Growth factor therapy in patients with partial-thickness burns: a systematic review and meta-analysis

Advancing burn wound treatment: exploring hydrogel as a transdermal drug delivery system

Burn injuries are prevalent and life-threatening forms that contribute significantly to mortality rates due to associated wound infections. The management of burn wounds presents substantial challenges. Hydrogel exhibits tremendous potential as an ideal alternative to traditional wound dressings such as gauze. This is primarily attributed to its three-dimensional (3D) crosslinked polymer network, which possesses a high water content, fostering a moist environment that supports effective burn wound healing. Additionally, hydrogel facilitates the penetration of loaded therapeutic agents throughout the wound surface, combating burn wound pathogens through the hydration effect and thereby enhancing the healing process. However, the presence of eschar formation on burn wounds obstructs the passive diffusion of therapeutics, impairing the efficacy of hydrogel as a wound dressing, particularly in cases of severe burns involving deeper tissue damage. This review focuses on exploring the potential of hydrogel as a carrier for transdermal drug delivery in burn wound treatment. Furthermore, strategies aimed at enhancing the transdermal delivery of therapeutic agents from hydrogel to optimize burn wound healing are also discussed.

Consensus on the treatment of second-degree burn wounds (2024 edition)

Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.

An Overview of Recent Developments in the Management of Burn Injuries

According to the World Health Organization (WHO), around 11 million people suffer from burns every year, and 180,000 die from them. A burn is a condition in which heat, chemical substances, an electrical current or other factors cause tissue damage. Burns mainly affect the skin, but can also affect deeper tissues such as bones or muscles. When burned, the skin loses its main functions, such as protection from the external environment, pathogens, evaporation and heat loss. Depending on the stage of the burn, the patient's condition and the cause of the burn, we need to choose the most appropriate treatment. Personalization and multidisciplinary collaboration are key to the successful management of burn patients. In this comprehensive review, we have collected and discussed the available treatment options, focusing on recent advances in topical treatments, wound cleansing, dressings, skin grafting, nutrition, pain and scar tissue management.

Mesenchymal Stem Cell Extracellular Vesicles from Tissue-Mimetic System Enhance Epidermal Regeneration via Formation of Migratory Cell Sheets

BACKGROUND

The secretome of adipose-derived mesenchymal stem cells (ASCs) offers a unique approach to understanding and treating wounds, including the critical process of epidermal regeneration orchestrated by keratinocytes. However, 2D culture techniques drastically alter the secretory dynamics of ASCs, which has led to ambiguity in understanding which secreted compounds (e.g., growth factors, exosomes, reactive oxygen species) may be driving epithelialization.

METHODS

A novel tissue-mimetic 3D hydrogel system was utilized to enhance the retainment of a more regenerative ASC phenotype and highlight the functional secretome differences between 2D and 3D. Subsequently, the ASC-secretome was stratified by molecular weight and the presence/absence of extracellular vesicles (EVs). The ASC-secretome fractions were then evaluated to assess for the capacity to augment specific keratinocyte activities.

RESULTS

Culture of ASCs within the tissue-mimetic system enhanced protein secretion ~ 50%, exclusively coming from the > 100 kDa fraction. The ASC-secretome ability to modulate epithelialization functions, including migration, proliferation, differentiation, and morphology, resided within the "> 100 kDa" fraction, with the 3D ASC-secretome providing the greatest improvement. 3D ASC EV secretion was enhanced two-fold and exhibited dose-dependent effects on epidermal regeneration. Notably, ASC-EVs induced morphological changes in keratinocytes reminiscent of native regeneration, including formation of stratified cell sheets. However, only 3D-EVs promoted collective cell sheet migration and an epithelial-to-mesenchymal-like transition in keratinocytes, whereas 2D-EVs contained an anti-migratory stimulus.

CONCLUSION

This study demonstrates how critical the culture environment is on influencing ASC-secretome regenerative capabilities. Additionally, the critical role of EVs in modulating epidermal regeneration is revealed and their translatability for future clinical therapies is discussed.

Treatment and Improvement of Healing after Surgical Intervention

The development of abnormal scars has a great impact on people's well-being, and improving scarring outcomes after surgery is a field that currently lacks consensus. This review aims to identify newly researched approaches to improving the quality of surgical scars. A systematic search of PubMed, Scopus, Web of Science, and ScienceDirect was conducted between 13 May 2023 and 17 May 2023, in accordance with the recommendations of the PRISMA Statement. Study selection and analysis of methodological quality were performed in parts, independently and blindly, based on eligibility criteria. The 21 prospective, comparative, and randomized studies reviewed included 1057 subjects and studied approaches such as topical applications of creams with herbal extracts and silicone gels, growth factors, negative pressure dressings, oligonucleotides, intralesional injection of compounds such as botulinum toxin, skin closure techniques such as suturing and tissue adhesive, and laser treatments. There are recent research techniques that generate good results and are really promising to improve the results of surgical scars; however, the available evidence is extremely limited in some cases, and it is necessary to deepen its analysis to obtain reliable action protocols in each type of surgery.

[Low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) therapy for chronic venous leg ulcers, 10-year follow-up]

BACKGROUND

The treatment of leg ulcers is an enormous problem worldwide. Chronic venous ulceration affects 1% of the population and often has a protracted course. Recurrence rate is high, ranging up to 69% in the first year after healing.

OBJECTIVES

To determine whether topical application of low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) is safe in venous leg ulcer treatment, and whether it accelerates healing rates and reduces recurrence rates.

MATERIALS AND METHODS

Consecutive patients with chronic venous leg ulcers received topical treatment with low-dose rhu GM-CSF (10 µg/mL 0.9% sodium chloride solution; 1.0-2.3 µg rhu GM-CSF/cm²) in combination with treatment of venous insufficiency. All patients were previously treated with other topical wound remedies for several weeks (median 8 weeks) without success.

RESULTS

In 119 of 130 patients, the wounds healed completely (91.5%). No local or systemic adverse reactions were observed. The mean time to healing was 24 weeks (median 14 weeks). Median follow-up of the 119 patients with healed ulcers was 84 months. The recurrence rates were 5.2% after 1 year, 18.9% after 4 years and 32.0% after 10 years.

CONCLUSIONS

Topical low-dose rhu GM-CSF proved to be safe and highly effective. Healing rates were comparable to those reported in the ESCHAR study (Effects of Surgery and Compression on Healing And Recurrence in venous ulceration) and recurrence rates were the lowest reported in the literature. Topical therapy with rhu GM-CSF can be applied in an outpatient setting and does not require hospitalization.

EVALUATING SEPSIS CRITERIA IN DETECTING ALTERATIONS IN CLINICAL, METABOLIC, AND INFLAMMATORY PARAMETERS IN BURN PATIENTS

ABSTRACT

Sepsis has become the leading cause of death in burn patients. Furthermore, sepsis and septic complications result in significant morbidities and longer hospitalization, which has profound impacts on the healthcare system. Despite this, sepsis in burn patients is surprisingly poorly understood and characterized. This retrospective, single-institution cohort study aimed to increase our understanding of the septic response after burns. We hypothesized that different sepsis definitions will results in distinctive septic trajectories and biochemical patterns after injury. Sepsis was defined by our burn center-specific prospective definition, the American Burn Association criteria, Sepsis-3 criteria, and the Mann-Salinas criteria. Applying these definitions, we compared clinical, metabolic, and inflammatory markers in septic and nonseptic burn patients. We found that the Sepsis-3 criteria are the most reliable screening tool used before clinical diagnoses for detecting sepsis trajectories and biochemical patterns. Moreover, we characterized distinct temporal alterations in biomarkers during the pre- and post-septic periods in burn patients, which may be incorporated into future sepsis definitions to improve the accuracy of a sepsis diagnosis in burn patients.

An active ingredient isolated from Ganoderma lucidum promotes burn wound healing via TRPV1/SMAD signaling

The mushroom Ganoderma lucidum is a traditional Chinese medicine and G. lucidum spore oil (GLSO) is the lipid fraction isolated from Ganoderma spores. We examined the effect of GLSO on burn wound healing in mice. Following wounding, GLSO was applied on the wounds twice daily. Repair analysis was performed by Sirius-Red-staining at different time points. Cell proliferation and migration assays were performed to verify the effect of GLSO on growth. Network pharmacology analysis to identify possible targets was also carried out, followed by Western blotting, nuclear translocation, cell proliferation, and immunofluorescence assays for in-depth investigation of the mechanism. Our study showed that GLSO significantly promoted cell proliferation, and network pharmacology analysis suggested that GLSO might act through transient receptor potential vanilloid receptor 1 (TRPV1)/SMAD signaling. Furthermore, GLSO elevated SMAD2/3 expression in skin burn and promoted its nuclear translocation, and TRPV1 expression was also increased upon exposure to GLSO. Cell proliferation and immunofluorescence assays with TRPV1 inhibitor showed that GLSO accelerated skin burn wound healing through TRPV1 and SMADs signaling, which provides a foundation for clinical application of GLSO in the healing of deep skin burns.

The clinical effectiveness and safety of using epidermal growth factor, fibroblast growth factor and granulocyte-macrophage colony stimulating factor as therapeutics in acute skin wound healing: a systematic review and meta-analysis

Background

Promoting wound healing is crucial to restore the vital barrier function of injured skin. Growth factor products including epidermal growth factor (EGF), fibroblast growth factor (FGF) and granulocyte-macrophage colony stimulating factor (GM-CSF) have been used for decades although no systematic evaluation exists regarding their effectiveness and safety issues in treating acute skin wounds. This has resulted in a lack of guidelines and standards for proper application regimes. Therefore, this systematic review and meta-analysis was performed to critically evaluate the effectiveness and safety of these growth factors on skin acute wounds and provide guidelines for application regimes.

Methods

We searched PubMed/Medline (1980–2020), Cochrane Library (1980–2020), Cochrane CENTRAL (from establishment to 2020), ClinicalTrials.gov (from establishment to 2020), Chinese Journal Full-text Database (CNKI, 1994–2020), China Biology Medicine disc (CBM, 1978–2019), Chinese Scientific Journal Database (VIP, 1989–2020) and Wanfang Database (WFDATA, 1980–2019). Randomized controlled trials (RCTs), quasi-RCTs and controlled clinical trials treating patients with acute skin wounds from various causes and with those available growth factors were included.

Results

A total of 7573 papers were identified through database searching; 229 papers including 281 studies were kept after final screening. Administering growth factors significantly shortened the healing time of acute skin wounds, including superficial burn injuries [mean difference (MD) = −3.02; 95% confidence interval (CI):−3.31 ~ −2.74; p < 0.00001], deep burn injuries (MD = −5.63; 95% CI:−7.10 ~ −4.17; p < 0.00001), traumata and surgical wounds (MD = −4.50; 95% CI:−5.55 ~ −3.44; p < 0.00001). Growth factors increased the healing rate of acute skin wounds and decreased scar scores. The incidence of adverse reactions was lower in the growth factor treatment group than in the non-growth factor group.

Conclusions

The studied growth factors not only are effective and safe for managing acute skin wounds, but also accelerate their healing with no severe adverse reactions.

Fibroblast growth factor in the treatment of burns: A systematic review

INTRODUCTION

A burn is a trauma that breaks the skin barrier, causing local and systemic responses. Treatment is complex, multiprofessional and expensive. In addition to surgical treatment, topical dressings can be used to keep the wound moist, reduce the risk of infection and stimulate healing. Clinical studies show that topical use of fibroblast growth factors may accelerate healing. An assessment of the quality of the available evidence and its strength of recommendation is necessary.

OBJECTIVE

This study aimed to evaluate the effectiveness and safety of topical use of fibroblast growth factor, compared to other topical treatments or placebo, in the healing of burns, to determine the strength of recommendation.

METHOD

Based on a defined search strategy, randomized and quasi-randomized clinical trials, available in electronic databases, were gathered. These compare the topical use of FGF versus other topical or non-treatment. The primary outcome was healing and as adverse effects: pain, infection and mortality. The systematic review protocol was registered on the PROSPERO platform (CRD42018089556), developed in accordance with the "Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 2015" and within the "SWiM guideline 2019". GRADEpro was used for the critical analysis of the methodology of the studies.

RESULTS

Four clinical trials were found, in which FGF reduced the healing time and improved the appearance of the scar. Two trials were determined to be of low strength, while two others have a moderate recommendation strength.

CONCLUSION

This review gathered available evidence, between low and moderate recommendation strength for the use of FGF as a topical dressing. Further rigorous trials are needed to improve the strength of recommendation for topical use of FGF for burns.

Treatment of Scars with Laser-Assisted Delivery of Growth Factors and Vitamin C: A Comparative, Randomised, Double-blind, Early Clinical Trial

BACKGROUND

Scarring can jeopardize the final result of plastic surgeries. Deep dermal injuries activate dermal fibroblasts that produce excessive amount of collagen and inflammatory cytokines and growth factors, which contributes to increased fibrous tissue and scarring tissue formation.

OBJECTIVES

The aim of this early study, double-blind, prospective, randomised clinical trial was to investigate the use of laser-assisted drug delivery (LADD) for scar improvement to support the establishment of LADD as standard therapy modality and to indicate suitable drugs for dermal administration.

MATERIAL AND METHODS

In total, 132 patients seeking scar treatment were consented and randomised. The control group (64 patients) received laser resurfacing immediately followed by skin surface application of Vitamin C and 68 patients received laser treatment followed by skin surface application of a cosmeceutical containing growth factors (GFs) and Vitamin C. Photographs were obtained before and three months after the procedure and submitted to three-dimensional reconstruction by the software Dermapix^®. Objective measurements provided by the software were statistically analysed and established the differences in the treatment result between the two groups.

RESULTS

There was a significant reduction in scar roughness and volume in both groups (p < 0.01). Mann-Whitney test confirmed that the group treated vitamin C and GFs presented significantly better results than the group treated with vitamin C alone (p < 0.01).

CONCLUSION

LADD has proven efficient as scars were reduced in both study groups. Furthermore, the addition of growth factors provided statistically significant better outcomes and resulted in more inconspicuous scars. No adverse reactions were observed.

CLINICAL TRIAL REGISTRATION

Plataforma Brasil under the number CAAE: 63710716.2.0000.5664.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Recent advances in nanotherapeutics for the treatment of burn wounds

Moderate or severe burns are potentially devastating injuries that can even cause death, and many of them occur every year. Infection prevention, anti-inflammation, pain management and administration of growth factors play key roles in the treatment of burn wounds. Novel therapeutic strategies under development, such as nanotherapeutics, are promising prospects for burn wound treatment. Nanotherapeutics, including metallic and polymeric nanoformulations, have been extensively developed to manage various types of burns. Both human and animal studies have demonstrated that nanotherapeutics are biocompatible and effective in this application. Herein, we provide comprehensive knowledge of and an update on the progress of various nanoformulations for the treatment of burn wounds.

A systematic review and meta-analysis of randomized trials evaluating the efficacy of autologous skin cell suspensions for re-epithelialization of acute partial thickness burn injuries and split-thickness skin graft donor sites

BACKGROUND

This systematic review evaluated the efficacy of autologous skin cell suspensions (ASCS) on the re-epithelialization of partial thickness burn injuries and skin graft donor site wounds.

METHODS

Four databases (EMBASE, Google Scholar, MEDLINE, Web of Science), grey literature and select journal hand-searching identified studies from 1975 - 2020. Randomized trials evaluating partial thickness burn management with non-cultured ASCS compared to any other intervention were included. Time to re-epithelialization (TTRE) was the primary outcome. Three independent researchers completed screening, data extraction and certainty of evidence assessment using Cochrane Risk of Bias Tool and Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Five trials (n = 347) reported on adults (2 trials) and children (1 trial) with burn wounds, and adults with donor site wounds (2 trials). The effect of ASCS compared to control on TTRE in adult burn wounds was not estimable. TTRE was shorter in pediatric burn wounds (SMD -1.75 [95% CI: -3.45 to -0.05]) and adult donor site wounds (SMD-5.71 [95% CI: -10.61 to-0.81]) treated with ASCS. The certainty of evidence was very low.

CONCLUSION

Compared to standard care, ACSC may reduce pediatric partial thickness burn wound and adult split-thickness skin graft donor site TTRE.

REGISTRATION

PROSPERO CRD42019133171.

Comparative Study on the Outcome of Periorbital Wrinkles Treated with Laser-Assisted Delivery of Vitamin C or Vitamin C Plus Growth Factors: A Randomized, Double-blind, Clinical Trial

Background

Despite promising results, laser-assisted drug delivery (LADD) is not yet considered as standard therapies and published data rely mainly on laboratory tests, animal experiments or cadaver skin.

Objectives

This double-blind, prospective, randomized clinical trial investigates the impact in topical application of vitamin C and a cosmeceutical containing growth factors (GFs) on periorbital wrinkles primarily treated with laser skin resurfacing.

Material and Methods

In total, 149 female patients with periorbital wrinkles were consented and randomized into two study groups, R-C (receiving vitamin C only) and R-CGF (receiving vitamin C and a cosmeceutical containing growth factors). The statistical analysis evaluated the efficacy of each treatment regimen using software readouts provided by a three-dimensional stereophotogrammetry system prior to treatment and three months after the procedure. Results were compared to confirm if there was a significant change in the skin roughness and the average depth of the wrinkles between the two groups after treatment.

Results

There was a significant reduction in both skin roughness and average depth of the wrinkles in the group treated with vitamin C and growth factors (p <0.01) than those treated with LADD followed by topical application of vitamin C alone. There were no cutaneous reactions or adverse systemic reactions observed in this study related to LADD with vitamin C and GFs.

Conclusion

Controlled laser application might have a great potential to facilitate the absorption of exogenous macromolecules by the skin. Periorbital wrinkles were reduced in both groups, but LADD using vitamin C and GFs provided significantly better results.

Level of Evidence II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Efficacy and safety of blood purification in the treatment of deep burns: A systematic review and meta-analysis

INTRODUCTION

This meta-analysis aimed to systematically review and evaluate randomized controlled trials (RCTs) and cohort studies examining the efficacy and safety of blood purification in the treatment of patients with deep burns.

METHODS

The PubMed, Cochrane Library, and Embase databases and relevant references were systematically searched for RCTs and cohort studies published until the end of September 2020 to investigate the potential of blood purification in improving the prognosis of severely burned patients. The primary outcome of this systematic review was overall patient mortality; secondary outcomes included the incidence of sepsis and infection prevention (vital signs and routine blood tests).

RESULTS

A total of 6 RCTs and 1 cohort study were included, with a total of 538 burn patients (274 patients who received blood purification and 264 control patients). Compared with patients who received conventional treatment, those treated with blood purification displayed significant 2-day reduction in mortality and sepsis with relative risks of 0.62 and 0.41, respectively (95% confidence intervals [CIs], 0.74-0.82 and 0.25-0.67, respectively; P < .05). In terms of vital signs and blood biochemistry, the respiratory rates and blood urea nitrogen levels of patients in the blood purification group 3 days post-treatment were significantly higher than those in the control group (randomized standard deviations (SMDs), 0.78 and 0.77, respectively; 95% CIs, 0.33-1.23 and 1.22-0.31, respectively; P < .05). However, there were no significant differences between groups on day 3 with regard to temperature (P = .32), heart rate (P = .26), white blood cell count (P = .54), or neutrophil count (P = .74), potentially owing to the small sample size or the relatively short intervention time. Heterogeneous differences existed between the groups with respect to blood urea nitrogen (SMD = -1.22; 95% CI, -2.16 to -0.40; P < .00001) and Cr (SMD = -3.13; 95% CI, -4.92 to -1.33; P < .00001) on day 7. No systematic adverse events occurred.

CONCLUSIONS

Blood purification treatment for deep burn patients can significantly reduce the mortality rate and the incidence of complications.

Effectiveness of growth factor-induced therapy for skin rejuvenation: A case series

BACKGROUND

Microneedling in combination with the use of growth factors can help with a range of indications, including skin rejuvenation. There is an increase in request for safe minimally invasive procedures with no-to-minimal downtime. This procedure offers regeneration and is becoming popular as part of the regenerative, minimally invasive era.

AIMS

To examine the efficacy of a course of two sessions of growth factor-induced therapy using propriety preparation of AQ recovery serum.

METHODS

Thirty women with various ethnic backgrounds (Chinese, Caucasian and Latino) with an average age of 38 years old participated and mild-moderate visual facial aging signs Two sessions with 2-week intervals were completed using a derma stamp (transdermal drug delivery method) and 2 mL of growth factor serum (AQ Skin Solution recovery serum-contain a mixture of contains a mix of transforming growth factor beta (TGF-β), granulocyte monocyte-colony-stimulating factor, and platelets-derived growth factor with patented technology for extraction and composition at each session. The procedures were carried out for anti-aging and skin rejuvenation. Clinical assessment, VISIA photography, independent assessment of before and after photographs baseline and six weeks by two clinicians and two laypersons were carried out. The participants used FACE-Q questionnaire (outcome satisfaction) and scored changes in terms of their skin texture, radiance, pore size, wrinkles, pigmentation, tightness and overall skin appearance.

RESULTS

Physician's global assessment revealed growth factor-induced therapy resulted in skin rejuvenation in all races with 95% confidence, and this increased to 98% confidence for Latinos and Caucasians within the six weeks. Participants' subjective rating revealed improvement of overall skin appearance with 95% confidence. Most noted improvements were in brightness, skin texture, and tightness.

CONCLUSION

This study revealed improvement in overall skin appearance, brightness, skin texture, and tightness. The treatment is non-invasive, safe, with no or minimal downtime and resulted in high participant satisfaction.

Intralesional epidermal growth factor application is a potential therapeutic strategy to improve diabetic foot ulcer healing and prevent amputation

Objectives

This study aimed to investigate the efficacy of intralesional epidermal growth factor (EGF) in preventing the extremity from a major amputation and its effects on wound healing in chronic diabetic foot ulcers (DFUs).

Material and Methods

Thirty-three patients with DFUs were treated with intralesional EGF application between January 2013 and January 2017. The first endpoint was to determine the prevention rate of major amputation within 12 months following treatment. The second endpoints were the recovery of ulcer surface area with ≥ 50% granulation following two months and the healing of ulcer surface area with ≥ 75% granulation following six months after the first application of EGF.

Results

After three patients were excluded because of major side effects in the remaining 30 patients (48 DFUs), granulation rate of ≥ 50% was achieved in 24 (37 DFUs) patients, and not achieved in 6 (11 DFUs) patients eight weeks following the EGF application. A granulation rate of ≥ 75% was achieved in 21 (31 DFUs) patients after six months. At 12 months following the treatment, one major and seven minor amputations were performed, a total of 10 DFUs in five patients were not healed, and the DFUs in 17 patients completely recovered.

Conclusion

Intralesional EGF application has positive results in addition to good foot care in DFUs, and promising results can be obtained by protecting the extremity from amputation by using it in patients whose vascular intervention methods are not appropriate and have DFUs that do not heal with conventional wound care treatments.

Effectiveness of fire needle combining with moist healing dressing to promote the growth of granulation tissue in chronic wounds: A case report

In this case study, we analyzed the wound-healing process of a patient with a chronic wound who underwent fire needle treatment, and we tracked the coverage of granulation tissue and decrease of slough and exudate. An 85-year-old man had repeated right shoulder and back pain, itching, and skin festering for more than 1.5 years. A fire needle was administered combined with moist dressing once every 5 days to promote wound healing. After six rounds of fire needle treatment, granulation tissue formed over the surface of the wound base, the depth of the wound had become shallow, and the wound area was reduced. No complications occurred during the intervention. Fire needle therapy combined with a moist wound-healing dressing can be an effective alternative approach in managing chronic wounds.

FGF8, FGF10 and FGF receptor 2 in foreskin of children with hypospadias: an analysis of immunohistochemical expression patterns and gene transcription

INTRODUCTION

Fibroblast growth factors (FGFs) play a crucial role in early embryogenesis of the genital tubercle and are involved in the development of hypospadias, affecting both endo- and ectodermally derived tissues. It was hypothesized that expression of FGFs could be qualitatively or quantitatively altered in skin of children with hypospadias.

OBJECTIVE

The objective of the study was to investigate expression patterns and transcription levels of FGF8, FGF10, and FGF Receptor 2 (FGFR2) in patients with hypospadias compared to normal controls.

PATIENTS AND METHODS

Skin samples from the ventro-lateral aspect of the foreskin of 32 patients with hypospadias (17 distal and 15 proximal, mean age 25 months) and 10 normal foreskin samples (mean age 77 months) were analyzed by immunohistochemistry. Staining, localization, and distribution of positive cells in epidermis and dermis were categorized independently by two researchers. Complementary DNA (cDNA) samples prepared from messenger RNA (mRNA) isolates of the same samples were analyzed by quantitative polymerase chain reaction (qPCR), comparing expressions of FGF8, FGF10, and FGFR2 with loading controls.

RESULTS

Patients with hypospadias consistently showed aberrant immunohistochemical staining patterns for FGF8/FGF10/FGFR2 in epidermis and dermis compared to patients without penile malformation (p < 0.01 for all markers). qPCR displayed no difference in expression levels on mRNA level (FGFR2 p = 0.44, FGF8 p = 0.77, and FGF10 p = 0.17) comparing normal foreskin with foreskin from patients with hypospadias. Figure.

DISCUSSION

The results point at an impact of FGF signaling during embryological development of hypospadias on skin, as an ectodermally derived tissue. Similar to the urethral development, this might be a result of mesothelial-epithelial interactions. The differing expression patterns in immunohistochemistry are not matched by a quantitative difference in marker expression on the mRNA level, putatively caused by post-translational modifications or alterations of the downstream pathway. FGFs, particularly FGF10 and FGFR2, are critically involved in wound healing.

CONCLUSIONS

There are significant differences in localization and distribution of FGF8, FGF10, and FGFR2 in comparisons of normal foreskin to foreskin of patients with hypospadias, whereas there is no difference in the quantitative expression of these markers on the mRNA level. This confirms the notion that penile skin is affected as well by the embryological aberrations during the embryogenesis of hypospadias.

Efficacy and safety of nano-silver dressings combined with recombinant human epidermal growth factor for deep second-degree burns: A meta-analysis

OBJECTIVE

The purpose of this meta-analysis was to assess the efficacy and safety of nano-silver dressing combined with recombinant human epidermal growth factor for deep second-degree burns.

METHODS

PubMed, Web of Science, EMBASE, Cochrane Library and other databases were searched to identify relevant randomised controlled trials.

RESULTS

Twelve studies that assessed nano-silver dressing combined with recombinant human epidermal growth factor were identified. Nano-silver dressing combined with recombinant human epidermal growth factor for deep second-degree burns could significantly reduce the duration of wound healing (mean difference -5.68, 95% CI -7.38 - -3.99, P<0.00001), the wound healing rate (risk ratio [RR] 0.34, 95% CI 0.23-0.48, P<0.00001), the rate of scar hyperplasia (RR 0.67, 95% CI 0.54-0.84, P=0.0004), the wound bacterial positive rate (RR 0.50, 95% CI 0.28-0.89, P=0.02), and the adverse reactions rate (RR 0.31, 95% CI 0.16-0.58, P=0.0003).

CONCLUSION

This comprehensive meta-analysis of the available evidence suggest that the use of nano-silver dressing combined with recombinant human epidermal growth factor results in shorter duration of wound healing, reduced wound bacterial positive rates and adverse reactions rate, and improved wound healing rates.

Skin tissue regeneration for burn injury

The skin is the largest organ of the body, which meets the environment most directly. Thus, the skin is vulnerable to various damages, particularly burn injury. Skin wound healing is a serious interaction between cell types, cytokines, mediators, the neurovascular system, and matrix remodeling. Tissue regeneration technology remarkably enhances skin repair via re-epidermalization, epidermal-stromal cell interactions, angiogenesis, and inhabitation of hypertrophic scars and keloids. The success rates of skin healing for burn injuries have significantly increased with the use of various skin substitutes. In this review, we discuss skin replacement with cells, growth factors, scaffolds, or cell-seeded scaffolds for skin tissue reconstruction and also compare the high efficacy and cost-effectiveness of each therapy. We describe the essentials, achievements, and challenges of cell-based therapy in reducing scar formation and improving burn injury treatment.

Advancements in Regenerative Strategies Through the Continuum of Burn Care

Burns are caused by several mechanisms including flame, scald, chemical, electrical, and ionizing and non-ionizing radiation. Approximately half a million burn cases are registered annually, of which 40 thousand patients are hospitalized and receive definitive treatment. Burn care is very resource intensive as the treatment regimens and length of hospitalization are substantial. Burn wounds are classified based on depth as superficial (first degree), partial-thickness (second degree), or full-thickness (third degree), which determines the treatment necessary for successful healing. The goal of burn wound care is to fully restore the barrier function of the tissue as quickly as possible while minimizing infection, scarring, and contracture. The aim of this review is to highlight how tissue engineering and regenerative medicine strategies are being used to address the unique challenges of burn wound healing and define the current gaps in care for both partial- and full-thickness burn injuries. This review will present the current standard of care (SOC) and provide information on various treatment options that have been tested pre-clinically or are currently in clinical trials. Due to the complexity of burn wound healing compared to other skin injuries, burn specific treatment regimens must be developed. Recently, tissue engineering and regenerative medicine strategies have been developed to improve skin regeneration that can restore normal skin physiology and limit adverse outcomes, such as infection, delayed re-epithelialization, and scarring. Our emphasis will be centered on how current clinical and pre-clinical research of pharmacological agents, biomaterials, and cellular-based therapies can be applied throughout the continuum of burn care by targeting the stages of wound healing: hemostasis, inflammation, cell proliferation, and matrix remodeling.

Burn wounds in the young versus the aged patient display differential immunological responses

BACKGROUND

Individuals in the geriatric age range are more prone than younger individuals to convert their partial thickness thermal burns into full thickness injuries. We hypothesized that this often observed clinical phenomenon is strongly related to differential local injury responses mediated by the immune system.

MATERIALS & METHODS

Skin samples from areas with partial thickness thermal burns were obtained during routine excision and grafting procedures between post burn days 2-6. Tissue samples were grouped by age ranges with young patients defined as <30 years of age or aged patients defined as >65. Formalin fixed samples were used to confirm depth of burn injury and companion sections were homogenized for multiplex analysis using a Luminex platform. Immunohistochemical staining was used to quantify total macrophage numbers as well as the M1 and M2 subpopulations.

RESULTS

Our analysis includes samples derived from 11 young subjects (mean age=23) and 3 aged subjects (mean age=79.2). Our initial survey of analytes examined 31 cytokines/chemokines. Twelve were excluded from consideration as they were present in concentrations either above or below the optimal detection range. Two analytes emerged as candidate molecules with significant differences between the young and the aged patient responses to burn injury. EGF levels were on average 21.69pg/ml in young vs 14.87pg/ml in aged (p=0.032). RANTES/CCL5 levels were on average 14.86pg/ml in young vs 4.26pg/ml in aged (p=0.026). Elevated macrophage numbers were present within wounds of younger patients compared to the old (p<0.01), with a higher concentration of the M1 type in the elderly (p>0.05).

CONCLUSION

Our study has identified at least 2 well known cytokines, CCL5 (RANTES) and EGF, which are differentially regulated in response to burn injury by young versus aged burn victims. Evidence suggests that a proinflammatory environment can explain the high conversion rate from partial to full thickness burns. Our data suggest the need for future studies at the point of injury (cutaneous targets) that may be modulated by post burn release of cytokines/chemokines.

Systematic Reviews in Burns Care: Poor Quality and Getting Worse

The objective of this article is to investigate adherence to reporting standards and methodological quality in systematic reviews on burns care published in peer-reviewed journals to determine their utility for guiding evidence-based burns care. PubMed, Embase, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports were searched from 2009. Any systematic review on any question on therapeutic interventions in burns care was eligible for inclusion. Critical appraisal and data extraction were performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist by two independent reviewers. The overall quality of the 44 included burns care systematic reviews was low, with an average methodological quality of 55% and an average compliance with reporting guidelines of 70%. Correlation analysis showed that adherence to reporting guidelines has been relatively stable, but methodological quality has deteriorated (r = -.32, P < .05). Cochrane reviews had lower citation rates than reviews published in other journals, whereas reviews that included meta-analyses had more citations. Quality did not have a significant effect on citation rate. Health professionals working in burns should be able to expect that systematic reviews published in their field are of a high standard. Unfortunately, this is not the case. To address this problem, established guidelines on the conduct and reporting of systematic reviews should be adhered to by researchers and editors.

Poor methodological quality and reporting standards of systematic reviews in burn care management

The methodological and reporting quality of burn-specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free-text terms such as 'burn', 'systematic review' or 'meta-analysis'. Additional studies were identified by hand-searching five discipline-specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11-item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on 'a priori' design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta-analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.

Surgical treatment algorithms for post-burn contractures

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.

Mesenchymal Stem Cells in Chronic Wounds: The Spectrum from Basic to Advanced Therapy

Significance: Almost 7 million Americans have chronic cutaneous wounds and billions of dollars are spent on their treatment. The number of patients with nonhealing wounds keeps increasing worldwide due to an ever-aging population, increasing number of obese and diabetic patients, and cardiovascular disease. Recent Advances: Advanced treatments for difficult wounds are needed. Therapy with mesenchymal stem cells (MSCs) is attractive due to their differentiating potential, their immunomodulating properties, and their paracrine effects. Critical Issues: New technologies (including growth factors and skin substitutes) are now widely used for stimulating wound healing. However, in spite of these advances, the percentage of complete wound closure in most clinical situations is around 50-60%. Moreover, there is a high rate of wound recurrence. Future Directions: Recently, it has been demonstrated that MSCs speed up wound healing by decreasing inflammation, by promoting angiogenesis, and by decreasing scarring. However, there are some potential limitations to successful MSC therapy. These limitations include the need to improve cell delivery methods, cell viability, heterogeneity in MSC preparations, and suboptimal wound bed preparation. Further large, controlled clinical trials are needed to establish the safety of MSCs before widespread clinical application.

Systemic granulocyte colony-stimulating factor (G-CSF) enhances wound healing in dystrophic epidermolysis bullosa (DEB): Results of a pilot trial

BACKGROUND

Chronic nonhealing wounds are the norm in patients with inherited epidermolysis bullosa (EB), especially those with dystrophic EB (DEB). A possible benefit in wound healing after subcutaneous treatment with granulocyte colony-stimulating factor (G-CSF) was suggested from an anecdotal report of a patient given this during stem cell mobilization before bone-marrow transplantation.

OBJECTIVE

We sought to determine whether benefit in wound healing in DEB skin might result after 6 daily doses of G-CSF and to confirm its safety.

METHODS

Patients were assessed for changes in total body blister and erosion counts, surface areas of selected wounds, and specific symptomatology after treatment.

RESULTS

Seven patients with DEB (recessive, 6; dominant, 1) were treated daily with subcutaneous G-CSF (10 μg/kg/dose) and reevaluated on day 7. For all patients combined, median reductions of 75.5% in lesional size and 36.6% in blister/erosion counts were observed. When only the 6 responders were considered, there were median reductions of 77.4% and 38.8% of each of these measured parameters, respectively. No adverse side effects were noted.

LIMITATIONS

Limitations include small patient number, more than 1 DEB subtype included, and lack of untreated age-matched control subjects.

CONCLUSIONS

Subcutaneous G-CSF may be beneficial in promoting wound healing in some patients with DEB when conventional therapies fail.