EXPERT ANALYSIS FROM ODAC 2018
MIAMI (FRONTLINE MEDICAL NEWS) – Another reason not to prescribe opioids for postoperative pain – besides potentially adding to the epidemic the nation – comes from evidence showing these agents can impair wound healing.
In addition, epidermal sutures to close dermatologic surgery sites may be unnecessary if deep suturing is done proficiently. These and other pearls to optimize wound closure were suggested by Robert S. Kirsner, MD, PhD, professor and chair of the department of dermatology and cutaneous surgery at the University of Miami.
Avoid opioids for postoperative pain
“We know the opioid epidemic is a big problem. An estimated 5-8 million Americans use them for chronic pain,” Dr. Kirsner said at the Orlando Dermatology Aesthetic and Clinical Conference. “And there has been a steady increase in the use of illicit and prescription opioids.”
Emerging evidence suggests opioids also impair wound healing ( J Invest Dermatol. 2017;137:2646-9 ). This study of 715 patients with leg ulcers, for example, showed use of opioids the most strongly associated with nonhealing at 12 weeks. “We found if you took an opioid you were less likely to heal,” Dr. Kirsner said. They found opioids significantly impaired healing, even when the investigators controlled for ulcer area, duration, and patient gender.
“The take-home message is that for the first time we have patient-oriented data that suggests that opioids impair healing,” Dr. Kirsner said. “So avoid opioids if at all possible.”
The precise mechanism remains unknown. The most likely explanation, he said, is that opioids inhibit substance P, a peptide that promotes healing in animal models. Interestingly, he added, adding the opioid antagonist naltrexone in animal studies improves healing.
Consider skipping epidermal sutures in some cases
Dermatologists who place really good deep sutures when closing a wound might be able to forgo traditional epidural suturing, Dr. Kirsner said. “If you believe the literature, you can actually forget epidermal sutures. That’s hard for us. We’re trained to put epidermal sutures in, and changing habits can be difficult.”
A prospective, randomized study demonstrated no difference in cosmesis at 6 months, for example, in a split scar study where half of each wound was closed with epidural suturing and half was not ( Dermatol. Surg. 2015;41:1257-63 ). In another randomized study, researchers found something similar when comparing buried interrupted subcuticular suturing of wounds with and without adhesive strips to close the epidermis ( JAMA Dermatol. 2015;15:862-7 ). “When they looked at the scars, complications, and cosmesis at 6 months, there was no difference,” Dr. Kirsner said.
“Forget epidermal sutures if you’re brave enough,” he said.
Dr. Kirsner acknowledged that some dermatologists might point out a requirement to evert wound edges with epidermal stitches. “It turns out you don’t need to, again, if you believe the literature.” He cited a randomized, controlled, split scar trial that revealed no difference in cosmetic outcomes according to blinded physician ratings or patient reports at 3 months ( J Am Acad Dermatol. 2015;72;668-73 ). “So maybe the concept of wound eversion is not as important as we were originally taught.”
And speaking of wound edges …
When debriding a nonhealing wound …
There may be something highly abnormal about a nonhealing wound edge, Dr. Kirsner said. In fact, they can be phenotypically and genotypically different from surrounding tissue, including characteristic overexpression of c-Myc and beta catenin. These two factors in higher amounts can inhibit the migration of keratinocytes into a wound to promote healing.
“Sometimes we debride the wound because it’s necrotic,” Dr. Kirsner said. But in the case of a nonhealing wound, it can be more effective to debride the edges to remove the abnormal tissue. “You can change the fortune of a wound by debriding the edge. You want to remove all the abnormal tissue, and give it a chance to heal.” Pathology supports the elevated presence of the c-Myc and beta catenin factors in the “healing incompetent” tissue around the edges of nonhealing wounds, he added.
If a patient is unusually anxious or stressed
Stress can impair wound healing by 40%, Dr. Kirsner said ( Psychosom Med. 1998;60:362-5 ). Some anxiety before a dermatologic surgery procedure is normal for many patients, but there also are unusual circumstances. For example, “if a patient comes for cyst excision but learns while in the waiting room that his dog just died,” he said. It’s often better to reschedule the procedure than to proceed.
“What you can do on a daily basis is create a stress-free environment” as well, Dr. Kirsner said.
“From a practical standpoint, things that can impair healing include patient depression, negativism, isolation, and postoperative pain,” he added. The mechanism between elevated stress and impaired wound healing includes release of catecholamines that induce the action of endogenous steroids. This, in turn, can cause a cascade of events that reduce inflammatory cells and their pro-healing cytokines, thereby leading to poor healing.
“All of this is mediated through the love hormone, oxytocin. Maybe someday we will be able to give oxytocin to speed healing.”
Two technologies still look good for scarless donor sites
Epidermal grafting and technology based on fractional laser treatments continue to show promise for achieving a scarless donor site for patients who need grafting to promote wound healing, Dr. Kirsner said.
With epidermal grafting, dermatologists can apply a device to lift up on the epidermis from a donor site. The CelluTome Epidermal Harvesting System, for example, achieves this feat by applying both a little heat and some suction. “It creates little domes [of epidermis] in this Easy Bake oven looking device,” Dr. Kirsner said. Without any anesthetic, you place this device on the skin and you get these epidermal grafts in 30 minutes. Then you can transfer them to a sterile dressing and place them on the wound.”
As pointed out in a previous report in Dermatology News, avoiding the need for donor site anesthesia is one advantage of the epidermal grafting technique. In addition, the procedure is generally bloodless because the device does not go deep enough to reach the blood vessels, Dr. Kirsner said. In addition, healing of the donor site can be seen on histology in as little as 2 days.
Transferring the epidermis can promote healing because it also transfers keratinocytes and melanocytes to the wound.
“This technique is also excellent to add skin or cells to someone with pyoderma gangrenosum,” Dr. Kirsner said. “Because of the simplicity and the lack of trauma, you don’t get the pathergy you normally see on someone with pyoderma gangrenosum.”
An Autologous Regeneration of Tissue or ART device that transfers columns of healthy skin to a wound to help regenerate tissue and promote healing is a second technology with a lot of potential, Dr. Kirsner said. “With a fractional laser, you create a hole, and that hole heals without scarring. Instead of making holes, R. Rox Anderson, MD , professor of dermatology at Harvard University, Boston, created a device that picks out the microcolumns of skin.” When these full skin thickness columns of skin are transferred to a wound, Dr. Kirsner noted, “in 3 weeks you can pretty much have no visible or a much improved cosmetic scar. Histologically you don’t see a scar either.”
Dr. Kirsner said he had no relevant financial disclosures.
