July 2017 - Volume 30 - Issue 7

  • Richard "Sal" Salcido, MD
  • 1527-7941
  • 1538-8654
  • 12 issues per year
  • 1.088

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Literature Review

Clinical Management Extra

Welcome to Wound Clinical Solutions Investigation (CSI). See if you can make the diagnosis.

Q.  A 76-year-old retired school teacher developed a skin tear on the dorsal surface of her left hand. What is the best approach to manage skin tears?


 Skin tears 2017.jpg

A. According to the International Skin Tear Advisory Panel (ISTAP), a skin tear often results from trauma on the extremities, such as the arms, hands, pretibial areas and feet. Significant friction or shear forces the epidermis to be detached from the underlying dermal layer exposing deeper structure. As with other injuries, patients develop exquisite pain and fear further injury. This affects their quality of life and mobility. More than 1 in 4 patients within the healthcare system has evidence of skin tears at any given time. The ISTAP created a classification system to describe skin tears based on the amount of tissue loss. Skin tears can be described as type 1 with an intact skin flap and no tissue loss; type 2 involves partial tissue loss; and type 3 with complete tissue loss.


The ISTAP system is simple to easy and has been translated and validated in various languages, including Dutch, French, and Portuguese to date. The purpose is to create a universal language to describe skin tears that can match different treatment approaches. In the photos here, the patient suffered from a type 1 skin tear. She was at risk because of her age, dry skin, falls risk, and chronic use of a steroid, making her skin paper thin. The key to managing this type of skin tear is to ensure the skin flap is rolled back into its original position to approximate the edges and cover the exposed tissue; sterile strips and sutures should be avoided. Alternatively, acrylate type agents can be applied or sprayed on the edges of the skin tear to keep the flap in place. Dressing selection is based on the volume of drainage from the skin tear. In general, atraumatic nonadherent dressings are preferred to cover and leave in place for 7 days. Whatever dressing material that is chosen to cover the skin tear, it is advisable to draw an arrow to indicate the direction from which the dressing should be removed. If the dressing is removed in the opposite direction, the skin flap will likely be ripped off completely, causing more extensive damage. To prevent recurrence, daily moisturization is crucial.


For further information, readers are encouraged to review the following article published in this journal: LeBlanc K, Baranoski S, Christensen D, et al. The Art of Dressing Selection: A Consensus Statement on Skin Tears and Best Practice. Adv Skin Wound Care 2016;29:32-46.









Modulator for Macrophages Identified

Diabetic foot ulcers are very difficult to heal due to poor blood circulation, neuropathy, and other risk factors. Macrophages are essential for tissue repair and they play a key role in the normal wound healing process maintaining a balance between inflammatory and anti-inflammatory reactions (pro-reparation). Canadian researchers affiliated with the University of Montreal Hospital Research Centre discovered a way to modify macrophage behavior to promote anti-inflammatory and pro-reparatory reaction by means of a special protein called Milk Fat Globule Epidermal Growth Factor-8, or MFG-E8.  The researchers developed a treatment by adoptive cell transfer using a patient's own cells, which are harvested, treated, and re-injected to exert their action on an organ. This immunotherapeutic has been shown to also be useful in reprogramming cells to facilitate healing of the skin.


Parasite Tested for Wound Healing

Scientists from the Australian Institute of Tropical Health and Medicine (AITHM) are testing a molecule, granulin, produced by a Thai liver parasite, Opisthorchis viverrini, for the treatment of chronic wounds.  The researchers worked to establish which parts of the molecule were critical to wound healing, and to find a way to reproduce the active parts of granulin molecules (peptides).


Histone Deacetylase Proteins Inhibitors for Healthier Skin

Psoriasis is one of the most common skin disorders, characterized by red, flaky patches on the body. Histone deacetylase (HDACs) proteins inhibitors, already widely used to treat cancer, may be an effective therapy for psoriasis. The HDACs are a class of enzymes that remove acetyl groups (O=C-CH3) from an ε-N-acetyl lysine amino acid on a histone, allowing histones to wrap DNA more tightly. They have shown that HDAC3 inhibitors help increase expression of aquaporin-3, or AQP3, a channel that transports glycerin, a natural alcohol and water attractor that aids healthy production and maturation of high-turnover skin cells by producing phosphatidylglycerol.  Since the immune system is believed to play a key role in psoriasis, many current treatments generally suppress the immune response, which increases the risk of infections, even cancer. In the future, scientists hope they can directly enhance the presence of AQP3 and commensurate increase in glycerin.


MicroRNA Inhibitors Investigated as Local Therapeutic Agents

MicroRNAs are interesting target structures for new therapeutic agents. They can be blocked through synthetic antimiRs. However, to date it was not possible to use these only locally. Researchers at Goethe University Frankfurt have successfully used light-inducible antimiRs for the treatment of wound healing. MicroRNAs are small gene fragments that bond onto target structures in cells and prevent certain proteins from forming. As they play a key role in the occurrence and manifestation of various diseases, researchers have developed what are known as antimiRs, which block microRNA function. The disadvantage of this approach is, however, that the blockade can lead to adverse effects throughout the entire body since microRNAs can perform different functions in various organs. Researchers at Goethe University Frankfurt have developed antimiRs that can be activated very effectively over a limited local area by using light of a specific wavelength. To this purpose, the antimiRs were locked in a cage of light-sensitive molecules that disintegrate as soon as they are irradiated with light of a specific wavelength.  The researchers injected the antimiRs in the light-sensitive cage into the skin of mice and then released the therapeutic agent into the tissue with the help of light. They were able to prove that pinpointed activation of an antimiR against microRNA-92a helps wounds to heal.


Bacteria-fighting Ingredient Found in Crustaceans

A research team at Lodz University of Technology in Poland has developed a hydrogel dressing that can speed up aspects of wound healing by incorporating antibacterial and biodegradable substance called chitosan, extracted from the shells of crustaceans, within the dressing itself.  The extraction process involves isolating a substance called chitin that is found in the shells.  The resulting chitosan is useful to stop bleeding and has been known for its antimicrobial properties for decades.


Thrombin Used for Wound Healing

The researchers from Lund University in collaboration with researchers in Copenhagen and Singapore have discovered that fragments of thrombin, a common blood protein found in wounds, can aggregate both bacteria and their toxins. The aggregation of bacteria and endotoxins takes place quickly in the wound and removed by the body's inflammatory cells to minimize the spread of infection.


Selective Nonoperative Management of Abdominal Gunshot Wounds

Selective nonoperative management (SNOM) of abdominal gunshot wounds is safe and avoids unnecessary laparotomies that may minimize postoperative complications. This is an alternative for less severe injuries that do not involve any major organ damage or significant blood loss.  Analysis of data from the Research Consortium of New England Centers for Trauma (ReCoNECT) indicated SNOM patients had significantly lower rates of complications (8.5% vs 34.7% for patients who underwent an operation) and death (0.5% vs 5.2%), and shorter stays in the intensive care unit (median of 0 days vs 1) and hospital overall (median of 2 days vs 8).