The Healing Power of Fish Skin for Atypical Wounds

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Listen while the expert panelists share their cases and clinical insights on how this innovative treatment has lead to positive outcomes for patients with challenging wounds.

Transcript:

Elizabeth Faust, MSN, CRNP, CSWS, CWOCN-AP:
Welcome to the live studio today at SAWC Spring 2024. Today we have a great panel of female powerhouses in the wound care community. Thank you to Kerecis for asking us to speak about our experiences. 

So, my name is Lizzie Faust. I'm a nurse practitioner from Pennsylvania, and I own a consulting business called Lizzie Wounds. With us today we have Dr. Thea Price. She's a surgeon and wound care director, and then we have Roxana Reyna, who is a nurse practitioner who specializes in neonatal and pediatric wound care.

You know, we come to these conferences, and we hear about chronic wounds, diabetic foot ulcers, venous leg ulcers, pressure injuries. And there's a lot of literature in that space.
And that's not our day-to-day of living with that. You know, there's a wide variety of wounds out there that require a wide variety of treatments. And sometimes the literature doesn't necessarily cover in a large fashion or evidence what we're doing.

So, we'd like to talk to you today about atypical wounds and our experiences with treating them. So, I'm going to kick it off talking about one of my case studies, and I'm sure it's something you guys see as well. So, I'd love to hear your input on it as well. 

So, this is a 56-year-old female who was admitted to one of my smaller community hospitals. We didn't have dermatology, we don't have rheumatology. We actually don't even have a full-time wound care person there. So, general surgery had done a lap colostomy on this patient for a perforated diverticulitis about 2 weeks earlier. And the photo that you see on the upper left-hand side was one of her lap sites for that surgery. She was sent in by the home health nurse for what they thought was a lap site wound infection. And when I got called by the general surgeon from her office, I said, oh, well, I believe she has pyoderma gangrenosum based upon the image and her symptoms. And I believe we should admit her to treat her for infection, but also to get a handle on this wound. 

And really one of the biggest things was that she was having so much pain. It was terrible pain. So, we admitted her to the hospital. We treated her with systemic antibiotics. And then we did just local nontraumatic wound care for her and we brought her to the operating room on Tuesday. So admitted her Friday, on Tuesday she came to the OR, we had the infection under control. We did a debridement of a pyoderma gangrenosum and took a biopsy in multiple places in order to figure out, you know, is this really what we're dealing with? And then we immediately placed a Kerecis fish skin graft after the debridement, fixated it with negative pressure wound therapy, and within 8 weeks and 1 application, she was completely healed. We also treated her pyoderma with corticosteroids and then initially got her to follow up with the derm as an outpatient.

But one of the things that I love is that you can think about, okay, Kerecis has anti-inflammatory properties, it's going to improve the pain of the patient because we're covering it. So what's interesting was she had such exquisite pain prior to going to the OR. Usually patients report such severe pain after an OR trip, after a debridement. And she said, since she came back from the OR and it was covered, she had no pain. And what was nice was she could then get on. She was horrified at the appearance of it. And even just the scar quality for it. So, I mean, that's an 8-week scar quality for these things, and I think it's just profound how quickly this can resolve for something that could have gotten much worse over time.

Thea Price, MD:
I love this case, Lizzie, because that first picture really shows a lot of the pathognomonic findings of pyoderma gangrenosum. So, you can see the violaceous discoloration around the border. You can see that zone of hyperemia all the way around it. And, you know, the classic teaching for us surgeons is to never debride pyoderma. 

A question I had for you is, I debride it as well when it is infected, but prior to these connective tissue products like Kerecis, we were always taught to stop debridement about half a centimeter from the skin edge, from the dermal edge, in order to stop that pathergic response. It looks to me that your surgeon went all the way to the skin edge, is that correct? 

Faust:
Yes. 

Dr. Price:
And that is what I have seen with the application of Kerecis on pyoderma is you can debride all the way out to the edge, and it will stop that pathergy. And I have seen it multiple times to the point now that it's my standard of care that even if I go and debride a pyoderma wound, I will, even if the middle of the wound isn't necessarily healthy enough for Kerecis at at first, I will sprinkle it around the edges to stop that pathologic response. So I think this is a really great case to kind of show that the standard of care on this is starting to shift. Because of these things that we have now. 

Faust:
Yeah. Well, that leads us right into your amazing case. So, why don't you guide us to what's happening here? 

Dr. Price:
Well, if you know me, I have been basically screaming to the entire wound community for many years now about hidradenitis suppurativa. I work in the Chicagoland area and we see a huge amount of it. And this is part of my end-stage hidradenitis clinic. So who you see here is a patient who, obviously these symptoms had been going on for far longer than the 1.5 years since he had been diagnosed. But that just shows you how long it typically takes for patients to get diagnosed. On average, I see about a 10-year gap in between when they first start having symptoms, and they're just called boils or furuncles or ingrown hairs, until somebody actually says, "Hey, this is an autoimmune illness." 

So, I became very passionate about it, and we started seeing these patients, and at first I was performing radical excision and then treating them with secondary intention. So I started to think about the properties of Kerecis, the anti-inflammatory action, the moderate bacterial resistance. I started thinking to myself, I wonder if we could excise, and in the single stage, in that initial operation, go ahead and apply the Kerecis, even in an area like the perianal region, which is very dirty, so to say, or contaminated, maybe is a better word. And you can see here, too, that we didn't size his contralateral butt cheek, and so there was still some active infection and inflammation there, so this is probably not a case where many physicians would say let's put a connective tissue product on, but we did it. So, we placed it in that first operation, he had it for approximately 2 weeks, this wound, and then after the a couple applications of codfish skin, we then took him back for a fish skin graft, and it took beautifully, 100% take. And what you see there, in his last picture, is actually his 2-year follow-up, where you see not only doing radical excision on that one side, have it heal in a beautiful fashion with the Kerecis, with barely any scar at all. But it actually calmed down  the other side and after that large burden of disease was removed, he;s remained dormant on that contralateral buttock. And so we never had to do any further treatment on that.

So this is really exciting because typically the traditional teaching of hidradenitis is to perform radical excision. And then they quote healing times of up to 2 years for these patients where they may have to be off work. They may not be able to do their activities of daily living. And so to shorten this man's healing time down to maximally 2 months pretty amazing.

Faust:
We've used the cellular tissue products, particularly Kerecis, in the same fashion with our trauma patients, where you have this large soft tissue deficit or a big dermal drop where you're just trying to get that tissue or kind of the soil of the wound to a healthy state so that then you can get a skin graft in place and things like that. And particularly like our necrotizing fasciitis population, it's been wildly successful. 

Dr. Price:
And I've even found that even if you just take a couple of days with the Kerecis in place before you skin graft, you're going to get a better quality than if you just single-stage skin grafted in that first radical excision, which I've also played around with doing. 

Faust:
I cannot agree more. 

Dr. Price:
Much better cosmetic results. And honestly, The Kerecis side healed almost as fast as the skin graft in a different patient. So I really do feel like we're getting to the place also where we don't need as many skin grafts as we used to perform. And for somebody who used to be a burn surgeon and still plays a lot in that space, that is the holy grail. We all knew as burn surgeons that skin grafts are not going to be the end all be all answer, because they cause contractions. They cause scarring. You have pruritus, you know, you can't feel, you don't emote or sweat or have hair anymore. And so we all knew that that wasn't going to be the case. To get people to regenerate is really what all, I think, wound care providers are after. We want to grow people back like salamanders. 

Faust:
Yes. (laughs) Oh, that's awesome. And I know you have a great necrotizing fasciitis or what was the other name you called it, Thea? 

Dr. Price:
Ludwig’s angina is when necrotizing soft tissue infection is in the head and the neck. 

Faust:
I learn something new every day. So particularly in the pediatric population,
this has to be a huge challenge. 

Roxana Reyna, APRN, CWON-AP:
And just like you talked about, there's not that much literature out there in pediatrics to begin with or neonatal patients. 

Dr. Price:
Well, I feel like people always say, "Oh, it's a kid, you can spit on them, they'll heal." You know, they think it's not a problem. 

Reyna:
And that's a very good point because they think that babies and kids will heal automatically or what type of wounds do you heal in babies and kids? But these are the types of wounds that I take care of. I'm not a surgeon, I'm a nurse practitioner, but I do work a lot with surgery as well. And I'm able to take care of the atypical wounds that can't go to surgery.

So, this patient was a preterm patient that came in from an outside hospital because of the neck fascia. And surgery was not able to or would not take the patient on, that was general surgery, ENT, plastics, the patient was very critically ill in the ICU. So, with this patient, we had to do a debridement, like an autolytic debridement, and in using medical grade honey to do that, to achieve that and that second picture that you see was after achieving the autolytic debridement. I was a little concerned because I didn't see like a beefy red tissue and that was like as healthy as I could get to at that point, and then I did my first application of the Kerecis particulate. I mix my particulate with medical grade honey. I have better control of use over it, and I just love using it as such. The third picture was 3 days after the application. So that wound went to half, it decreased half its size in 3 days. 

Dr. Price:
You could also note a significant decrease in the slough burden. Which is interesting considering you applied a connective tissue product that then has to disintegrate. So, I love how it dealt with that. And maybe it was that mixture of the medical grade honey that dealt with that slough burden, but that's a beautiful result. 

Reyna:
So it went to half its size. And you could see one of the interesting things with Kerecis is the budding of tissue is how I document that. You might say it could be leading towards hypergranulation maybe. So, and another question would be like, why I did, I take that off at 3 days instead of 7 days? And it's because when I have a concern, and I want to see really where it's headed, I will take it off a little bit sooner, the dressing off so that I can be able to assess that. And for me, in assessing that, then I had more blood profusion to the site, and it was a lot smaller, like half the size. Then at the same time, I was noting that maybe it's going to hypergranulate. So, at that point, I was able to be okay about it, put my dressing back on, just lay foam on there, secure bolstered, and for 7 more days, and the next picture is 7 days later. 

Faust:
Wow, wow, wow. 

Reyna:
Okay, so there you have complete rehabilitation, closed wound, and then the last picture is a baby at 5 months, 10 days post graft.

Yes, so one of the things that I refer back to are some of the articles that we've read, people that have written on honey and their use in burns, the integration of the Kerecis product, how it incorporates a lot faster, the healing time is faster, and also the scar and the pliability. There is a reference out there or a paper written and how they measured the flexibility of the scar, maybe also the moisture content of a scar. So I haven't gotten into those studies, but it'd be very interesting. I'll continue to follow this patient to see what exactly happens with that scar.

Dr. Price:
I mean, to be honest, I thought the bottom right picture was after they were born before they developed the illness, because I can't even see a scar. I can't even see a scar there. And what I love too is that you showed her full range of motion. So, the baby can clearly turn its head all the way to touch that left shoulder, which is really important. 

I think also you made a great point about, this is what I love about the Kerecis particulate, is that you can see through it, you can push it out of the way, and it incorporates a little bit faster. So, if you do have a wound, I actually prefer it as well, harkening back to my previous case, in these areas that are heavily contaminated. I tend to prefer the particulate also because you can see through it. You can see the bottom of the wound. And it disintegrates and incorporates faster so that you're, I'm not as worried about what's going on underneath it. You know, I think we've all used connective tissue products where they have to stay in place for a very long time, and you can't see what's going on underneath, and it gives you a certain sense of fear, of insecurity, because you're not really sure what's going on underneath that. So I think that's a great case. The foam also will help with the hypergranulation tissue. I know that sometimes people wonder what to do with that. They don't necessarily want to silver nitrate or sharply debride on a child or if the pathology isn't correct. So, I think it's a good point also that these foams will also help decrease this granulation tissue.

Reyna:
So one of the things that I did on that was, how do you keep it in place? Well, the way I did that was apply the foam to bolster it, as other surgeons I've seen also referenced to that. And to keep it in place with a neck tie, like a trach tie. So, it's how I did that. So, I went ahead and I put my particulate with honey, put that on the in bed, covered it with a foam, a white foam, and then I used a silicone border dressing to keep that in place, and then also secured that with a trach tie. So, it was able to stay on and keep it bolstered in such a difficult area. 

Dr. Price:
Since we're talking about dressings, to harken back to your case, do you put a non-adherent on underneath the wound vacuum? 

Faust:
Yes. I do. We like the silicone contact layers for our patient population. What's nice about that is you're fixating. Even if you don't suture or staple it, you can still fixate with that contact layer, particularly the silicone, because there's no shifting, and it doesn't tend to bunch underneath the negative pressure as well. And what do you use for bolstering?

Dr. Price:
I use Xeroform. So if it's in this perianal region, I just use Xeroform. We layer that, we bolster it with a lot of fluffs and ABD pads. So, if the patient were to stool, it would just get that first layer dirty and then we would be able to take it off. A lot of times if the wound needs a little bit more moisture, I will butter my Xeroform with Bacitracin, just a triple antibiotic ointment.

But it's great that, you know, just in this panel, we use 3 different dressings, and all of them worked really well, which I think is also a great boon. You know, there are connective tissue products out there where, if you use a vacuum, you can only vacuum at 75 suction and then there are some where, oh, you can't put this on because it'll, you know, it'll kill it. Or you can't, you know, put, oh, vac, there's some particulates I can't put a vac on at all because it'll just blow it, it'll just completely blow it off. I don't know if you've had that experience. So, I think the wide variety of dressings that you can utilize over top of this is also one of its strengths, for sure. 

Faust:
Well, and also just the way with using the particulate, what you mix it with, because I personally would use like a hydrogel or mix it with a hypochlorous acid sometimes,
and I've done a variety of things. 

Dr. Price:
I mixed it with betadine. Yeah, the paste is really fascinating. The reason I've mixed it with betadine is sometimes I'm trying to seal down a soft tissue envelope or put it in a tunnel. And since betadine is also a sclerosing agent that can be used to collapse cavities, seromas, things like that, I started thinking to myself, well, if I mix this with the betadine and then put it in, will I get that anti-infectious action, that sclerosing, make it want to seal, cause that inflammatory response and then have the connective a product? So, it's fascinating how many things you can mix it with, as well. And I'm going to steal this medical honey thing though. I'm 100 % for it. 

Reyna:
Right, that's what you want exactly. Is to just give information out there to be able to let people know we're applying it in a different manner, but achieving that end result that we want, which is a good outcome. 

Faust:
Right, and so I think all of these case studies really highlight the fact that, as long as you're using the mechanisms of action and what literature we can have in these atypical wounds, that we're really able to have solutions for our patients that deal with both quality of life, those great outcomes that you talked about with maybe decreasing the number of procedures, decreasing length of stay, improved aesthetics of the wound as well, and even just the pain aspect as well. So, I think there's a larger variety of literature that needs to be published and needs to be explored. But again, because of kind of the critical nature of how our research needs to be conducted, there's no way we're going to get it on these. So we need to have these larger conversations, like you said with, are we moving the needle on kind of the old wives' tales of how we treat these things, and really be progressive for our patients and their outcome?

Reyna:
One of the impressive things that I'd like to emphasize is that usually if we have a patient that's in an ICU and they're very sick, we're not going to do anything to open up a wound. We usually leave it, allow for it to declare itself, that kind of thing, right? And then hopefully if they can turn around and they might go into surgery, have their plastic surgery they need to, and so on. But with Kerecis, I'm able to treat patients that are in a critical state, which is very different. Because, and I go back to thinking the anti-inflammatory response to the product and how that works. And it has been great because now we're preventing them to go into the operating room, you know? Saving that time.

Dr. Price:
And decreasing the burden of disease. I mean, we forget that skin is your largest organ. So, if you can treat the skin, then you've done a lot towards helping support other organs that might also be in failure. And, you know, I'm also an ICU intensivist, and I'm always harping on my dieticians that if we have a patient with a stage 4 wound, they're constantly leaking protein from that. And so it's making them more deconditioned and sicker, and they require sometimes double the amount of protein in order to improve. So, if you can treat that wound at the bedside while that patient is critically ill and actually decrease its size, to your point, that is a huge improvement in the patient's outcome and possibility for survival. So yeah, it's a very, very, it's a well-taken point, absolutely.

Faust:
Thank you guys so much for doing this panel with me. I learn so much every time I talk to you guys, and I appreciate you sharing that wisdom with our audience as well. Again, thank you to Kerecis for having us, and thank you guys for watching.