Scar quality and physiologic barrier function restoration after moist and moist-exposed dressings of partial-thickness wounds

The Effect of Using Ofloxacin Ear Drops in Traumatic Tympanic Membrane Healing: A Systematic Review and Meta-Analysis

Objectives: To evaluate the effectiveness of ofloxacin ear drops versus no intervention in the repair of traumatic tympanic membrane (TM) perforations from randomized controlled trials (RCTs). Data Sources: Medline/PubMed, CENTRAL, Clinical Trials.Gov, and Google Scholar. Study Selection: Inclusion criteria: (1) English language; (2) RCT studies; (3) reported the outcomes on the application of ofloxacin and outcomes of spontaneous healing. Exclusion criteria: (1) studies without a control group; (2) patient with severe otologic disease such as chronic suppurative otitis media or ossicular disruption or patients with craniocerebral injury; (3) studies with no pretreatment values or single-arm clinical studies. Data Extraction: Country, year of publication, number of participants in each arm, patient characteristics such as age, sex, intervention details, laterality, cause of TM perforation, position of perforation, follow-up time, hearing gain, rate of TM closure, and closure time. Results: A total of 6 RCTs studies were analyzed. A total of 502 participants were included; the relative risk for closure rate of ofloxacin treatment was 1.18 [95% confidence interval (CI), 1.08 to 1.28, P < .001] and the mean difference (MD) for healing time was -18.4 (95% CI, -19.96 to -16.82, P < .001), suggesting ofloxacin has a significant effect on closure of TM perforations. However, no clinically significant effect in hearing (SMD: 0.21, 95% CI, 0.02 to 0.40, P = .03) was seen in ofloxacin group. Also, patients in the ofloxacin group were associated with a 13% reduction in the risk of infections compared to their observation-assigned counterparts, but this estimate was not statistically significant. Conclusion: Ofloxacin use in patients with traumatic TM perforation is effective in reducing healing time and increasing rate of TM perforation closure. No evidence of increased risk of hearing loss or infection rates are encountered when ofloxacin is prescribed to patients with traumatic TM perforation.

Severity of Wound-Related Pain and Associated Factors Among Patients Who Underwent Wound Management at Teaching and Referral Hospital, Northwest Ethiopia

Background

Wound management is one of the commonly performed procedures in hospitals. It can be a major source of pain and pain may be a frequently experienced but under-considered component of wound management. Therefore, we aimed to determine the severity of wound-related pain and identifying factors associated with it among patients who underwent wound management.

Patients and Methods

An institutional-based, cross-sectional study was conducted from March to May, 2020 in the University of Gondar Comprehensive Specialized Hospital. A total of 424 patients were included in this study. Data were collected by direct observation, chart review, and interview of patients by using questionnaires. Statistical analysis had performed using SPSS 25.00 version statistical software. Descriptive statistics were conducted to summarize patients’ information and to determine the prevalence of pain. Bi-variable analysis was performed to determine each of the independent variables and only variables with a P-value<0.2 were entered into the multivariable analysis. The strength of the association was present by odds ratio and 95% Confidence interval. P-value<0.05 was consider as statistically significant.

Results

The prevalence of moderate-to-severe wound-related pain during wound management was 94.1% (95% CI=91.7–96.2). Anxiety (AOR=18.16; 95% CI=4.83–68.23), acute wound (AOR=11.49; 95% CI=1.013–130.2), baseline pain (AOR=3.51; 95% CI=1.18–10.46), and analgesia intake (AOR=0.026; 95% CI=0.001–0.895) were significantly associated with the severity of wound-related pain.

Conclusion

The prevalence of moderate-to-severe wound-related pain was considerably high. Anxiety, type of wound, baseline pain, and analgesia intake were the independent risk factors. Therefore, wound care providers should assess the severity of wound-related pain and manage accordingly. Additionally, more emphasis should be given for patients who have baseline pain, anxiety, and acute wound.

Development and Evaluation of a Polyvinylalcohol -Cellulose Derivative-Based Film with Povidone-Iodine Predicted for Wound Treatment

The aim of this study was to develop and assess a polyvinyl alcohol-cellulose derivatives-based film with incorporated povidone-iodine (PVP-I) predicted for applications in the treatment of periodontitis. Films were fabricated by solvent-casting, and their physical characteristics, such as their surface and structure morphology, mechanical properties, and disintegrating time, were evaluated. For in vitro iodine release studies and evaluation, the antimicrobial activity was tested using a modified disc diffusion method against five microbial strains. For further use, we selected the film with polyvinyl alcohol-hydroxypropyl methylcellulose (PVA/HPMC_B) based on acceptable physicochemical properties. To assess the subacute toxicity of the film composition, the tissue regeneration process was tested in rats and compared to a conventional dressing commonly used in wound healing (Spongostan). Seven days after implantation, dorsal skin sections and blood samples (n = 10, in total n = 30) were examined. The wound area, epithelium, and dermis were evaluated microscopically, while the blood collected from the rats underwent biochemical analysis. The blood biochemistry results were comparable in all three groups. No significant histological differences between the Spongostan and the placebo film developed after subcutaneous implantation were observed. In contrast, the inflammation stage was reduced and the “scar” in the dermis was smaller when PVP-I and PVA/HPMC_B films were used. A smaller local inflammatory response inflicted less tissue damage, leading to the activation of subsequent regeneration phases and restoration of the area to its original state. The results obtained confirmed that PVP-I incorporated into PVA-hydroxypropyl methylcellulose film is a promising drug carrier, working faster and more effectively than the other two dressing materials evaluated. These developments provide a promising alternative in tissue regeneration and the wound healing process.

Functional Testing of a Skin Topical Formulation In Vivo: Objective and Quantitative Evaluation in Human Skin Scarring Using a Double-Blind Volunteer Study with Sequential Punch Biopsies

Objective: Many topicals claim an efficacious role in skin scar management with limited evidence. Our aim is to present a clear format for functional testing of a skin scarring ointment, using noninvasive and invasive measurements, categorizing findings under the physiological, structural, and mechanical parameters of a scar. Approach: A double-blinded, randomized volunteer research study of 45 subjects receiving an ointment composing of natural ingredients against a widely used antiscarring topical used as a positive control with temporal sequential punch biopsies (up to 16 weeks) was evaluated using noninvasive quantitative devices and validated by gene and protein studies. Results: Outcome measures included physiological, mechanical, and structural features of scars. Significant non-invasive findings included an increase in skin hydration (p < 0.05) at week (W) 4, 8, and 12, and elasticity (W16; p = 0.009). These findings were validated by immunohistochemistry (IHC) and quantitative real-time PCR (qRT-PCR). Hyaluronic acid IHC (W4 p = 0.014, W12 p = 0.034, and W16 p = 0.042), qRT-PCR (W16 p = 0.049); Collagen I (W16 p = 0.034, and 0.049) IHC and qRT-PCR, respectively. Collagen III qRT-PCR (W12 p = 0.035, and W16 p = 0.32); elastin IHC (W12 p = 0.044); and fibronectin IHC (W4 p = 0.009, W12 p = 0.038, and W16 p = 0.026). Innovation: Utilizing this model allows for quantitative, objective evaluation of any topical, where previously there has been a paucity of relevant methods to evaluate their effect. Conclusions: The positive effect of a topical formulation with an unknown mechanism of action on early cutaneous scar maturation over progressive sequential time points is now evidenced using noninvasive and invasive techniques with the findings categorized on the basis of scarring parameters.

Synthetic polymeric biomaterials for wound healing: a review

Wounds are of a variety of types and each category has its own distinctive healing requirements. This realization has spurred the development of a myriad of wound dressings, each with specific characteristics. It is unrealistic to expect a singular dressing to embrace all characteristics that would fulfill generic needs for wound healing. However, each dressing may approach the ideal requirements by deviating from the 'one size fits all approach', if it conforms strictly to the specifications of the wound and the patient. Indeed, a functional wound dressing should achieve healing of the wound with minimal time and cost expenditures. This article offers an insight into several different types of polymeric materials clinically used in wound dressings and the events taking place at cellular level, which aid the process of healing, while the biomaterial dressing interacts with the body tissue. Hence, the significance of using synthetic polymer films, foam dressings, hydrocolloids, alginate dressings, and hydrogels has been reviewed, and the properties of these materials that conform to wound-healing requirements have been explored. A special section on bioactive dressings and bioengineered skin substitutes that play an active part in healing process has been re-examined in this work.

The effect of different topical agents (silver sulfadiazine, povidone-iodine, and sodium chloride 0.9%) on burn injuries in rats

It was aimed to comparatively evaluate the effects of dressing methods with silver sulfadiazine, povidone-iodine, and saline which have a common use in routine practices for burn injuries. Twenty-eight Sprague Dawley adult female rats were used in this study. All the rats were divided into 4 groups: the control group, the povidone-iodine group, the saline group, and the silver sulfadiazine group. On each rat, a second degree burn which covered less than 10% of the body surface area was created under general anesthesia by a metal comb including four probes with 2 × 1 cm area. The control group did not have any treatment during the experiment. Povidone-iodine, saline, and silver sulfadiazine administrations were performed under ether anesthesia every day. On 0, 7th, 14th, and 21st days of the study, tissue samples were taken for histological analyses. The sections taken from the paraffin blocks were stained and avidin-biotin-peroxidase method was used for collagen immune-reactivity. In the light microscope analyses, number of inflammatory cells, vascularization, fibroblast proliferation, collagen formation and epithelialization were evaluated histologically in all groups and analysed statistically. The agents that we used for injury healing in the treatment groups did not show any significant better results in comparison with the control group. In conclusion, further studies with the use of sodium chloride, silver sulfadiazine, and povidone-iodine by creating deeper and/or larger burn injury models are needed in order to accept these agents in routine treatment.

Role of epidermal stem cells in repair of partial-thickness burn injury after using Moist Exposed Burn Ointment (MEBO(®)) histological and immunohistochemical study

Moist Exposed Burn Ointment (MEBO(®)) is widely used topical agent applied on skin burn. This study investigated the effect of MEBO topical application on activation and proliferation of epidermal stem cells through the immunohistochemical localization of cytokeratin 19 (CK19) as a known marker expressed in epidermal stem cells. Biopsies from normal skin and burn wounds were taken from 21 patients with partial thickness burn 1, 4, 7, 14, 21, and 28 days after treatment with MEBO. Tissue sections were prepared for histological study and for CK19 immunohistochemical localization. In control skin, only few cells showed a positive CK19 immune-reaction. Burned skin showed necrosis of full thickness epidermis that extended to dermis. Gradual regeneration of skin accompanied with an enhancement in CK19 immune-reactivity was noted 4, 7, 14 and 21 days after treatment with MEBO. On day 28, a complete regeneration of skin was observed with a return of CK19 immune-reactivity to the basal pattern again. In conclusion, the enhancement of epidermal stem cell marker CK19 after treatment of partial thickness burn injuries with MEBO suggested the role of MEBO in promoting epidermal stem cell activation and proliferation during burn wound healing.

Clinical Evaluation of NIKS-Based Bioengineered Skin Substitute Tissue in Complex Skin Defects: Phase I/IIa Clinical Trial Results

BACKGROUND

Complex skin defects, such as burns and acute cutaneous trauma, are life-threatening injuries, often requiring temporary allograft placement to maintain fluid homeostasis and prevent infection until permanent wound closure is possible.

THE PROBLEM

The current standard of care for the management of full-thickness wounds that are unable to be closed in a single surgical stage is temporary coverage with cadaver allograft until an acceptable wound bed has been established. This approach has limitations including limited availability of human cadaver skin, the risk of disease transmission from cadaveric grafts, and inconsistent cadaver allograft quality.

BASIC/CLINICAL SCIENCE

Near-diploid neonatal human keratinocyte cell line (NIKS)-based human skin tissue is a full-thickness, living human skin substitute composed of a dermal analog containing normal human dermal fibroblasts and a fully-stratified, biologically and metabolically active epidermis generated from NIKS keratinocytes, a consistent and unlimited source of pathogen-free human epidermal progenitor cells.

CLINICAL CARE RELEVANCE

NIKS-based human skin tissue is a living bioengineered skin substitute (BSS) intended to provide immediate wound coverage and promote wound healing through sustained expression by living cells of wound healing factors.

CONCLUSION

A phase I/IIa clinical trial found that NIKS-based BSS was well tolerated and comparable to cadaver allograft in the ability to prepare full-thickness complex skin defects prior to autografting. There were no deaths and no adverse events (AE) associated with this BSS. Exposure of the study subjects to the skin substitute tissue did not elicit detectable immune responses. Notably, this tissue remained viable and adherent in the wound bed for at least 7 days.

Comparing oil based ointment versus standard practice for the treatment of moderate burns in Greece: a trial based cost effectiveness evaluation

BACKGROUND

The local treatment of burn wounds has long been a subject of debate. The objective of this study was to compare the cost and the effectiveness of Moist Exposed Burn Ointment -MEBO versus a combination of povidone iodine plus bepanthenol cream for partial thickness burns.

METHODS

The study was carried out in the Burn Center of a state hospital in Athens, Greece. 211 patients needing conservative therapy were prospectively selected according to the depth of the burn wound. The treatment was allocated according to the Stratified Randomization Design. The outcomes measured were mean cost of in-hospital stay, rate of complications, time of 50% wound healing, pain scores, in hospital stay diminution. We have adopted a societal perspective.

RESULTS

In the total groups MEBO presented lower cost, (although not significantly different: p = 0.10) and better effectiveness. The data suggest that MEBO is the dominant therapy for superficial partial burn wound with significantly lower costs and significantly higher effectiveness due to a lesser time of recovery and consequently lower time of hospitalization and follow-up. MEBO presented similar percentages of complications with the comparator, lower pain levels and smaller time of no healthy appearance of the burn limits for superficial partial thickness burns.

CONCLUSIONS

The data suggested that topical application of MEBO may be considered for further investigation as a potential first-line treatment modality for superficial partial thickness burns.

TRIAL REGISTRATION

The trial has been registered on the International Standard Randomised Controlled Trial Number Register (ISRCTN) and given the registration number ISRCTN74058791.

Reverse tissue expansion by liposuction deflation for revision of post-surgical thigh scars

Scars hypertrophy and widen when stretching mechanical forces are applied to resilient newly formed collagen before it reaches final maturity marring the final result of many surgical procedures and resulting in a clinical problem for many patients. Scar revision by surgical excision remains the traditional treatment for hypertrophic or widespread scars. It relies upon recruitment of local tissues for closure of the ensuing defect. Providing tension-free skin closure is the best option to avoid recurrence. Although tissue expansion procedure is a valuable and reliable technique for scar revision, it has its own disadvantages and potential complications. We describe an alternative method for scar revision that may be applicable in certain situations. Instead of expanding the soft tissues to make available additional skin, deflation by liposuction may be affected to relax the skin envelope thus indirectly providing additional skin for scar revision. We call this method 'reverse tissue expansion'.

Modulation of wound contracture alpha-smooth muscle actin and multispecific vitronectin receptor integrin alphavbeta3 in the rabbit's experimental model

The myofibroblast, a major component of granulation tissue, is a key cell during wound healing, tissue repair and connective tissue remodelling. Persistence of myofibroblasts within a fibrotic lesion leads to excessive scarring impairing function and aesthetics. Various wound-healing cytokines can be modulated by topical application of active agents to promote optimal wound healing and improve scar quality. Thus, the myofibroblast may represent an important target for wound-healing modulation to improve the evolution of conditions such as hypertrophic scars. The purpose of this work is to study the modulation of myofibroblasts and integrin alphavbeta3 in a full thickness wound performed on rabbits treated with different topical agents using: (1) saline, (2) Tegaderm occlusive dressing (3) silver sulfadiazine and (4) moist exposed burn ointment (MEBO). The reepithelialisation was 4 days faster in the MEBO group compared with the other therapies with less oedema formation, delayed contraction, less inflammatory cells and the lowest transepidermal water loss (TEWL) resulting in a soft scar. Although alpha-smooth muscle actin (alpha-SMA) was the highest around day 12 in the MEBO group, wound contraction and myofibroblast's activity were the least for the same period probably because of a downregulation of the integrin alphavbeta3. It seems that the effect of MEBO could be more pronounced on force transmission rather then on force generation. Greater insight into the pathology of scars may translate into non surgical treatments in the future and further work in myofibroblast biology will eventually result in efficient pharmacological tools, improving the evolution of healing and scar formation.

The use of a semiocclusive dressing reduces epidermal inflammatory cytokine expression and mitigates dermal proliferation and inflammation in a rat incisional model

Occlusive wound dressings are utilized clinically to accelerate wound healing and improve the final appearance of scars. In vivo and in vitro evidence suggests that one mechanism for this effect is maintenance of normal hydration in the epidermis, although the molecular signals remain uncharacterized. We sought to elucidate histological changes and some of the molecular signals involved in this effect in a rat model of wound semiocclusion. We utilized a rat linear incision model with surgical tape occlusion. Histological stains and quantitative real-time PCR analysis were used to characterize the cellular and molecular effects of semiocclusion on the wound healing response. Semioccluded wounds demonstrated decreased epidermal thickness and cellularity and less mitotic epidermal activity when compared with nonoccluded control wounds. Associated dermal cellularity was similarly attenuated by semiocclusion. Finally, levels of proinflammatory cytokines interleukin-1-alpha and tumor necrosis factor-alpha were significantly decreased on postoperative day 3 at the transcriptional level when compared with nonoccluded wounds. Semiocclusive wound treatments significantly decrease epidermal thickness, cellularity, mitotic activity, and dermal cellularity as well as transcriptional levels of important epidermal mediators of inflammation in a rat incisional wound model.

Pharmacological modulation of wound healing in experimental burns

Factors involved in wound healing and their interdependence are not yet fully understood; nevertheless, new prospects for therapy to favor speedy and optimal healing are emerging. Reports about wound healing modulation by local application of simple and natural agents abound even in the recent literature, however, most are anecdotal and lack solid scientific evidence. We describe the effect of silver sulfadiazine and moist exposed burn ointment (MEBO), a recently described burn ointment of herbal origin, on mast cells and several wound healing cytokines (bFGF, IL-1, TGF-beta, and NGF) in the rabbit experimental burn model. The results demonstrate that various inflammatory cells, growth factors and cytokines present in the wound bed may be modulated by application of local agents with drastic effects on their expression dynamics with characteristic temporal and spatial regulation and changes in the expression pattern. Such data are likely to be important for the development of novel strategies for wound healing since they shed some light on the potential formulations of temporally and combinatory optimized therapeutic regimens.

Successful combined treatment with total parenteral nutrition fluid extravasation injuries in preterm infants

Extravasation injuries in the neonatal intensive care unit are not rare during parenteral hyperalimentation. There have been many different methods of management. We report five premature infants with wounds of hyperalimentation fluid extravasation managed by the antibacterial ointment (Terramycin ophthalmic ointment and sesame oil and a antiinflammatory herbal mixture (MEBO).) The mean gestational age of patients was 31(+2) weeks (range, 28(+4) to 35(+6) weeks), and the mean weight at extravasation was 1,930 g (range, 1,140 to 2,680 g). Extravasation occurred within the mean of 32 days (range, 17 to 50 days). The method of dressing was application of a thick layer of this mixture covered by vaseline and wet gauze renewed at an interval of 8-12 hr after irrigating the wounds thoroughly with normal saline. The mean duration of dressing was 30 days (range, 20-50 days). The wounds had healed completely leaving a small size of contracture without functional abnormality. We conclude that this therapy may be considered for an alternative treatment and warrants clinical trials for the confirmation of the local management of extravasation injury.

Characterization strategies for the functional assessment of the cutaneous lesion

Assessment of wound healing is a complex task, especially when the lesion is associated to significant (full thickness) loss of the skin. The clinical observation, essentially subjective and highly dependent on the observer's experience, creates difficulties in the comparison of results. Scoring scales were introduced in the clinical practice to create comparable semi-quantitative data and promote better management of resources, but its usefulness in a clinical perspective is still limited. New non-invasive biometric methodologies, although infrequently used, have opened new possibilities. While complementing the clinical observation and contributing to therapeutic decisions and prognosis, they may also help to look further into the pathophysiological mechanisms of scarring drugs rehabilitation. Following previous work in this arena, the authors review, the state-of-the-art of cutaneous wound healing clinical and biometric follow up, proposing a diagnosis correlation for the most relevant descriptors found in both strategies in order to fully characterise the different stages of the healing process.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Moist exposed therapy: an effective and valid alternative to occlusive dressings for postlaser resurfacing wound care

BACKGROUND

Laser resurfacing has now become an accepted and important component of facial rejuvenation. With the introduction of computerized scanning systems, the actual laser resurfacing technique has been greatly simplified; however, the final outcome still depends to a large extent on the efficiency of the postlaser wound care in promoting wound healing and preventing early and late complications. It has been repeatedly confirmed that a moist environment is the single most important external factor affecting the rate of re-epithelialization. Occlusive moisture-retentive dressings, however, are difficult to apply and maintain in position and may as well be complicated by serious infections.

OBJECTIVE

Moist exposed burn ointment has been shown to maintain adequate moisture for optimal healing by frequent ointment application without the need for a secondary overlying dressing. It would be ideal for postoperative laser care.

METHODS

Twenty-eight consecutive patients treated with coherent ultrapulse CO2 laser in Toulouse, France, were included in the trial. Moisture-retentive ointment was applied over the treated areas every 4 to 6 hours. Healing was assessed clinically and with repeated transepidermal water loss measurements. Swab cultures were taken, and pain was evaluated with a visual analog scale. Colorimetric analysis of pictures taken was statistically compared with picture analysis of 20 patients treated earlier with an occlusive dressing.

RESULTS

Uneventful timely healing occurred in all patients with minimal pain and discomfort. Healing with moist exposed therapy resulted in faster recovery of cutaneous erythema, as evidenced by colorometry.

CONCLUSION

Moist exposed burn ointment application can be safely considered a good and valid alternative to occlusive dressings for postoperative laser care.