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Using Skin Replacement Products to Treat Burns and Wounds
From the New NursingCenter http://www.nursingcenter.com/
 
NOTE: The graphic are very sensitive and have been added to the bottom of this page.
 
Advances in Skin & Wound Care: The Journal for Prevention and Healing
January/February 2001 
Volume 14 Number 1
Page 37
Sean L. Hansen, BS
David W. Voigt, MD
Pamela Wiebelhaus, BSN, RN
Chester N. Paul, MD, FACS

PURPOSE

To offer an educational experience that will help to improve the participants understanding of the indications for various skin replacement products and how these products are used in clinical practice to manage burns and wounds.

TARGET AUDIENCE STATEMENT

This CME/CE activity is intended for physicians and nurses with an interest in the prevention, diagnosis, and treatment of chronic wounds and burns.

LEARNING OBJECTIVES

At the conclusion of this course, participants should be able to:

  1. Describe the various skin replacement products.
  2. Describe the process for selecting the appropriate skin replacement product based on clinical conditions.
  3. Summarize the risks and benefits of the various skin replacement products.

Submitted August 31, 1999; accepted in revised form March 14, 2000. ADV SKIN WOUND CARE 2001;14:37-46.

Recent advances in the treatment of burns have led to the increased survival of extensively burned patients. Early excision and skin grafting of a burn is quite possibly the single greatest advance in burn care that has increased patient survival.1-4 With the early excision and grafting of devitalized tissue, the major source of infection is eliminated.5 However, many patients with large total body surface area burns cannot be completely grafted, due to a lack of viable donor sites. Although split-thickness skin grafts may be meshed and expanded to increase wound closure, this technique may cover only a relatively small portion of the wound bed. This dilemma has prompted the development and use of various artificial and biologic skin replacement products.

Over the past several years, burn center clinicians have used skin replacement products in the treatment of burns. This experience and their experience managing wounds have given burn clinicians the confidence to transition skin replacement products for use in the treatment of chronic wounds. Skin replacement products offer another effective tool for burn and wound care clinicians. Table 1 summarizes the indications and clinical considerations for use of these products.

Table 1.
Skin Replacement Products: Indications For Use
 
PRODUCT INDICATIONS FOR USE CLINICAL CONSIDERATIONS
Temporary Skin Replacement Products
Allograft Temporary covering for excised burns or wounds; may be used as a protective covering over autografts
  • If well-adhered to the wound bed, can remain intact for 2 to 3 weeks
  • Biobrane Temporary covering for clean, debrided superficial and partial-thickness burns and donor sites; may also be used as a protective covering over meshed autografts
  • Minimizes painful dressing changes
  • May be left open to air
  • Remains in place until wound is healed, then is trimmed away
  • TransCyte Temporary covering for mid-dermal to indeterminate-depth burns that typically require debridement and may be expected to heal without surgical intervention; also indicated as a temporary covering for surgically excised full-thickness and deep partial-thickness burns prior to autografting
  • Minimizes painful dressing changes
  • Remains in place until wound is healed
  • Contraindicated in patients with a known hypersensitivity to porcine dermal collagen or bovine serum albumin
  • Permanent Skin Replacement Products
    Integra For treatment of life-threatening full-thickness or deep partial-thickness thermal injury where sufficient autograft is not available at the time of excision or not desirable due to the physiologic condition of the patient
  • Provides immediate postexcisional physiologic wound closure
  • Allows the use of a thin epidermal autograft of 0.005 inch
  • Must remain in place for 21 days before epidermal autografting; must be protected against shearing forces and mechanical dislodgment
  • Contraindicated in patients with a known hypersensitivity to bovine collagen or chondroitin materials
  • Contraindicated in the presence of infection
  • AlloDerm For treatment of full-thickness burns and use in plastic and oral surgery
  • Immunologically inert
  • Allows for immediate wound closure with thin epidermal autografting during same procedure
  • Postoperative dressing may remain in place for 14 days or longer
  • Apligraf (Graftskin) For use in conjunction with standard compression for treatment of noninfected partial- and full-thickness skin ulcers due to venous insufficiency of greater than 1 month's duration that have not adequately responded to conventional ulcer therapy; for use with conventional diabetic foot ulcer care in the management of diabetic foot ulcers of greater than 3 weeks' duration
  • Does not require additional autografting
  • Contradicted for use on clinically infected wounds, in patients with a known allergy to bovine collagen, and in patients with a known hypersensitivity to the contents of the agarose shipping medium
  • Dermagraft For treatment of foot ulcers in diabetic patients (Canada and United Kingdom); clinical trials ongoing in the United States for treatment of diabetic foot ulcers
  • Applied weekly for up to 8 weeks to promote healing
  • Does not require additional autografting
  • Cultured Epidermal Skin Replacement Product
    Epicel (cultured epidermal autografts) For treatment of deep dermal or full-thickness wounds where sufficient donor sites are unavailable.
  • Cultured keratinocytes can be grown in 3 weeks
  • Graft take varies from poor to fair
  • Process is expensive
  • Grafts extremely fragile and may remain so for months after grafting
  •  

    Temporary Skin Replacement Products

    Allograft

    Structurally and functionally, the best temporary skin replacement is fresh human cadaver allograft skin. However, availability is limited due to the risk for transmission of disease and difficulties associated with handling and transporting the material. For this reason, frozen human allograft skin is more commonly used.

    Cadaver skin is used by most burn centers in the United States to achieve temporary wound closure in excised burn wounds.6 Skin banks, where allogenic split-thickness skin grafts are frozen, were first introduced by Bondoc and Burke in 1971.7 At a skin bank, skin is usually harvested within 24 hours of death at a thickness of 0.015 inches.8 The harvested skin is frozen in a cryopreserved fluid containing 10% glycerol and is stored in liquid nitrogen vapor.9 Once thawed and placed on the excised wound bed, cadaver skin effectively closes the wound and begins to prepare the area for definitive grafting with the patients skin. After allograft skin has adhered to the wound bed, it is removed and usually will leave a vascularized wound base to accept an autograft, increasing the chance that the autograft will be successful. The immunosuppression that occurs in large burns allows the allograft to remain in place for several weeks without rejection.10

    Allograft has proven very useful in preparing chronic wound beds for skin grafting as well. However, as a chronic wound begins to granulateand appears healthy enough to accept autograftit may be heavily colonized with microrganisms that sometimes delay or inhibit autograft adherence.

    There are disadvantages associated with using cadaver allograft skin in the treatment of chronic wounds. Because it is in high demand, cadaver allograft is not always available in sufficient quantities. In addition, the quality of the allograft may vary, depending on the age of the donor and the body location of the harvested skin. Prolonged storage in ultra-low temperature freezers may diminish allograft viability. Furthermore, epidermal sloughor separation of epidermis from the dermal layerhas been observed following the placement of frozen allograft on the wound bed. This phenomenon is rarely associated with the use of fresh allograft; however, the availability of fresh allograft is even more limited than frozen allograft.

    One of the most serious drawbacks of using allograft skin in the treatment of burns or wounds is the potential for disease transmission. The Food and Drug Administration (FDA) and the American Association of Tissue Banks have issued guidelines for mandatory screening, testing of acute and chronic infections, and documenting the donors medical history before skin harvesting.11-13 Prior to these guidelines, disease transmission had been reported in association with donor allografts.14

    Biobrane

    Biobrane (Bertex Pharmaceuticals, Morgantown, WV) has been successfully used as a temporary skin replacement for burn wounds that do not require surgical excision, such as partial-thickness burns.15 It is indicated as a temporary covering for clean, debrided superficial and partial-thickness burns and donor sites (Figure 1 and Figure 2) and may be used as a protective covering over meshed autografts.

    Biobrane is a knitted nylon mesh that is bonded to a thin silicone membrane. The silicone membrane provides a barrier against bacteria invasion and water-vapor transmission. The application of Biobrane minimizes painful burn wound care and dressing changes. Biobrane may be left open to air or covered with a light dressing for the first few days after application. As a burn wound heals, Biobrane is trimmed away from the site.

    Biobrane has been used successfully in the treatment of superficial partial-thickness burns, especially in the outpatient setting and in the treatment of donor sites.16-18 Biobrane has not been used for the treatment of chronic wounds because it has no antimicrobial properties.

    One report examined the use of Biobrane in 106 pediatric partial-thickness scald burns.19 The Biobrane was applied immediately after resuscitation and debridement. Once stable, the patients were discharged and treated as outpatients, decreasing the cost of burn wound care and hospitalization. In this study, the authors found Biobrane to be an acceptable option in treating partial-thickness burns.

    Fluid accumulation was the only reported complication in the clinical trials of Biobrane.

    TransCyte Temporary Skin Substitute

    With TransCyte (Advanced Tissue Sciences, La Jolla, CA), the concept of Biobrane has been taken a step further. TransCyte is a human fibroblast-derived temporary skin substitute consisting of a polymer membrane and newborn human fibroblast cells cultured under aseptic conditions in vitro on a porcine collagen coated nylon mesh. The membrane is biocompatible and protects the burn wound surface from environmental insults. In addition, the membrane is semipermeable, allowing for fluid and gas exchange. As the fibroblasts proliferate within the nylon mesh, they secrete human dermal collagen, matrix proteins, and growth factors.

    TransCyte is frozenno cellular metabolic activity remains. However, the bioengineered human dermal matrix contains essential structural proteins (collagen types I, III, and V), provisional matrix proteins (fibronectin, tenascin, and SPARC), glycosaminoglycans (versican, decorin), and growth factors (transforming growth factor­beta1, keratinocyte growth factor, vascular endothelial growth factor, and insulin-like growth factor-1).

    TransCyte is indicated for use as a temporary skin replacement for mid-dermal to indeterminate depth partial-thickness burns (Figure 3). TransCyte is also indicated as a temporary covering for surgically excised full-thickness and deep partial-thickness burns prior to autografting.

    After the burn wound bed has been thoroughly cleansed and debrided, TransCyte is applied in a sterile fashion. Adhesive strips or surgical adhesives may be used to ensure adequate adherence to the burn wound bed. TransCyte should be dressed with a bulky dressing for at least 24 hours and inspected after placement. Similar to Biobrane, TransCytes mesh is not biodegradable; it should be removed after healing has occurred.

    Recently published studies have discussed the use of TransCyte in the treatment of partial-thickness burns. Noordenbos et al conducted a prospective, randomized comparison study of silver sulfadiazine and TransCyte using paired burn wound sites on 14 patients and a noncomparison evaluation of 18 patients.20 The investigators found that the burn wounds treated with TransCyte healed more rapidly than the burn wounds treated with silver sulfadiazine (mean = 11.4 days to 90% epithelialization vs 18.14 days; P = .002). No infections occurred in the 32 burn wounds treated with TransCyte. In addition, burn wound site evaluations completed at 3, 6, and 12 months revealed less hypertrophic scarring on the TransCyte-treated wounds (P <.001 at 3 and 6 months, P = .006 at 12 months).

    In a study by Demling and DeSanti, TransCyte was compared with bacitracin ointment in the treatment of partial-thickness facial burns.21 Twenty-one patients were included in the study; 10 were treated with TransCyte. Patients in the control group were treated using open dressings with bacitracin ointment applied 2 to 3 times a day. The authors found a significant decrease in wound care time (0.35 0.1 hours vs 1.9 0.5 hours); a decrease in pain (2 1 vs 4 2, on a 0 to 10 scale, where 0 = no pain and 10 = extreme pain); and a decrease in reepithelialization time (7 2 days vs 13 4 days) in the patients treated with TransCyte.

    Fluid accumulation was the only reported complication in the clinical trials of TransCyte.

    TranCyte should be applied as soon as possible after injury. As the wound epithelizes, TransCyte will develop an opaque appearance. After approximately 7 days, TransCyte can be removed from healed wound sites by trimming or peeling. If the product remains tightly adhered to the wound bed, postpone removal for 1 to 2 days.

    Permanent Skin Replacement Products

    Integra Artificial Skin

    Integra (Integra Life Sciences, Plainsboro, NJ) was approved by the FDA in 1996 for use in the treatment of burns. Integra is indicated for the postexcisional treatment of life-threatening full-thickness or deep partial-thickness thermal injury where sufficient autograft is not available at the time of excision or is undesirable due to the physiologic condition of the patient (Figure 4, Figure 5 and Figure 6).22

    Integra is composed of a bilaminate membrane consisting of a bovine collagen-based dermal analogue and a temporary epidermal substitute layer of silicone.23,24 The dermal replacement layer of Integra consists of a porous matrix of fibers of bovine type I collagen that is crosslinked with chondroitin-6-sulfate, and glycosaminoglycan (GAG) extracted from shark cartilage. The porous matrix is designed to serve as a template for infiltration of the patients fibroblasts, macrophages, lymphocytes, and capillaries.25 The outer silicone layer of Integra serves as a temporary epidermis and allows for water flux, protection from microbial invasion, and prevention of burn wound desiccation.

    Integra allows the physician another option to accomplish early excision of extensive burns without the need for immediate donor sites. Once Integra has been placed on an excised wound, it must remain there for approximately 2 to 3 weeks. During that time, the dermal component incorporates itself into the patients cell-producing neodermis. After the neodermis has formed, the silicone layer is removed and a thin epidermal autograft of 0.005 inch may be applied. During the period between placement and epidermal autografting, the Integra grafts should be protected from mechanical dislodgment and observed daily for signs and symptoms of infection or hematoma formation. In 1 study, Integra remained successfully in place for 73 days prior to epidermal autografting.26

    In 1988, Heimbach et al conducted an 11-center, prospective, randomized trial using Integra on 139 burn wound sites of 106 patients.26 The control materials were autograft, allograft, xenograft, and a synthetic dressing. The investigators found that the median artificial dermis (Integra) take was 80% when compared with 95% for all comparative sites. However, the Integra take was equivalent to that of the nonautograft control materials. In this study, subjects were followed for 1 year after their injury. At the completion of the study, the investigators found less hypertrophic scarring of the artificial dermis when compared with control materials. The investigators also found that more patients preferred the artificial dermis to the control graft.

    In a 1990 histologic evaluation of Integra by Stern et al,27 336 serial biopsies were obtained from 131 patients during a period of 7 days to 2 years after application. The authors found an intact dermis was achieved with definitive closure of a complete epidermal layer with minimal scarring.

    Of the adverse events reported in clinical trials of Integra, none were directly related to the use of the product with the exception of wound fluid accumulation and positive wound cultures. Currently, a multicenter postapproval study on Integra is under way. Because the neodermis requires 3 weeks for vascularization and a second operative procedure for the application of the ultra-thin autograft, cost issues should be considered.

    AlloDerm Acellular Dermal Graft

    AlloDerm (Life Cell Corporation, The Woodlands, TX) is a chemically treated cadaver allograft in which the epidermal antigenic cellular components are removed, leaving an immunologically inert acellular dermal matrix. Clinical studies of AlloDerm have demonstrated that it can accept and maintain the viability of ultra-thin split-thickness autografts.28-31

    AlloDerm is produced by first treating screened allograft with a high-salt solution in which the epidermis is removed. The dermis is then decellularized and freeze-dried for storage. This process does not disrupt matrix proteins and preserves the basement membrane complex. It appears that the preservation of the basement membrane complex plays a crucial role in the success of the epithelial growth on AlloDerm.32-34

    For the treatment of burns, AlloDerm is applied to an excised burn wound and, unlike Interga, an ultra-thin split-thickness (0.003- to 0.006-inch) autograft is applied during the same operation, allowing for complete wound closure (Figure 7). Postoperative dressings may be left in place for 14 days or longer to ensure complete graft take. In addition to its use in the treatment of burn patients, AlloDerm has also been used in oral and plastic surgery.35

    A study published by Livesey et al indicated that AlloDerm could be used successfully in the treatment of full-thickness burns and wounds with no apparent immune effect.36 The authors used a porcine model to investigate the processing methods to produce an acellular dermal matrix. In vivo examinationin a rat subcutaneous implant studyconfirmed the absence of local and systemic toxicity. The study also investigated the use of this dermal matrix with a meshed split-thickness autograft. Histologic assessment revealed no inflammatory cell infiltrate or cell-mediated immune response.

    Sheridan et al conducted a 1-year follow-up study of 6 children who received AlloDerm.37 End points in the study were identified by initial engraftment and Vancouver scar scores. All patients received acellular allodermis with autograft thickness of 0.0074 0.0007 inch, in addition to matched control sites with conventional autograft of 0.0102 0.0008 inch. Nine of the surgical procedures were reconstructive and 1 was performed during an acute burn wound excision. During follow-up examination at 43.7 3.6 weeks (range 26 to 52 weeks), the subjects Vancouver scar scores were no different for treated sites when compared with control sites.

    Apligraf, a Human Skin Equivalent

    Apligraf (Graftskin; Organogenesis Inc, Canton, MA) is the only bilayered living skin equivalent approved by the FDA for use in the treatment of venous and diabetic foot ulcers.38

    Apligraf is composed of type I bovine collagen, allogenic keratinocytes, and fibroblasts39; the cellular components are derived from human neonatal foreskin. In the manufacturing of Apligraf, the fibroblasts are combined in a preparation of type I bovine collagen and heated to create a matrix of the fibroblasts. After a week of gel contraction, keratinocytes are added to form an epidermal layer. Several days after the keratinocytes have been added, the mixture is exposed to air, allowing keratinocyte differentiation and the formation of a stratum corneum. At this time, the construct is able to produce matrix components, including cytokines and growth factors.40

    Apligraf is similar to human skin in many ways. In addition to being biochemically and metabolically similar, the cell proliferation rate is comparable to that of human skin.41,42 Apligraf is only available fresh and has a shelf life of 5 days at room temperature.

    An investigation by Eaglstein et al evaluated Apligraf in the treatment of surgical wounds caused by the removal of skin cancers.43 The study consisted of 15 patients with an 80% graft take and showed no toxicity or evidence of rejection with Apligraf.

    Falanga et al conducted a larger multicenter study that investigated the use of Apligraf in 293 patients with nonhealing venous ulcers.44 In this study, patients were randomized for treatment with Apligraf and compression therapy or compression therapy alone. Each patient was evaluated for product safety, complete ulcer healing, time to wound closure, wound recurrence, and immune response. Examination of patients healed at 6 months showed that Apligraf and compression therapy was more effective than compression therapy alone (63% vs 49%). In addition, rate of healing was greatly reduced with the use of Apligraf (61 days vs 181 days). As was found in previous studies, no signs or symptoms of rejection were noted with Apligraf.

    Dermagraft

    Dermagraft (Advanced Tissue Sciences, La Jolla, CA) is a living dermal equivalent that contains allogenic neonatal fibroblasts on a bioabsorbable polyglactin mesh. Dermagraft is available in Canada and several European countries for the treatment of diabetic foot ulcers, with FDA approval pending the results of an additional pivotal clinical trial in the United States. Clinical trials of Dermagraft in the management of venous ulcers and pressure ulcers are ongoing. The science behind this product is similar to TransCyte because the fibroblasts produce a dermal matrix of collagen, proteins, and growth factors. TransCyte, however, does not consist of a bioabsorbable material.

    There are 3 major production steps in the manufacturing of Dermagraft. First, fibroblasts from human neonatal foreskin are screened, enzymatically treated, and either banked or placed into a tissue culture. Allogenic dermal fibroblasts are then seeded onto a bioabsorbable polyglactin mesh. Last, the cells proliferate and produce dermal collagen, growth factors, GAGs, and fibronectin during a 2- to 3-week period.

    A multicenter, randomized, single-blinded pilot study evaluated healing in 50 patients with diabetic foot ulcers treated with Dermagraft.45 Ulcer healing was evaluated by percentage of wounds that achieved complete or 50% closure, time to closure, volume, and area measurements. Subjects who received the highest doses of Dermagraft1 piece applied weekly for 8 weekshealed significantly more often and faster than subjects treated with traditional wound closure methods. A larger randomized, controlled, single-blinded study of diabetic foot ulcers on 281 patients also concluded that Dermagrafts healing rate was higher when compared with the control group. In addition, Dermagraft appeared to delay ulcer recurrence in this study.46

    Dermagraft can support the take of meshed split-thickness skin grafts on excised burn wounds.47 Clinical studies to further examine this phenomenon are being conducted in the United States.

    Cultured Epidermal Replacement Product

    Epicel

    In 1975, Rheinwald and Green described a method of in vitro cultivation of epidermal cells that produced viable keratinocyte sheets.48 By 1979, in vitro prepared cells were available for human transplantation and, in 1988, cultured epithelial autografts (CEA) became commercially available as Epicel (Genzyme Tissue Repair Corporation, Cambridge, MA).49

    Epicel is indicated for the treatment of deep dermal or full-thickness wounds requiring skin grafting (Figure 8 and Figure 9). The use of Epicel is contraindicated in patients who have a history of previous hypersensitivity or serious toxic reactions to penicillin, streptomycin, or gentamicin. The CEA production process requires a small biopsy of a patients skin and a 2- to 3-week time frame for cultivation. This process is expensive and can range from $6,000 to $10,000 per 1% total body surface area.

    Epicel sheets are thin and fragile and should be handled with extreme care during and after application. Studies have found that healed epithelium can be very fragile and the skin can be prone to contraction and breakdown.50,51 Postoperative wound care should be meticulous, with special attention paid to the prevention of shearing the epidermal grafts.

    Numerous clinical trials have been published on the use of Epicel in burns and wounds.52-57 One of the largest of these clinical trials examined 16 patients with an average burn size of 68% (range 42% to 85%) and an average age of 29 years old (range 10 to 56 years). Mean body surface area of definitive wound closure of the Epicel graft was found to be 4.7% (range 0% to 18.6%).58

    A retrospective review documented the use of Epicel in 5 patients with burns in excess of 90% total body surface area.59 The average patient age was 11.5 years (range 7 months to 37 years), with an average burn size of 94% (range 90% to 96%). At the time of grafting with Epicel, all subjects had vascularized allodermis present. Initial graft take of the Epicel was 51% (range 20% to 80%), with a delayed average loss of 60% (range 20% to 100%). After exclusion of 2 subjects who had 100% loss of Epicel, the delayed graft loss was 33% (range 20% to 50%) and the definitive closure rate was 12.5% (range 11.2% to 15%). A later study by Chalumeau et al that examined Epicel use in 6 children produced a definitive closure rate of 45% (range 18% to 57%).60

    Summary

    Much progress has been made toward the development of artificial skin replacement products. Continued research promises to bring more products to the marketplace, and each new product seems to develop a niche in the field of skin replacement. However, although each skin replacement product has unique properties and advantages, nothing works as well as a patients own skin. Clinicians can only hope for an off-the-shelf skin replacement product that can be applied to a wound and yield a permanent, dependable dermis and epidermal skin replacement for all patients.


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    From the Saint Elizabeth Regional Burn and Wound Care Center, Lincoln, NE

    Sean L. Hansen, BS * Burn Research Coordinator

    David W. Voigt, MD * Director of Burn Research

    Pamela Wiebelhaus, BSN, RN * Director of Burn Services

    Chester N. Paul, MD, FACS * Burn Center Medical Director

    Mr Hansen, Dr Voigt, Ms Wiebelhaus, and Dr Paul are the recipients of research grants from Integra LifeSciences. The Saint Elizabeth Regional Burn and Wound Care Center was a clinical site for the FDA Post Approval Study for Integra Artificial Skin in 1999. Mr Hansen served as the study coordinator and Dr Voigt served as the primary investigator. Ms Weibelhaus and Dr Paul participated in the study.

    FIGURES

    Figure 1
    Biobrane Glove Applied In The Operating Room

    Figure 4
    Integra Application To Lower Leg

    Figure 6
    Integra Grafts To Bilateral Legs With Elastic Net Dressings In Place

    Figure 8
    Application of Cultured Epidermal Autografts

    Figure 2
    Mature Donor Site (Thigh) Covered With BioBrane
    Figure 3
    7-Day-Old Transcyte on The Abdomen and Chest (Partial-Thickness Burn)
    Figure 5
    Integra Application To Thigh (Full-Thickness Burn)

    Figure 7
    Alloderm Application To Thigh (Full-Thickness Burn)

    Figure 9
    Cultured Epidermal Autografts Applied to the Hand and Arm