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Topical silicone in wound healing
 

Topical silicone in wound healing

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  • Before discussing chronic wounds and chronic wound management, it may be important to review the healing process that occurs with acute wounds (surgical or traumatic).
  • To summarize the biochemical differences between healing wounds and chronic wounds: In healing wounds there is a high level of mitogenic activity. For example fluids collected from acute mastectomy wounds added to cell cultures stimulated DNA synthesis. In contrast fluid collected from chronic venous leg ulcers did not stimulate DNA. There is a distinct difference in the cytokine environment. In the healing wound there is a balance of pro-inflammatory cytokines and their natural inhibitors whereas in the chronic wounds there are increased levels of the pro-inflammatory cytokines. The pro-inflammatory cytokines also influence the levels of matrix metalloproteinases (MMP). Again in the healing wound there is a balance between MMPs and TIMPs however in the chronic wound MMPs levels are significantly elevated. Analysis of chronic wound fluids revealed a 116-fold higher level of protease activity as compared to mastectomy fluids. The high levels of MMPs also degrade various growth factors. The final point here is that while much research has been focused on the molecular environment there must also be consideration of the cells ability to respond to the molecular regulators. There is some interesting data demonstrating that the fibroblasts from venous leg ulcers present for more than 3 years grew more slowly and responded poorly when compared to venous ulcers present less than 3 years. This suggest that fibroblasts in ulcers that have been present for a long time may become senescent Schultz G, Mast B. Molecular Analysis of the Environment of Healing and Chronic Wounds: Cytokines, Proteases and Growth Factors. Wounds 1998;10:1F-9F
  • While there is still much to learn, this model has been hypothesized to explain the chronic wound. Unlike the acute wound with normal healing, the chronic wound has a persistent pro-inflammatory stimulus. It may be one or several of the factors listed. Repetitive trauma Local tissue ischemia Necrotic tissue Heavy bacterial burden Tissue breakdown The inflammatory cells (neutrophils and macrophages) are drawn to the wound bed. The activated macrophages secrete the inflammatory cytokines Tumor Necrosis Factor-alpha (TNF-  ) and interlukin one-beta (IL-1  ). Tumor Necrosis Factor-alpha (TNF-  ) and interlukin one-beta (IL-1  ) increase the production of matrix MMPs and reduce the synthesis of TIMPs. (Tissue inhibitors of MMPs) The elevated MMPs degrades the extracellular matrix which impairs cell migration and connective tissue deposition. MMPs also degrade growth factors and their target cell receptors. This prevents the wound from entering the proliferative phase of healing and continues the vicious cycle of the chronic wound. Mast BA, Schultz GS. Interactions of cytokines, growth factors, and proteases in acute and chronic wounds. Wound Repair and Regeneration 1996;4:411-420
  • The International Advisory Panel on Wound Bed Preparation offered the TIME principles for wound management, an excellent tool for recognizing and managing the barriers to healing. The barriers are observed as: Tissue nonviable or deficient Infection or inflammation Moisture imbalance Edge of Wound non advancing or undermined. The model addresses proposed pathophysiology, clinical actions of the TIME principles and the effect of that action on the wound. Debridement may be episodic or continuous. Various methods of debridement will be discussed later in the presentation. Infection or inflammation may be addressed with topical or systemic antimicrobial/anti-inflammatory agents. Moisture balance can be achieved by either adding moisture to a dry wound with a dressing such as a hydrogel. Absorptive dressing may the appropriate choice for wounds with moderate to large amounts of exudate. Compression therapy may reduce chronic wound fluid associated with edema among patients with venous insufficiency. For the non-advancing wound edge, interventions include addressing the cause and implementing corrective measures: biological agents, skin grafts, debridement and/or adjunct therapies.
  • When thinking about wound bed preparation there are five methods of debridement: surgical, mechanical, autolytic, enzymatic and biological (larvae). Biological, although returning as an option, is not as commonly used as the others. Therefore this presentation will focus on surgical, mechanical, autolytic and enzymatic debridement. While there are advantages and disadvantages for each method, there are also clinical indications for each method. It is important to considers the patient ’ s overall condition and the goals of care when selecting a debridement method. While there are advantages and disadvantages for each method, there are also clinically appropriate indications for each method. It is important to consider the patient ’ s overall condition and the goals for care when selecting the method of debridement.
  • Autolytic debridement is defined as the process by which the wound bed utilizes phagocytic cells and proteolytic enzymes to remove debris. Maintaining a moist wound bed helps to promote and enhance autolytic debridement. The process of autolytic debridement results in liquification of necrotic tissue and can result in significant wound fluid and this is a consideration when selecting the appropriate dressing. It is important to remember that when using occlusive dressings there will be an accumulation of wound fluids that have a tan opaque appearance. This is an anticipated normal occurrence (point out picture on slide).
  • Over the years enzymatic agents have been used to debride necrotic tissue from the wound bed and have become a well established practice among wound care providers. Enzymatic debridement is defined as the use of proteolytic substances, applied topically to the wound, to stimulate the breakdown of necrotic tissue. Enzymatic debriders use chemical agents which are biologically capable of degrading eschar, protein and other nucleic acids. There are several preparations on the market for example Collagenase and Papain-Urea.
  • Remember that the right method of debridement is a clinical decision that requires judgment of the clinician
  • It is clear that while bacteria are present on intact skin, infection is rarely a problem. This is attributed to the mechanisms that are in place to control bacteria: The outer layer of the skin provides a physical barrier to invasion The slightly acidic pH of the skin is not conducive to bacterial growth The skin normally secretes fatty acids and antibacterial polypeptides that inhibit bacterial growth The presence of normal flora help to prevent potentially pathogenic bacteria from becoming established. The presence of a wound creates a portal of entry for bacteria. One of the most significant predisposing factors for a wound infection is inadequate blood supply. For example in pressure ulcers or ischemic leg ulcers
  • It has been well documented that when bacterial levels reach greater than 10 5 there is a negative effect on healing. This has been seen in both the acute and chronic wound.
  • Silver has been used for centuries for its antimicrobial activity. In fact, ancient Romans used it as a disinfectant for storage of water. More recently is was used by NASA to maintain water purity on the space shuttle. Reports of cytotoxicity with the use of silver preparations has been associated with the carriers and not the silver, The traditional delivery systems used with silver nitrate and silver sulfadiazine required repeated applications. The new technology allows for the consistent delivery of silver over time. Silver has a broad spectrum of activity including MRSA and VRE. There are no documented cases of bacterial resistance to silver and it is unlikely that resistance could occur due to the complex mechanisms by which the silver cation is toxic to the bacteria. These include binding to and disruption of bacterial DNA, respiratory enzymes and cell wall.
  • When evaluating silver products, one may benefit by understanding the minimum bactericidal concentration (MBC). MBC is the amount of antimicrobial agent required to kill a given microbe. MBC is represented by a log reduction of 3 – for example, decreasing the number of bacteria from 10 7 to 10 4 .
  • Additional benefits of a moist wound environment include: Decreased healing time Capacity for autolysis Decreased rates of infection Reduced wound trauma Decreased pain Fewer dressing changes Cost effectiveness - When defined as total cost of care to achieve desired outcome and not just cost of dressing. It is the evidence of improved healing and the benefits that have influenced the development of advance wound therapies.
  • With a small amount of exudate it may be necessary to use hydrogels which will add moisture to the wound environment. Hydocolloids may also be used to maintain a moist wound environment in partial thickness wounds. As the amount of exudate increases it becomes necessary to use a topical dressing capable of absorbing exudate and foams are a good choice for wounds with moderate to large amounts of exudate. Alginate dressing are also appropriate for wound with moderate to large amouns of exudate. It may be necessary to use a specialty absorptive product as the secondary or cover dressing.
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Topical silicone in wound healing Topical silicone in wound healing Presentation Transcript

  • A 9 YearA 9 Year Clinical Experience with Kelo-coteClinical Experience with Kelo-cote ®® The Role of Topical Silicone In Wound HealingThe Role of Topical Silicone In Wound Healing Rex Moulton-Barrett, MDRex Moulton-Barrett, MD Plastic and Reconstructive SurgeryPlastic and Reconstructive Surgery Oakland, CaliforniaOakland, California
  • Not all wounds are created equallyNot all wounds are created equally • Fresh surgical: sharp edges, tensionless epidermis, layered dermal repairFresh surgical: sharp edges, tensionless epidermis, layered dermal repair • Traumatized tissue: crushed irregular edges, tensionTraumatized tissue: crushed irregular edges, tension • Thermal and chemical burns: basal layer and dermis may be absentThermal and chemical burns: basal layer and dermis may be absent • Post-scar ( hypertrophic/keloid ) excision: tendency to recurPost-scar ( hypertrophic/keloid ) excision: tendency to recur • Scar prone locations: chin to xiphoid, intra-mucosalScar prone locations: chin to xiphoid, intra-mucosal • Scar prone races: related to Fitzpatrick skin types: tan easily=scar easilyScar prone races: related to Fitzpatrick skin types: tan easily=scar easily Epidermis: 40 - 150 microns Dermis: 140 - 400 microns E & D: 180 >/= 550 microns
  • Choices In Topical TherapyChoices In Topical Therapy Dry WoundsDry Wounds • TapesTapes: control tension, shear through surface protection, hydration: control tension, shear through surface protection, hydration • Oil based antibiotic ointmentsOil based antibiotic ointments: Polymyxin, Bacitracin, Bactroban,: Polymyxin, Bacitracin, Bactroban, NeosporinNeosporin • Skin substitutesSkin substitutes: Biobrane, Alloderm: Biobrane, Alloderm • Silicone gel:Silicone gel: Kelo-cote, Scarfade, MedermaKelo-cote, Scarfade, Mederma • Silicone gel sheetingSilicone gel sheeting : Cica-care, Epiform, Mepilex,: Cica-care, Epiform, Mepilex, Mepitel, SilgelMepitel, Silgel • Collagens: Clayton ChagallCollagens: Clayton Chagall • Tissue adhesivesTissue adhesives: cyanoacrylate-Dermabond, Epiglu, Indemil,: cyanoacrylate-Dermabond, Epiglu, Indemil, LiquibandLiquiband • Barrier filmsBarrier films: fast drying carrier solvent: Cavillon, Comfeel,: fast drying carrier solvent: Cavillon, Comfeel, SuperskinSuperskin
  • Choices In Topical TherapyChoices In Topical Therapy Wet WoundsWet Wounds • Silver dressingsSilver dressings: Acticoat, Actisorb, Avance, Flamazine: Acticoat, Actisorb, Avance, Flamazine • FoamsFoams: absorptive for exudates-Allevyn, Flexipore: absorptive for exudates-Allevyn, Flexipore • AlginatesAlginates: seaweed based very absorptive- Meligisorb, Algisite, Sorbsan: seaweed based very absorptive- Meligisorb, Algisite, Sorbsan • HydrogelsHydrogels: >70% water,minimally absorptive- Aquaform, Intrasite, Nu-Gel: >70% water,minimally absorptive- Aquaform, Intrasite, Nu-Gel • HydrocolloidsHydrocolloids: semi-permaeable-Aquacel, Cutinova: semi-permaeable-Aquacel, Cutinova • Vapour permaeable filmsVapour permaeable films: semi-permeable, fluid accululates-Tegaderm: semi-permeable, fluid accululates-Tegaderm • Low-Adherance DressingsLow-Adherance Dressings: Telfa, Medipore, Cutilin, Xeroform: Telfa, Medipore, Cutilin, Xeroform • Multi-layer bandagesMulti-layer bandages: useful for venous ulceration- Profore: useful for venous ulceration- Profore
  • Components of Normal Wound HealingComponents of Normal Wound Healing •CoagulationCoagulation processprocess •InflammatoryInflammatory processprocess •Migratory/Migratory/ ProliferativeProliferative processprocess •RemodelingRemodeling processprocess Injury: hours / days weeks A) Immediate to 2-5 days B) Hemostasis : Vasoconstriction , Platelet aggregation , Thromboplastin clot C) Inflammation: Vasodilation , Phagocytosis A) 2 days to 3 weeks B) Granulation: Fibroblasts lay collagen, Fills & new capillaries C) Contraction: Wound edges pull together to reduce defect D) Epithelialization: Crosses moist surface up to 3 cm A) 3 weeks to 2 years B) New collagen forms which increases tensile strength C) Scar tissue is only 80 percent as strong as original tissue
  • Biochemical DifferencesBiochemical Differences HealingHealing woundswounds ChronicChronic woundswounds • cell mitosiscell mitosis • pro-inflammatory cytokinespro-inflammatory cytokines • matrix metalloproteinasesmatrix metalloproteinases • growth factorsgrowth factors • cells capable of respondingcells capable of responding to healing signalsto healing signals
  • TIMETIME Principles of Wound Bed PreparationPrinciples of Wound Bed Preparation Wound bed preparation accelerates healingWound bed preparation accelerates healing Tissue non viable or deficient Infection or inflammation Moisture imbalance Edge of wound non advancing or undermined Defective matrix and cell debris High bacterial counts or prolonged inflammation Desiccation or excess fluid Non-migrating keratinocytes Non-responsive wound cells Debridement Antimicrobials Dressings compression Biological agents Adjunct Therapies Debridement Restore wound base and ECM proteins Low bacterial counts and controlled inflammation Restore cell migration, maceration avoided Stimulate keratinocyte migration
  • Debridement MethodsDebridement Methods • Surgical: exciseSurgical: excise • Mechanical: adherence, sheer, irrigateMechanical: adherence, sheer, irrigate • Autolytic: topicalAutolytic: topical • Enzymatic: topicalEnzymatic: topical • Biological: topicalBiological: topical
  • Autolytic DebridementAutolytic Debridement •The process by which the woundThe process by which the wound bed utilizes phagocytic cells andbed utilizes phagocytic cells and proteolytic enzymes to removeproteolytic enzymes to remove debrisdebris •This process can be promotedThis process can be promoted and enhanced by maintaining aand enhanced by maintaining a moist wound environmentmoist wound environment
  • Autolytic Debridement ConsiderationsAutolytic Debridement Considerations • Less aggressiveLess aggressive • SlowerSlower • Easy to performEasy to perform • Little or no discomfortLittle or no discomfort • Performed in any settingPerformed in any setting • Contraindication: infectionContraindication: infection
  • Enzymatic DebridementEnzymatic Debridement •The use of topically appliedThe use of topically applied chemical agents to stimulate thechemical agents to stimulate the breakdown of necrotic tissuebreakdown of necrotic tissue •Common Topical AgentsCommon Topical Agents – Papain-UreaPapain-Urea – Papain-Urea-ChlorophyllinPapain-Urea-Chlorophyllin – CollagenaseCollagenase
  • Enzymatic DebridementEnzymatic Debridement Collagenase • Derived from Clostridium Hystoliticum • Highly specific for peptide sequence found in collagen • Less aggressive debridement • Site of action – collagen fibers anchoring necrotic tissue to the wound bed 10 Harper (1972) 11 Boxer (1969) 12 Varma (1973)
  • Enzymatic DebridementEnzymatic Debridement Papain-UreaPapain-Urea • Proteolytic enzyme derived papayaProteolytic enzyme derived papaya66 • Urea is added as a denaturantUrea is added as a denaturant66 • Site of action – cysteine residues on proteinSite of action – cysteine residues on protein88 6 Falabella (1998) 8 Sherry and Fletcher (1962)
  • Enzymatic Debridement ConsiderationsEnzymatic Debridement Considerations • Should be painlessShould be painless • Less traumatic thanLess traumatic than surgical or mechanicalsurgical or mechanical debridementdebridement • Easy dressing changeEasy dressing change • Observe caution withObserve caution with infected woundsinfected wounds *Agency for Healthcare Research and Quality (1994) • Consider for individuals who:Consider for individuals who: – Cannot tolerate surgeryCannot tolerate surgery – long-term-care facilitylong-term-care facility – home care*home care*
  • The right method is a clinical decision that requires judgment Autolytic Collagenase Papain-Urea-Chlorophyllin
  • Bacterial BalanceBacterial Balance • Intact skin is a physical barrierIntact skin is a physical barrier • Skin secretes fatty acids and antibacterialSkin secretes fatty acids and antibacterial polypeptidespolypeptides • Normal flora prevent pathogenic floraNormal flora prevent pathogenic flora from establishingfrom establishing
  • 13 Robson (1997) 14 Dow (2001) Bacterial BurdenBacterial Burden • Tissue bacterial levelsTissue bacterial levels > 10> 105/gram5/gram havehave consistently resulted in impaired healingconsistently resulted in impaired healing causing:causing: • Metabolic loadMetabolic load • Produces endotoxins and proteasesProduces endotoxins and proteases
  • Efficacy of traditional topical antibioticsEfficacy of traditional topical antibiotics • Leyden & Kligman, 1979Leyden & Kligman, 1979: Neomycin contact sensitivity < 1% skin testing: Neomycin contact sensitivity < 1% skin testing • Booth, etal,1994Booth, etal,1994:: Minimum Inhibitory Concentration mg/LMinimum Inhibitory Concentration mg/L Bacteria A:NeomycinBacteria A:Neomycin B:Bacitracin C:Polymyxin B (TAO): A+B+CB:Bacitracin C:Polymyxin B (TAO): A+B+C Staph AureusStaph Aureus 11 5454 6161 synergysynergy Pseudomonas aerug.Pseudomonas aerug. 3232 >6917>6917 88 synergysynergy Enteric bacillus 8 >6917 1Enteric bacillus 8 >6917 1 synergysynergy • Dire, et al, 1995Dire, et al, 1995: Uncomplicated sutured soft tissue trauma wounds: Uncomplicated sutured soft tissue trauma wounds Topical Agent Infection RateTopical Agent Infection Rate Bacitracin ZincBacitracin Zinc 5.5%5.5% TAOTAO 4.5%4.5% PetroleumPetroleum 17.6%17.6%
  • 33 ““RulesRules”” for Topical Antimicrobial Agents ?for Topical Antimicrobial Agents ? • Do not useDo not use antibiotics that are usedantibiotics that are used systemicsystemically – ability toally – ability to breed resistant organisms (topicalbreed resistant organisms (topical gentamicingentamicin, tobramycin), tobramycin) • Do not useDo not use agents that are commonagents that are common allergensallergens (neomycin,(neomycin, gentamicin, amikacin, tobramycin,gentamicin, amikacin, tobramycin, bacitracinbacitracin, lanolin), lanolin) • Do not use agentsDo not use agents that have highthat have high cellular toxicitycellular toxicity in healablein healable wounds (povidone iodine, chlorhexidine,wounds (povidone iodine, chlorhexidine, hydrogen peroxidehydrogen peroxide)) 22 Sibbald 2003
  • Topical Antimicrobials:Topical Antimicrobials: SilverSilver • Centuries of useCenturies of use • Cytotoxicity associated with carriers not silver - ex.Cytotoxicity associated with carriers not silver - ex. SilverSilver nitratenitrate, Silver, Silver sulfasulfadiazinediazine • Traditional delivery required repeated applicationsTraditional delivery required repeated applications due to binding with chlorine and proteinsdue to binding with chlorine and proteins • New silver dressings allow for continued silverNew silver dressings allow for continued silver release in to the dressing - up to 7 daysrelease in to the dressing - up to 7 days 17 Demling and DeSanti (2001)
  • Why Silver for Wound Bed Preparation?Why Silver for Wound Bed Preparation? • Broad spectrum antimicrobial: yeasts, molds &Broad spectrum antimicrobial: yeasts, molds & bacteria, including MRSAbacteria, including MRSA • Kills microbes on contact: inhibition cellular respirationKills microbes on contact: inhibition cellular respiration denatures nucleic acidsdenatures nucleic acids alters cell membrane permeabilityalters cell membrane permeability • Does not induce resistance: if used at adequate levelsDoes not induce resistance: if used at adequate levels • Low mammalian cell toxicityLow mammalian cell toxicity
  • Nanocrystalline SilverNanocrystalline Silver • Decreased size of silver particlesDecreased size of silver particles leads to increased proportion ofleads to increased proportion of surface atomssurface atoms • The nanocrystalline structure isThe nanocrystalline structure is responsible for the rapid and longresponsible for the rapid and long lasting actionlasting action1515 17 Demling and DeSanti (2001) Magnification of normal Silver Magnification of Nanocrystalline Silver (< 1 micron)
  • Evaluating Silver ProductsEvaluating Silver Products • Minimum bactericidal concentration (MBC)Minimum bactericidal concentration (MBC) - amount of antimicrobial agent- amount of antimicrobial agent required to kill a given microberequired to kill a given microbe MBC is represented by a log reduction of 3MBC is represented by a log reduction of 3 Stratton et al (1991)Stratton et al (1991) – The silver required varies from 5ppm - 50+ ppmThe silver required varies from 5ppm - 50+ ppm for clinically relevant microbesfor clinically relevant microbes Yin et al (1999) & Hall (1987)Yin et al (1999) & Hall (1987) – MBC of silver for MRSA = 60.5 ppmMBC of silver for MRSA = 60.5 ppm Calculated from Maple et al (1992)Calculated from Maple et al (1992)
  • Moist Wound EnvironmentMoist Wound Environment Additional benefitsAdditional benefits •Faster healingFaster healing •Capacity for autolysisCapacity for autolysis •Decreased rates of infectionDecreased rates of infection •Reduced wound traumaReduced wound trauma •Decreased painDecreased pain •Fewer dressing changesFewer dressing changes •Cost effectiveCost effective
  • • DifferentDifferent from acute woundfrom acute wound • ImbalanceImbalance of growth factors andof growth factors and pro-inflammatory cytokinespro-inflammatory cytokines • Excessively high levels ofExcessively high levels of proteasesproteases • DegradesDegrades ECM and selectivelyECM and selectively inhibitsinhibits proliferating cellsproliferating cells 21 Enoch and Harding, 2003 Exudate from a Chronic Wound
  • Managing Moisture ImbalanceManaging Moisture Imbalance • FilmsFilms • HydrogelHydrogel • HydrocolloidHydrocolloid • AlginateAlginate • FoamsFoams • Specialty AbsorbentSpecialty Absorbent • Suction VacSuction Vac • Exudate amountExudate amount None Small Moderate Large
  • Suction Vac TherapySuction Vac Therapy Management of open woundsManagement of open wounds • increases granulation rate> 5xincreases granulation rate> 5x ’’ss • success depends on pore size, -125mmHgsuccess depends on pore size, -125mmHg • reduces wound volumereduces wound volume • requires changing every 2 daysrequires changing every 2 days • vascular ingrowth andvascular ingrowth and healing appear to be due cell deformationhealing appear to be due cell deformation • early epithelial cells lack rete pegs andearly epithelial cells lack rete pegs and are easily strained to 5-20%,are easily strained to 5-20%, postulated mechanismpostulated mechanism Saxena, etal, 2004: PRS 114(5)Saxena, etal, 2004: PRS 114(5)
  • Modern Scar Concepts (1)Modern Scar Concepts (1) • New keratinocytes lack rete pegs, are fragile, deformableNew keratinocytes lack rete pegs, are fragile, deformable and produce many fibrotic growth factorsand produce many fibrotic growth factors • Fibroblasts within the injury zone are more sensitive toFibroblasts within the injury zone are more sensitive to these and other growth factorsthese and other growth factors • Sulphated side chains develop from chondroitin producedSulphated side chains develop from chondroitin produced from these fibroblastsfrom these fibroblasts • The side chains cause water binding and subsequent scarThe side chains cause water binding and subsequent scar rigidityrigidity
  • Modern Scar Concepts (2)Modern Scar Concepts (2) CollagenesisCollagenesis - Deposition - Resorption- Deposition - Resorption CollagenesisCollagenesis • Scar volume is dependent on the volume of collagenScar volume is dependent on the volume of collagen • Collagen formation: mRNA mediatedCollagen formation: mRNA mediated • Fibroblast interferon ß( IFN- ß): inhibitor of collagenesisFibroblast interferon ß( IFN- ß): inhibitor of collagenesis • Transforming Growth Factor TGF ß 1 (adult): stimulates collagenesisTransforming Growth Factor TGF ß 1 (adult): stimulates collagenesis • TGF ß 3 (infant): inhibits collagenesisTGF ß 3 (infant): inhibits collagenesis • Renovo/ Retinae: inhibitors of TGF- ß1 activation: reduced collagenesisRenovo/ Retinae: inhibitors of TGF- ß1 activation: reduced collagenesis improving scarsimproving scars • Gamma interferons and other cytokines down regulate collagen andGamma interferons and other cytokines down regulate collagen and matrix synthesis and increase monocyte retention within the woundmatrix synthesis and increase monocyte retention within the wound
  • Modern Scar Concepts (3)Modern Scar Concepts (3) Collagenesis -Collagenesis - Deposition -Deposition - ResorptionResorption Collagen Deposition & ResorptionCollagen Deposition & Resorption • Fibroblast and monocyte collagenase:Fibroblast and monocyte collagenase: reduce collagen depositionreduce collagen deposition • MetalloproteinasesMetalloproteinases inhibit collagenasesinhibit collagenases: promoting collagen deposition: promoting collagen deposition • Expression of fetal metalloproteinase: loss of scarless healingExpression of fetal metalloproteinase: loss of scarless healing • Intralesional steroids inhibit fibroblast growthIntralesional steroids inhibit fibroblast growth inhibit collagen deposition:inhibit collagen deposition: -- increaseincrease monocytemonocyte collagenasecollagenase secretionsecretion - no influence on metalloproteinase- no influence on metalloproteinase - no influence on collagen production- no influence on collagen production
  • Modern Scar Concepts (4)Modern Scar Concepts (4) ++ The Role of Tissue HypoxemiaThe Role of Tissue Hypoxemia -- • -- impedes epithelialisationimpedes epithelialisation • -- increases infection: neutrophil dependentincreases infection: neutrophil dependent • + reduces collagenesis in an epithelialised wound+ reduces collagenesis in an epithelialised wound • + compression and radiation lead to local fibroblastic+ compression and radiation lead to local fibroblastic hypoxemiahypoxemia • : Compression and radiation should be used: Compression and radiation should be used afterafter epithelialisation is completeepithelialisation is complete
  • Summary of Treatments for Hypertrophic Scar andSummary of Treatments for Hypertrophic Scar and KeloidsKeloids • SurgerySurgery • Laser ExcisionLaser Excision • Pulse Dye Laser ReductionPulse Dye Laser Reduction • CryotherapyCryotherapy • Pressure TherapyPressure Therapy • RadiotherapyRadiotherapy • Steroid, Interferon, 5-FU Injections, ColchicineSteroid, Interferon, 5-FU Injections, Colchicine • Topical Aldara 5%Topical Aldara 5% • Prolonged tapingProlonged taping** • Silicone gel/sheetingSilicone gel/sheeting** ** patient controlledpatient controlled inexpensiveinexpensive non-prescriptionnon-prescription few if any complicationsfew if any complications well toleratedwell tolerated
  • Prolonged Paper Tape To ScarProlonged Paper Tape To Scar • 70 pts acute scars: s/p caesarian section, Brisbane, Australia70 pts acute scars: s/p caesarian section, Brisbane, Australia • Micropore tape to randomized 1/2 pts after staple removal 4-7 days post-opMicropore tape to randomized 1/2 pts after staple removal 4-7 days post-op • Tape applied continuously for 12 weeksTape applied continuously for 12 weeks • The control group received no treatmentThe control group received no treatment • Scar volume was assessed by ultrasoundScar volume was assessed by ultrasound • Scar volume was reduced in the treatment group (p<0.05)Scar volume was reduced in the treatment group (p<0.05) • High correlation between subjective scar rating & intradermal scarringHigh correlation between subjective scar rating & intradermal scarring ( p<0.001)( p<0.001) • Authors postulate that tension is the cause of significant scarringAuthors postulate that tension is the cause of significant scarring Atkinson,et al, PRS Nov 2005; 116 (6), 1648-Atkinson,et al, PRS Nov 2005; 116 (6), 1648-
  • Management of Common KeloidsManagement of Common Keloids • Earlobe - If primary excision:Earlobe - If primary excision: 3 x daily peroxide and triple antibiotic3 x daily peroxide and triple antibiotic remove nylon 5.0 sutures at 10-14 days, then:remove nylon 5.0 sutures at 10-14 days, then: Dermajet inject Kenalog (trimacinolone 40mg/ml)Dermajet inject Kenalog (trimacinolone 40mg/ml) start Kelo-cote after sutures out for at least 3 monthsstart Kelo-cote after sutures out for at least 3 months start compressive clampstart compressive clamp ““ear-ringear-ring”” : no Nickel: no Nickel return every 6 weeks for further injectionsreturn every 6 weeks for further injections • Berman B, Bieley HC.  Dermatol Surg 1996 Feb;22(2):126-30 – excision alone: 45-100 % recurrence – excision and Kenalog injection: < 50 % recurrence – excision and irradiation: < 10% recurrence – excision and button compression: no recurrences
  • www.delasco.comwww.delasco.com tel: 1 800 320-9612tel: 1 800 320-9612
  • Management of Common KeloidsManagement of Common Keloids • Earlobe - if secondary excision:Earlobe - if secondary excision: excise and within 14 days: post-op irradiationexcise and within 14 days: post-op irradiation either one dose of 10 Gy or up to 15 Gy in 2-4 fractionseither one dose of 10 Gy or up to 15 Gy in 2-4 fractions sutures out 14 days post-opsutures out 14 days post-op Kenalog injection, compressive ear-ring and 6 week follow-upKenalog injection, compressive ear-ring and 6 week follow-up Klumpar DI, Murray JC, Anscher M.  J Am Acad Dermatol 1994 Aug;31(2 Pt 1):225-31 - Dose irradiation most important factor: give >900c Gy- Dose irradiation most important factor: give >900c Gy - Irradiation completed within 1-3 weeks equally effective- Irradiation completed within 1-3 weeks equally effective - ear lobe 98% successful at > 1 yr follow-up- ear lobe 98% successful at > 1 yr follow-up - small subsequent recurrences can be re-irradiated: 15 Gy- small subsequent recurrences can be re-irradiated: 15 Gy
  • Improvement of Erythematous and Hypertrophic Scars by heImprovement of Erythematous and Hypertrophic Scars by he 585-nm Flashlamp-pumped Pulsed Dye Laser,585-nm Flashlamp-pumped Pulsed Dye Laser, Tina Alster.Tina Alster. Ann Plast Surg 1994;32:186-190Ann Plast Surg 1994;32:186-190 • 14 healthy subjects with hypertrophic and or erythematous scars as a results14 healthy subjects with hypertrophic and or erythematous scars as a results of traumaof trauma • Scars were at least 2 years oldScars were at least 2 years old • Candela flashlamp-pumped dye laser: 6.5-6.75 J/cm2 1-2 treatmentsCandela flashlamp-pumped dye laser: 6.5-6.75 J/cm2 1-2 treatments • 57% improved: lightening and flatter after one treatment57% improved: lightening and flatter after one treatment • 83% improved after 2 treatments83% improved after 2 treatments • Continued improvement over 6 monthsContinued improvement over 6 months • Improvement was not location specific,Improvement was not location specific, depth of scar not assesseddepth of scar not assessed
  • Irradiation mostly contraindicatedIrradiation mostly contraindicated Re-resection definitely harmfulRe-resection definitely harmful Laser excision usually harmfulLaser excision usually harmful Pulse Dye lasers not helpfulPulse Dye lasers not helpful Aldara 5% not helpfulAldara 5% not helpful Silicone sheeting not helpfulSilicone sheeting not helpful Steroid injections very helpfulSteroid injections very helpful Kelo-cote helpful if < 5mm raisedKelo-cote helpful if < 5mm raised
  • Kelo-cote® unique formulationKelo-cote® unique formulation • Kelo-cote® composition:Kelo-cote® composition: – Long chain polymers of siliconeLong chain polymers of silicone (Polysiloxanes)(Polysiloxanes) – Minimal Silicone dixoide cross links polymersMinimal Silicone dixoide cross links polymers – A volatile solvent allows silicone to dry on theA volatile solvent allows silicone to dry on the stratum corneum in an ultra-thin sheetstratum corneum in an ultra-thin sheet
  • Silicone CompositionSilicone Composition Silanes: monomers R Characteristics Methyl Hydrophobicity & Low surface tension Higher Alkyl Organic-compatibility and Paintability Phenyl Thermo-stabile,Organo-compatible, Hydrophobic CF3CH2CH2 Solvent resistant Siloxanes: polymers more crosslinked: more solid recurring silicone / oxygen backbone end / side chains determine functionality ie.: amine,carboxy, hydroxyl,epoxyl RR RR R:R:
  • Favorable properties related to scar reductionFavorable properties related to scar reduction • Intermediate forms: elastomers: gel, rubberIntermediate forms: elastomers: gel, rubber • Solid-liquid binding requires catalystSolid-liquid binding requires catalyst ‘‘curingcuring’’: ie. platinum,: ie. platinum, stannous octoatestannous octoate • Delivery in an evaporative solvent may provide the ability to changeDelivery in an evaporative solvent may provide the ability to change the properties of the silicone upon deliverythe properties of the silicone upon delivery • Properties influencing scar reduction include:Properties influencing scar reduction include: – Thickness:Thickness: < 0.254mm< 0.254mm – Moisture vapor transmission rate:Moisture vapor transmission rate: <15mg/cm2/day<15mg/cm2/day – Oxygen permeability:Oxygen permeability: > 600cc/100 in.sup.2/day> 600cc/100 in.sup.2/day – High stretch:High stretch: ,1.5lbs/in stretches > 110% length,1.5lbs/in stretches > 110% length – Tensile strength:Tensile strength: >100g>100g – Penetrability:Penetrability: 4-7mm4-7mm – Peel strength:Peel strength: 2-6 g2-6 g
  • Silicone Mode of ActionSilicone Mode of Action • Potential TheoriesPotential Theories – Hydration: increasesHydration: increases – Oxygenation: decreasesOxygenation: decreases – Protection: increasesProtection: increases – Cellular Strain: increases ?Cellular Strain: increases ? – Modulation of growth factorsModulation of growth factors
  • Silicone Mode of ActionSilicone Mode of Action HydrationHydration • Kelo-cote is semi-occlusive aerating and hydratingKelo-cote is semi-occlusive aerating and hydrating • Silicone absorption is limited to the epidermisSilicone absorption is limited to the epidermis • Stratum corneum regulates fibroblast /collagenesisStratum corneum regulates fibroblast /collagenesis • Hydration normalises the collagen synthesisHydration normalises the collagen synthesis
  • Silicone Mode of ActionSilicone Mode of Action HydrationHydration • But not all breathable dressings will reduce scarsBut not all breathable dressings will reduce scars • In a study comparing silicone and hydrogel dressings,In a study comparing silicone and hydrogel dressings, silicone normalised collagen synthesis,silicone normalised collagen synthesis, other breathable non-silicone dressings did notother breathable non-silicone dressings did not • Silicone has a scar reducing characteristic not seen withSilicone has a scar reducing characteristic not seen with polyurethanespolyurethanes • Further research ongoingFurther research ongoing
  • Silicone Mode of ActionSilicone Mode of Action ProtectionProtection • Microbial, chemical or physical irritation promote excessive collagenMicrobial, chemical or physical irritation promote excessive collagen production in early scars:production in early scars: • Keratinocyte dependent: exposed cell release growth factorsKeratinocyte dependent: exposed cell release growth factors • Fibroblast dependent: Staph epidermidis Immortalization TheoryFibroblast dependent: Staph epidermidis Immortalization Theory • Intact dermis is necessary for normal wound healingIntact dermis is necessary for normal wound healing
  • Silicone Mode of ActionSilicone Mode of Action Modulation TheoryModulation Theory • Silicones oils and sheeting appear to have an influence onSilicones oils and sheeting appear to have an influence on Fibroblast growth factors and transforming growth factorsFibroblast growth factors and transforming growth factors • Silicone reduces FGFSilicone reduces FGF growth factors in vivo, yetgrowth factors in vivo, yet ( opposite in vitro )( opposite in vitro ) – Fibroblast are reducedFibroblast are reduced – Collagenase is increasedCollagenase is increased • ““Collagen production is normalisedCollagen production is normalised””
  • History of Silicone in Scar ReductionHistory of Silicone in Scar Reduction • Perkins et al, 1983Perkins et al, 1983: reported silicone a new treatment for hypertrophic scars: reported silicone a new treatment for hypertrophic scars • Ahn, et al, 1989Ahn, et al, 1989: silicone gel improved texture, color, thickness and: silicone gel improved texture, color, thickness and itching from small hypertrophic scarsitching from small hypertrophic scars • Sawada & Sone, 1990Sawada & Sone, 1990: 20% silicone gel 82% improved hypertrophic: 20% silicone gel 82% improved hypertrophic scars and keloids a.c.t. glycerin 22% improvedscars and keloids a.c.t. glycerin 22% improved • Sawada &Sone, 1992Sawada &Sone, 1992: silicone gel an elastomer sheeting vs. petroleum,: silicone gel an elastomer sheeting vs. petroleum, 6 months f/u silicone group much softer, less red6 months f/u silicone group much softer, less red • Pamieri, et al, 1995Pamieri, et al, 1995: Found Vit E enhanced hypertrophic scar and keloids: Found Vit E enhanced hypertrophic scar and keloids • Phillips, et al. 1996Phillips, et al. 1996: hydrocolloid dressings no evidence to support reduce: hydrocolloid dressings no evidence to support reduce scarring after hypertrophic scar or keloid establishedscarring after hypertrophic scar or keloid established Good review: Mustoe, et al, PRS 2002:110(2) 560-Good review: Mustoe, et al, PRS 2002:110(2) 560- Literature lacks double blind placebo controlled studiesLiterature lacks double blind placebo controlled studies
  • Placebo Controlled Pilot Study Evaluating Kelo-cotePlacebo Controlled Pilot Study Evaluating Kelo-cote in the Reduction of Scarring Following Cleft Lip Repairin the Reduction of Scarring Following Cleft Lip Repair 10 days post-op10 days post-op 8 weeks post-op8 weeks post-op 8 months post-op8 months post-op • 33 patients, Santiago, Chile, 199633 patients, Santiago, Chile, 1996 • Methods: mm vertical scar shortening (A-Methods: mm vertical scar shortening (A- B)B) mm depth lip notchmm depth lip notch *average width scar mm*average width scar mm scar softness 0-3 gradescar softness 0-3 grade scar erythema 0-3 gradescar erythema 0-3 grade • 6 week follow-up results6 week follow-up results ** AA BB
  • Markedly reduced erythema (p< 0.005)Markedly reduced erythema (p< 0.005) Reduced horizontal scar width ( p<0.05)Reduced horizontal scar width ( p<0.05)
  • Chan, et al, 2005: PRS Sept 15Chan, et al, 2005: PRS Sept 15 • Placebo controlled study prospective clinical trialPlacebo controlled study prospective clinical trial of silicone gel ( Scarfadeof silicone gel ( Scarfade ®®) in the prevention of) in the prevention of hypertrophic median sternotomy scarshypertrophic median sternotomy scars – 100 wounds/50 pts Malaysia100 wounds/50 pts Malaysia – Reduction of:Reduction of: pigmentation (p=0.02)pigmentation (p=0.02) vascularity (p=0.001)vascularity (p=0.001) pliability (p=0.001)pliability (p=0.001) height (p=0.001)height (p=0.001) pain (p=0.001)pain (p=0.001) itchiness (p=0.001)itchiness (p=0.001)
  • Sebastian et al, 2005Sebastian et al, 2005 •• Non-placebo controlled study Kelo-cote on scars: all-comers, up to 48Non-placebo controlled study Kelo-cote on scars: all-comers, up to 48 month follow-upmonth follow-up • Data 111 patients Germany, Switzerland & AustriaData 111 patients Germany, Switzerland & Austria • Study: legal requirement forStudy: legal requirement for ‘‘newnew’’ productsproducts • Independent studyIndependent study • Data is on all types of scarsData is on all types of scars • Different ages of scarsDifferent ages of scars • Measurement tool is Vancouver scar scale, whichMeasurement tool is Vancouver scar scale, which is standard measurement for scarsis standard measurement for scars
  • Sebastian et al, 2005Sebastian et al, 2005 • Patients & physicians assessment ofPatients & physicians assessment of tolerability and efficacy using 4 point scaletolerability and efficacy using 4 point scale • Vancouver scar scaleVancouver scar scale
  • Sebastian et al, 2005Sebastian et al, 2005 Results of patient and physician assessment - EfficacyResults of patient and physician assessment - Efficacy 0 10 20 30 40 50 60 % of respondents Very G ood G ood M oderate U nsatisfactory Patient and Physician assesement of efficacy Doctor Patient
  • Sebastian et al, 2005Sebastian et al, 2005 Results of patient and physician assessment - TolerabilityResults of patient and physician assessment - Tolerability 0 20 40 60 80 100 % of respondents V ery G oo d G o od M o d erate U nsatisfactory Patient and Physician assesement of Tolerability Doctor Patient
  • Sebastian et al, 2005Sebastian et al, 2005 Decrease in Vancouver Scar Scale - RednessDecrease in Vancouver Scar Scale - Redness
  • Sebastian et al, 2005Sebastian et al, 2005 Decrease in Vancouver Scar Scale - ElevationDecrease in Vancouver Scar Scale - Elevation
  • Sebastian et al, 2005Sebastian et al, 2005 Decrease in Vancouver Scar Scale - HardnessDecrease in Vancouver Scar Scale - Hardness
  • Sebastian et al, 2005Sebastian et al, 2005 Decrease in Vancouver Scar Scale - PainDecrease in Vancouver Scar Scale - Pain
  • Sebastian et al, 2005Sebastian et al, 2005 Results by type of scarResults by type of scar Type of scar (%) Mature Scar 10% Major Keloid 10% Widespread Hypertrophic scar 6%Linear Hypertrohic scar 40% Immature scar 17% Minor Keloid 17%
  • Sebastian et al, 2005Sebastian et al, 2005 Results by age of scarResults by age of scar Age of scar (%) 3-6 months 18% 6-12months 23% 12-24 months 11% >24 months 21% < 3months 27%
  • Summary of studySummary of study • Kelo-coteKelo-cote® rated:good/very good > 80% patients & physicians® rated:good/very good > 80% patients & physicians • Physicians rated tolerability:Physicians rated tolerability: good/very good 100% of patientsgood/very good 100% of patients • Kelo-coteKelo-cote® decreased: redness, elevation, hardness,itchiness® decreased: redness, elevation, hardness,itchiness and pain of scars over a two month periodand pain of scars over a two month period • Kelo-coteKelo-cote® can be used on old and new scars® can be used on old and new scars • Kelo-cote® can be used to treat all types of scarsKelo-cote® can be used to treat all types of scars
  • Indications for useIndications for use • Kelo-cote® is indicated for the management of:Kelo-cote® is indicated for the management of: – Acute healing scarsAcute healing scars – Hypertrophic scarsHypertrophic scars – KeloidsKeloids • Kelo-cote®™ has also been used for scars resulting from:Kelo-cote®™ has also been used for scars resulting from: – TraumaTrauma – BurnsBurns – SurgerySurgery – AcneAcne – Post laser erythemaPost laser erythema
  • Length of treatmentLength of treatment • Minimum treatment should be 2 monthsMinimum treatment should be 2 months • Treat larger and older scars >3 monthsTreat larger and older scars >3 months • Active persons apply usually in amActive persons apply usually in am • May treat with other topicals in pmMay treat with other topicals in pm
  • Instructions for use 0.5 oz Kelo-coteInstructions for use 0.5 oz Kelo-cote • Ensure the area is clean and dry.Ensure the area is clean and dry. • ApplyApply a very thin layer and allow to drya very thin layer and allow to dry • Apply once daily, or twice dailyApply once daily, or twice daily • Maximum effect, 24 hours of continuous contactMaximum effect, 24 hours of continuous contact • Once dry, OK to cover with pressure garments, sun block orOnce dry, OK to cover with pressure garments, sun block or cosmeticscosmetics • If not dried within 4–5 minutes: too muchIf not dried within 4–5 minutes: too much • Gently remove the excess and allow the dryingGently remove the excess and allow the drying • Larger and older scars > 90 daysLarger and older scars > 90 days • 0.5 oz contains enough Kelo-cote®, for: 7.5–10cm 2x/day for 90 days0.5 oz contains enough Kelo-cote®, for: 7.5–10cm 2x/day for 90 days • Reduce drying time hotter climates, keep in the refrigeratorReduce drying time hotter climates, keep in the refrigerator • In colder weather, use low setting on hair dryer to reduce drying timeIn colder weather, use low setting on hair dryer to reduce drying time
  • Warnings and PrecautionsWarnings and Precautions • Avoid direct contact with eyes, mucousAvoid direct contact with eyes, mucous membranes, & open woundsmembranes, & open wounds • Kelo-cote® may stain clothing if notKelo-cote® may stain clothing if not completely drycompletely dry • Store below 77°F (25°C)Store below 77°F (25°C) • Do not use after the expiration dateDo not use after the expiration date
  • Mederma: $25, 50g, EtOH, water,PEG-4,xanthum gum,Mederma: $25, 50g, EtOH, water,PEG-4,xanthum gum, sorbic acidsorbic acid Scarguard: $72, 100g, with hydrocortisone, Vit EScarguard: $72, 100g, with hydrocortisone, Vit E Cimeosil: $56, 14 gram, polysiloxanesCimeosil: $56, 14 gram, polysiloxanes Skin Esthetique: $24, 170g,dimethicone, arnika, copper,Skin Esthetique: $24, 170g,dimethicone, arnika, copper, seaweedseaweed    Scarfade: $25, 50g, silicone dioxide, micro quartz crystalsScarfade: $25, 50g, silicone dioxide, micro quartz crystals +/- vit E,K, co-enzyme Q-10+/- vit E,K, co-enzyme Q-10 Pro-Sil: $17.50, glide-on, siliconePro-Sil: $17.50, glide-on, silicone ““creams and oilscreams and oils””
  • • Kelo-cote® is a uniqe patent protected silicone gelKelo-cote® is a uniqe patent protected silicone gel • 80% patients rate Kelo-cote® as good or very good in scar reduction80% patients rate Kelo-cote® as good or very good in scar reduction • 100% physicians rate Kelo-cote® good or very good in pt tolerability100% physicians rate Kelo-cote® good or very good in pt tolerability • Kelo-cote® softens, flattens &reduces the redness of old & new scarsKelo-cote® softens, flattens &reduces the redness of old & new scars • Kelo-cote® is a comaparatively cost effective treatmentKelo-cote® is a comaparatively cost effective treatment
  • Clinicial Care:Clinicial Care:’’OlsenOlsen’’s Rules Rule’’ • ““Most wounds heal proportionate to the time andMost wounds heal proportionate to the time and attention they are givenattention they are given”” • Steristrip minimum of 4 - 7 days & then another 5 daysSteristrip minimum of 4 - 7 days & then another 5 days after changing stripsafter changing strips • Early application of Kelo-cote, avoid any contact withEarly application of Kelo-cote, avoid any contact with clothing for 6 weeks minimum: diapers OKclothing for 6 weeks minimum: diapers OK • All open wounds treated with 1/2 peroxide, bacitracin,All open wounds treated with 1/2 peroxide, bacitracin, minimum of twice dailyminimum of twice daily
  • HandHand
  • Breast ReductionBreast Reduction
  • Breast AugmentationBreast Augmentation
  • Mastopexy AugmentationMastopexy Augmentation
  • Verbal testimonial: Mastopexy AugmentationVerbal testimonial: Mastopexy Augmentation
  • Breast Cancer ReconstructionBreast Cancer Reconstruction • Bilateral Transverse Rectus Abdominus Myocutaneous FlapBilateral Transverse Rectus Abdominus Myocutaneous Flap
  • AbdominoplastyAbdominoplasty <Olsen<Olsen’’s Rules Rule
  • Facial TraumaFacial Trauma
  • FaceliftFacelift
  • Head and Neck Excisional SurgeryHead and Neck Excisional Surgery
  • Cleft Lip SurgeryCleft Lip Surgery
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