Essential Insights On Using Skin Substitutes
Furthermore, from a reimbursement standpoint, Dr. Bell says skin substitute application would be appropriate when an ulcer of diabetic and/or venous etiology has been present for a duration set forth in the policies of the patient’s insurance company or payer.
What is the rationale for using a skin substitute versus a skin graft?
As Dr. Satterfield notes, the key reason to use skin substitutes rather than grafts in patients with diabetes is the enhanced potential for healing as well as additional growth factors and living cells that the bioengineered substitute brings to the wound.
“By making this new deposit of living cells that include not only growth factors but proteins and collagen — all cells required to heal a wound — we are, we hope, giving them a wealth of cellular mass to heal that wound,” says Dr. Satterfield.
Dr. Lullove says one should use skin substitutes rather than autologous skin grafting in cases in which the patient is immunocompromised, has poor skin turgor or in those who are unable to undergo major surgery to harvest the graft. Dr. Suzuki says most patients who present to his wound care centers are of advanced age with very fragile skin quality and an autologous skin graft would be an inappropriate therapy option.
Dr. Lullove also cautions against using skin substitutes when the wound does not indicate for an autologous skin graft but might do better with secondary collagen filling. Drs. Bell and Suzuki note that the harvesting of skin graft creates another trauma that the patient has to heal. “The rationale is strong for considering a skin substitute over a skin graft for this reason alone,” says Dr. Bell.
Additional factors to consider are the potential pain, expense to the patient and insurers (due to operating room time and costs), and overall logistics of a bedside or office treatment versus a trip to the OR, according to Dr. Bell. He says skin substitutes are his preferred first line treatment due to their safety and efficacy.
Dr. Suzuki emphasizes informing patients of all of the treatment options. He says they often choose to go with skin substitute as opposed to the skin graft, given the excellent safety and efficacy data on wound closure demonstrated by some of the skin substitute products, such as Apligraf (Organogenesis) and Dermagraft (Advanced BioHealing).4,5
Do you differentiate the use and timing of skin grafts and skin substitutes, or do you use them as separate products?
Citing the acuity of his patients and their overall successful outcomes, Dr. Bell favors skin substitutes over skin grafting. However, in an acute setting, he says skin grafting would be the gold standard.
Dr. Suzuki believes that an autologous skin graft is for the wound that has granulated to the skin surface and is ready to be closed. On the other hand, he says skin substitutes may also be considered as “growth factor supplements” to further promote the granulation tissue and wound closure at the same time, based on the biological studies and multiple growth factors found in many skin substitutes.
One should make every attempt in most cases involving geriatric patients to prevent surgical procedures that would increase the risk of infection, according to Dr. Lullove. As he notes, skin substitutes allow the application and surgical fixation of dermal regenerative products. These products can supply the wound with needed type I or III collagen matrices to allow the wound to contract itself to healing. Dr. Lullove says one can also apply skin substitutes in an outpatient office setting as opposed to the operating room.
Dr. Satterfield has not often used the autograft in patients with diabetes to cover a non-healing ulcer. In her opinion, the patient with chronic wounds is deficient in many of those biochemical factors needed to heal the ulcer in the first place. “To use an autograft to heal an ulcer would be akin to using a patch from a blown-out tire to cover another blowout on that same tire,” she concludes.