Fish Skin Compared to Cadaver Skin as Temporary Cover for Full Thickness Burns

Overview

Objectives and rationale: Optimal burn management involves removing all the dead or burned tissue as early as feasible and cover with an autograft called split thickness skin graft (STSG) taken from the patient. This procedure creates a new wound on the patient and sometimes, when the burn covers very large portion of the patient body, there is a lack of healthy skin to use for this purpose. Under those circumstances, donated cadaver skin is used as a temporary coverage until the patient´s own donor site wound has healed enough to be used again. The proposed clinical study aims to determine if treatment with fish skin is an alternative to cadaver skin as a temporary coverage for debrided full-thickness burns prior to STSG in terms of autograft take, time to heal, quality of healing (scarring), pain and adverse effects.

Mortality after severe burns has diminished during the last decades and survival is no longer considered the primary end point of care. More attention is paid to the final functional and cosmetic outcome of the affected area but outcomes are still far from optimal. For the time being, one of the main goals in burn treatment is to achieve reduced scar formation from the time of injury. A temporary or permanent covering of the wound bed should be achieved at the time of excision. In burn wounds the gold standard is to use split thickness skin graft, or STSG, which includes epidermis, basement membrane, and a part of upper dermis. Yet the use of skin grafts has many shortcomings: there is only a limited amount of skin available for grafting, the donor sites are susceptible to infections, to pain, to pigmentation changes, and to scarring especially when re harvested. Therefore, for complicated burns, initial treatment is often with temporary coverage where cadaver skin has been the accepted standard of care. In recent years there has been progress in the development of advanced wound care products. This has resulted in a third generation of wound treatment, known as acellular dermal grafts or skin substitutes. Aims The goal of this clinical trial is to demonstrate that fish skin is an alternative to cadaver skin as early cover before STSG in burn wounds. This trial will be open to patients who are scheduled to receive meshed STSG of any ratio. Fish skin or cadaver skin will be applied after initial debridement in order to prepare the wound area for STSG. 5 to 10 patients will be prospectively enrolled and two burn sites on their body will randomized to initial treatment after debridement with either fish skin or cadaver skin for 7+/-3 days. After the initial treatment, the test sites will be grafted with STSG. The histological differences and the functional outcomes will be assessed for 12 months. Products will be applied by experienced burn surgeons at a burn center. At approximately Day 7, or when the treating physician deems the wound to be ready for grafting, the products will be removed. Prior to grafting, a second blinded burn surgeon will assess the burn wound bed. Important dates for blinding are on Day 7 prior to STSG treatment and on Days 14, 21 and 28 for graft take, epithelialisation and wound closure. Scar assessment at 3 and 12 months via the Vancouver Scar Sale will also be fully blinded. Key interventions: Randomized to either cadaver skin or fish skin after initial debridement Two areas each of 10-20 x 7 cm side by side. Other areas will be treated as per local Standard of care (SOC). Concomitant medications will be given, e.g. painkiller, antibiotics, as needed. Wound dressings changed approximately every three days until allograft or xenograft removal. Approximately one week after placement the fish skin and cadaver allografts removed as required. Subsequent meshed autograft placement if donor sites are available. Autografts covered with secondary antimicrobial/silver dressing and dressings approximately every 3 days until healed. Autografts monitored for adherence, color, autograft take, and visual signs of infection. During the operation, a 3 or 4 mm punch biopsy will be harvested from the excised wound bed before covering with any material.