Effectiveness of Suprathel® Application in Partial Thickness Burns, Frostbites and Lyell Syndrome Treatment

Multidisciplinary Treatment in Toxic Epidermal Necrolysis

Toxic epidermal necrolysis, Leyll's syndrome (TEN), is a rare mucocutaneous blistering disease burdened with high mortality rates. The diagnosis of TEN is based on clinical symptoms and histopathological findings. In approximately 90% of cases, it is a severe adverse reaction to drugs. In TEN, not only is the skin affected, but also mucosa and organs' epithelium. There are no unequivocal recommendations in regard to systemic and topical treatment of the patients. The aim of this paper is to review available literature and propose unified protocols to be discussed. Early management and multidisciplinary treatment are necessary to improve patients' outcome. Treatment of patients with TEN suspicions should be initiated with early drug withdrawal. TEN patients, like patients with burns, require intensive care and multidisciplinary management. Each patient with TEN should be provided with adequate fluid resuscitation, respiratory support, nutritional treatment, pain control, infection prophylaxis, anticoagulant therapy, and gastric ulcer prophylaxis. The key to local treatment of patients with TEN is the use of nonadherent dressings that do not damage the epidermis during the change. The aim of the systemic treatment is purification of the blood stream from the causative agent. The most efficient way to clarify serum of TEN patients' is the combination of plasmapheresis and IVIG. Immunomodulatory therapy can reduce the mortality five times in comparison with the patients with immunosuppression or lack of full protocol.

Use of a biosynthetic wound dressing to treat burns: a systematic review

OBJECTIVE

Accelerating the process of wound healing, reducing infection risks, and decreasing pain and discomfort in the burn area are important goals of burn treatment. To achieve these goals, the use of biosynthetic wound dressings has increased in recent years. Suprathel (PolyMedics Innovations, Germany) is a biosynthetic wound dressing used to treat both partial-thickness burns and split-thickness skin graft (STSG) donor sites, full-thickness wounds, large-scale abrasions, and scar revisions.

METHOD

This study is a systematic review of empirical evidence reported on the application of the biosynthetic wound dressing in burns up to 2017. Keywords such as 'Suprathel', 'effectiveness', 'safety', and 'cost' were searched in PubMed, Cochrane, Scopus and Embase databases.

RESULTS

A total of 14 publications were identified, based on the inclusion and exclusion criteria. The findings reported in the literature reviewed were classified in terms of safety, effectiveness and cost-effectiveness of use of the biosynthetic wound dressing. Regarding safety and effectiveness, the dressing was found to yield desirable results, particularly for partial thickness burns and STSG donor sites. As of 2017 no health economics assessments have been carried out.

CONCLUSION

Despite the desirable advantages of the biosynthetic wound dressing with respect to its effectiveness, safety and ease of use, its major limitation was found to be its cost. However, in the absence of comprehensive studies on the quantification of all factors, there is scant scientific evidence for making reliable conclusions from this systematic review.

Porcine Xenograft and Epidermal Fully Synthetic Skin Substitutes in the Treatment of Partial-Thickness Burns: A Literature Review

Background and Objectives: Porcine xenografts have been used successfully in partial thickness burn treatment for many years. Their disappearance from the market led to the search for effective and efficient alternatives. In this article, we examine the synthetic epidermal skin substitute Suprathel^® as a substitute in the treatment of partial thickness burns. Materials and Methods: A systematic review following the PRISMA guidelines has been performed. Sixteen Suprathel^® and 12 porcine xenograft studies could be included. Advantages and disadvantages between the treatments and the studies’ primary endpoints have been investigated qualitatively and quantitatively. Results: Although Suprathel had a nearly six times larger TBSA in their studies (p < 0.001), it showed a significantly lower necessity for skin grafts (p < 0.001), and we found a significantly lower infection rate (p < 0.001) than in Porcine Xenografts. Nonetheless, no significant differences in the healing time (p = 0.67) and the number of dressing changes until complete wound healing (p = 0.139) could be found. Both products reduced pain to various degrees with the impression of a better performance of Suprathel^® on a qualitative level. Porcine xenograft was not recommended for donor sites or coverage of sheet-transplanted keratinocytes, while Suprathel^® was used successfully in both indications. Conclusion: The investigated parameters indicate that Suprathel^® to be an effective replacement for porcine xenografts with even lower subsequent treatment rates. Suprathel^® appears to be usable in an extended range of indications compared to porcine xenograft. Data heterogeneity limited conclusions from the results.

Made in Germany: A Quality Indicator Not Only in the Automobile Industry But Also When It Comes to Skin Replacement: How an Automobile Textile Research Institute Developed a New Skin Substitute

Successful research and development cooperation between a textile research institute, the German Federal Ministry of Education and Research via the Center for Biomaterials and Organ Substitutes, the University of Tübingen, and the Burn Center of Marienhospital, Stuttgart, Germany, led to the development of a fully synthetic resorbable temporary epidermal skin substitute for the treatment of burns, burn-like syndromes, donor areas, and chronic wounds. This article describes the demands of the product and the steps that were taken to meet these requirements. The material choice was based on the degradation and full resorption of polylactides to lactic acid and its salts. The structure and morphology of the physical, biological, and degradation properties were selected to increase the angiogenetic abilities, fibroblasts, and extracellular matrix generation. Water vapor permeability and plasticity were adapted for clinical use. The available scientific literature was screened for the use of this product. A clinical application demonstrated pain relief paired with a reduced workload, fast wound healing with a low infection rate, and good cosmetic results. A better understanding of the product's degradation process explained the reduction in systemic oxidative stress shown in clinical investigations compared to other dressings, positively affecting wound healing time and reducing the total area requiring skin grafts. Today, the product is in clinical use in 37 countries. This article describes its development, the indications for product growth over time, and the scientific foundation of treatments.

From Grafts to Human Bioengineered Vascularized Skin Substitutes

The skin plays an important role in the maintenance of the human's body physiological homeostasis. It acts as a coverage that protects against infective microorganism or biomechanical impacts. Skin is also implied in thermal regulation and fluid balance. However, skin can suffer several damages that impede normal wound-healing responses and lead to chronic wounds. Since the use of autografts, allografts, and xenografts present source limitations and intense rejection associated problems, bioengineered artificial skin substitutes (BASS) have emerged as a promising solution to address these problems. Despite this, currently available skin substitutes have many drawbacks, and an ideal skin substitute has not been developed yet. The advances that have been produced on tissue engineering techniques have enabled improving and developing new arising skin substitutes. The aim of this review is to outline these advances, including commercially available skin substitutes, to finally focus on future tissue engineering perspectives leading to the creation of autologous prevascularized skin equivalents with a hypodermal-like layer to achieve an exemplary skin substitute that fulfills all the biological characteristics of native skin and contributes to wound healing.

Growth characteristics of human juvenile, adult and murine fibroblasts: a comparison of polymer wound dressings

OBJECTIVE

Fibroblasts are important for the successful healing of deep wounds. However, the influence exerted by Cuticell, a natural polymer on fibroblasts and by the synthetic polymer, Suprathel, made of poly-L-lactic acid, is not sufficiently characterised. This study compared the survival and growth characteristics of human juvenile and adult dermal fibroblasts as well as murine fibroblast cell line L929, on a natural polymer with those of a synthetic polymer using different culture models.

METHOD

Murine, juvenile and adult human fibroblasts were seeded on both the natural and synthetic polymers using statical slide culture or the medium air interface and dynamical rotatory culture. Cell adherence, viability, morphology and actin cytoskeleton architecture were monitored for 1-7 days. Biomaterial permeability was checked with a previously established diffusion chamber.

RESULTS

The majority of the murine and adult human fibroblasts survived in slide and rotatory cultures on both wound dressings. The fibroblasts seeded on the synthetic polymer exhibited phenotypically a typical spread shape with multiple cell adhesion sites earlier than those on the natural polymer. The highest survival rates in all tested fibroblast species over the entire observation time were detected in rotatory culture (mean: >70%). Nevertheless, it led to cell-cluster formation on both materials. In the medium air interface culture, few adult fibroblasts adhered and survived until the seventh day of culture on both the natural and synthetic polymers, and no viable juvenile and L929 fibroblasts could be found by day seven. Apart from a significant higher survival rate of L929 in slide culture on the natural polymer compared with the synthetic polymer at the end of the culturing period (p<0.0001), and a higher cell survival of L929 on the natural polymer in medium air interface culture, only minor differences between both materials were evident. This suggested a comparable cytocompatibility of both materials. Permeability testing revealed slightly higher permeance of the natural polymer compared with the synthetic polymer.

CONCLUSION

Cell survival rates depended on the culture system and the fibroblast source. Nevertheless, the juvenile skin fibroblasts were the most sensitive. This observation suggests that wound dressings used in treating children should be tested beforehand with juvenile fibroblasts to ensure the dressing does not compromise wound healing. Future experiments should also include the response of compromised fibroblasts, for example, from burn patients.

A bio-degradable synthetic membrane to treat superficial and deep second degree burn wounds in adults and children - 4 year experience

INTRODUCTION

A new bio-degradable synthetic membrane was recently introduced to treat second degree burns in adults and pediatric patients.

OBJECTIVE

To assess complications and outcomes using this absorbable synthetic membrane to treat second degree burns.

METHODS

229 burn patients, 138 pediatric, with superficial and deep second -degree wounds, treated with the absorbable synthetic membrane (Suprathel®, Polymedics, Denkendorf, Germany) were included in this study. Patients were treated under anesthesia or moderate sedation. The wound bed was prepared by using either rough debridement or dermabrasion excision. After hemostasis, the membrane was applied to the wound with an outer layer dressing of fatty gauze, bridal veil, absorptive gauze and an ACE® wrap. The outer dressing was removed every one to four days, depending on exudate, in order to closely follow the wound through the translucent membrane and fatty gauze layers. After complete epithelialization, the dressing separated and could be removed. The study focused on the need for subsequent grafting, healing time, patient pain level, hypertrophic scarring and rate of infection.

RESULTS

All wounds in this study that were treated with Suprathel® healed without grafting. The average TBSA (Total Body Surface Area) was 8.9% (1%-60%). Average time to healing was 13.7 days for ≥ 90% epithelialization with 11.9 days for pediatric patients versus 14.7 days for adults. Throughout the treatment period, the average pain level was 1.9 on a 10-point scale. 27 patients developed hypertrophic scarring in some areas (11.7%). Average Length of stay (LOS) was 6.9 days. The rate of infection was 3.8% (8/229). Failure or progression to full thickness in part of the wounds was 5.2% (12/229).

CONCLUSION

In treating second degree burn wounds, this membrane provides a simple, effective solution alternative with good outcomes and less pain than conventional and previously studied treatment options in the same institution. Fewer dressing changes and easier overall management of the wounds contribute to its favorable profile.

Feasibility of Pure Silk for the Treatment of Large Superficial Burn Wounds Covering Over 10% of the Total Body Surface

Large, superficial burn wounds require many painful dressing changes and, thus, dressings that can stay on the wound and peel off during re-epithelization such as Biobrane® and Suprathel® are preferred, but they are costly. Natural silk has shown good outcomes with respect to wound healing, scarring, and patient satisfaction. This study aimed to evaluate the efficacy of natural silk compared with that of initially used dressings for the treatment of superficial burn wounds greater than 10% of the TBSA. Patients with superficial burns covering &gt;10% of the TBSA were treated with pure silk for the first time (treatment group). Complications during wound healing with respect to the need for further surgery and scarring were compared with those of patients with similar burns of more than 10% TBSA and treated with nylon mesh and collagen instead of silk (treatment group). The treatment and control group comprised 25 and 13 patients, respectively. In total, 88% of patients in the treatment group did not require further treatment, while two patients with chemical burns needed further surgeries. Moreover, patients reported high satisfaction with respect to scarring and aesthetic outcome. Meanwhile, 85% of patients in the control group healed without further surgery and showed higher median hypopigmentation and hyperpigmentation after 12 months. Silk is an effective wound dressing for the treatment of large superficial burn wounds. It avoids painful dressing changes and yields satisfactory aesthetic outcomes. However, especially in large burns, careful initial wound depth assessment is crucial to prevent infection and reoperations.

Bioengineered smart trilayer skin tissue substitute for efficient deep wound healing

Skin substitutes for deep wound healing require meticulous designing and fabrication to ensure proper structural and functional regeneration of the tissue. Range of physical and mechanical properties conducive for regeneration of different layers of skin is a prerequisite of an ideal scaffold. However, single or bilayer substitutes, lacking this feature, fail to heal full thickness wound. Complete scar free regeneration of skin is still a big challenge. This study reports fabrication of a trilayer scaffold, from biodegradable polymers that can provide the right ambience for simultaneous regeneration of all the three layers of skin. The scaffold was developed through optimization of different fabrication techniques, namely, casting, electrospinning and lyophilisation, for obtaining a tailored trilayer structure. It has mechanical strength similar to skin layers, can maintain a porosity-gradient and provides microenvironments suitable for simultaneous regeneration of epidermis, dermis and hypodermis. A co-culture model, of keratinocytes and dermal fibroblasts, confirms the efficiency of the scaffold in supporting proliferation and differentiation of different types of cells, into organized tissue. The scaffold showed improved and expedited wound healing in-vivo. Taken together, these compelling evidences successfully established the engineered trilayer scaffold as a promising template for skin tissue regeneration in case of deep wound.

Tissue repair in neonatal and paediatric surgery: Analysis of infection in surgical implantation of synthetic resorbable biomaterials

BACKGROUND

There has been increased interest in the use of biomaterials that resorb completely leaving only the patient's native tissue. Synthetic materials are advantageous for tissue repair because they are highly customisable. The infection rate of using resorbable natural materials in paediatric surgery has recently been outlined, but there has not yet been a review of the use of synthetic resorbable materials in paediatric surgery.

OBJECTIVES

This systematic review analyses the risk of infection after implantation of fully resorbable synthetic biomaterials in paediatric cases.

METHODS

The literature was searched from January 1970 to January 2018 (inclusive), specifically searching for paediatric cases (0-18 years old), use of synthetic resorbable materials and infection.

RESULTS

The infection rate in 3573 cases of synthetic resorbable material implantation was 1.1% (41 cases). A Chi-squared test for independence found infection rate to vary among materials. Of the many biomaterials identified in this review, the highest infection rates were seen in Suprathel's use in burns injuries (12.1%).

CONCLUSIONS

This review found a low infection rate in synthetic resorbable materials used in paediatric surgery, with particularly strong evidence for low infection risk in LactoSorb® use.

Evaluation of commonly used temporary skin dressings and a newly developed collagen matrix for treatment of superficial wounds

OBJECTIVE

In the authors' experience, extended superficial-thickness wounds often were treated with the application of synthetic temporary wound dressings. There is a broad range of expensive products available in this market. The aim of this study was to compare commonly used temporary skin dressings with a newly developed collagen matrix.

METHODS

A total of 56 standardized superficial skin defects were generated on the back of 28 adult male Lewis rats using a skin dermatome. The wounds were treated with Biobrane (Smith & Nephew, St Petersburg, Florida) (n = 14), Suprathel (PolyMedics, Denkendorf, Germany) (n = 14), and newly developed Collagen Cell Carrier (Naturin Viscofan, Weinheim, Germany) (CCC; n = 14). Histological evaluation was performed at 3 months' postoperative in regard to quality of newly formed skin.

RESULTS

In regard to epidermal cell count and thickness of skin, Biobrane and Suprathel demonstrated comparable values, whereas CCC demonstrated higher epidermal cell count and thicker neoepidermis. The epidermal thickness of CCC was comparable to untreated, healthy skin.

CONCLUSIONS

The presented results reveal the potential of CCC in the treatment of superficial skin defects and encourages further evaluation of CCC in surgical applications and regenerative medicine.

Use of a copolymer dressing on superficial and partial-thickness burns in a paediatric population

OBJECTIVE

Despite extensive research into the treatment of partial-thickness burns, to date there has not been the emergence of a preeminent modality. This pilot study, the first such study to be performed in a burn unit in the US, was designed to evaluate the efficacy and outcomes of the application of copolymer dressing (Suprathel; PolyMedics Innovations Corporation, Stuttgart, Germany) for both superficial and deeper partial-thickness burns.

METHOD

The copolymer dressing was used as a primary wound dressing to treat superficial and deep partial-thickness burns (average 5% total body surface area) in paediatric patients. Burns were debrided within 24 hours, at bedside, in the burn unit or in the operating room. The copolymer dressing was then applied directly to the wound and covered with a non-adherent second layer and an absorptive outer dressing. After discharge, patients were seen every 5-7 days until healed. Parameters evaluated included average hospital length of stay, average number of intravenous doses of narcotics administered, pain score at first follow-up visit, average time to complete re epithelialisation, incidence of burn wound infection, and patient/parent satisfaction on a 4-point scale. We also evaluated our experience with the dressing. Data were evaluated retrospectively under an Investigational Review Board approved protocol.

RESULTS

Of the 17 patients assessed the average hospital length of stay was 1.4 days during which the average number of intravenous narcotic doses administered before copolymer dressing application was 1.5 and after was 0.1 doses. At the first follow-up visit, average pain score was 1.2 on a 10-point scale and the average time to re epithelialisation was 9.5 days. There was no incidence of burn wound infection. Patient/parent satisfaction was average of 3.66 on a 4-point scale. The staff had found that the self-adherence and elasticity of the dressing made it easy to apply and stay adherent, especially in areas of difficult contour. There were no readmissions for further debridement or skin grafting.

CONCLUSION

Our experience shows that patients may be discharged shortly after the application of the copolymer dressing, with manageable pain scores and ease of use as determined by the caretakers high satisfaction. This new, fully synthetic copolymer dressing is easy to apply, does not require any additional antimicrobial coverage and may be used to successfully manage deeper partial-thickness burns, donor sites or burns in areas of contour, where many other dressings might not be considered or be appropriate.

DECLARATION OF INTEREST

None declared.

Development and Characterization of an Engraftable Tissue-Cultured Skin Autograft: Alternative Treatment for Severe Electrical Injuries

BACKGROUND/AIMS

Optimizing the treatment regimens of extensive or nonhealing defects is a constant challenge. Tissue-cultured skin autografts may be an alternative to mesh grafts and keratinocyte suspensions that are applied during surgical defect coverage.

METHODS

Autologous epidermal and dermal cells were isolated, in vitro expanded and seeded on collagen-elastin scaffolds. The developed autograft was immunohistochemically and electron microscopically characterized. Subsequently, it was transplanted onto lesions of a severely burned patient.

RESULTS

Comparability of the skin equivalent to healthy human skin could be shown due to the epidermal strata, differentiation, proliferation markers and development of characteristics of a functional basal lamina. Approximately 2 weeks after skin equivalent transplantation the emerging new skin correlated closely to the adjacent normal skin.

CONCLUSION

The present study demonstrates the comparability of the developed organotypic skin equivalent to healthy human skin and its versatility for clinical applications.