) and one case report. Clinical findings showed upper dermal homogenisation with preserved deep dermis, vascular congestion correlating with pinpoint bleeding, and pseudoeschar formation via transepidermal elimination. Conclusions: Preclinical evidence supports selective enzymatic debridement with dermal preservation. However, clinical histological data are limited to nine patients after over 13 years of use. This highlights a critical translational gap and underscores the need for prospective clinical histological studies.