Split-thickness skin grafting (STSG) continues to be a fundamental reconstructive procedure for the management of extensive skin loss resulting from burns, trauma, chronic ulcers, infections, and post-surgical defects, primarily due to its ability to achieve rapid wound coverage with relatively low donor-site morbidity [1]. However, the donor site itself represents a controlled partial-thickness wound that heals by re-epithelialization from residual dermal appendages, and is frequently associated with significant postoperative concerns such as pain, delayed healing, itching, bleeding, and long-term scarring, all of which can negatively impact patient comfort and overall recovery [2]. In many cases, the donor site may be more symptomatic than the recipient area, making its management a critical aspect of postoperative care.

Optimal dressing selection plays a central role in enhancing donor-site healing by maintaining an appropriate moist environment, reducing infection risk, and minimizing trauma during dressing changes. Traditional dressings such as paraffin gauze and acriflavine-glycerine gauze remain widely used because of their affordability and accessibility, but they are often associated with adherence to the wound bed, increased pain during removal, and inconsistent moisture control [3,4]. In contrast, modern wound care emphasizes biologically active materials that promote faster healing. Among these, collagen-based dressings have gained considerable attention due to their ability to mimic the extracellular matrix, support fibroblast activity, enhance angiogenesis, and facilitate epithelial migration while also reducing inflammation and protease activity [5–7].

Pain and itching are two of the most distressing symptoms following STSG donor-site creation, often quantified using validated tools such as the Visual Analogue Scale (VAS). Persistent inflammation and delayed epithelialization can further contribute to poor scar outcomes. The quality of scarring, now recognized as a multidimensional outcome, is best evaluated using comprehensive tools like the Patient and Observer Scar Assessment Scale (POSAS), which integrates both clinical and patient-reported parameters [8–10]. Despite advances in dressing materials, there remains a lack of robust comparative evidence, particularly in the Indian clinical setting, regarding the superiority of collagen dressings over conventional options such as acriflavine-glycerine gauze.

Against this background, the present study aims to determine whether collagen dressing offers superior outcomes compared to conventional acriflavine-glycerine gauze in STSG donor-site management. The objectives include evaluating time to complete re-epithelialization, assessing postoperative pain and itching using VAS, and comparing scar quality using POSAS. By integrating both objective healing parameters and patient-centered outcomes, this study seeks to generate evidence that can guide optimal dressing selection, improve patient comfort, and standardize donor-site care practices in routine surgical settings.

MATERIAL AND METHODS

After obtaining approval from the Institutional Ethics Committee, this hospital-based prospective randomized controlled study was conducted among patients undergoing split-thickness skin grafting (STSG) in the Department of General Surgery at Mahatma Gandhi Memorial Medical College and M.Y. Hospital, Indore, along with the Department of Plastic Surgery at S.S. Hospital, Indore, over a period of one year. Written informed consent was obtained from all participants prior to enrolment. Confidentiality of patient data and voluntary participation were strictly maintained throughout the study.

The sample size was calculated using a standard formula for comparison of two means, assuming a confidence level of 95% and power of 80%, based on previously reported differences in POSAS scores. A minimum of 50 participants per group was required. To ensure adequate statistical validity, a total of 100 patients were included in the study and were randomly allocated into two groups using a closed envelope method.

Inclusion and Exclusion Criteria:

Patients aged 18 years and above undergoing STSG for various indications such as burns, trauma, diabetic ulcers, venous ulcers, and chronic non-healing wounds, with a donor-site wound size of at least 10 cm² and willingness to participate in follow-up were included. Whereas, patients with known allergy to collagen, immunocompromised status, presence of local infection at the donor site, severe systemic illness affecting wound healing, refusal to consent, or loss to follow-up were excluded.

Procedure

After obtaining consent, eligible patients were enrolled consecutively at the time of admission. A detailed clinical history was recorded using a predesigned structured proforma, including demographic details (age, sex), indication for grafting, and relevant comorbidities. A thorough clinical examination was performed, and baseline parameters were documented.

All patients underwent split-thickness skin grafting under standard aseptic conditions. The donor site, commonly the lateral thigh, was prepared and the graft was harvested using a dermatome at a standardized thickness. Hemostasis was achieved using adrenaline-soaked gauze where necessary. Immediately following graft harvest, patients were allocated to one of two groups. In Group A, collagen sheet dressing was applied over the donor site, whereas in Group B, conventional dressing using acriflavine glycerine gauze or liquid paraffin gauze was applied. Dressings were secured with sterile bandaging, and all patients received standard postoperative care.

Postoperative monitoring included daily assessment of pain using the Visual Analogue Scale (VAS) for the first two weeks, followed by twice-weekly assessment during the third and fourth weeks. Patients were instructed to maintain a diary to record pain and itching scores. Donor-site wound healing was assessed clinically, and time to complete epithelialization was recorded, defined as complete healing without raw areas or crusting.

Outcome Assessment included evaluation of both primary and secondary parameters. The primary outcomes were time to complete epithelialization, defined as healing of the donor site without raw areas or crusting, and scar quality assessed using the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes included assessment of pain intensity and itching severity using the Visual Analogue Scale (VAS), along with the incidence of donor-site complications such as infection, bleeding, hematoma, and pruritus. Scar evaluation was performed at predefined intervals by an independent blinded observer to minimize assessment bias.

Follow-up Protocol: Patients were followed up during their hospital stay and subsequently at regular intervals on postoperative day 21, at one month, and at three months. During each follow-up visit, wound healing status, pain, itching, and scar quality were assessed. Any complications or delayed healing were documented.

Statistical Analysis

Data were recorded using a predesigned structured proforma, including demographic details, indication for grafting, donor-site characteristics, pain and itching scores, time to epithelialization, POSAS scores, and postoperative complications. Patient-reported outcomes were documented using diaries. The data were entered into Microsoft Excel and analyzed using SPSS software version 26.0. Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. Group comparisons were performed using the unpaired t-test and Chi-square test, with a p-value <0.05 considered statistically significant.

RESULTS

The present study included 100 patients undergoing split-thickness skin grafting (STSG), who were randomly allocated into two groups: collagen dressing (Group A, n=50) and conventional dressing (Group B, n=50). The baseline demographic and clinical characteristics of the study population were comparable between the two groups, with no statistically significant differences observed. The majority of patients belonged to the 31–50 years age group, with a slight male predominance in both groups. The most common aetiologies of wounds were mechanical trauma and thermal burns, while hypertension and diabetes mellitus were the most frequent comorbidities. The thigh was the most commonly used donor site in both groups. These findings indicate adequate randomization and homogeneity of the study population [Table 1].

Table 1: Baseline Demographic and Clinical Characteristics of Study Subjects

Baseline wound characteristics were also comparable between the two groups. The mean wound size in the collagen group was 87.43 ± 27.80 cm² compared to 82.20 ± 24.43 cm² in the conventional group. Similarly, the mean duration of wound prior to grafting was 46.40 ± 24.27 days in Group A and 53.94 ± 23.61 days in Group B. These differences were not statistically significant (p > 0.05), indicating similar wound profiles at baseline [Table 2].

Table 2: Comparison of Wound Characteristics Between Study Groups

Postoperative pain assessment using the Visual Analogue Scale (VAS) demonstrated significantly lower pain scores in the collagen dressing group at all time points from Day 1 to Day 28 (p < 0.001). A progressive decline in pain was observed in both groups; however, patients treated with collagen dressing experienced faster pain relief, with near-complete resolution by Day 28. Similarly, itching scores were significantly lower in the collagen group across all follow-up weeks (p < 0.001), indicating superior symptomatic control [Table 3].

Table 3: Comparison of Pain and Itching Scores Between Study Groups

Scar quality assessment using the Patient and Observer Scar Assessment Scale (POSAS) revealed significantly better outcomes in the collagen dressing group. Both observer and patient scores were consistently lower in Group A at Day 21, 1st month, and 3rd month (p < 0.001). The combined POSAS scores further confirmed superior scar quality with collagen dressing. Additionally, analysis of individual scar parameters at 3 months demonstrated significantly improved vascularity, pigmentation, thickness, pliability, and overall appearance in the collagen group, along with better patient-reported outcomes such as reduced pain, itching, and stiffness (p < 0.001) [Table 4 & Table 5].

Table 4: Comparison of POSAS Total Scores Between Study Groups

Table 5: Comparison of Individual POSAS Parameters at 3rd Month

With respect to complications and healing outcomes, collagen dressing showed clear clinical advantages. The incidence of bleeding at the donor site on Day 21 was significantly lower in the collagen group (10.0%) compared to the conventional group (30.0%) (p = 0.012). Pruritus severity was also reduced, with a higher proportion of patients reporting no pruritus and fewer experiencing severe pruritus in the collagen group (p = 0.010). Furthermore, the mean time to complete re-epithelialization was significantly shorter in the collagen group (14.62 ± 3.11 days) compared to the conventional group (19.38 ± 3.29 days), demonstrating faster wound healing (p < 0.001) [Table 6].

Table 6: Comparison of Complications and Healing Outcomes Between Study Groups

Graph 1: Summary Comparison of Key Outcome Parameters Between Group A and Group B

DISCUSSION

The present study was undertaken to compare collagen dressing with conventional dressing in the management of split-thickness skin graft (STSG) donor sites, with emphasis on wound healing, postoperative symptoms, and scar quality. Donor-site morbidity remains a clinically relevant issue, often underestimated despite its significant contribution to patient discomfort, delayed recovery, and dissatisfaction. By evaluating both objective healing parameters and patient-centered outcomes such as pain, itching, and scar perception, this study provides a comprehensive assessment of donor-site management strategies. The findings demonstrate that collagen dressing offers clear advantages over conventional dressing in terms of faster epithelialization, reduced morbidity, and improved scar outcomes.

Baseline characteristics including age, gender distribution, aetiology of wound, comorbidities, donor-site location, wound size, and duration before grafting were comparable between the two groups, ensuring internal validity. The mean age and gender distribution were similar (p > 0.05), consistent with randomized trials such as Dornseifer et al. [11] and Higgins et al. [12], although these studies did not provide detailed demographic stratification. Similarly, wound aetiology and comorbidity profiles were evenly distributed, minimizing confounding factors that could influence healing. Many previous studies, including those by Bista et al. [13] and Jain et al. [14], primarily focused on outcomes rather than detailed baseline comparability, making the present study methodologically robust.

Pain reduction was one of the most significant findings. The collagen group showed consistently lower VAS pain scores at all time points from Day 1 to Day 28 (p < 0.001), with faster resolution of pain. These findings are in agreement with Jain et al. [14], who reported a rapid decline in VAS scores with collagen compared to petroleum gauze, and Bista et al. [13], who also observed significantly lower pain scores with collagen. Dornseifer et al. [11] similarly reported reduced pain with advanced dressings, although Higgins et al. [12] and Nouri et al. [15] found no significant difference in pain outcomes. The superior pain control observed in the present study may be attributed to the non-adherent nature of collagen and its ability to maintain a moist wound environment, thereby reducing trauma during dressing changes.

Itching is another important but often underreported symptom in donor-site healing. In the present study, VAS itching scores were significantly lower in the collagen group across all follow-up intervals (p < 0.001). Furthermore, categorical analysis showed a higher proportion of patients with no or mild pruritus and fewer with severe pruritus in the collagen group. In contrast, studies such as McBride et al. [16] and Ismail et al. [17] reported no significant differences in itching among various dressing types. The improved itching profile in the present study may be explained by the biological properties of collagen, which provide a protective scaffold, reduce inflammatory mediators, and promote stable epithelial regeneration.

Scar quality assessment using POSAS demonstrated consistent superiority of collagen dressing in both observer and patient domains. Observer scores, patient scores, and combined scores were significantly lower in the collagen group at all follow-up intervals (p < 0.001), indicating better scar maturation. These findings align with studies by Hecker et al. [18] and Alsaif et al. [19], which reported improved cosmetic outcomes with advanced dressings. However, several studies including Dornseifer et al. [11], McBride et al. [16], and Ismail et al. [17] did not observe significant long-term differences in scarring despite improvements in early healing. The present study strengthens the evidence by demonstrating concordant improvements in both subjective and objective scar parameters.

Analysis of individual POSAS components further revealed that collagen dressing improved all aspects of scar morphology, including vascularity, pigmentation, thickness, pliability, and surface characteristics (p < 0.001). Patient-reported parameters such as pain, itching, stiffness, and irregularity were also significantly better. These findings suggest that collagen not only accelerates healing but also modulates the quality of tissue regeneration. Similar observations have been reported by Hecker et al. [18], while earlier studies such as Nouri et al. [15] and McBride et al. [16] did not demonstrate such comprehensive benefits.

Complication rates were significantly lower in the collagen group. Persistent bleeding at Day 21 was reduced (10.0% vs 30.0%, p = 0.012), indicating improved wound stability. Comparable findings have not been consistently reported in previous literature, although Jain et al. [14] observed reduced complications with collagen. Higgins et al. [12] reported differences in exudate and dressing changes, indirectly suggesting variability in wound stability across dressing types. The reduced bleeding in the present study may be attributed to faster epithelial coverage and better structural support provided by collagen.

Pruritus severity was also significantly reduced in the collagen group (p = 0.010), reinforcing its role in improving patient comfort. Unlike prior studies such as Ismail et al. [17] and McBride et al. [16], which did not find significant differences in itching, the present study demonstrates both quantitative and qualitative improvement in pruritus, suggesting a stronger anti-inflammatory and protective effect of collagen dressing.

Time to complete re-epithelialization was significantly shorter in the collagen group (14.62 ± 3.11 days vs 19.38 ± 3.29 days, p < 0.001), representing a reduction of approximately 4.76 days. This finding is consistent with multiple studies including Dornseifer et al. [11], Barret et al. [20], Cheema et al. [21], Bista et al. [13], and Jain et al. [14], all of which demonstrated faster healing with advanced or biologic dressings. However, some studies such as Higgins et al. [12], McBride et al. [16], and Nouri et al. [15] did not observe significant differences, indicating that healing outcomes may depend on the specific dressing material used.

Overall, the present study provides strong evidence that collagen dressing is superior to conventional dressing in STSG donor-site management. It offers significant benefits in reducing pain, itching, complications, and healing time, while also improving scar quality. These findings support the routine use of collagen dressing as an effective and patient-friendly option for donor-site care.

Despite its strengths, the study was limited by its single-center design, moderate sample size, and short follow-up duration. Lack of blinding, absence of cost-effectiveness analysis, and limited evaluation of infection outcomes may introduce bias. Additionally, comparison with only conventional dressing and unassessed patient-related factors could influence the results.

CONCLUSION

Collagen dressing demonstrated clear superiority over conventional dressing in the management of split-thickness skin graft donor sites. It significantly reduced postoperative pain, itching, and complication rates while promoting faster re-epithelialization. Additionally, both observer- and patient-based scar assessments showed improved outcomes with collagen, indicating better scar quality and patient satisfaction. These findings suggest that collagen provides a more favorable wound-healing environment by maintaining moisture balance and minimizing tissue trauma. Given its clinical benefits, collagen dressing can be considered an effective and reliable option for routine donor-site management, with potential to enhance recovery, reduce morbidity, and improve overall postoperative outcomes in patients undergoing skin grafting.

REFERENCES

1. Atiyeh BS, Costagliola M, Hayek SN. Skin grafts and skin substitutes in burn management: An overview. Ann Burns Fire Disasters. 2005;18(1):8-14.
2. Nouhi A, Nabavizadeh MR, Mohammadi AA. Donor site morbidity after split-thickness skin grafts. World J Plast Surg. 2012;1(2):78-82.
3. Laurence A, Tadeusz A. Modern wound dressings: A systematic review. J Wound Care. 2017;26(3):123-30.
4. Snow G, Hasl D. Donor-site complications in split-thickness skin grafts. Clin Plast Surg. 2009;36(4):587-92.
5. Dhivya S, Padma VV, Santhini E. Wound dressings: A review. BioMedicine. 2015;5(4):22-30.
6. Chattopadhyay S, Raines RT. Review of collagen-based biomaterials for wound healing. Biopolymers. 2014;101(8):821-33.
7. Shoulders MD, Raines RT. Collagen structure and stability. Annu Rev Biochem. 2009;78:929-58.
8. Summer GJ, Puntillo KA, Miaskowski CA. Pain from donor sites: A clinical challenge. J Burn Care Res. 2007;28(3):398-405.
9. Ständer S, Weisshaar E, Mettang T. Clinical scoring systems for itch. Acta Derm Venereol. 2013;93(1):5-11.
10. Draaijers LJ, Tempelman FRH, Botman YAM. The Patient and Observer Scar Assessment Scale (POSAS). Plast Reconstr Surg. 2004;113(7):1960-5.
11. Dornseifer U, Lonic D, Herter F, Fichter A, Holm C, Schuster T, Ninković M. The ideal split-thickness skin graft donor-site dressing: a clinical comparative trial of a modified polyurethane dressing and Aquacel. Plast Reconstr Surg. 2011;128(4):918–924.
12. Higgins L, Wasiak J, Spinks A, Cleland H. Split-thickness skin graft donor site management: a randomized controlled trial comparing polyurethane with calcium alginate dressings. Int Wound J. 2012;9(2):126–134.
13. Bista CB, Deshmukh PA, Anand S, Roy N, Narayanan R. A randomized controlled trial comparing collagen sheet dressing with Vaseline gauze dressing in assessing pain in split thickness skin graft donor site. Indian J Surg. 2022;85(3):565–569.
14. Jain AP, Aaudichya AS, Rathwa A, Jain PA, Patel P. Collagen dressing versus conventional Vaseline gauze dressing in reducing pain and infection at the donor area for skin grafting: a prospective interventional study. Int J Anat Radiol Surg. 2022;11(2):SO01–SO04
15. Nouri M, Ebrahimi M, Bagheri T, Fatemi M, Najafbeygi A, Araghi S, Molaee M. Healing effects of dried and acellular human amniotic membrane and Mepitel as coverage of skin graft donor areas: a randomized clinical trial. Bull Emerg Trauma. 2018;6(3):195–200.
16. McBride CA, Kimble RM, Stockton KA. Prospective randomised controlled trial of Algisite™ M, Cuticerin™, and Sorbact® as donor site dressings in paediatric split-thickness skin grafts. Burns Trauma. 2018;6:13
17. Ismail S, Khan FAA, Gulzar S, Sami W, Zulfiqar B, Kumar S, Naz E. A single centre, randomized control trial of donor site wound dressings after split-thickness skin grafting. J Ayub Med Coll Abbottabad. 2023;35(4):645–649
18. Hecker A, Lumenta DB, Brinskelle P, Sawetz I, Steiner A, Michelitsch B, Friedl H, Gmainer D, Kamolz LP, Winter R. A randomized controlled trial of three advanced wound dressings in split-thickness skin grafting donor sites—a personalized approach? J Pers Med. 2022;12(9):1395.
19. Alsaif A, Karam M, Aldubaikhi A, Alghufaily A, Aldekhayel S. Polyurethane versus calcium alginate dressings for split-thickness skin graft donor site: a systematic review and meta-analysis. Cureus. 2021;13(12):e20027.
20. Barret JP, Podmelle F, Lipovy B, Rennekampff HO, Schumann H, Schwieger-Briel A, Zahn T, Metelmann HR. Accelerated re-epithelialization of partial-thickness skin wounds by a topical betulin gel: results of a randomized phase III clinical trials program. Burns. 2017;43(6):1284–1294
21. Cheema L, Manzoor S, Khalid U, Shamim R, Hashaam, Tayyab Z, Bashir M. Suprathel dressing at split-thickness skin graft donor site for pain control and wound healing. Pak J Med Health Sci. 2022;16(10):1016–1020.