Contact sensitization in patients with chronic wounds: Results of a prospective investigation

Advances in tissue engineering and biofabrication for in vitro skin modeling

The global prevalence of skin disease and injury is continually increasing, yet conventional cell-based models used to study these conditions do not accurately reflect the complexity of human skin. The lack of inadequate in vitro modeling has resulted in reliance on animal-based models to test pharmaceuticals, biomedical devices, and industrial and environmental toxins to address clinical needs. These in vivo models are monetarily and morally expensive and are poor predictors of human tissue responses and clinical trial outcomes. The onset of three-dimensional (3D) culture techniques, such as cell-embedded and decellularized approaches, has offered accessible in vitro alternatives, using innovative scaffolds to improve cell-based models' structural and histological authenticity. However, these models lack adequate organizational control and complexity, resulting in variations between structures and the exclusion of physiologically relevant vascular and immunological features. Recently, biofabrication strategies, which combine biology, engineering, and manufacturing capabilities, have emerged as instrumental tools to recreate the heterogeneity of human skin precisely. Bioprinting uses computer-aided design (CAD) to yield robust and reproducible skin prototypes with unprecedented control over tissue design and assembly. As the interdisciplinary nature of biofabrication grows, we look to the promise of next-generation biofabrication technologies, such as organ-on-a-chip (OOAC) and 4D modeling, to simulate human tissue behaviors more reliably for research, pharmaceutical, and regenerative medicine purposes. This review aims to discuss the barriers to developing clinically relevant skin models, describe the evolution of skin-inspired in vitro structures, analyze the current approaches to biofabricating 3D human skin mimetics, and define the opportunities and challenges in biofabricating skin tissue for preclinical and clinical uses.

Potential Allergens in Wound Care Products

Background: Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible. Objective: With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures. Methods: Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020. Results: Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol. Conclusions: Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Potential Allergens in Wound Care Products

BACKGROUND

Patients with chronic wounds have an increased risk of developing allergic contact dermatitis (ACD). Reports of ACD to wound care products are not uncommon. To minimize contact sensitization in patients with chronic wounds, allergenic ingredients should be avoided when possible.

OBJECTIVE

With more than 5000 wound care products available in the United States, it is essential to understand which products can be chosen to minimize allergen exposures.

METHODS

Ingredients in wound care products in 5 wound care clinics across 2 institutions were cross-referenced with the American Contact Dermatitis Society core allergen series 2020.

RESULTS

Of the 267 wound care products included, 97 (36.3%) contained at least one allergen, including 31 dressings/wraps (22.3%), 25 medications (69.4%), 12 cleaning supplies (36.3%), 16 tapes/glues (80%), 2 instruments (14.3%), 8 emollients and vehicles (61.5%), 1 ostomy product (11.1%), and 2 odor-eliminating products (66.7%). Thirty-four different allergens were identified across all products. The most common allergens present in the included items were acrylates and propylene glycol, followed by parabens, cetyl stearyl alcohol, tocopherol, fragrance, and phenoxyethanol.

CONCLUSIONS

Many wound care products contain at least one contact allergen, highlighting the importance of clinician education on ACD in the context of wound care product selection.

Wound Antiseptics and European Guidelines for Antiseptic Application in Wound Treatment

Issues arising in wound healing are very common, and chronic wound infections affect approximately 1.5% of the population. The main substances used in wound washing, cleansing and treatment are antiseptics. Today, there are many compounds with a known antiseptic activity. Older antiseptics (e.g., boric acid, ethacridine lactate, potassium permanganate, hydrogen peroxide, iodoform, iodine and dyes) are not recommended for wound treatment due to a number of disadvantages. According to the newest guidelines of the Polish Society for Wound Treatment and the German Consensus on Wound Antisepsis, only the following antiseptics should be taken into account for wound treatment: octenidine (OCT), polihexanide (PHMB), povidone-iodine (PVP-I), sodium hypochlorite (NaOCl) and nanosilver. This article provides an overview of the five antiseptics mentioned above, their chemical properties, wound applications, side effects and safety.

[Modern management of chronic wounds]

The treatment of patients with chronic wounds is a multiprofessional challenge. Based on a comprehensive diagnosis and integrated into a causal treatment concept, patients should always be treated with a modern wound therapy. This wound therapy should try to take into account many different factors such as the wound healing phases, infection status, exudate levels, but also individual patient wishes. Especially in the case of chronic wounds of the lower extremities and edema, compression therapy is also very important for therapy and recurrence prophylaxis. In addition, the pain, which is usually very distressing, should be recorded and adequately treated or avoided. Modern moist wound therapy can then support the healing of patients with chronic wounds, reduce complications and thus improve their quality of life.

Contact dermatitis: An important consideration in leg ulcers

The prevalence of chronic wounds is increasing with the aging population, with 1% to 2% of the worldwide population experiencing leg ulcers and positive patch tests reported in up to 75% of this population. With the introduction of modern dressings and compression therapies, clinicians should be cognizant of the potential risk of contact dermatitis in patients with leg ulcers. Contact dermatitis (both allergic and irritant) to wound products may present as maceration, pain, and overall impaired wound healing. Herein, we review the literature on contact dermatitis to wound-care products.

Postsurgical Treatment of Split Skin Graft Donor Sites in Dermatological Departments

The surgical removal of split skin grafts (SSGs) leads to superficial wounds that can be covered with different wound dressings. Currently, international guidelines that recommend a standard treatment of the donor sites are not yet established. We developed a questionnaire to evaluate the treatment of SSG donor sites and sent it to all dermatological departments in Germany. Altogether 78 of the 115 contacted departments in Germany participated in our cross-sectional trial. Our analysis reveals that multiple wound dressings with different frequencies of replacement are used. On an average, complete reepithelialization of the donor site takes 14-21 days. Foams and coated gauzes are used in 73% of all surgical procedures for postsurgical treatment of SSG donor sites. Still, neither a significant faster reepithelialization nor a lower rate of wound healing disorders can be assigned to any of the wound dressings. The results of our study indicate that a large number of wound care products and treatment strategies are currently applied on SSG donor sites in dermatological departments in Germany. The selection of the wound dressing is not based on scientific data but rather on the experience of individual experts.

Compression therapy in patients with venous leg ulcers

Wund-D.A.CH. is the umbrella organization of the various wound care societies in German-speaking countries. The present consensus paper on practical aspects pertinent to compression therapy in patients with venous leg ulcers was developed by experts from Germany, Austria, and Switzerland. In Europe, venous leg ulcers rank among the most common causes of chronic wounds. Apart from conservative and interventional wound and vein treatment, compression therapy represents the basis of all other therapeutic strategies. To that end, there are currently a wide variety of materials and systems available. While especially short-stretch bandages or multicomponent systems should be used in the initial decongestion phase, ulcer stocking systems are recommended for the subsequent maintenance phase. Another - to date, far less common - alternative are adaptive Velcro bandage systems. Medical compression stockings have proven particularly beneficial in the prevention of ulcer recurrence. The large number of treatment options currently available enables therapists to develop therapeutic concepts geared towards their patients' individual needs and abilities, thus resulting in good acceptance and adherence. Compression therapy plays a crucial role in the treatment of patients with venous leg ulcers. In recent years, a number of different treatment options have become available, their use and application differing among German-speaking countries. The present expert consensus is therefore meant to outline concrete recommendations for routine implementation of compression therapy in patients with venous leg ulcers.

Wound-Related Allergic/Irritant Contact Dermatitis

PURPOSE

To provide information from a literature review about the prevention, recognition, and treatment for contact dermatitis.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to:1. Identify signs and symptoms of and diagnostic measures for contact dermatitis.2. Identify causes and risks for contact dermatitis.3. Select appropriate treatment for contact dermatitis and its prevention.

ABSTRACT

Contact dermatitis to wound care products is a common, often neglected problem. A review was conducted to identify articles relevant to contact dermatitis.A PubMed English-language literature review was conducted for appropriate articles published between January 2000 and December 2015.Contact dermatitis is both irritant (80% of cases) or allergic (20% of cases). Frequent use of potential contact allergens and impaired barrier function of the skin can lead to rising sensitization in patients with chronic wounds. Common known allergens to avoid in wound care patients include fragrances, colophony, lanolin, and topical antibiotics.Clinicians should be cognizant of the allergens in wound care products and the potential for sensitization. All medical devices, including wound dressings, adhesives, and bandages, should be labeled with their complete ingredients, and manufacturers should be encouraged to remove common allergens from wound care products, including topical creams, ointments, and dressings.

Contact allergy to compression stockings: Is this possible?

In der Therapie der chronisch venösen Insuffizienz oder des Lymphödems sind Kompressionsstrümpfe ein Standard der Therapie. Trotzdem ist die Akzeptanz der Patienten relativ gering. Ein Grund dafür sind unter anderem auch Symptome wie Juckreiz, Brennen oder Rötung, die vom Patienten, aber auch häufig vom behandelnden Arzt als Allergie auf die Kompressionsstrümpfe gewertet werden. Die Übersichtsarbeit geht auf die Grundlagen der Kontaktallergien ein, zeigt wie häufig Allergien auf Kompressionsstrümpfe auftreten, welche Auslöser dafür in Frage kommen und beschreibt kurz die häufigen Differenzialdiagnosen, ihre Auslöser und Prävention.

Consensus on Wound Antisepsis: Update 2018

Wound antisepsis has undergone a renaissance due to the introduction of highly effective wound-compatible antimicrobial agents and the spread of multidrug-resistant organisms (MDROs). However, a strict indication must be set for the application of these agents. An infected or critically colonized wound must be treated antiseptically. In addition, systemic antibiotic therapy is required in case the infection spreads. If applied preventively, the Wounds-at-Risk Score allows an assessment of the risk for infection and thus appropriateness of the indication. The content of this updated consensus recommendation still largely consists of discussing properties of octenidine dihydrochloride (OCT), polihexanide, and iodophores. The evaluations of hypochlorite, taurolidine, and silver ions have been updated. For critically colonized and infected chronic wounds as well as for burns, polihexanide is classified as the active agent of choice. The combination 0.1% OCT/phenoxyethanol (PE) solution is suitable for acute, contaminated, and traumatic wounds, including MRSA-colonized wounds due to its deep action. For chronic wounds, preparations with 0.05% OCT are preferable. For bite, stab/puncture, and gunshot wounds, polyvinylpyrrolidone (PVP)-iodine is the first choice, while polihexanide and hypochlorite are superior to PVP-iodine for the treatment of contaminated acute and chronic wounds. For the decolonization of wounds colonized or infected with MDROs, the combination of OCT/PE is preferred. For peritoneal rinsing or rinsing of other cavities with a lack of drainage potential as well as the risk of central nervous system exposure, hypochlorite is the superior active agent. Silver-sulfadiazine is classified as dispensable, while dyes, organic mercury compounds, and hydrogen peroxide alone are classified as obsolete. As promising prospects, acetic acid, the combination of negative pressure wound therapy with the instillation of antiseptics (NPWTi), and cold atmospheric plasma are also subjects of this assessment.

Ruocco's immunocompromised cutaneous district

The concept of 'locus minoris resistentiae' (lmr) is an old but still effective way of thinking in Medicine. In Dermatology, there are many reports of privileged localization of cutaneous diseases on injured skin, which therefore represents a typical condition of lmr. Lately the innovative concept of immunocompromised cutaneous district (ICD) has been introduced to explain why a previously injured cutaneous site may become in time a privileged location for the outbreak of opportunistic infections, tumors, and immune reactions. An ample documentation of multifarious disorders (infectious, neoplastic, immune) appearing in ICDs was delineated by Ruocco et al. in 2009. These cases were grouped according to the clinical settings responsible for the local immune imbalance: regional chronic lymphedema; herpes-infected sites, which feature the well-known Wolf's isotopic response; and otherwise damaged areas, comprising sites of vaccination, ionizing or UV radiation, thermal burns, and traumas. In the following five years, what was a "novel" pathogenic concept has been extended to an enlarging variety of clinical conditions. This paper focuses on ICD and the expanding spectrum of this now established pathogenic concept.

Evaluation of a new silicone adhesive tape among clinicians caring for patients with fragile or at-risk skin

OBJECTIVE

To evaluate performance of a new silicone tape among clinicians caring for patients with fragile skin.

DESIGN

An international, multisite, 2-week-use evaluation.

PARTICIPANTS AND SETTINGS

Caregivers (n = 217) from acute care hospitals in the United States, United Kingdom, and France who regularly use tapes on patients with fragile skin.

INTERVENTIONS

The silicone tape was substituted for current-use gentle tapes for a 2-week trial period. Preuse and postuse questionnaires were collected.

MAIN OUTCOME MEASURES

The main outcome measure was tape preference. Secondary outcomes included (1) satisfaction with current-use tapes, (2) willingness to replace current-use tapes with silicone tape, (3) performance comparisons between tapes, (4) clinician-reported problems with the silicone tape, and (5) case study information.

RESULTS

The sample group consisted of nurses (98.1%), assistants (1.4%), and physicians (0.5%). Hospital units (n = 100) included oncology (31%), medical-surgical (14%), dialysis (12%), infusion/intravenous therapy (16%), critical care (10%), wound care (10%), and other units (7%). Overall preference was 92.0% for the silicone tape, 7.5% for current-use tapes, and 0.5% no preference. Dissatisfaction was 61.2% for current-use tapes, and most clinicians (90.2%) would change to the silicone tape. Evaluators favored (≥71.5%) the silicone tape on 10 performance attributes and on overall performance (91.6%). Most evaluators (75.1%) did not experience problems with the silicone tape, and those who did found problems related to adhesion (77.8%), gentleness (16.0%), and residue (6.2%).

CONCLUSION

These results indicate that the silicone tape fills a performance-expectation gap of current acrylic tapes among users of tapes on patients with fragile or at-risk skin.

Treating a chronic wound in a nonadherent patient: a case study

BACKGROUND

Limited evidence suggests that various formulations containing Balsam of Peru, castor oil, and trypsin (BCT) exert multiple actions that may promote wound healing such as shedding damaged skin cells, stimulation of localized blood flow, antimicrobial actions, and local analgesic actions.

CASE

An 81-year-old man was referred to our home-based wound care center for treatment of an excoriation-induced chronic dehiscence of an abdominal surgical wound. He had failed multiple topical therapies, primarily owing to persistent pruritus of the wound and periwound skin, resulting in removal of his dressing to scratch the wound and periwound skin. We used a spray containing BCT to promote wound healing and relieve pruritus; this addition resulted in wound closure within 38 days of treatment.

CONCLUSIONS

We recommend considering BCT spray when maintenance of dressing is impaired and wound healing delayed owing to pruritus. We found the BCT spray easy to use and well-accepted by our patient who was unable to tolerate other forms of topical therapy over a period of 6 months.

[Cutaneous wound healing. Therapeutic interventions]

In modern medicine chronic wounds are an interdisciplinary major therapeutic and financial issue. Essential for therapy is both the causal treatment of the underlying disease and the symptomatic treatment depending on the phase of wound healing. The physiological process of cutaneous wound healing is divided into three overlapping phases: inflammation, proliferation and tissue remodelling. The choice of a suitable therapy depends on the extent of the wound, the localization, exudation and bacterial infestation. In recent years a number of novel findings were made about this complex biological process and the insights gained have resulted in new therapeutic concepts. In the following article we give an overview about possible therapeutic options and present the various modern wound dressings.

Contact sensitization in patients with lower extremity dermatitis in the South Moravian region, Czech Republic

Objectives

The aim of the study was to determine the frequency of contact sensitization in patients with lower extremity dermatitis.

Methods

Between the years 2001 and 2007, the authors investigated 462 patients (mean age 49.1 years, 196 men and 266 women) with the eczema/dermatitis localized on their lower extremities, including feet. The patients were investigated with epicutaneous tests of the European Standard Series and also with other special patch tests.

Results

The most frequent allergens were balsam of Peru, 44/462 (9.5%); wool alcohols, 41/462 (8.9%); nickel sulphate, 39/462 (8.4%); propolis, 35/462 (7.6%); fragrance mix, 34 (7.4%) and colophony, 29/462 (6.3%).

Conclusions

In patients with lower extremity dermatitis the frequency of contact sensitization is still high, and therefore investigation with epicutaneous tests should belong to the routine dermatological diagnostic procedure in these patients.