The main objective here is to understand the prevailing misconcepts in the usage of biological/bioengineered scaffolds like skin substitutes and collagen dressings in the treatment of chronic Diabetic ulcers.
There are some collagen preparations that perform better than a dressing, but not properly recognized as a better product due to lack of scientific background and evidence. Since knowing the difference makes all the difference, let’s look at the scientific facts that differentiate one membrane from the rest.
Misconcept 1:
Misconcepts of usage of a material for wound healing:
Non-biological Scaffolds for Diabetic Ulcer Management may NOT be the ideal treatment option:
Normal materials that are used to cover an ulcer are non-biological synthetic polymeric sheets and sponges, cotton gauze, and Vaseline. All such materials are able to protect wound as a wound cover and may absorb the secreted fluid (exudate). The purpose of an exudate is to maintain a moist environment, to prevent dehydration of the cells as well as to avoid the physical contact of the exposed cell surface from non-friendly materials of non-biocompatible nature.
Under such circumstances, cells may not feel comfortable when they come in contact with such a non-biological scaffold. Accordingly, this would un-necessarily delay the wound healing process because the exudation will continue until the cells are comfortable with the surrounding environment.
On the other hand, biological dressings may provide a better result. However, all biological materials are not the same.
Solution: Use of non-biological Scaffolds for Diabetic Ulcer Management must be intervened by a biological skin substitute. Using an advanced biological skin substitute like biomaterial will not disturb the cells on the surface of the wound involved in the tissue granulation process.
The cells will recognize the chemically undifferentiated scaffold to be a natural surface to adhere. A bioactive and biocompatible scaffold will help protect the ulcer by maintaining a moist environment, hydrating the cells surrounding the wound and boosting the tissue granulation process.
Misconcept 2:
All biological skin substitutes accepted in the market may NOT be ideal biocompatible matrices:
Biological matrices commercially used belong to two categories:
- Reconstituted Collagen membranes: This includes products made of high purity biocompatible type-I collagen versus other membranes made of all types of collagen with non-biocompatible molecules like elastin and GAGs and other types of membranes made of denatured collagen (like gelatin) and also some products made of broken peptides of collagen which are all commercially allowed to be used as collagen products without realizing the biological impact of such molecules in terms of their impaired bioactivity towards tissue regeneration and remodeling.
- Intact tissue membrane derived products: This includes intact tissue membrane derived products that are made from the membranes of amnion, pericardium, intestinal wall, urinary bladder etc. The above-mentioned membranes must be contaminated with approximately 15% elastin, type-III collagen, lipids and other proteoglycans which are all highly immunogenic. Such products have to be cross-linked to minimize their immunogenicity. While doing so, biologically valuable type-I collagen contained in those products are also chemically modified and loses the bioactivity and other binding abilities that significantly impairs the tissue regenerative and wound healing abilities.
In the view of these misconcepts in the usage of biological materials, it is our scientific responsibility to identify the technical difference between such products.
Solution: It is the responsibility of the Experts in the wound care industry to identify and recognize the drawbacks of using wound healing materials especially every Advanced Biological Skin Substitutes whether they are ideal for the treatment of Diabetic Ulcers. Those manufacturers falsely advertise their biological matrices without realizing the scientific facts behind their biomaterials must be cautioned.
To be more specific, the ideal advanced biological skin substitutes should be capable of faster wound healing by enhancing matrix-cell interaction resulting in “cell signal transduction” through which the floating stem cells are converted to appropriate cell-lines to regenerate the damaged tissue in the wound region. If the material is not chemically modified or cross-linked, it can effectively be accepted as a natural, comfortable scaffold by the cells and the tissues involved in the granulation process.
Misconcept 3:
Compression dressing without a biological material may not be sufficient for wound healing:
Compression dressing is perceived in general to reduce leg swelling by directing the blood flow to the heart (Ref 1). However, just compressing the wound region may have other purposes to enhance the Tissue-Matrix interaction especially for the effective performance of bioactive matrices like advanced biological skin substitutes.
Solution: For a better clinical outcome during the treatment of an ulcer wound, it is effective to compress a biological skin substitute for an intense surface contact with the exposed cells of the wound to aid in tissue formation and faster wound healing. Please note the added reason for the compressive dressing is to establish direct contact between the wound surface and the biomaterial.
Particularly when a non-cross linked and therefore chemically unmodified skin substitute is in close proximity to the wound site, tissue-forming cells will attach themselves onto the membrane as it would act as a natural, comfortable scaffold.
Conclusion: It is important to learn the scientific facts to make the clinical decision on how one biological skin substitute membrane is different from others. Based on the technical explanation provided here for the existing misconcepts in this field as well as the solution to overcome such hurdles using an ideal bioactive and biocompatible material for the ulcer treatment especially for the non- healing Diabetic ulcers must be clear. In the view of this information, one could treat a wound only using selective biological scaffolds to ensure an acceptable clinical outcome.