The purpose of this investigation was to explore the healing potential of combining 2 alternative treatments for chronic wounds that conventional treatments have failed to close. Wounds presented here had proved extremely difficult to treat with duration histories ranging from 4 months to 2 years. The patients also presented with complex comorbidities that likely contributed to preventing the closure of the wounds through conventional means. These complicating conditions included an abscess adjacent to the target wound, trauma from an old wartime injury, gouty tophi, and a rare manifestation of a completely regressed melanoma. In marked contrast to the failure of conventional treatment, the combination of the advanced decellularized dermis graft and the electroceutical wound dressing completely healed all wounds in 3 to 6 weeks.
An advanced decullarized dermis graft is an acellular dermis that provides a scaffold to allow host recellularization, revascularization, and cellular infiltration.11 The unique decellularization process allows this ADM to be stored fully hydrated at ambient temperature and sterile with a sterility assurance level (SAL) of 1 x 106 while still retaining biomechanical and biocompatible properties.5 The graft has been used successfully in wound healing for both burn repair12 and breast reconstruction following mastectomy.13,14 The use of the graft for wound repair of chronic diabetic foot ulcers (DFUs) has also been explored with favorable preliminary results.15,16 The success of an advanced decellularized dermis graft in treating a variety of wound types prompted the investigation of its use on the complex and treatment-resistant wounds presented here.
The dressing is a silver-zinc coupled electroceutical wound dressing. The dressing contains silver and zinc elements that generate an electric field similar to the microcurrent found in skin injuries.17 This dressing is also able to inhibit biofilm formation by generating superoxides, and it can overcome bacterial antibiotic resistance by disrupting quorum sensing.18 Preliminary clinical studies19,20 have shown a significant increase in healing speed over standard wound care for a variety of acute and chronic wound types (34.6%, P = 0.015; 45.4%, P = 0.036, respectively). Infection is a constant concern when treating chronic wounds, and the ability of the electroceutical wound dressing to disrupt biofilm formation provides a strong tool for protecting open, treatment-resistant wounds.
The cases presented here display a variety of extremely complex wounds. Diabetic foot ulcers are notoriously difficult to close and a successful healing method will integrate both revascularization and removal of pathogens.21 An aid to assist in revascularization, such as an ADM, may be useful as there are more than 100 physiological factors that can cause healing deficiencies in patients with diabetes.22 Diabetic foot ulcers create an environment receptive to chronic infections caused by biofilms, a symbiotic and synergistic colony of multiple species of bacteria that traditional antibiotics may be ineffective against.23,24 A treatment that can successfully target biofilms, such as an electroceutical dressing, may allow the wound to heal without the interference of chronic infection. To date, to the best of the author’s knowledge, no studies in the literature have been found to combine ADMs with electroceutical dressings to treat DFUs. While this paper only focused on these 3 patients with unusual wounds, it is the author’s experience that these 2 products used in combination result in a greater decrease in healing time than in instances of individual use. The decrease in healing times reduces the overall cost of wound care despite the initial higher cost compared to standard of care. As an example, the patient in Case 1 received more than 1 year of standard of care treatment without healing but was able to finally heal in just 6 weeks using the application of the combined therapy presented here.
There is also a paucity of research concerning gout and delayed wound healing, although a recently published case series25 indicated there may be evidence of delays in ulcers with gouty tophi. The patient in Case 2 suspected the hard areas he felt in his leg were retained shrapnel, although it’s now known it was actually gout deposits. Unusual presentations of gouty tophi formation may be connected to local tissue changes related to previous tissue trauma or necrosis.26,27 The patient’s previous injury probably predisposed him to have gout in this area.
Completely regressed melanoma tumors are extremely rare with only 34 known cases as of 2005.28 It seems likely there is some mechanism at work in the regressed tumor that prevented earlier healing of the wound. Tumors are able to grow and progress through a process called angiogenesis or blood vessel growth, which is partly driven by the structural protein perlecan.29,30 In metastatic melanoma tumors, elevated perlecan messenger RNA levels may be correlated to the degree of the invasiveness of the cancer cells.31 It is possible that a regressed melanoma tumor contains abnormally high amounts of perlecan, though lower levels than a metastatic tumor, which prevents the healing of the wound through ongoing angiogenesis; but more research would be needed in this area. Regardless of what mechanism caused the tumor to be treatment resistant, the advanced decellularized dermis graft and the electroceutical wound dressing were able to rapidly close this 2-year-old wound in just 3 weeks.