Old and New Pearls for Wound Healing

Robert S Kirsner, MD, PhD, chairman and Harvey Blank Professor at the Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery at the University of Miami in Coral Gables, Florida, offered 1 old and 5 new pearls to deliver better outcomes for wound healing in a presentation at Maui Derm for Dermatologists 2022 held January 24 to 28, 2022, in Maui, Hawaii and virtual.¹

What to Keep

Use evidence to drive care and stay current with the literature. This old pearl is as pertinent as ever, Kirsner said. While there are many available products on the market for wound healing, dermatologists need to use evidence-based therapies, especially when considering which of the more than 80 cell- and tissue-based products would benefit the individual patient most.¹ Examples of those products with evidence include bi-layered cellular products (Apligraf; Organogenesis Inc) for venous leg ulcers (VLU) and diabetic foot ulcers (DFU); acellular products such as porcine (Oasis; Smith+Nephew) for VLU and DFU; cadaveric grafts (GraftJacket; Wright Medical Group) for DFU, and combined shark cartilage and bovine collagen (Omnigraft; Integra) for DFU; and placental agents, such as Epifix (MiMedX) and Grafix (Smith+Nephew) for DFU.¹

What to add in 2022

1. Give patients hope. Kirsner said thatwhen wound treatment is difficult, creative methods are needed. He referenced a study by Jockenhöfer and colleagues that reported if patients saw that the provider was excited and believed in the product used for their treatment, patients did better than those who were told they were receiving the standard of care, even if they never received the new product.²
2. Debride the wound edge and use patient technology to improve patient satisfaction. He explained that wound edges have abnormal cells, and science-based treatment indicates the need for debridement. He also mentioned new technologies for debridement, including a tool called EZ-Debride (MDM Ventures).³ Results of a study examining its effectiveness pointed out, “Cutting flutes on the head of the tool permit uniform removal of dead tissue while lessening the risk of deeper injury.”³ Other noteworthy technologies in development include the use of the enzymatic debridement agent bromelain, and the use of an enzyme (Aurase; SolasCure) engineered to replicate enzymes produced by maggots, according to Kirsner.⁴ Technology in the form of virtual reality (VR) can also help patients reduce pain, Kirsner said. He noted a systematic review that showed VR’s effectiveness in pain management.⁵
3. Harness the power of viruses and bacteria. Kirsner cited a 2021 study that showed the presence of S aureus increased regeneration of tissue (less scarring) rather than merely repair.⁶ At least experimentally, “having some bacteria in a wound may be beneficial,” he told Dermatology Times®. Another example was delivering genetically modified bacteria, lactobacillus, which produces a growth-promoting substance that speeds wound healing. He also discussed specific viruses that infect bacteria (bacteriophages), which “can recognize, infect and kill most bacteria, including antibiotic-resistant strains,” Kirsner said. Alternatively, vaccines can be made to targetbacteriophages, destroying them and as a consequence destroy the bacteria in which they reside. All these treatments are in trials and hopefully will come to fruition in the coming years, Kirsner said.
4. Wounding with fractional laser, which destroys a very small column of skin and heals without scarring, can reduce skin cancer development. He highlighted a 2021 study that reported that fractional laser use in elderly skin stimulated the protein insulin-like growth factor 1 (IGF-1), which is found in lesser quantity in aged skin.⁷ Skin treated in this way was at reduced risk for actinic keratosis and skin cancer, Kirsner said, noting that this has been shown in both animal and human studies.
5. Monitor research onreplicating scarless embryonic healing. He said this has been evolving over the last 30-plus years. New data capitalizes on the mechanisms and pathways that cause fibroblast phenotypic differences between fetuses and adults.⁸ Devices and drugs which target these pathways may help reduce scarring.

In an interview with Dermatology Times®, Kirsner said, “Often dermatologists don’t think much about wound healing, but dermatologists can leverage the research, tools, and technologies to improve patient outcomes both currently and in the future.” He said dermatologists should be alert to new information as integration of wound healing with the dermatologic procedures know may represent novel ways to address common skin diseases such as skin cancer.

References:

1. Kirsner RS,. What’s new and what’s known in wound healing for dermatologists.Presented at: Maui Derm 2022; January 26, 2022; Wailea, Hawaii.
2. Jockenhöfer F, Knust C, Benson S, Schedlowski M, Dissemond J. Influence of placebo effects on quality of life and wound healing in patients with chronic venous leg ulcers. J Dtsch Dermatol Ges. 2020;18(2):103-109. doi:10.1111/ddg.13996.
3. Al-Jalodi O, Serena LM, Breisinger K, Patel K, Harrell K, Serena TE. A novel debridement device for the treatment of hard-to-heal wounds: a prospective trial. J Wound Care. 2021;30(Sup5):S32-S36. doi:10.12968/jowc.2021.30.Sup5.S32.
4. Dumville JC, Worthy G, Bland JM, et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ. 2009;338:b773. Published 2009 Mar 19. doi:10.1136/bmj.b773.
5. Luo H, Cao C, Zhong J, Chen J, Cen Y. Adjunctive virtual reality for procedural pain management of burn patients during dressing change or physical therapy: A systematic review and meta-analysis of randomized controlled trials. Wound Repair Regen. 2019;27(1):90-101. doi:10.1111/wrr.1.
6. Wang G, Sweren E, Liu H, et al. Bacteria induce skin regeneration via IL-1β signaling. Cell Host Microbe. 2021;29(5):777-791.e6. doi:10.1016/j.chom.2021.03.003.
7. Spandau DF, Chen R, Wargo JJ, et al. Randomized controlled trial of fractionated laser resurfacing on aged skin as prophylaxis against actinic neoplasia. J Clin Invest. 2021;131(19):e150972. doi:10.1172/JCI150972.
8. Mascharak S, desJardins-Park HE, Davitt MF, et al. Preventing Engrailed-1 activation in fibroblasts yields wound regeneration without scarring. Science. 2021;372(6540):eaba2374. doi:10.1126/science.aba2374.