Review Article Skin Substitutes: A Brief Review of Types and Clinical Applications

Lath Alrubay,1 Kathem K. Al-Rubay2

Abstract
Replacng skn defects has wtnessed several developments over the centures. It started wth the ntroducton of skn graftng by Reverdn n 1871. Snce then, varetes of skn graftng technques have been used successfully. Despte beng clncally useful, skn grafts have many lmtatons ncludng the avalablty of the donor ste especally n crcumstances of extensve skn loss, mmune rejecton n allogenc skn grafts, pan, scarrng, slow healng and nfecton.1,2 For these reasons, scentst have worked hard to find skn substtutes to replace skn defects wthout the need for a natural skn graft. These materals whch are used to cover skn defects are called Skn substtutes. Ths artcle brefly dscusses the common types of skn substtutes and ther clncal uses.
From the 1Department of Medicine, Ysbyty Gwynedd NHS Trust, Bangor, UK; 2 Department of Dermatology, Basra College of Medicine, University of Basra. Received: 15 Oct 2008 Accepted: 12 Dec 2008 Address correspondence and reprint request to: Dr. Laith Alrubaiy, Department of Medicine, Ysbyty Gwynedd NHS Trust, Bangor, UK. E-mail: laithalrubaiy@gmail.com

Introduction

eplacng skn defects has wtnessed several developments over the centures. It started wth the ntroducton of skn graftng by Reverdn n 1871.1 Snce then, varetes of skn graftng technques have been used successfully.2 Despte beng clncally useful, skn grafts have many lmtatons ncludng the avalablty of the donor ste especally n crcumstances of extensve skn loss, mmune rejecton n allogenc skn grafts, pan, scarrng, slow healng and nfecton.1,2 For these reasons, scentsts have worked hard to find skn substtutes to replace skn defects wthout the need for a natural skn graft. Treatng wounds wth skn substtutes dates back to 1880 when Joseph Gamgee descrbed an absorbent dressng made of cotton wool sandwched between layers of gauze.3 In 1895, Mangoldt descrbed a technque of epthelal cell seedng as a way of treatng chronc wounds. He harvested epthelal cells by scrapng off superfical epthelum from skn wth a surgcal blade untl fibrn exudates from the wound. He then seeded these cells onto the wounds.1 In 1897, Lunggren recounted that fragments of skn can be kept alve when noculated n asctc flud at room temperature.4,5 The definng moment n culturng skn was n 1975 when Rhenwald and Green successfully grew human keratnocytes on lethally rradated murne fibroblasts.4 In 1981, OConner and hs group used cultured autologous epthelum to cover burn defects for the first tme.3 To construct a lvng alternatve, a dermal substtute based on collagen I gel was created wth mesenchymal cells such as fibroblasts. When an epdermal layer s added, ths approach became known as skn equvalent, composte culture or organotypcal culture.4,5

Commonly used skin substitutes

Tssue engneered skn refers to a materal made up of cells, extracellular matrx or combnaton of both.6 Skn substtutes can be classfied nto several types: 1. Acellular skin substitutes 1.1 Biobrane The use of Bobrane skn substtute started n the late 1970s and t s now wdely used as a temporary skn substtute. It conssts of a nylon mesh, whch acts as a derms and a slcon membrane whch acts as an epderms. Both are embedded n porcne collagen and ncorporated by chemcal lnkage to enhance ts bond to the wound base.1,7 It s manly used as a temporary coverage for superfical or md-dermal partal thckness wounds, burns, donor stes and congental dseases such as epdermolyss bullosa,8,9 and n hydradents suppuratva.10 Bobrane vrtues are ts ready avalablty, low pan, short hosptal admsson tme, accelerated wound healng, and buyng tme untl skn graft materal s avalable. However, there s a rsk of nfecton and some studes have reported cases of toxc shock syndrome due to accumulaton of exudate underneath t.8,9 1.2 Integra The Integra skn substtute s base on work done by Yannas and Burke.7 It s a b-layered skn substtute made of a slcone membrane as an epdermal layer. It s mpermeable to water and protects aganst nfecton. The dermal part s made of bovne collagen and shark chondrotn-6-sulphate glycosamnoglycan.1 , 6 , 7 After coverage, the

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Skin Substitutes... Alrubaiy

wound becomes revascularzed wthn 2-3 weeks.1 At ths stage, the superfical slcone layer s removed and replaced by a very thn splt skn graft appled onto the neo-derms bed. The advantages are mmedate avalablty, allowng tme for the neo-derms formaton, and good aesthetc results. However, the dsadvantages are that t needs a two-step operaton, beng expensve, and accumulaton of exudate underneath t that may lead to nfecton. It also needs 3-4 weeks for culture.2,7 Integra has been wdely used n certan dsaster stuatons such as n the management of burn vctms of Pat Sn Range fire that happened on 10th February 1996 n Hong Kong.3 1.3 Alloderm The Alloderm skn substtute s essentally formed from acellular matrx derved from a cadaverc derms. The alloderms s processed by salt to remove the epderms and then extracted wth a soluton to remove any cellular materal. It s then freeze-dred to render t nert mmunologcally, although ts basement membrane remans ntact.1,7 It has no epdermal layer. However, the acellular matrx provdes a good natural medum for fibroblast and endothelal cells to regenerate from the neoderms.6 2. Cellular allogenic skin substitutes 2.1 Transcyte The Transcyte tssue engneered skn substtute s made from a nylon mesh and a slastc sem permssble and bocompatble layer. Allogenc fibroblasts from neonatal foreskn are embedded n the mesh and allowed to grow for 3-6 weeks to produce a cellular matrx of collagen and growth factors whch may enhance wound healng.8, 9 It s left n place untl ether spontaneous separaton occurs whch ndcates wound bed healng or the wound s dealt wth surgcally.6 It has been lcensed by the FDA for use n burns. 2.2 Dermagraft The Dermagraft skn substtute s smlar to Transcyte but t lacks the slcone layer and also contans vable fibroblasts. It s produced by mxng lvng neonatal foreskn fibroblasts wth a bodegradable mesh from polyglycolc acd (Dexon or Vcryl) n a bag wth crculatng nutrents. The fibroblasts are cryopreserved at -80C to mantan vablty and when mplanted to the wound, these start to prolferate and produce a varety of growth factors and extracellular collagen matrx components.11 The polyglycolc acd mesh s absorbed wthn 3-4 weeks. It has been used effectvely n vestbuloplasty after mucogngval juncton and supra-perosteal dssecton.1,7 2.3 Apligraf (Graftskin) Aplgraf represents an example of a composte skn graft, skn

equvalent or organo-typcal skn substtute as t has both lvng derms and epderms. The FDA approved t for clncal use n 1998 as the first true composte skn graft for the treatment of venous ulcers or neuropathc dabetc ulcers.1,7 It s prepared by mxng lvng fibroblasts from neonatal foreskn wth bovne collagen type I and then exposng them to heat to produce a loose matrx. Then ths s left for two weeks durng whch tme new collagen and matrx are formed gvng a dense fibrous network. A suspenson of lvng neonatal foreskn keratnocytes (from the same or dfferent neonatal donor) s seeded on the surface of the dermal fibrous matrx and left for 4 days to prolferate and dfferentate n mnmally supplemented basal medum. On the last two days, the calcum concentraton s ncrease n the culture medum and the keratnocytes are rased to a lqud ar nterface to allow dfferentaton and stratum corneum formaton for 7-10 days. At ths stage, t s ready for clncal use.2,4 The lcensed ndcatons of Aplgraf are for the treatment of non-nfected partal or full thckness venous ulcers whch have not responded to conventonal treatment for at least one month. It s also ndcated for neuropathc dabetc ulcers that have faled to respond to conservatve treatment for three weeks.3 The clncal effect of Aplgraf may be due to both ts occlusve propertes and bologcal medators.12 Aplgraf has been used for treatment of venous and dabetc ulcers, and managng wounds n epdermolyss bullosa, donor stes, surgcal excson of skn cancer and burns.1,7 3. Cellular autologous skin substitutes Most of the prevously descrbed skn substtutes are useful n provdng temporary coverage of raw skn surfaces. However, they usually need to be replaced later on by a splt skn graft or re-graftng as n large wounds or by spontaneous gradual epthelalzaton from the wound tself n smaller wounds. In several types of wound coverage there s a need to use cultured autologous keratnocytes for permanent skn coverage. Culturng these cells s based on orgnal technques developed by Rhenwald and Green.4,7 3.1 Cultured Epidermal Autograft (CEA) The culture of autologous keratnocytes nvolves takng a skn bopsy from the patent, removng the derms and subcutaneous tssue and then mncng the epderms wth trypsn enzymes. The suspended keratnocytes are then cultured on lethally rradated 3T3 mouse fibroblasts. The culture medum contans essental elements ncludng epdermal growth factors.4,7 An mportant pont s that once cultured over a few weeks, the keratnocytes are dfficult to handle and therefore they need a delvery system or a supportng dressng.1,3 Commercally avalable, cultured, epdermal autografts dffer n terms of ther delvery or carrer systems. The

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other mportant aspect s that keratnocytes alone may not help n full thckness wounds or burns. Therefore, blsters may develop even followng small amounts of frcton snce the dermal epdermal juncton s not completely developed. Scarrng, contracture and hyperkeratoss may also develop.7 In addton, cultured epdermal autografts are susceptble to the dgestve effects of collagenase enzymes wthn the wound bed so the take rate s unpredctable and vares from 0-100% but s usually about 30-80%. One opton to deal wth ths s to condton the wound bed wth cadaverc allogenc skn for about four days before graftng. The allo-epderms s then strpped away and replaced by autologous cells. Several groups have reported success usng ths method.3,6 3.2 Cultured Skin Substitutes (CSS) From the name, cultured skn substtutes ndcate graftng materals that have both epdermal and dermal components. It s an autologous graft so there s mnmal rsk of nfecton transmsson. It acts as a permanent coverage. It can be handled easly and does not form blsters because the dermal-epdermal juncton s well formed. However, lke CEA, t takes a finte perod to be prepared and t s expensve.1,6,7 Several types were developed recently wth dfferent dermal bosynthetc scaffolds. The most commonly used type s a hyaluronc acd derved substtute. Hyaluronc acd (Hyaluronan) s a naturally occurrng polymer wthn the skn and t has been found to be pro angogenc thus stmulatng blood vessel growth. In contrast to collagen, hyaluronc acd s hghly conserved between speces. It was found first n the vtreous humor of the eye n 1934 and subsequently syntheszed n vtro n 1964. It s modfied by esterficaton to render t watersoluble.12 Hyaluronc acd facltates the growth and movement of fibroblasts, controls matrx hydraton and osmoregulaton. It s also a free radcal scavenger and an nflammatory regulator.13 Hstologcal studes showed areas of acanthoss, contnuous epderms wth nterdgtaton a dermoepdermal juncton that resembles rete rdges.14

that such cells may have an ncreased rsk of future malgnances or perhaps some physologcal dfferences durng wound healng or skn agng. One development for the future may be to try to recaptulate more of the propertes of in vivo skn.

References:
1. Horch RE, Jeschke MG, Splker G, Herndon DN, Kopp J. Treatment of Second-Degree Facal Burns wth Allografts-Prelmnary Results. Burns 2005; 31:597-602. Lee KH. Tssue-engneered human lvng skn substtutes: development and clncal applcaton. Yonse Med J 2000; 41:774-779. Wa-Sun Ho. Skn substtutes: an overvew. Ann Coll Surg 2002; 6:102-108. Legh IM, Watt FM. Keratnocyte methods. Cambrdge: Cambrdge Unversty Press 1994. Legh IM, Watt FM. The culture of human epdermal keratnocytes, Keratnocyte handbook. Cambrdge: Cambrdge Unversty Press, 1994 pp 4351. Bello YM, Falabella AF, Eaglsten WH. Tssue-engneered skn. Current status n wound healng. Am J Cln Dermatol 2001; 2:305-313. Supp DM, Boyce ST. Engneered skn substtutes: practces and potentals. Cln Dermatol 2005; 23:403-412. Shakespeare P, Shakespeare V. Survey: use of skn substtute materals n UK burn treatment centres. Burns 2002; 28:295-297. Shakespeare PG. The role of skn substtutes n the treatment of burn njures. Cln Dermatol 2005; 23:413-418.

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10. Melkun ET, Few JW. The use of bosynthetc skn substtute (Bobrane) for axllary reconstructon after surgcal excson for hdradents suppuratva. Plast Reconstr Surg 2005; 115:1385-1388. 11. Raguse JD, Gath HJ. The buccal fat pad lned wth a metabolc actve dermal replacement (Dermagraft) for treatment of defects of the buccal plane. Br J Plast Surg 2004; 57:764-768. 12. Prce RD, Myers S, Legh IM, Navsara HA. The role of hyaluronc acd n wound healng: assessment of clncal evdence. Am J Cln Dermatol 2005; 6:393-402. 13. Edmonds M, Bates M, Doxford M, Gough A, Foster A. New treatments n ulcer healng and wound nfecton. Dabetes Metab Res Rev 2000; 16:51-54. 14. Harrs PA, d Francesco F, Barson D, Legh IM, Navsara HA (1999). Use of hyaluronc acd and cultured autologous keratnocytes and fibroblasts n extensve burns. Lancet 1999; 353:35-36. 15. OLeary R, Arrowsmth M, Wood EJ (2002). Characterzaton of the lvng skn equvalent as a model of cutaneous re-epthelalzaton. Cell Bochem Funct 2002; 20:129-141.

Future potential of skin substitutes

The future seems to be promsng for skn substtutes. Havng an artfical skn may be very helpful n many aspects. A key queston, however, s how fathful s the skn substtute to the normal skn state because some studes have shown that skn equvalent keratnocytes are n an actvated state?15 Ths rases the theoretcal possblty

Oman Medical Journal 2009, Volume 24, Issue 1, January 2009