By Louise Gagnon – Correspondent, The Chronicle
Lasers, pressure-sensing socks for patients with diabetic wounds, the identification of harmful and beneficial entities present in wounds, 3D printers that print skin tissue, and the use of ultraviolet light therapy are some innovations in wound care that Canadian clinicians are incorporating or planning to incorporate in their care of patients with wounds, particularly non-healing wounds.
Whether wounds heal or worsen is dependent upon factors such as microbial colonization, the formation of biofilm, and if infection is present or not, according to Dr. Afsaneh Alavi, a staff dermatologist at Women’s College Hospital in Toronto, assistant professor in the Faculty of Medicine (Division of Dermatology) at the University of Toronto, and regional director (Ontario) of the Canadian Dermatology Association.
“Investigators have shown that certain strains of common pathogens of Staph aureus were strongly linked with failure to heal and poor outcomes,” said Dr. Alavi in an interview with The Chronicle of Skin & Allergy. “Staph aureus is a pathogen that is difficult to treat and is present in many wounds.”
Indeed, one particular study sought to determine the role of colonizing microbiota in wound healing, clinical outcomes, and response to therapy in patients with diabetic foot ulcers. They found the use of debridement, as opposed to antibiotic treatment, shifted the microbiota of the ulcers and that the microbiota in diabetic foot ulcers, including the presence of strains of Staph aureus, could serve as a marker for clinical outcomes and response to therapies (Cell Host Microbe 2019 May 8; 25(5):641–655.e5)
But there are also entities that assist in the wound healing process, such as the perforin-like protein (perforin-2), said Dr. Alavi. “There may be a lack of expression of perforin-2,” she said.
Published research has shown that perforin-2 is a critical element of host defense against a large spectrum of infectious bacteria in studies involving animal models. Mice that lacked perforin-2 did not survive bacterial infections (J Innate Immun 2013; 5(2):185–194).
“With the identification of things like perforin-2 that are beneficial [in the wound healing process], we can help develop a treatment strategy for non-healing wounds,” said Dr. Alavi.
New technologies to help wound care
One of the emerging technologies that will likely find a place in wound care is “smart socks” to mitigate early threats of various foot conditions, pointed out Dr. Alavi.
The socks, which wirelessly offer continuous temperature monitoring for daily wear and home use, are suitable for patients with diabetes and neuropathy in an effort to identify warning signs of conditions such as foot ulcer, Charcot foot, and re-ulceration. “The sensors are sensitive to temperature change,” explained Dr. Alavi.
Temperature studies that were conducted demonstrated that the sensors were accurate in detecting temperature and the results were consistent with clinical observations. One specific study of 35 patients with diabetic peripheral neuropathy supported the use of the socks. Moreover, the socks are tolerable as wearers found no difference in wearing them compared to standard socks (J Med Internet Res 2018 Dec 17; 20(12):e12460).
The use of 3D printers represents an exciting opportunity in wound healing, noted Dr. Karen Cross, a plastic, reconstructive and aesthetic surgeon, and assistant professor, Department of Surgery, University of Toronto.
“This could provide skin grafts and eliminate the need for donors [donor grafts],” said Dr. Cross.
Biofilm has become a challenge in wound healing. To tackle issues such as biofilm, Dr. Laurie Parsons, a dermatologist and clinical associate professor of dermatology, Section of Dermatology, Department of Medicine, University of Calgary, and medical director of the Wound Clinic, noted that using ultraviolet light therapy is generating some benefit.
“It is relatively new to wound healing,” said Dr. Parsons. “We are seeing some interesting results in our clinic [with the use of ultraviolet therapy].”
Lasers in wound healing
Lasers can be employed in wound healing, in particular in the treatment of scars, according to Dr. Lisa Kellett, a dermatologist and medical director at DLK on Avenue in Toronto.
“We can individualize treatment [for scars],” said Dr. Kellett. “We can use lasers in keloid scars, hypertrophic scars, and atrophic scars.”
Skin type is something to consider when treating scars with lasers, noted Dr. Kellett.
“You have to adjust the fluence appropriate to the skin type,” she said. “You would use a longer pulse duration and lower fluence for a darker skin type.”
Prevention is still key
Patients with wounds will often have significant co-morbidities that impair healing such as diabetes that is not controlled, and a wound that fails to heal can bring devastating consequences, noted Dr. Parsons.
“If the neuropathy is bad enough and the patient ends up with ulceration, and if the wound does not heal, it can result in amputation,” she said. “Once you lose a limb, there is increased risk of developing another ulcer.”
The steps that a patient needs to take to allow a wound to heal, such as off-loading when a foot ulcer is present, will also quickly result in a patient becoming unfit, emphasized Dr. Parsons. “We know how important exercise is for everyone’s overall health,” she said.
“Anytime we do that [ask the patient to off-load], and we are asking the patient to walk as little as possible to take away the pressure completely, we know that they can decondition quickly and lose muscle. The more fat they gain and muscle they lose, the metabolic rate goes down and they gain weight. It becomes a self-perpetuating cycle.”
Proper nourishment is also a vital ingredient in the recipe for optimal wound healing, said Dr. Parsons.
“One of the things that can sometimes be completely overlooked is nutrition,” said Dr. Parsons. “A wound may be stalled [in healing] because patients do not eat enough protein. Try to make sure patients are eating eggs or doing things like putting protein powders in their oatmeal.”
“It is about starting at the beginning with things like diet and exercise, and watching your weight and blood sugar control,” said Dr. Parsons. “The goal should be to help patients not get into the situation [where they have a non-healing ulcer] in the first place. The global health of the patient is so important.”