NEW YORK — Wound-healing instructions often involve disturbing photographs of severe diabetic ulcers, angry autoimmune blisters and oozing lesions caused by rare genetic disorders, but daily dermatological care of wounds, however dramatic, relies on both foundations and new approaches, according to a well-known wound care expert.
Wound repair is relevant to all specialties involved in invasive procedures, but dermatologists are at zero level and should have appropriate skills, it is suggested Robert S. Kirsner, MD, PhDwho is director of the Wound Clinic at Jackson Memorial Hospital and chairman of the Department of Dermatology and Cutaneous Surgery at the University of Miami, Miami.
“We as a specialty do and we repair more wounds than any other specialty,” said Kirsner, who provided data to make his point. In a table he showed, the number of repairs done annually by dermatologists was several times that of surgeons, the second highest group, and the numbers declined rapidly from there.
Speaking on 27th Annual Winter Symposium – Advances in Medical and Surgical Dermatology (MSWS) 2024Kirsner offered a series of clinical gems, reinforcing some basics and pointing to well-supported strategies that he believes are too often overlooked.
Medicines reused for wound healing
On clinical pearls, he spoke about the reuse of multiple agents for wound care. His first example was the monoclonal antibody dupilumabwhich inhibits interleukin (IL) 4 and IL-13 signaling, to heal selected patients with leg ulcers. The potential for this drug was taken from a patient with a leg ulcer who presented with concomitant pruritus nodularis and biliary cirrhosis. When dupilumab was offered for the comorbidities, it provided a “dramatic” benefit with respect to the ulcer, according to Kirsner.
The explanation for the answer is that IL-4 and IL-13 have been shown to be upregulated in some patients with leg ulcers. Based on several cases, Kirsner spoke of a phenotype of non-healing leg ulcers from which elevated IL-4 and IL-13 can be isolated. These are the candidates for adding dupilumab to wound care, he said.
Topical beta-blockade was another example of a therapy being repurposed for wound healing, according to Kirsner. He said beta blockers are already a standard of care for burns, but the mechanism is relevant to other wound types.
Several studies have now looked at this phenomenon, with experimental studies showing that skin healing is impaired when beta-2 receptors are tormented but accelerated when blocked.
Beta-blockade accelerates wound healing
A recently reviewed of these mechanisms in soft tissue wound healing pointed to an anti-inflammatory effect, acceleration of keratinocyte migration, pro-re-epithelialization effects and inhibition of bacterial virulence. Beta blockers were first implicated as mediators of wound healing more than a decade ago, but Kirsner indicated that there is now more attention to this therapy within a comprehensive approach in severe cases.
Although not specific for wound healing, the potential for teprotumumab to improve control of pretibial myxedema was another example of a repurposed therapy for a challenging skin disease. A monoclonal antibody targeting the insulin-like growth factor 1 receptor, teprotumumab is approved for active thyroid eye disease, but Kirsner cited data showing compelling evidence of benefit in this cutaneous complication of Graves’ disease.
As for the basics, Kirsner spent some time emphasizing the importance of compression therapy to improve leg vascularization. This is not something to just consider. Rather, he considers it part of standard practice. “Compress all leg ulcers,” was Kirsner’s simple message.
Citing encouraging work identifying targetable molecular events in wound healing, Kirsner suggested that treatment may increasingly be guided by biomarkers. He pointed to ongoing work to characterize wound exudate as a source of biomarkers.
“The discarded dressing contains a wealth of information,” he said, referring to cell types and proteins, such as growth factors. He thinks the ongoing studies of exudates, which have shown that molecular processes detected in the periphery are often different from those at the focal site of injury, hold great promise for identifying new targets for treatment.
Virtual Reality to counteract pain
From a practical standpoint, Kirsner looked at a well-studied but still underutilized adjunct to wound debridement and surgical repair. That’s the distraction offered by relatively low-cost virtual reality systems. He described it as a simple way to help patients keep their minds off the pain. It’s not a new idea: It’s been studied for this use multiple times, and the evidence of benefit is essentially uniform, according to Kirsner.
He said efficient and sophisticated systems can now be purchased for just hundreds of dollars, and no training is needed. In fact, he said, pediatric patients can usually explain how the system works if the doctor doesn’t know.
“If you can improve their experience (during wound repair), you can make their life and your life better,” he said.
Joshua Zeichner, MD, associate professor of dermatology at Mount Sinai in New York City, agreed that the evidence supports this approach, and it’s easy to do. “I’m all for anything that improves the patient experience,” said Zeichner, who chaired the portion of the meeting where Kirsner spoke.
Kirsner said he practices what he preaches. “I routinely use virtual reality for simple surgical procedures or procedures that patients may find uncomfortable,” he said. He acknowledged that doctors may have heard this message before, but he believes that those who have not yet incorporated this into their practice should consider it.
Kirsner reported no potential conflicts of interest. Zeichner has acted as a consultant for Beiersdorf.
Ted Bosworth is a medical journalist based in New York City.
