Topical antimicrobial (silver-sulfonamide) Pregnancy: Avoid near term — neonatal jaundice/kernicterus risk from sulfonamide component. Use alternative dressings in third trimester and at term.

Silver Sulfadiazine 1% Cream

Brand names: Flamazine (1% cream)

Adult dose

Dose: Apply 3–5 mm thickness to wound, cover with dressing; renew every 24 hours

Route: Topical (applied directly to burn wound or under occlusive dressing)

Frequency: Once daily or every 24–48 hours

Max: Apply to entire wound surface — large burns require monitoring for systemic absorption

Partial-thickness burns (2nd degree) and full-thickness burns: standard of care for wound infection prophylaxis. Apply a 3–5 mm thick layer to clean wound surface. Cover with non-adherent dressing. In large burns (>20% BSA): risk of significant systemic sulfonamide and silver absorption — monitor WBC, renal function, and electrolytes.

Paediatric dose

Route: Topical

Frequency: Once daily

Max: Apply to wound — monitor closely in neonates and infants

Concentration: 1% cream (10 mg/g silver sulfadiazine) Application/ml

Neonates: caution — risk of kernicterus (sulfonamide displaces bilirubin from albumin). Avoid in premature infants and neonates <2 months. Infants and children: use with caution; monitor FBC and renal function in large burns.

Dose adjustments

Renal

Caution in renal impairment with extensive application — risk of systemic sulfonamide accumulation.

Hepatic

Caution with extensive use in hepatic impairment.

Clinical pearls

Flamazine (SSD) has been standard burn wound care for decades but is increasingly replaced by modern silver-containing dressings (Mepilex Ag, Aquacel Ag) in specialist burn centres due to superior wound-bed maintenance and less frequent changes
Leukopenia: monitor WBC in burns >20% BSA — transient and resolves without dose change in most cases, but discontinue if severe
Sulfonamide allergy: cross-reactivity with sulfonamide antibiotics — always check allergy history
Facial burns: generally avoid SSD on face — use paraffin gauze or non-adherent alternatives
Burns >20% BSA: refer to specialist burns unit — systemic absorption monitoring essential

Contraindications

Neonates and premature infants (risk of kernicterus)
Near-term pregnancy and breastfeeding (sulfonamide neonatal risk)
Hypersensitivity to sulfonamides
G6PD deficiency (haemolytic anaemia risk with systemic absorption)

Side effects

Leukopenia (transient, reversible — occurs in up to 20% of patients with large burns)
Skin hypersensitivity reactions
Systemic sulfonamide toxicity with large burns (rare with small areas)
Argyria (grey skin discolouration — very rare, chronic silver exposure)
Wound healing may be impaired (compared to modern dressings — evidence controversial)

Interactions

Other sulfonamides — additive toxicity with systemic absorption
Enzymatic debridement agents (collagenase) — silver inactivates enzymatic activity; do not use concurrently

Monitoring

FBC (especially WBC — leukopenia monitoring in large burns)
Renal function in extensive burns
Wound healing and infection signs
Serum electrolytes (large burns)

Reference: BNFc; BNF; NICE Burn Wound Management Guidelines; British Burns Association Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Pathways