When a wound proves challenging to heal, physicians may choose a biologic product as an additional therapy. Accordingly, the panelists discuss their experiences with various biologic options, including preferred clinical scenarios, settings and cautions regarding cost and proper use.
What biologic agents do you routinely use in your wound care practice? What benefits do you personally find in the use of these products?
Kazu Suzuki, DPM, CWS uses amniotic membrane grafts as well as synthetic collagen dressings.
“I find that they accelerate wound closure when one optimizes the wound healing environment, including perfusion, infection control and host issues such as blood sugar fluctuations and nutrition,” notes Dr. Suzuki.
Dr. Suzuki says cost is a consideration. For example, he shares that Grafix® cryopreserved placental membrane (Smith & Nephew) works exceedingly well in his hands for wound closure but requires pre-authorization due to cost. On the other hand, Dr. Suzuki adds that ColActive® Plus (Covalon Technologies) collagen matrix dressing is less expensive and he uses it on many non-infected wounds to assist in healing.
Eric Lullove, DPM, CWSP, FAPWH(c) says he favors platelet-rich fibrin, amniotic products, fish-derived and ovine collagens along with synthetic collagen products. He explains that most of the benefits he sees with these products are in accelerated wound healing and reduction of inflammatory markers, allowing a more rapid progression to closure.
While he finds many biologic products aid in wound healing, Tammer Elmarsafi, DPM, MBBCh, AACFAS notes there are a few that he personally prefers, including PuraPly® AM (Organogenesis) for wounds that require biofilm remediation. Dr. Elmarsafi also chooses this option in some cases when a wound is ready for split-thickness skin grafting.
For large-volume wounds, Dr. Elmarsafi notes anecdotally that overlying MicroMatrix® micronized porcine urinary bladder matrix (ACell) with a two-layer fenestrated porcine urinary bladder allograft such as Cytal® (ACell) can produce robust and rapid granulation. Dr. Elmarsafi says an additional benefit of the porcine urinary bladder allograft is its activity against gram-positive organisms but he still supports appropriate use of antibiotics in these cases.
When a wound finally shows neodermal ingrowth, Dr. Elmarsafi chooses a living human epidermal keratinocyte/dermal fibroblast collagen matrix (Apligraf®, Organogenesis) to support native skin closure in diabetic foot ulcers (DFUs) and venous stasis ulcers (VLUs). For wounds that do not fit in these categories, he cites Grafix as an alternative option.
Under what circumstances do you find that one can best employ a biologic product?
“Any biologic therapy works best when the wound environment is under control with reduced bioburden, reduced inflammation and reduced edema,” maintains Dr. Lullove. “One must employ basics of wound management prior to utilization of biologic products. Wounds tend to ebb and flow with the inflammatory conditions within the wound. It is important to continue to assess wound signs and symptoms prior to applying biologics. Otherwise, you will have a failure and further delay the progression of wound healing.”
“The first questions to answer every time I evaluate a patient is ‘What do I need to accomplish in order to improve the current state of the wound?’ and ‘How can I get that to happen?’ Wounds are in a constant state of flux and thus need consistent reevaluation to find ways to reach the desired outcome,” notes Dr. Elmarsafi.
In general, he summarizes that he uses biologics adjunctively when a wound is transitioning through various stages of healing including biofilm management, granulation and closure.
Dr. Suzuki explains he is fairly selective when using amniotic membrane grafts due to the cost investment, reserving these modalities for wounds that have failed to close four weeks after best practices of conventional wound care. He adds that each insurer may have slightly different guidance of when one may choose skin substitute grafts and biologic tissue grafts.
In what place of service do you typically use these types of modalities and why?
Each of the panelists relate possible office- and wound center-based usage of biologics with additional potential applications in the inpatient OR or ambulatory surgery center, depending on indications and availability.
“In the hospital OR, I prefer autologous split-thickness skin grafts that work very well … as long as the patient is able to provide ‘good’ skin for harvesting,” says Dr. Suzuki. “I may rely on biologic skin substitute grafts if I have a patient of extreme age (i.e. over the age of 90) or a chronic steroid user (for example, patients with rheumatoid arthritis), who may have less than ideal skin.”
Is there any other information you would like to share regarding biologics and wound care?
”Biologic interventions are best employed in chronic wounds or DFUs with prolonged wound histories and increased bioburden. Addressing the bioburden and inflammation is the first goal to meet prior to biologic interventions. Failing to do so results in poor management of the wound and thus biologic failure,” adds Dr. Lullove.
Dr. Suzuki notes the significant healing power of amniotic membrane grafts in closing wounds with exposed tendon, bone or hardware. In his experience, these kind of wounds would usually require a combination of negative pressure wound therapy (NPWT) and a skin flap.
“Having said that, due to the high expense of these amniotic grafts, we have to be diligent in patient selection to avoid overutilization,” adds Dr. Suzuki.
Dr. Elmarsafi echoes the importance of responsible, thoughtful use of biologics in wound care. He stresses that the timing of application is crucial to success and emphasizes that use of biologics does not circumvent, or alleviate the need for proper wound care and other interventions.
“I would share that I only use biologics when there is a profound compromise in the patient’s ability to heal,” points out Dr. Elmarsafi. “While there are certainly exceptions to every rule, one should be aware that most allografts come with cost of use and have a high rate of non-response. Responsible use is imperative.”
Dr. Elmarsafi is a fellowship-trained foot and ankle surgeon in practice in Woodbridge and Chantilly, Va.
Dr. Lullove is the Chief Medical Officer and is in private practice at the West Boca Center for Wound Healing in Coconut Creek, Fla. Dr. Lullove discloses that he is the Wound Healing Society Liaison to the Alliance for Wound Care Stakeholders, a consultant for Kerecis, LLC and Hydrofera, LLC, and a consultant and Scientific Advisor for Moleculight, Inc.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@ cshs.org.