CLINICAL UPDATE
Quest for scarless healing in burn injury
The burn-injured patient has complex evolving pathophysiology that impacts on all body systems. Improving burn healing requires both a broad understanding and a subspecialist focus on treatment. Debilitating scarring limits the life of survivors so a vision of scarless healing aims to improve outcomes for life. It has led to the exploration of regeneration.
By Winthrop Prof Fiona Wood,
Director of the Burns Service WA & UWA Burn Injury
Research Unit
Focus both wide and narrow
The 2005 MJA-published future vision of clinical care, points to a number of disciplines:
“ Assessment is key to understanding the extent of injury. Debridement is focused on tissue salvage. Reconstruction balances repair with regeneration.
�� �������������������������������������� scale characterisation, including confocal microscopy and synchrotron technology will quantify assessment.
�� ����������������������������������������� control techniques with image guided physical methods will ensure the vital tissue frameworks are retained.
�� ��������������������������������������� self-assembly nano-particles will provide the framework to guide cells to express the appropriate phenotype in reconstruction.
To solve the clinical problem a multidisciplinary scientific approach is needed to ensure the quality of the scar is worth the pain of survival.”
Currently, many of these highlighted technologies are available and innovative research can move them towards safe implementation if they are matched with clinical observations, those that result from close working relationships between research and service delivery. The clinical research framework brings together basic science, population health and clinical research.
We know that every intervention from the time of injury impacts on the scar worn for life: first aid and pre-hospital care; disaster response; wound and scar assessment; oedema management focused on tissue salvage; cell-based therapies to guide healing, in particular the impact of the nano chemistry and architecture; rehabilitation that begins at the time of injury and is measured by function for life; the influences of genetics and epigenetics; the neurological and psychological response to injury; and population data linkage that reports on the lifelong impact of burn injury.
Incorporating innovation into practice requires education that includes telehealth, and is subject to audit.
Many options to explore
In burns, the repair of injured skin is essential to protect underlying tissues and re-establish an intact barrier with all related functions. Whether this can be achieved using conservative or surgical methods depends on the extent of injury in terms of surface area and depth. Frequently, to ensure survival, rapid wound cover is essential and for many years, split thickness skin graft( SSG) has been considered the gold standard. A SSG, taken from a non-injured site, creates an additional wound and retains the characteristics of the site of origin. The result is always a scar. Therefore, fundamental to the quest for scarless healing is the exploration of techniques of tissue salvage and therapy that make up a new gold standard.
Traditionally, the fundamental requirements for skin healing were considered to be:
�� ������������������������������� differentiation into the tissue lost, and
�� �������������������������������� cells to migrate into and express the appropriate phenotype.
However, just as complex tissues have self-organised into the adult body, there are parallels with tissue repair after burns. Although the drivers to self-organisation are not fully understood, they require:
�� ���������������������������������� damage and the relationship to the intact surrounding tissues, and
�� ������������������������������������ � organisation.
In our quest for scarless healing within the framework of this working hypothesis, key pieces of the jigsaw have been uncovered.
We now know that the skin at a contralateral site, which has not been injured, has long term changes of the nerve fibres within the skin construct. We postulate that the changes are related to alterations in the CNS homunculus. Acute changes related to neural plasticity become established long-term, as seen in phantom limb syndromes.
Burn injury is related to an aggressive and prolonged inflammatory response that results in the development of a scar with an abnormal extracellular matrix( ECM). The ongoing abnormal ECM( in shape and chemistry) is permitted by the immune system for which we now ask:
�� ������������������������������������ lead to an increased lifetime risk related to an alteration in the immune response e. g. cancer? Conversely, will a recovered immune system mitigate against this risk?
� Burns telehealth flyer
�� ������������������������������������� the homunculus be used to drive regenerative nerve repair within the skin?
�� ������������������������������������������� tissue level facilitate a regenerative healing pattern?
�� �������������������������������� structure be associated with normal phenotypic expression of skin cells?
�� �������������������������������������������� or even dependent upon systemic recovery of the immune system?
Although we are living in a time where science and technology are advancing exponentially, harnessing this knowledge to clinical practice is a challenge. Meanwhile, maybe our greatest challenge is translating what we know now into routine practice, such as the impact of first aid education in the community on the scar someone will wear for life( see image).
Declaration: Author competing interests: No relevant disclosures.
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