Using a Dermal Skin Substitute in the Treatment of Chronic Wounds Secondary to Recessive Dystrophic Epidermolysis Bullosa: A Cas

Results

Data from six patients (ages 8 years to 23 years, four girls, two boys) with chronic wounds secondary to generalized RDEB who attended the outpatient clinic and were treated were analyzed. Patient participation was determined according to need; these individuals constantly require wound care. In all cases, the diagnosis of generalized RDEB had been made shortly after birth and was confirmed by electron microscopy of skin biopsy. A skin biopsy from some of the areas being treated showed less than 1.0 x 10⁶ colony forming units per gram of bacteria using semi-quantitative culture techniques. The skin substitute was applied as described. Only one adverse event was recorded and was deemed not to be a result of the therapy provided. At weeks 1 to 2, epidermal coverage ranged between 80% and 100%. The mean epidermal coverage at 8 weeks for all patients at all sites was 74%. Some of the sites had persistent coverage and others had subsequent breakdown.

Case Studies

Patients with EB generally have recurrent wound episodes throughout their lives — a continual cycle of breakdown and healing, regardless of precautionary measures. The patients studied here had wounds that had been present for prolonged periods of time or reoccurred frequently. Each case study focused solely on location of the wounds and the extensive range of previous treatments (see Table 2 and Table 3).
Case 1. Miss A, an 8-year-old Caucasian girl with RDEB, had wounded areas that included her face, hands, arms, torso, chest, back, and feet. Her wounds previously were treated with silver sulphadiazine cream, polymyxin-gramicidin cream, fusidic acid cream, petrolatum ointment, nanocrystalline silver antibacterial dressings, moisture balance dressings, non-adherent dressings, and gauze. No debridement was performed before skin substitute application, which she received two times. On August 28, 2001, four pieces were applied to her right anterior shin, right heel, and the dorsum of her right foot, persistently open areas before treatment. On September 11, 2001 (13 days later,) all areas exhibited signs of healing except the dorsum of the right foot remained unchanged. On September 26, 2001 (4 weeks after application) another piece of skin substitute was applied — half on the right medial malleolus and the other on the lateral side (see Figure 4a, b).
Miss A had Staphylococcus aureus cultured from her right shin on the date of application, which explained the lack of improvement when compared to other treatment sites. The wound was treated and infection resolved by the time of the next assessment. Infection was a recurring event with Miss A but did not appear to hinder skin substitute take in other areas.
A second round of application to other wounded sites was scheduled for October 24, 2001 where a piece of skin substitute was applied to Miss A’s right elbow. At the first follow-up on November 6, 2001, the wound was healing. At the next follow-up visit on December 5, 2001, the skin substitute on both the right elbow and the right knee were intact and healing.
Case 2. Mr. B, a 12-year-old Caucasian boy with RDEB, exhibited esophageal dilatation and had most of his teeth pulled because of EB in his mouth. He also had an equinus deformity of the right foot. Other wounded areas included his face, hands, arms, torso, chest, back, and feet. His wounds were previously treated with silver sulphadiazine cream, nanocrystalline silver antibacterial dressing, silicone-coated sheets, silicone non-adherent mesh, and silicone non-adherent foam. No debridement was performed before skin substitute application.
Mr. B received three skin substitute applications. The first was April 18, 2001 to his right foot. On April 25, 2001, residual skin substitute was present and on May 30, 2001 (42 days later), the top of the right foot had a clean base and epithelial tissue was observed at the edge.
On July 10, 2001, most application sites were healing. On August 21, 2001, skin substitute was applied to the dorsum of his right foot, lateral right leg, buttocks, left hip, right scapula area, and left back. Two additional pieces were applied to the dorsum of his right foot, right medial leg, and right lateral leg on November 7, 2001. On December 11, 2001 (4 weeks later) the wounds had reduced by between 50% and 70%, indicating good wound healing progress. The longer-term follow-up visit on March 13, 2002 showed further reduction in wound size on the dorsum of his right foot (90%); other wounds had achieved complete healing. However, new areas had opened up elsewhere on his foot and shin. At the June 8th, 2002 follow-up, his right foot was completely healed even though Mr. B was suffering from a major skin breakout and itching in other areas (see Figure 5a, b, c).
Case 3. Ms. C was a 20-year-old Caucasian woman with RDEB. Her wounds had been treated previously with silver sulphadiazine cream, fusidic acid cream, emollient base cream, topical corticosteroid cream, nanocrystalline antibacterial dressings, foams, and alginate dressings. She received several applications of skin substitute. The first (nine pieces on July 21, 2000) involved her left anterior leg and back. On November 30, 2000 (4 months later), the skin substitute sites showed sustained healing. On December 18, 2000, additional skin substitute was applied to her back, with improvement noted by January 11 (4 weeks later). On May 8, 2001 additional skin substitute was applied to both buttocks after blisters were de-roofed using scissors (clinicians were unaware of these open areas before treatment). At Ms. C’s follow-up visit on June 12, 2001, significant improvement of her back was noted and on July 19, 2001, the skin on her back was healed.
On August 23, 2001, 20 additional pieces of skin substitute were applied to the center of Ms. C’s left back, right leg, and left leg; by September 13, 2001 the wound on her left back was healing.
Ms. C also exhibited progressive digital fusion of the hand with adduction of the thumb and flexion contractures of the fingers and underwent surgery when she was 6 years and 17 years old. Surgery was performed on her right hand on September 10, 2001, and skin substitute was applied to the web spaces post finger release surgery. The skin substitute was covered with a nanocrystalline silver dressing for bacterial balance and alginate carrier for moisture balance with a dry dressing bolster for retention. Ten days later, although slight maceration was noted on dressing removal, her hand was healing well. Approximately 2 months post surgery, her hand was in good condition with improving functionality. On March 16, 2002 (6 months later), her hand was doing generally well but an extra area had opened on her thumb and wrist. By May, Ms. C’s hands had almost completely healed (the skin was intact and in excellent condition) and by June 10, 2002, her hands were completely healed. No adverse events were reported for Ms. C and no infections were observed post surgery. She reported a high level of comfort after the surgery (see Figure 6a, b, c, d).
Case 4. Ms. D, a 23-year-old Caucasian woman with RDEB, had wounds that previously had been treated with silver sulphadiazine cream, fusidic cream, emollient cream base, moderate potency topical steroid, nanocrystalline antibacterial dressings, foam, and alginate dressings. She received several applications of skin substitute. The first (three pieces) was on December 1, 1999 to her left anterior leg and tibial area. One week later, the skin substitute remained adhered and healing had been stimulated. At that visit, additional skin substitute was applied to Ms. D’s right shoulder and right thigh. Fifteen days later, the shoulder wound exhibited general improvement. On December 23, 1999, granulation was noted on her right thigh and the other areas had healed. On January 28, 2000, skin substitute was applied her left thigh. By this time, her shoulder was 100% healed, her right thigh was 50% and her left pretibial area was 95% re-epithelialized.
Significant improvement in the treated wounds was noted during Ms. D’s follow-up visit on March 2, 2000; her left thigh had completely healed. However, new erosions had occurred elsewhere. On August 16, 2000 skin substitute (five pieces) was applied to her left leg and lower back and side. Ten months later, her left thigh remained healed.
On August 21, 2001, skin substitute (seven pieces) was applied to Ms. D’s lower left leg, left and right posterior thigh, left shin, right knee, right thigh, and behind her left knee; these areas exhibited new erosions after the patient began the study. Additional skin substitute was applied to the left and right posterior lower leg on September 13. Ten days later, healing was evident.
On October 18, 2001, more skin substitute (two pieces) was applied to Ms. D’s left lateral calf and left medial ankle, areas that also had never been open before treatment. Additional pieces were applied to her left leg on November 22, 2001 and February 7, 2002.
Ms. D also exhibited progressive digital fusion and flexion contractures of the fingers. She had previous surgeries when she was 8 and 19 years old. Surgery was performed on her left hand on September 10, 2001, and skin substitute was applied to the finger webs post surgery and covered with a nanocrystalline silver-coated dressing and a dry dressing for retention. Ten days later, her left hand was slightly macerated but the wound was healing. Two weeks post surgery, maceration had resolved and the skin substitute application site had healed.
Additional skin substitute was applied on November 15, 2001 to persistent defects on Ms. D’s legs, at which time it was noted that the general condition of the patient’s skin had improved. More skin substitute was applied to extensive erosion on Ms. D’s right leg and to new erosion on her left side. Although Ms. D’s case presented a significant clinical challenge, the skin substitute proved beneficial in other areas; further applications were made to her upper left leg and left knee on January 31, 2002. At that time, clinicians noted that her left hand was not healing well post surgery. Although no infections were observed and she reported a high level of comfort after the surgery compared to previous surgeries, her web spaces had re-fused approximately 1 month after the initial surgery. Surgery was repeated on October 22, 2001 and two pieces of skin substitute applied 4 days later.
The second surgery was successful and although by March 26, 2002 some wounds remained open between her fingers, generally her hand was doing well and her abdomen, back, and left leg were in good condition. A follow-up visit on May 28, 2002 showed the hand to be completely healed — approximately 7 months post surgery. At subsequent follow-up in June 2002, Ms. D reported that her hand remained healed but that she was using a splint at night (see Figure 7a, b, c, d).
Case 5. Miss E, a 10-year-old Caucasian girl with RDEB, had wounded areas that included her face, hands, arms, torso, chest, back, and feet. Her wounds were previously treated with silver sulphadiazine cream, polymyxin-gramicidin cream, fusidic acid cream, silver-coated antibacterial dressings, silicone-coated sheets, silicone non-adherent mesh, and silicone non-adherent foam. Minimal debridement was necessary before skin substitute application. Miss E received several skin substitute applications — the first was on July 27, 1999 to her right medial leg, left under arm, and the dorsum of her right foot.
On October 30, 2000 seven more pieces were applied to her right lateral leg and left posterior leg. Nine days later, her wounds exhibited a healthy granulation base with signs of re-epithelialization at the edges.
On December 18, 2000, six additional pieces were applied to Miss E’s left shoulder/back and right leg. At her follow-up visit on January 3, 2001, her wounds showed improvement at all sites and most were healed. No severe wound infections were noted during the treatment and Ms. E’s scar quality was found to be superior when compared with previous clinical experience using other therapies. However, an insignificant adverse events was noted — she had a mild wound infection on her right leg that with appropriate systemic medication resolved within 7 days and was determined not to be a result of skin substitute use.
Surgery for Ms. E’s progressive digital fusion and flexion contractures of the fingers could now commence. She had previous surgeries in 1996 and 1999 on her right hand and in 1998 on her left hand. On September 3, 2001, surgery was performed on her right hand and subsequently skin substitute was applied to the webs and epidermal defects on her fingers and covered with nanocrystalline silver dressing, small adhesive strips, Telfa™ dry dressing (Tyco Health Care/Kendall, Mansfield, Mass.), and a retention bandage.
On April 10, 2002, Miss E’s right hand improved, with a few open areas in the finger webs. By her follow-up visit in May 2002, her hand had completely healed and functionality was improved. No infections were observed post surgery. She reported a high level of comfort after the surgery compared to previous surgeries. Her hand grip and handwriting both were better, as was the scar quality. At Miss E’s follow-up visit on June 7, 2002, her mother commented on faster, more complete healing with no contraction or web formation with sustained healing. No changes in physiotherapy requirements of the fingers were necessary over the next 8 months and no splint adjustments were necessary — all of which were requirements of previous surgeries (see Figure 8a, b, c, d, e, f).
Case 6. Mr. F, a 10-year-old Caucasian boy with RDEB, had wounded areas that included his face, hands, arms, torso, chest, back, and feet. His wounds previously were treated with silver sulphadiazine cream, polymixin-gramicidin cream, fusidic acid cream, nanocrystalline antibacterial dressing, silicone coated sheets, non-adherent mesh, and non-adherent foam. Most recently, the patient had been treated with Apligraf® (Organogenesis, Inc., Canton, Mass.). Minimal debridement was performed before skin substitute application.
Mr. F received several applications of skin substitute. The first five pieces were applied on December 1, 1999 to his left scapula and back and the upper/lower right back (see Figure 9a, b, c, d).
Five days later, it was estimated by clinical observation that approximately 50% coverage was achieved on all sites . On January 28, 2000, additional skin substitute was applied Mr. F’s right scapula and lower left side (see Figure 9e, f). Three more pieces were applied to his lower back on April 14, 2001 (see Figure 9g). The remainder of his back was in excellent condition. No infections were noted during the treatment and Mr. F’s scar quality was better with the skin substitute than with previous therapies.
The patient exhibited progressive digital fusion and flexion contractures of the fingers. He had three previous surgeries in 1996, 1998, and 1999, all of which involved autologous grafts from the thighs and prolonged casting of the limbs to prevent disturbance. This was a fairly traumatic procedure for a young child. On April 25, 2001, surgery was performed on his left hand and skin substitute was applied to the webs and epidermal defects on the fingers post surgery. The dermal substitute was covered with the dressings used in Case 5.
At the follow-up visit on May 4, 2001, Mr. F’s surgical wounds showed significant improvement with some re-epithelialization over the fingers and thumbs. By March 28, 2002, he had some function in his left hand. On June 7, 2002, many areas remained healed — something that had never happened for Mr. F before dermal substitutes were used. He had some open areas with blisters but, in general, was in better overall condition, although he had a GI tube inserted for feeding due to complications caused by his EB. No infections were observed in the pre- and postoperative period and his mother reported a high level of comfort after the surgery compared to previous surgeries and a much less traumatic postsurgical period compared to previous clinical experience. His hand grip and handwriting both were better, as was the scar quality. The most significant difference was the sustained healing compared to previous procedures.
Hand surgery. As noted above, four of the patients who had presented with pseudosyndactyly (digital flexural contraction) and adduction (contractures of the thumb secondary to generalized RDEB) underwent a surgical degloving procedure to one hand. All four patients had undergone similar operations in the past using split-thickness skin grafting. For their most recent surgeries, the dermal skin substitute was applied to open areas on the finger webs and fingers immediately postoperatively; thereby, precluding the need for split-thickness autografts. Prophylactic antibiotics were given to all patients and antibiotic digital beads inserted where possible. Postoperatively, patients reported being more comfortable and subjectively reported faster healing times compared to previous operations using split-thickness skin grafts. In all patients, the procedure improved hand function.

Discussion

Recessive dystrophic EB results from a mutation in the gene COL7A1 that encodes the anchoring fibril protein, type VII collagen. Quantitative electron microscopy and immunoelectron microscopy have shown that anchoring fibrils in this condition are either decreased in number, morphologically altered, or completely absent.^45,46 Absence of fully functional anchoring fibrils results in easy separation of the dermis from the epidermis with sublamina densa blister formation and erosions or ulcers developing in response to minimal trauma or friction. Therapy for these skin lesions, in the absence of a cure, is supportive. To date, patients with EB have been treated with varying degrees of success either with epidermal or composite skin grafts. This is the first case series where a dermal skin substitute was used in patients with generalized RDEB. The mean epidermal coverage at 8 weeks for all patients at all sites was 74%, which is similar to that found in other studies.^42,43,47 In this group of patients, all treated areas had approximately 95% coverage by week 4, but some re-injury resulted in a lower mean coverage at week 8 of approximately 93%. No adverse events were recorded, with the exception of one patient who developed a fever post application that was attributed to an infected nutrition line rather than to the skin substitute. The use of dermal skin substitute in patients with RDEB appears to be well tolerated.
The exact mechanism by which skin substitutes facilitate healing is, as yet, unknown. It has been postulated that they may provide growth factors in physiological concentrations. Alternatively, they may favorably modulate local cytokine activity for wound healing that, together with a moist, occluded environment, promotes wound healing.
Research to elicit the time skin substitutes remain in situ is ongoing. Studies suggest that bilayered living skin equivalents may persist in the healed skin of patients with RDEB for up to 8 to 11 months before being replaced by host skin.⁴⁷ In the cohort of patients addressed here, some of the treated areas remained healed and intact for between 6 and 12 months postgrafting. This may be due to the persistence of fibroblasts within the dermal skin substitute. Alternatively, the deficient or absent anchoring fibril protein, type VII collagen may persist or be regenerated following skin substitute application.⁴⁸ Further research needs to be directed at determining how long both dermal and epidermal components persist and the exact mode by which healing is facilitated.
Although preliminary results suggest that skin substitutes facilitate healing of RDEB wounds, they do not replace best practices of wound care. Patients with this condition often have malnutrition, anemia, and an abnormal immune status.^49,50 These, together with the tendency to develop chronic wounds, expose patients with EB to infection and sepsis. Additionally, patients with EB and their families have an impaired quality of life.^51-54 Patients’ lives are affected by restriction of everyday activities in an attempt to prevent blisters and erosions, pain, and lengthy dressing changes that can take up to 6 hours each day. Although standards of wound care in patients with EB have not been established,⁵⁵ the authors’ experience suggests that skin substitutes may be important to optimizing both patient and wound-related factors (see Table 4).⁵⁶
Patient-centered concerns such as pain and itching should be addressed. Appropriate attention to bacterial balance and moisture control appear to be important to optimize the take of the skin substitute. Debridement, if necessary, must be gentle and nontraumatic.
The results of this case series are encouraging and suggest similar or better results than those reported using other dressings or skin substitute products.^30,57-63 Moist wound dressings were found to be beneficial in the short term in some earlier studies but longer-term benefits were absent and wound recurrence was a problem.³⁰ More recent studies evaluating epidermal autografts⁴³ showed they had some benefit but healing occurred over many months. Progress in laboratory research and biotechnology has led to the availability of cultured keratinocytes. Their evaluation in patients with EB demonstrated disappointing results without best wound care practices.^33,57 Recent studies in which a dermal component was introduced, often in addition to the cultured keratinocytes, showed significantly better results with faster healing and better long-term stability than cultured keratinocytes, with a low incidence of wound recurrence.^33,59-62
These results need to be validated by larger case series and controlled trials with long-term follow-up before the routine application of skin substitutes can be advocated on a widespread basis. Although skin substitutes improve quality of life in patients with EB in the short term,⁶³ it is hoped that in the future, the skin substitute will provide more dramatic, lasting results for these children when used as a vector for gene therapy. By using genetically modified autologous keratinocytes grown utilizing technology similar to that used for creating skin substitutes and transplanting them onto the patient, a “cure” may be developed for children with RDEB.³⁰ In the meantime, skin substitutes may play a role in temporary wound management, enhancing quality of life and reducing both pain and duration of dressing changes in these patients. The patients in this clinical case series have helped their clinicians define optimal wound bed preparation as well as improve quality of life for individuals with EB and their caregivers.

Conclusion

When used in addition to standard practices of wound care, dermal skin substitutes may aid in the healing of persistent skin erosions in patients with RDEB; when applied to web spaces and digits, dermal skin substitutes facilitate postoperative healing following surgical degloving procedures. No adverse effects were observed. Decreased itching and pain as well as the absence of donor site wounds may help promote this technique for specialized patient care.
Until a cure for patients with RDEB is found, dermal skin substitutes may play a role in temporary wound management, enhancing quality of life and reducing both pain and duration of dressing changes in these patients.

Acknowledgment

The authors dedicate this article to the children for their participation in this study and for their permission to share their individual pictures. The children were a pleasure to work with and show bravery and tolerance of the highest standard.
This work was part of a case series submitted to the US Food and Drug Administration for the purpose of obtaining Humanitarian Device Exemption approval for the use of Dermagraft® in children with Recessive Dystrophic Epidermolysis Bullosa.

1. Eady RA. Epidermolysis Bullosa: scientific advances and therapeutic challenges. J Dermatol. 2001;28(11):638–640.
2. Haynes L, Atherton DJ, Ade-Ajayi N, Wheeler R, Kiely EM. Gastrostomy and growth in dystrophic epidermolysis bullosa. Br J Dermatol. 1996;134(5):872–879.
3. Schober-Flores C. Epidermolysis bullosa: the challenges of wound care. Dermatol Nurs. 2003;15(2):135–140.
4. DEBRA website. Available at: http://www.debra.org. Accessed July 30, 2004.
5. Canadian DEBRA website. Available at: www.debracanada.org/whatiseb.htm. Accessed July 30, 2004.
6. DEBRA UK website. Available at: www.debra.org.uk/abouteb/faq.htm. Accessed July 30, 2004.
7. Marin-Bertolin S, Amaya Valero JV, Neira GC, Marquina VP, Amorrortu-Velayos J. Surgical management of hand contractures and pseudosyndactyly in dystrophic epidermolysis bullosa. Ann Plast Surg. 1999;43(5):555–559.
8. Vozdvizhensky SI, Albanova VI. Surgical treatment of contracture and syndactyly of children with epidermolysis bullosa. Br J Plast Surg. 1993;46(4):314–316.
9. Fine JD, Eady RAJ, Bauer EA, et al. Revised Classification system for inherited epidermolysis bullosa: report of Second International Consensus Meeting on Diagnosis and Classification of Epidermolysis Bullosa. J Am Acad Dermatol. 2000;42:1051–1066.
10. Lapioli-Zufelt A, Morris EJ. Skin and wound care management for a child with epidermolysis bullosa. J WOCN. 1998;25(6):314–316.
11. Ladd AL, Kibele A, Gibbons S. Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa. J Hand Surg [Am]. 1996;21(5): 888–897.
12. Schober-Flores C. Epidermolysis bullosa: a nursing perspective. Dermatol Nurs. 1999;11(4):243–256.
13. Clearihan L. Cottonwool babies. A case history. Aust Fam Physician. 1992;21(11):1595–1602.
14. Chiu YK, Prendiville JS, Bennett SM, Montgomery CJ, Oberlander TF. Pain management of junctional epidermolysis bullosa in an 11-year-old boy. Pediatr Dermatol. 1999;16(6):465–468.
15. Marin-Bertolin S, Amaya Valero JV, Neira Gimenez C, Marquina Vila P, Amorrortu-Velayos J. Surgical management of hand contractures and pseudosyndactyly in dystrophic epidermolysis bullosa. Ann Plast Surg. 1999;43(5):555–559.
16. Khavari PA. Gene therapy for genetic skin disease. J Invest Dermatol. 1998;110(4):462–467.
17. Pai S, Marinkovich MP. Epidermolysis bullosa: new and emerging trends. Am J Clin Dermatol. 2002;3(6):371–380.
18. Khavari PA, Rollman O, Vahlquist A. Cutaneous gene transfer for skin and systemic diseases. J Intern Med. 2002;252(1):1–10.
19. Christensen R, Jensen UB, Jensen TG. Cutaneous gene therapy — an update. Histochem Cell Biol. 2001;115(1):73–82.
20. Khavari PA. Therapeutic gene delivery to the skin. Mol Med Today. 1997;3(12):533–538.
21. Lin AN. Management of patients with epidermolysis bullosa. Dermatol Clin. 1996;14(2):381–387.
22. Sugawara S, Kusunose K, Kaneko, K. Treatment of hand deformities in a long term survivor with dermolytic bullous dermatosis recessive (DBD-R). Hand Surg. 2001;6(1):121–123.
23. Goldstein AM, Davenport T, Sheridan RL. Junctional epidermolysis bullosa: diagnosis and management of patient with the Herlitz variant. J Pediatr Surg. 1998;33(5):756–758.
24. Krasner DL. How to prepare the wound bed. Ostomy Wound Manage. 2001;47(4):59–61.
25. Ovington LG. Battling bacteria in wound care. Home Health Nurse. 2001;19(10):622–630.
26. Lapinski P, Lapiere JC, Traczyk T, Chan LS. Sporadic dystrophic epidermolysis bullosa with concomitant atopic dermatitis. Br J Dermatol. 1998;138(2):315–320.
27. Birge K. Nutrition management of patients with epidermolysis bullosa. J Am Diet Assoc. 1995;95(5):575–579.
28. Winter GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293–294.
29. Winter GD. Epidermal regeneration studied in the domestic pig. In: Mailbesch HI, Rovee DT, eds. Epidermal Wound Healing. Chicago, Ill.: Year Book Medical Publishers;1972:71–112
30. Eisenberg M. The effect of occlusive dressings on re-epithelializations of wounds in children with epidermolysis bullosa. J Pediatr Surg. 1986;21(10):892–894.
31. Ovington L. Dressings and adjunctive therapies: AHCPR guidelines revisited. Ostomy Wound Manage. 1999;45(1A Suppl):94S106S.
32. Casey G. Wound dressings. Paediatr Nurs. 2001;13(4):39–42.
33. Falabella AF, Valencia IC, Eaglstein WH, Schachner LA. Tissue-engineered skin (Apligraf) in the healing of patients with epidermolysis bullosa wounds. Arch Dermatol. 2000;136(10);1225–1230.
34. Browne AC, Sibbald RG. The diabetic neuropathic ulcer: an overview. Ostomy Wound Manage. 1999;45(1A Suppl):6S–20S.
35. Gath HJ, Hell B, Zarrinbal R, Beir J, Raguse JD. Regeneration of interoral defect after tumor resection with bioengineered human dermal replacement (DermagraftTM). Plast Reconstr Surg. 2002;109(3):889–893.
36. Jiang WG, Harding KG. Enhancement of wound tissue expansion and angiogenesis by matrix-embedded fibroblast (Dermagraft™), a role of hepatocyte growth factor/scatter factor. Int J Mol Med. 1998;2(2):203–210.
37. Naughton G, Mansbridge J, Gentzkow G. A metabolically active human dermal replacement for the treatment of diabetic foot ulcers. Artif Organs. 1997;21(11):1203–1210.
38. Pollack RA, Edington H, Jensen JL, Kroeker RO, Gentzkow GD. A human dermal replacement for the treatment of the diabetic foot ulcer. WOUNDS. 1997;9:75–183.
39. Gentzkow GD, Iwasaki SD, Hershon KS, et al. Use of DermagraftTM, a cultured human dermis, to treat diabetic foot ulcers. Diabetes Care. 1996;4:350–354.
40. Browne AC, Vearncombe M, Sibbald RG. High bacterial load in asymptomatic diabetic patients with neurotrophic ulcers retards wound healing after application of Dermagraft™. Ostomy Wound Manage. 2001;47(10):44–49.
41. Eaglstein WH. DermagraftTM treatment of diabetic ulcers. J Dermatol. 1998;25(12):803–804.
42. Eisenberg M, Llewelyn D, Moran K, et. al. Successful engraftment of cultured human allograft in a child with recessive dystrophic epidermolysis bullosa. Med J Aust. 1987;147:520.
43. Carter DM, Lin AN, Varghese MC, et al. Treatment of junctional epidermolysis bullosa with epidermal autografts. J Am Acad Dermatol. 1987;17:246—250.
44. Cutting KF, Harding KGH. Criteria for identifying wound infection. J Wound Care. 1994;3(4):198–201.
45. Tidman MJ, Eady RAJ. Evaluation of anchoring fibrils and other components of the dermal-epidermal junction in dystrophic epidermolysis bullosa by a quantitative ultrastructural technique. J Invest Dermatol. 1985;84:374–377.
46. McGrath JA, Ishida-Yamamoto A, O’Grady A, et al. Structural variations in anchoring fibrils in dystrophic epidermolysis bullosa: correlation with type VII collagen expression. J Invest Dermatol. 1993;100:366–372.
47. Fine JD. Skin bioequivalents and their role in the treatment of inherited epidermolysis bullosa. Arch Dermatol. 2000;136:1259–1260.
48. Eisenberg M, Llewelyn D. Surgical management of hands in children with recessive dystrophic epidermolysis bullosa: use of allogeneic composite cultured skin grafts. Br J Plastic Surg. 1998;51:608–613.
49. Chopra V, Tyring SK, Johnson L, et al. Patients with severe forms of inherited epidermolysis bullosa exhibit decreased lymphokine and monokine production. J Clin Immunol. 1990;10:321–329.
50. Chopra V, Tyring SK, Johnson L, et al. Peripheral blood mononuclear cell subsets in patients with severe inherited forms of epidermolysis bullosa. Arch Dermatol. 1992;128:201–209.
51. Fine JD, Bauer EA, Briggaman RA. Revised clinical and laboratory criteria for subtypes of inherited epidermolysis bullosa. A consensus report by the Subcommittee on Diagnosis and Classification of the National Epidermolysis Bullosa Registry. J Am Acad Dermatol. 1991;24(1):119–135.
52. Fine JD. Inherited Epidermolysis bullosa: selected outcomes and a revised classification system. Pediatr Dermatol. 2000;17(1):75–83.
53. Fine JD, Bauer EA, McGuire J, Moshell A. Epidermolysis Bullosa: Clinical, Epidemiologic, and Laboratory Advances and the Findings of the National Epidermolysis Bullosa Registry. Baltimore, Md.: The Johns Hopkins University Press;1999.
54. Lin AN, Carter DM, eds. Epidermolysis Bullosa: Basic and Clinical Aspects. New York, NY: Springer-Verlag;1992.
55. Uitto J, Eady R, Fine JD, et al. The DEBRA International Visionary/Consensus Meeting on Epidermolysis Bullosa: summary and recommendations (review). J Invest Dermatol. 2000;114:734–737.
56. Sibbald RG, Williamson D, Orsted H, et al. Preparing the wound bed — debridement, bacterial balance, and moisture balance. Ostomy Wound Manage. 2000;46(11):14–35.
57. Campiglio GL, Pajardi G, Rafanelli G. A new protocol for the treatment of hand deformities in recessive dystrophic epidermolysis bullosa (13 cases). Ann Chir Main Memb Super. 1997;16(2):91–100.
58. McGrath JA, Schofield OM, Ishida-Yamamoto A, et al. Cultured keratinocyte allografts and wound healing in severe recessive dystrophic epidermolysis bullosa. J Am Acad Dermatol. 1993;29(3):407–419.
59. Ozerdem OR, Wolfe SA, Marshall D. Use of skin substitutes in pediatric patients. J Craniofac Surg. 2003;14(4):517–520.
60. Fivenson DP, Scherschun L, Choucair M, Kukuruga D, Young J, Shwayder T. Graftskin therapy in epidermolysis bullosa. J Am Acad Dermatol. 2003;48(6):886–892.
61. Jiang QJ, Izakovic J, Zenker M, et al. Treatment of two patients with Herlitz junctional epidermolysis bullosa with artificial skin bioequivalents. J Pediatr. 2002;141(4):553–559.
62. Wollina U, Konrad H, Fischer T. Recessive epidermolysis bullosa dystrophicans (Hallopeau-Siemens) — improvement of wound healing by autologous epidermal grafts on an esterified hyaluronic acid membrane. J Dermatol. 2001;28(4):217–220.
63. McGuire J, Birchall N, Cuono C, et al. Successful engraftment of allogeneic keratinocyte cultures in recessive dystrophic epidermolysis bullosa. J Invest Dermatol. 1987;88:506.