Would Healing Toolbox Requires Frequent Updating

NEW YORK — Instructions on wound healing often involve disturbing photographs of severe diabetic ulcers, angry autoimmune blistering, and oozing lesions produced by uncommon genetic disorders, but day-to-day dermatologic care of wounds, whether they are dramatic, relies on both the basics and novel approaches, according to a well-known wound treatment expert.

Wound repair is relevant to any specialty involved in invasive interventions, but dermatologists are at ground zero and should have commensurate skills, suggested Robert S. Kirsner, MD, PhD, who is the director of the Wound Clinic at Jackson Memorial Hospital and chair of the Department of Dermatology and Cutaneous Surgery at the University of Miami, Miami.

“We as a specialty make and we repair more wounds than any other specialty,” said Kirsner, who provided data to make his point. In a table he displayed, the number of repairs made annually by dermatologists was several-fold higher than surgeons, the next highest group, and the numbers declined rapidly from there.

Speaking at the 27th Annual Winter Symposium — Advances in Medical and Surgical Dermatology (MSWS) 2024, Kirsner offered an array of clinical pearls, reinforced some basics, and pointed to well-supported strategies that he believes are too often overlooked.

Drugs Repurposed for Wound Healing

Of clinical pearls, he spoke of the repurposing of several agents for wound care. His first example was the monoclonal antibody dupilumab, which inhibits interleukin (IL) 4 and IL-13 signaling, to heal selected patients with leg ulcers. The potential of this drug was drawn from a patient with a leg ulcer who presented with concomitant pruritus nodularis and biliary cirrhosis. When offered for the comorbidities, dupilumab provided a “dramatic” benefit with regard to the wound, according to Kirsner.

The explanation for the response is that IL-4 and IL-13 have been found to be upregulated in some patients with leg ulcers. Based on numerous cases, Kirsner spoke of a phenotype of nonhealing leg ulcers from which elevated IL-4 and IL-13 can be isolated. These are the candidates for adding dupilumab to wound care, he said.

Topical beta-blockade was another example of a therapy repurposed for wound healing, according to Kirsner. He said beta-blockers are already a standard of care for burn wounds, but the mechanism is relevant to other wound types.

Several studies have now looked at this phenomenon, with experimental studies showing that skin healing is impaired when beta-2 receptors are agonized but accelerated when blocked.

Beta-Blockade Accelerates Wound Healing

A recent review of these mechanisms in soft tissue wound healing pointed to an anti-inflammatory effect, acceleration of keratinocyte migration, pro-reepithelization effects, and inhibition of bacterial virulence. Beta-blockers were first implicated as mediators of wound healing more than a decade ago, but Kirsner indicated that there is now more attention to this therapy within a comprehensive approach in difficult cases.

Although not specific to wound healing, the potential for teprotumumab to improve control of pretibial myxedema was another example of a repurposed therapy for a challenging skin disease. A monoclonal antibody that targets the insulin-like growth factor 1 receptor, teprotumumab is approved for active thyroid eye disease, but Kirsner cited data showing compelling evidence of benefit in this cutaneous complication of Graves disease.

As for basics, Kirsner devoted some time emphasizing the importance of compression therapy for improving leg vascularization. This is not something to just consider. Rather, he considers it part of standard practice. “Compress all leg ulcers,” was Kirsner’s simple message.

Citing encouraging work in identifying targetable molecular events in wound healing, Kirsner suggested that treatment might be increasingly guided by biomarkers. He pointed to ongoing work to characterize wound exudate as a source of biomarkers.

“The discarded dressing contains a wealth of information,” he said, referring to cell types and proteins, such as growth factors. He thinks that the ongoing studies of exudate, which have shown that molecular processes detected at the periphery are often different than those at the focal site of injury, have substantial promise for identifying new targets for treatment.

Virtual Reality to Address Pain

From the practical standpoint, Kirsner looked to a well-studied but still underused adjunct to wound debridement and surgical repair. It is the distraction offered by relatively low-priced virtual reality systems. He described it as a simple way to help patients keep their minds off the pain. It is not a new idea: It has been studied for this use numerous times, and the evidence of benefit is essentially uniform, according to Kirsner.

He said effective and sophisticated systems can now be purchased for just hundreds of dollars, and no training is needed. Indeed, he said pediatric patients can typically explain how the system works if the clinician does not know.

“If you can enhance their experience [during wound repair], you can make their lives and your life better,” he said.

Joshua Zeichner, MD, an associate professor of dermatology at Mount Sinai in New York City, concurred that the evidence supports this approach, and it is easy to do. “I am in favor of anything that improves the experience of the patient,” said Zeichner, who chaired the portion of the meeting during which Kirsner spoke.

Kirsner said he practices what he preaches. “I routinely employ virtual reality for simple surgical procedures or processes that patients might find unpleasant,” he said. He acknowledged that clinicians might have heard this message before, but he believes those who have not yet introduced this into their practice should consider it.

Kirsner reported no potential conflicts of interest. Zeichner has served as a consultant for Beiersdorf.

Ted Bosworth is a medical journalist based in New York City.