Bromelain-based enzymatic debridement as a decompressive strategy in circumferential and constrictive acute burns: A systematic review with institutional case series

Introduction Burn-induced compartment syndrome is a potentially limb- or life-threatening complication of circumferential or constrictive deep burns. Surgical escharotomy remains the standard treatment, but it is invasive and may be difficult to justify in early or uncertain cases. Bromelain-based enzymatic debridement with NexoBrid® enables selective eschar removal and may offer a minimally invasive decompressive alternative in selected patients. Methods A systematic review was performed according to PRISMA 2020 guidelines. PubMed/MEDLINE, Embase, Scopus, Web of Science and the Cochrane Library were searched in May 2026 for studies reporting the use of Nexobrid® in circumferential or constrictive burns. Risk of bias was assessed using the ROBINS-I tool. In addition, a retrospective institutional case series was included. Results The database search identified 289 records. After screening, six studies were included in the systematic review. None were randomized, and the overall risk of bias was considered serious, mainly due to confounding by indication, patient selection and heterogeneous outcome reporting. Enzymatic debridement was associated with successful decompression in selected circumferential burns, with most studies reporting no need for rescue surgical escharotomy. The institutional case series included four patients with upper limb, lower limb and thoracoabdominal constrictive burns. Discussion The available evidence suggests that Nexobrid® debridement may function as a minimally invasive decompressive strategy in carefully selected circumferential or constrictive burns at risk of burn-induced compartment syndrome. Its potential value appears greatest in early or uncertain cases, where clinicians may hesitate to perform surgical escharotomy. However, the evidence remains limited by small sample sizes, non-randomized designs, heterogeneous protocols and serious risk of bias. NexoBrid® should therefore be considered a preventive or early decompressive adjunct rather than a complete replacement for urgent surgical escharotomy in patients with acute vascular compromise.