Successful fish skin xenografting post-Mohs surgery on the lower extremities in a patient with complex regional pain syndrome (CPRS)

Introduction: surgery is a tissue-sparing dermatologic surgery utilized for the treatment of nonmelanomaskin cancers. Reconstruction of soft tissue defects following Mohs surgery can be challenging onthe lower extremities due to limited adjacent tissue laxity and higher rates of post-operative infections. Fishskin xenografts are known to promote healing, reduce pain, & prevent infection in various wounds and havebeen successfully employed in the post-Mohs setting. Herein we report the first ever use of fish skin torepair Mohs surgery wounds on the lower extremities of a patient with complex regional pain syndrome(CPRS). CPRS is a rare chronic disorder wherein excess and prolonged pain and inflammation occurfollowing an injury, often on the extremities. Identifying safe & effective reconstructive options in the CPRSpatient population is an unmet medical need.Methods:A 76-year-old white female with history of CPRS on the left lower extremity underwent Mohs surgicalremoval of three primary cutaneous squamous cell carcinomas located on the right distal calf, right distalpretibial, & left distal pretibial regions over a 7 day period. Surgical clearance of the carcinomas resulted in3 full-thickness ulcerations measuring 5.6cm2, 9.6 cm2, and 9.28cm2, respectively. All 3 lesions werereconstructed using 4cm2 micronized fish skin xenografts applied 1 week, 3 weeks, and 5 weeks post-Mohsfollowing gentle debridement. Between applications, the xenografts were left unadulterated within thewound bed beneath a fenestrated silicone dressing with secondary absorptive dressings changed daily.Results:All lower extremity ulcerations (3/3) healed completely within 9 weeks following just 3 applications ofxenograft. The patient experienced no significant pain, irritation, or flaring of her CRPS during the healingprocess. Minimal depression and contraction occurred, resulting in an excellent cosmetic and functionaloutcome.Discussion: Establishing safe & effective reconstructive options for surgical wounds in the CPRS patient population is an unmet clinical need. Trauma from surgery and/or reconstruction can often flare CPRS on the ipsilateral and/or contralateral extremities and the successful performance of fish skin xenografts in this patient’s multiple wounds supports additional larger studies for use in this population. We hypothesize that the previously reported anti-nociceptive properties of omega3 fatty acids in the fish skin xenografts may have been beneficial in controlling the patients concurrent CPRS. Similarly, the barrier protection and expedited wound healing provided by the xenografts may also have yielded protective effects.References: