Elsevier

Clinics in Dermatology

Volume 23, Issue 4, July–August 2005, Pages 388-395
Clinics in Dermatology

Treatment of nonhealing ulcers with allografts

https://doi.org/10.1016/j.clindermatol.2004.07.020Get rights and content

Abstract

Chronic wounds often represent a significant medical and economic challenge. Clinicians seek novel therapies poised to foster production of granulation tissue and subsequent healing. Cadaveric allograft remains the mainstay in burn therapy. Research, however, shows that this treatment functions adjunctively in complex nonhealing wounds by manipulating the microenvironment, preventing desiccation of underlying bone and tendon, augmenting wound-bed preparation, and producing rapid closure. The following review presents the rationale for incorporating skin allografts into the wound healing algorithm, including chronic wound biochemistry, wound-bed preparation, current applications, combination therapies, cost considerations, and case studies. Diagnosis and treatment of underlying etiologies remains essential. A multidisciplinary approach using accepted treatment protocols helps reduce morbidity and expense associated with these lesions.

Introduction

Wounds in the lower extremities represent a medical and surgical dilemma of global proportions. Consider these statistics:

  • 1.

    Venous ulcers, the most common type of leg ulcers, account for an estimated 70% to 90% of the cases. Recurrence is high, and the estimated cost of treating one episode can exceed $40,000.1

  • 2.

    Approximately 17 million people in the United States have diabetes, with more than 1 million cases diagnosed in 2000.2 Nonhealing foot ulcers represent a major cause of morbidity, immobility, and lower extremity amputation in the diabetic population.3 Amputation remains 15% more likely in individuals with diabetes.4 The estimated total cost of wound management exceeds $7 billion per year, with expected increases as the population ages.5

  • 3.

    The National Pressure Ulcer Advisory Panel reports wide ranges of prevalence among patients in the United States. Best estimates suggest that 2.5 million pressure ulcers require treatment annually in the hospital setting, with total annual costs of hospital-acquired pressure ulcers estimated at $2.2 to $3.6 billion.6

Clinicians treat many other chronic wound pathologies, including those related to arterial insufficiency, trauma, vasculitis, infection, pyoderma gangrenosum, and sickle cell disease. Additional etiologies include cryofibrinogenemia, cryglobulinemia, homocystinemia, rheumatoid arthritis, scleroderma, Buerger's disease, and calciphylaxis, among others. Wound care specialists also remain challenged by patients presenting with factitial wounds.

Unfortunately, the past few decades show little improvement in preventing morbidity and disability from chronic wounds, despite often-heroic efforts on the part of wound care professionals.7 Clinicians must seek out novel innovations to stimulate and/or accelerate wound healing.

Practitioners traditionally use skin allografts on burn patients for temporary wound coverage. In addition, allografts mitigate pain and aid in wound-bed preparation before placement of autografts. Research demonstrates many other applications in wound healing supporting the use of allografts as a true biologic dressing. Recently discovered nuisances unique to chronic wounds make allografts a formidable alternative as wound-bed preparation emerges as the standard of care for these lesions. Diagnosis and treatment of underlying wound etiologies remains essential. Intervention through a multidisciplinary approach using accepted algorithms helps reduce the extensive morbidity and expense associated with these lesions.

The following review presents the rationale for incorporating skin allografts into the wound healing algorithm, including discussions about chronic wound biochemistry, current applications, combination therapies, and case studies. The treatment of complicated wounds, including those with exposed tendon and bone, continues to represent an important adjunctive therapy and remains the focus of this text.

Section snippets

Rationale for the clinical use of cadaveric allograft

Allograft or homograft skin is tissue transplanted from a different individual within the same species, whereas autograft refers to skin taken from the same individual and transplanted from one part of the body to another.

The ideal wound dressing possesses several key characteristics, including adherence, water vapor transport, elasticity, creation of bacterial barrier, absence of toxicity and antigenicity, antisepsis, hemostatic activity, ease of application and removal, a long shelf life,

Conclusions

Wounds of all types and varieties are increasing at alarming rates, fostering creative therapies to promote healing. Cadaveric allograft represents the gold standard for adjunctive treatment of burns, yet research and clinical practice reveal that this therapy may be advantageous in other scenarios. Many wounds may benefit from allograft usage, including those created by venous disease, diabetes, pressure, trauma, vasculitis, and calciphylaxis, among others.

Allograft is an ideal dressing

References (83)

  • K. Buttenschoen et al.

    The influence of vacuum-assisted closure on inflammatory tissue reactions in the postoperative course of ankle fractures

    J. Foot Ankle Surg.

    (2001)
  • H.W. Kaiser et al.

    Cultured autologous keratinocytes in fibrin glue suspension, exclusively and combined with STS-allograft) preliminary clinical and histological report of a new technique)

    Burns

    (1994)
  • C.S. Burton

    Venous leg ulcers

    Am. J. Surg.

    (1994)
  • National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2000

    (2002)
  • Economic consequences of diabetes mellitus in the U.S. in 1997

    Diabetes Care

    (1998)
  • G.E. Reiber et al.

    Lower extremity foot ulcers and amputations in diabetes

  • D.J. Margolis et al.

    Risk factors associated with the failure of a venous leg ulcer to heal

    Arch. Dermatol.

    (1995)
  • K. Beckrich et al.

    Hospital-acquired pressure ulcers: a comparison on costs in medical vs. surgical patients

    Nurs. Econ.

    (1999)
  • G.E. Reiber

    Diabetic foot care: financial implications and practice guidelines

    Diabetes Care

    (1996)
  • M.J. Travis et al.

    Current status of skin substitutes

    Surg. Clin. North Am.

    (1978)
  • L. Wong

    The many uses of allograft skin

    Ostomy Wound Manage.

    (1995)
  • J.F. Burke et al.

    A method of secondary closure of heavily contaminated wounds providing “physiologic primary closure”

    J. Trauma

    (1968)
  • L. Bartholdson et al.

    Antibacterial effect of biological dressings in the treatment of infected wounds

    Scand. J. Plast. Reconstr. Surg.

    (1977)
  • A.M. Oliver et al.

    The differentiation and proliferation of newly formed epidermis on wounds treated with cultured epithelial allografts

    Br. J. Dermatol.

    (1991)
  • M.T. Rivas-Torres et al.

    Controlled clinical study of skin donor sites and deep partial-thickness burns treated with cultured epidermal allografts

    Plast. Reconstr. Surg.

    (1996)
  • L.I. Zaroff et al.

    Multiple uses of viable cutaneous homografts in the burned patient

    Surgery

    (1966)
  • J. Hussman et al.

    Use of glycerolized human allografts as temporary (and permanent) cover in adults and children

    Burns

    (1994)
  • L. Kirwan

    Management of difficult wounds with Biobrane

    Conn. Med.

    (1995)
  • D. Mackie

    Postal survey on the use of glycerol-preserved allografts in clinical practice

    Burns

    (2002)
  • V.I. Khrupkin et al.

    Application of viable cryopreserved alloderm transplants in the treatment of wound defects of soft tissues

    Vestn. Khir. Im. II Grek.

    (2002)
  • R.E. Salisbury et al.

    Biological dressings and evaporative water loss from burn wounds

    Ann. Plast. Surg.

    (1980)
  • E. Moerman et al.

    The temporary use of allograft for complicated wounds in plastic surgery

    Burns

    (2002)
  • R.G. Teep et al.

    Randomized trial comparing cryopreserved cultured epidermal allografts with tulle-gras in the treatment of split-thickness skin graft donor sites

    J. Trauma

    (1993)
  • M. Mila et al.

    Calciphylaxis and non-healing wounds: the role of the vascular surgeon in a multidisciplinary treatment

    J. Vasc. Surg.

    (2003)
  • M.G. Schwacha et al.

    Does burn wound excision after thermal injury attenuate subsequent macrophage hyperactivity and immunosuppression?

    Shock

    (2000)
  • H. Brem et al.

    Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing

    Arch. Surg.

    (2000)
  • Y.J. Bolivar-Flores et al.

    Frozen allogeneic human epidermal cultured sheets for the cure of complicated leg ulcers

    Dermatol. Surg.

    (1999)
  • D.N. Fedorov et al.

    Morphological and immunohistochemical characteristics of repair processes in non-healing wounds

    Arkh. Patol.

    (2002)
  • J.A. Carucci et al.

    Human cadaveric allograft for repair of nasal defects after extirpation of basal cell carcinoma by Mohs microscopic surgery

    Dermatol. Surg.

    (2002)
  • R.J. Snyder

    Graftskin (Apligraf) used to heal defects after Mohs surgery

  • R.J. Snyder

    Apligraf as an adjunct in the treatment of pyoderma gangrenosum

  • Cited by (81)

    • Pharmacological activation of Nrf2 promotes wound healing

      2020, European Journal of Pharmacology
      Citation Excerpt :

      Reactive oxygen species have been reported to inhibit keratinocyte migration to the wound site. Immune suppression caused due to the administration of drugs such as corticosteroids to treat diseases such as rheumatoid arthritis, systemic lupus erythematosus is responsible for delay in wound closure (Snyder, 2005). Glucocorticoids upregulate anti-inflammatory cytokines and repress the maturation, proliferation and differentiation of immune cells in our body (Allison and Ditor, 2015).

    View all citing articles on Scopus
    View full text