The way Dr. Adam Friedman sees it, dermatologists deserve a prominent place at the table when it comes to the treatment of acute and chronic wounds.
“As masters of the integument, we should be central to wound care, whether it be for research, in terms of developing better technologies, medications, approaches, diagnostics, but also in terms of managing these wounds, given the rich breadth of pathophysiology and biology we learn during our residency and maintain during our continuing education as practicing dermatologists,” said Dr. Friedman of the department of dermatology at George Washington University, Washington.
When the Journal of Drugs in Dermatology invited Dr. Friedman to serve as guest editor for a special feature section on wound care for its July 2015 issue, he jumped at the chance “to give the dermatology community a small taste of what’s going on in the wound healing world.”
Currently, he said, there is wide variability in the types of clinicians leading wound care centers in the United States, with dermatologists often sitting on the sidelines. “At one institution, it may be the vascular surgery service, at others it may be the family medicine service or even the emergency medicine department,” said Dr. Friedman, who is an editorial advisor to Dermatology News.
“That’s a big problem, in that there’s no uniformity from one center to the next in terms of who is expected to and should be taking responsibility for the wound healing service at their institutions. The reality is, it should be an interdisciplinary team, which not only involves dermatology but vascular surgery, nutrition, internal medicine, subspecialties of medicine like rheumatology, and rehab medicine. However, what is happening more often than not is that you’re getting just one or two of these elements, which cannot be as effective because you miss out on a broader, holistic view.”
There are two chief reasons why dermatologists aren’t more involved in wound care management, he continued. One stems from a lack of training on the topic. In one of the abstracts from the special JDD wound care section, researchers led by Dr. Emily Stamell Ruiz conducted an online survey of dermatology residents in the United States, to ask them about their preparedness to care for wounds and to assess the amount and type of training devoted to wound care during residency. Of the 175 respondents, 78% and 85% did not feel prepared to manage acute and chronic wounds, respectively, while 77% felt that more education is needed during their residency ( J Drugs Dermatol. 2015;14:716-20 ). “Residents felt that there was a clinical as well as a didactical gap, so they felt that they needed more training both through lectures as well as in clinics,” said Dr. Ruiz of the department of dermatology at Brigham and Women’s Hospital, Boston. “It’s not just a focal problem, it really is a universal curriculum problem. Future reforms to the current dermatology curriculum to include wound care training could help close the gap in wound care training.”
Another reason why dermatologists aren’t more involved in wound care management is the time commitment, said Dr. Friedman, who is also director of translational research at George Washington. The treatment of chronic wounds is “physically and financially burdensome,” he said. “It takes not only yourself being comfortable with managing the whole patient which includes the wound[s] with a side order of comorbidities, but your support staff as well – having nurses who know how to use the different wound dressings and how to help you with debridement. You need the right infrastructure. It also costs a lot on the provider side to manage wounds. You need a setup where you can get these patients in, have support staff to help with the wound dressings once you’ve identified what’s necessary, and be able to move on to the next patient.”
In another manuscript contained in the JDD special section, Dr. Friedman and his associates retrospectively reviewed the characteristics of 51 patients with burn injuries who were seen by seven different dermatologists at the Einstein-Montefiore division of dermatology from April 2010 to July 2014 ( J Drugs Dermatol. 2015;14:721-4 ). It found that the main mechanism of injury was burn from hot metal (22%), followed by contact with hot liquids (18%). It also found that silver sulfadiazine was the most commonly prescribed treatment, “even though there are considerable data illustrating that its use will delay wound closure and healing ( J Invest Dermatol. 2015 May;135:1459-62 ),” Dr. Friedman said. He went on to note that for patients who suffer an acute burn, “the ability to access a dermatologist is somewhat limited because their schedules are heavily booked well in advance, and the format doesn’t allow for these types of emergencies. More often than not they go to the ED or to primary care. That might not necessarily be the right decision because these are physicians who may not have the necessary training in terms of not only proper burn care, but skin care overall.”
Another manuscript in the special section describes a method in which partial thickness wounds were induced by cryosurgery to create wounds that could facilitate wound healing research and development. For the study, researchers led by Dr. Robert Kirsner, interim chairman of the department of dermatology and cutaneous surgery at the University of Miami, used liquid nitrogen spray to induce freeze injuries on the forearms of eight healthy adult volunteers ( J. Drugs Dermatol. 2015;14: 734-8 ). They delivered the spray onto a target area of a 1-cm circular opening at a distance from the cryodevice to the skin of 0.5-1 cm and implemented several freeze-thaw time cycles by administering pulses that ranged from 3-12 seconds.
After a 24-hour follow-up, Dr. Kirsner and his associates observed that freeze times exceeding 5 seconds caused a majority of study participants to develop blisters, while freeze times exceeding 8 seconds caused uniform blister formation. Time to healing among subjects in the 8-second freeze time group was 12-13 days, while time to healing among those in the 12-second time freeze group was 21 days.
“Cryo-induced wound healing is a little bit slower than you’d expect with a scalpel, but that wasn’t really surprising,” Dr. Kirsner said. “The fact that it healed a little bit slower was a pretty good thing because if everything healed too fast then it couldn’t serve as a model to speed or slow epithelialization. We were quite pleased.” He noted that the model “could be used as a safety test for chronic wound treatment and as an efficacy test for acute wound treatment. It’s relatively inexpensive and a relatively simple technique. If you’re developing a product for widespread use, it’s probably a minor cost in the whole development process.”
Other manuscripts in the JDD special section include a preclinical study using a murine multithermal burn model which found that N-acetylcysteine S-nitrosothiol nanoparticles prevent wound expansion and accelerate burn closure, and a practical, systematic approach to using wound dressings for the wound care novice. Dr. Friedman hopes that the special section not only stimulates further interest in wound care, but that it serves as “a call for action. We really need to be more involved in wound care from the acute and chronic perspective,” he said. “Wound centers around the country should be involving dermatologists. We have so much to offer from bench to bedside because the skin is our thing. I hope this is a reminder that we should be part of this picture.”
Dr. Friedman disclosed that he serves as a consultant for Galderma, Biogen, Aveeno, Intraderm, Puracore, La Roche-Posay, Amgen, Pfizer, PHD Skin Care. He also serves as an advisory board member for Nerium International, Valeant, Nano BioMed, MicroCures, and Novartis, and has received research grants from Valeant. Dr. Ruiz and Dr. Kirsner reported no financial disclosures.