Incubation of cultured skin substitutes in reduced humidity promotes cornification in vitro and stable engraftment in athymic mice

Advancements in cell-based therapies for thermal burn wounds: a comprehensive systematic review of clinical trials outcomes

BACKGROUND

Burn trauma is one of the major causes of morbidity and mortality worldwide. The standard management of burn wounds consists of early debridement, dressing changes, surgical management, and split-thickness skin autografts (STSGs). However, there are limitations for the standard management that inclines us to find alternative treatment approaches, such as innovative cell-based therapies. We aimed to systematically review the different aspects of cell-based treatment approaches for burn wounds in clinical trials.

METHODS

A systematic search through PubMed, Medline, Embase, and Cochrane Library databases was carried out using a combination of keywords, including "Cell transplantation", "Fibroblast", "Keratinocyte", "Melanocyte", or "Stem Cell" with "Burn", "Burn wound", or "Burn injury". Firstly, titles and abstracts of the studies existing in these databases until "February 2024" were screened. Then, the selected studies were read thoroughly, and considering the inclusion and exclusion criteria, final articles were included in this systematic review. Moreover, a manual search was performed through the reference lists of the included studies to minimize the risk of missing reports.

RESULTS

Overall, 30 clinical trials with 970 patients were included in our study. Considering the type of cells, six studies used keratinocytes, nine used fibroblasts, eight used combined keratinocytes and fibroblasts, one study used combined keratinocytes and melanocytes, five used combined keratinocytes and fibroblasts and melanocytes, and one study used mesenchymal stem cells (MSCs). Evaluation of the preparation type in these studies showed that cultured method was used in 25 trials, and non-cultured method in 5 trials. Also, the graft type of 17 trials was allogeneic, and of 13 other trials was autologous.

CONCLUSIONS

Our study showed that employing cell-based therapies for the treatment of burn wounds have significant results in clinical studies and are promising approaches that can be considered as alternative treatments in many cases. However, choosing appropriate cell-based treatment for each burn wound is essential and depends on the situation of each patient.

An overview on the manufacturing of functional and mature cellular skin substitutes

There are different types of skin diseases due to chronic injuries that impede the natural healing process of the skin. Tissue engineering (TE) has focused on the development of bioengineered skin or skin substitutes that cover the wound, providing the necessary care to restore the functionality of injured skin. There are two types of substitutes: acellular skin substitutes (ASSs), which offer a low response of the body, and cellular skin substitutes (CSSs), which incorporate living cells and appear as a great alternative in the treatment of skin injuries due to them presenting a greater interaction and integration with the rest of the body. For the development of a CSS, it is necessary to select the most suitable biomaterials, cell components, and methodology of biofabrication for the wound to be treated. Moreover, these CSSs are immature substitutes that must undergo a maturing process in specific bioreactors, guaranteeing their functionality. The bioreactor simulates the natural state of maturation of the skin by controlling parameters such as temperature, pressure, or humidity, allowing a homogeneous maturation of the CSSs in an aseptic environment. The use of bioreactors not only contributes to the maturation of the CSSs, but also offers a new way of obtaining large sections of skin substitutes or natural skin from small portions acquired from the patient, donor, or substitute. Based on the innovation of this technology and the need to develop efficient CSSs, this work offers an update on bioreactor technology in the field of skin regeneration.

Basic Quality Controls Used in Skin Tissue Engineering

Reconstruction of skin defects is often a challenging effort due to the currently limited reconstructive options. In this sense, tissue engineering has emerged as a possible alternative to replace or repair diseased or damaged tissues from the patient's own cells. A substantial number of tissue-engineered skin substitutes (TESSs) have been conceived and evaluated in vitro and in vivo showing promising results in the preclinical stage. However, only a few constructs have been used in the clinic. The lack of standardization in evaluation methods employed may in part be responsible for this discrepancy. This review covers the most well-known and up-to-date methods for evaluating the optimization of new TESSs and orientative guidelines for the evaluation of TESSs are proposed.

Unravelling effects of relative humidity on lipid barrier formation in human skin equivalents

Relative humidity (RH) levels vary continuously in vivo, although during in vitro generation of three-dimensional human skin equivalents (HSEs) these remain high (90-95%) to prevent evaporation of the cell-culture medium. However, skin functionality is directly influenced by environmental RH. As the barrier formation in HSEs is different, there is a need to better understand the role of cell-culture conditions during the generation of HSEs. In this study, we aim to investigate the effects of RH on epidermal morphogenesis and lipid barrier formation in HSEs. Therefore, two types of HSEs were developed at 90% or at 60% RH. Assessments were performed to determine epidermal morphogenesis by immunohistochemical analyses, ceramide composition by lipidomic analysis, and lipid organization by Fourier transform infrared spectroscopy and small-angle X-ray diffraction. We show that reduction of RH mainly affected the uppermost viable epidermal layers in the HSEs, including an enlargement of the granular cells and induction of epidermal cell activation. Neither the composition nor the organization of the lipids in the intercorneocyte space were substantially altered at reduced RH. In addition, lipid processing from glucosylceramides to ceramides was not affected by reduced RH in HSEs as shown by enzyme expression, enzyme activity, and substrate-to-product ratio. Our results demonstrate that RH directly influences epidermal morphogenesis, albeit the in vitro lipid barrier formation is comparable at 90% and 60% RH.

In vivo evaluation of an electrospun gelatin nonwoven mat for regeneration of epithelial tissues

One major objective in epithelial tissue engineering is to identify a suitable biomaterial that supports epithelial tissue formation. Therefore, the purpose of this study is to elucidate a novel electrospun gelatin nonwoven mat (NWM) for epithelial tissue engineering purposes in vivo. This NWM was seeded with either human gingival keratinocytes (GK, in coculture with gingival fibroblast) or human skin epithelial keratinocytes (EK, in coculture with skin dermal fibroblasts). These constructs were ex vivo cultured for 4 days before subcutaneous implantation into athymic nude mice. After 7 days, the constructs were explanted and investigated by immunohistology. Our results show that GK form a stratified epithelium on the surface of the NWM, mostly independent of a fibroblastic counterpart. Like native mucosa, the regenerated epithelium showed expression of epidermal growth factor receptor, cytokeratin-14 and -1, and involucrin. Only the expression of the basement membrane constituent laminin 5 was more pronounced in cocultures. Comparing GK and skin EK, we found that skin EK form a less developed epithelial tissue. Furthermore, the NWM allows not only for epithelial tissue formation by GK, but also for infiltration of human fibroblasts and mouse immune cells, thus representing a biomaterial with potential regenerative capacity for oral mucosa tissue engineering applications. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 1605-1614, 2019.

Tissue Engineered Skin Substitutes

The fundamental skin role is to supply a supportive barrier to protect body against harmful agents and injuries. Three layers of skin including epidermis, dermis and hypodermis form a sophisticated tissue composed of extracellular matrix (ECM) mainly made of collagens and glycosaminoglycans (GAGs) as a scaffold, different cell types such as keratinocytes, fibroblasts and functional cells embedded in the ECM. When the skin is injured, depends on its severity, the majority of mentioned components are recruited to wound regeneration. Additionally, different growth factors like fibroblast growth factor (FGF), epidermal growth factor (EGF), vascular endothelial growth factor (VEGF) are needed to orchestrated wound healing process. In case of large surface area wounds, natural wound repair seems inefficient. Inspired by nature, scientists in tissue engineering field attempt to engineered constructs mimicking natural healing process to promote skin restoration in untreatable injuries. There are three main types of commercially available engineered skin substitutes including epidermal, dermal, and dermoepidermal. Each of them could be composed of scaffold, desired cell types or growth factors. These substitutes could have autologous, allogeneic, or xenogeneic origin. Moreover, they may be cellular or acellular. They are used to accelerate wound healing and recover normal skin functions with pain relief. Although there are a wide variety of commercially available skin substitutes, almost none of them considered as an ideal equivalents required for proper wound healing.

Development of the stratum corneum

In 2015, Professor Ronald (Ronnie) Marks will celebrate his 80th birthday and the 35th year since assuming the Chair of Dermatology at the University of Wales College of Medicine in Cardiff, Wales. Ronnie's long and prolific career is well deserving of a celebratory Festschrift. Among his many accomplishments, Marks was an early champion of quantitative measurements and the application of bioengineering methods to clinical skin science, with particular focus on stratum corneum biology and the measurement of skin appearance. Appealing to Ronnie's wry sense of humour, I would characterize his career in the words of the native Welshman, Dylan Thomas, who published an unfinished novel in 1955 entitled Adventures in the Skin Trade. Ronnie Marks has been a quintessential and imaginative adventurer in the 'skin trade', and he continues to forge new trails for others to follow. The areas highlighted below are emblematic of Ronnie's varied research interests and his impact on stimulating experimental questions for me and future investigators of epidermal differentiation and stratum corneum development.

Review collagen-based biomaterials for wound healing

With its wide distribution in soft and hard connective tissues, collagen is the most abundant of animal proteins. In vitro, natural collagen can be formed into highly organized, three-dimensional scaffolds that are intrinsically biocompatible, biodegradable, nontoxic upon exogenous application, and endowed with high tensile strength. These attributes make collagen the material of choice for wound healing and tissue engineering applications. In this article, we review the structure and molecular interactions of collagen in vivo; the recent use of natural collagen in sponges, injectables, films and membranes, dressings, and skin grafts; and the on-going development of synthetic collagen mimetic peptides as pylons to anchor cytoactive agents in wound beds.

"Take" of a polymer-based autologous cultured composite "skin" on an integrated temporizing dermal matrix: proof of concept

This study aimed to investigate the ability of an autologous cultured composite skin (CCS) to close similar biodegradable temporizing matrix (BTM)-integrated wounds, and its effectiveness in healing fresh full-thickness wounds after the failure of cultured epithelial autograft in its two forms (sheets and suspensions) to epithelialize over an integrated polymer BTM. Using a porcine model, autologous split-skin grafts were harvested three of four dorsal 8 × 8 cm treatment sites. These three sites were subsequently converted to full-thickness wounds and BTMs were implanted. The grafts were used to produce autologous CCSs for each pig. These consisted of a 1 mm thick biodegradable polymer foam scaffold into which fibroblasts and keratinocytes harvested from the grafts were cocultured. At Day 28, on each animal, the autologous CCSs were applied to two of the integrated BTMs, an autologous split-skin graft was applied to the third integrated BTM, and one CCS was applied immediately into a fresh, "naked" (no BTM applied) wound. The CCSs were capable of generating a bilayer repair over the naked wound's fat base and BTM-integrated wounds, which consisted of dermal elements and a keratinized stratified squamous epidermis anchored with a basement membrane by day 7. The CCSs behaved in different ways: either as a delivery vehicle allowing similar development of a bilayer repair while the polymer foam was shed from the wound, or generating a bilayer repair with the foam scaffold being retained (composite "take"). These results conclude our porcine program and provide proof of concept that the integrated BTM can be closed with an autologous CCS. Once fully optimized, this may provide robust repair without resorting to the split-skin graft, important in those cases where unburned donor site is unavailable.

Optimizing in vitro culture conditions leads to a significantly shorter production time of human dermo-epidermal skin substitutes

INTRODUCTION

Autologous dermo-epidermal skin substitutes (DESS) generated in vitro represent a promising therapeutic means to treat full-thickness skin defects in clinical practice. A serious drawback with regard to acute patients is the relatively long production time of 3-4 weeks. With this experimental study we aimed to decrease the production time of DESS without compromising their quality.

METHODS

Two in vitro steps of DESS construction were varied: the pre-cultivation time of fibroblasts in hydrogels (1, 3, and 6 days), and the culture time of keratinocytes (3, 6, and 12 days) before transplantation of DESS on nude rats. Additionally, the impact of the air-liquid interface culture during 3 days before transplantation was investigated. 3 weeks after transplantation, the macroscopic appearance was evaluated and histological sections were produced to analyze structure and thickness of epidermis and dermis, the stratification of the epidermis, and the presence of a basal lamina.

RESULTS

Optimal DESS formation was obtained with a fibroblast pre-cultivation time of 6 days. The minimal culture time of keratinocytes on hydrogels was also 6 days. The air-liquid interface culture did not improve graft quality.

CONCLUSION

By optimizing our in vitro culture conditions, it was possible to very substantially reduce the production time for DESS from 21 to 12 days. However, pre-cultivation of fibroblasts in the dermal equivalent and proliferation of keratinocytes before transplantation remain crucial for an equilibrated maturation of the epidermis and cannot be completely skipped.

Fluorescein diacetate for determination of cell viability in 3D fibroblast-collagen-GAG constructs

Quantification of cell viability and distribution within engineered tissues currently relies on representative histology, phenotypic assays, and destructive assays of viability. To evaluate uniformity of cell density throughout 3D collagen scaffolds prior to in vivo use, a nondestructive, field assessment of cell viability is advantageous. Here, we describe a field measure of cell viability in lyophilized collagen-glycosaminoglycan (C-GAG) scaffolds in vitro using fluorescein diacetate (FdA). Fibroblast-C-GAG constructs are stained 1 day after cellular inoculation using 0.04 mg/ml FdA followed by exposure to 366 nm UV light. Construct fluorescence quantified using Metamorph image analysis is correlated with inoculation density, MTT values, and histology of corresponding biopsies. Construct fluorescence correlates significantly with inoculation density (p  <  0.001) and MTT values (p  <  0.001) of biopsies collected immediately after FdA staining. No toxicity is detected in the constructs, as measured by MTT assay before and after the FdA assay at different time points; normal in vitro histology is demonstrated for the FdA-exposed constructs. In conclusion, measurement of intracellular fluorescence with FdA allows for the early, comprehensive measurement of cellular distributions and viability in engineered tissue.

Effect of vernix caseosa on the penetration of chymotryptic enzyme: potential role in epidermal barrier development

The fetal epidermal barrier undergoes rapid development during late gestation despite conditions injurious to the skin postnatally, i.e. prolonged exposure to water (urine) and noxious substances such as pancreatic chymotrypsin. Nevertheless, at birth, term newborns have a superb epidermal barrier. Concomitant with formation of the stratum corneum in utero, vernix caseosa forms a natural multifunctional cream separating the skin surface from the amniotic fluid with possible unique barrier properties. Therefore, we investigated the effect of native vernix, synthetic vernix, and Desitin on penetration of chymotrypsin, a proteolytic enzyme present in both developing epidermis and meconium. Alpha-chymotrypsin penetration through test materials was conducted in vitro using a modified Franz diffusion cell. The presence of alpha-chymotrypsin in vernix and a possible inhibitory effect of vernix on alpha-chymotrypsin activity were investigated. Vernix films significantly impeded chymotrypsin penetration compared with controls during 24-h exposure experiments. Alpha-chymotryptic activity in vernix was undetectable, and vernix showed no endogenous inhibition of such activity. Both synthetic vernix and Desitin significantly impeded alpha-chymotrypsin penetration compared with controls during 9-h exposure experiments. With respect to the developing epidermal barrier, these results are consistent with the hypothesis that vernix films retain endogenous (epidermal) chymotrypsin while preventing exposure to exogenous (pancreatic) chymotrypsin.

Improvement of Epidermal Barrier Properties in Cultured Skin Substitutes after Grafting onto Athymic Mice

Barrier function in cultured skin substitutes (CSS) prepared from human cell sources was measured by noninvasive (surface hydration, transepidermal water loss) and invasive methods (water permeation, niacinamide flux) before and after grafting onto athymic mice. In vitro measurements were made on days 7 and 14. Although three of the four measures of barrier function improved markedly from day 7 to 14, the values obtained were still far from those obtained with native human skin controls. Additional CSS were grafted onto athymic mice on day 14, and skin was harvested 2 and 6 weeks after grafting. Grafting brought about a substantial decrease in all measurements by 2 weeks and almost complete normalization of barrier function after 6 weeks. The most sensitive measure of this recovery was niacinamide permeability, which decreased from (280 +/- 40) x 10(-4) cm/h in vitro to (17 +/- 30) x 10(-4) cm/h 2 weeks after grafting and (5 +/- 2) x 10(-4) cm/h 6 weeks after grafting, versus control values of (2 +/- 2) x 10(-4) cm/h in human cadaver skin and (0.6 +/- 0.4) x 10(-4) cm/h in human epidermal membrane prepared from freshly excised breast skin. These results demonstrate the reformation of epidermal barrier function after transplantation and provide insights for the development of a functional epidermal barrier in CSS in vitro.

Increased expression of integrins and decreased apoptosis correlate with increased melanocyte retention in cultured skin substitutes

Losses of human melanocytes (HM) in transplantation of cultured skin substitutes (CSS) may result from poor cellular attachments. To test this hypothesis, HM integrin expression was measured in four culture media: (a) melanocyte growth medium (MGM), an HM proliferation medium; (b) UCMC 160, a CSS maturation medium; (c) mMGM, modified MGM with 1.8 mM calcium; and (d) modified UCMC 160 with HM supplements (mUCMC 160). HM grew well in all media except UCMC 160. Increased expression of beta1, beta4, alpha3beta1 and alpha5 integrins on HM cultured in MGM and mMGM versus UCMC 160 was found by flow cytometry. Annexin V-allophycocyanin (APC) labeled HM in apoptosis and increased significantly in UCMC 160 (31.1%) compared with MGM (11.9%) or mMGM (13.9%). CSS were incubated in UCMC 160, mMGM or mUCMC 160 media, and grafted to athymic mice. In the mMGM group, grafts were darker as measured with a chromameter through 6 weeks and the average number of basal HM per field was greater at 12 weeks post-grafting. Increased graft loss was observed in the mMGM group which corresponded with the poor epidermal morphology in vitro. Although HM retention improved in vivo using mMGM to culture the CSS, the stability of the epidermis decreased. These results indicate that expression of integrins on HM in vitro correlates with HM retention in CSS and short-term survival after transplantation, but that long-term survival depends also on stable epithelium.

Engineered skin substitutes: practices and potentials

Wound healing can be problematic in several clinical settings because of massive tissue injury (burns), wound healing deficiencies (chronic wounds), or congenital conditions and diseases. Engineered skin substitutes have been developed to address the medical need for wound coverage and tissue repair. Currently, no engineered skin substitute can replace all of the functions of intact human skin. A variety of biologic dressings and skin substitutes have however contributed to improved outcomes for patients suffering from acute and chronic wounds. These include acellular biomaterials and composite cultured skin analogs containing allogeneic or autologous cultured skin cells.

Differential expression of matrix metalloproteinase-1 in vitro corresponds to tissue morphogenesis and quality assurance of cultured skin substitutes

OBJECTIVE

To determine if matrix metalloproteinase-1 (MMP-1) was involved in the premature degradation of the dermal component in cultured skin substitutes (CSS) prepared with cells from burn patients.

METHODS AND RESULTS

CSS 645 and 647 were prepared from clinical human fibroblasts (HF) and keratinocytes (HK) that demonstrated premature degradation of collagen-glycosaminoglycan sponges in vitro. The control CSS were prepared from clinical HF and HK, CSS 648, and a pre-clinical cell strain, CSS 644 that did not degrade the sponges. Surface electrical capacitance measures surface hydration and was significantly higher for CSS 647 from days 9 through 14. MTT (3-[4,5-dimethylthiazol-2-yl]- diphenyltetrazolium bromide) conversion, an indicator of cellular viability was significantly lower for the 6-mm punch biopsies from CSS 645 and 647 at day 15 as compared to control CSS. MMP-1 protein levels measured by ELISA were significantly higher in medium from HF 645 and 647 than controls on the day of CSS inoculation. At day 14 of incubation, the mean MMP-1 concentration was significantly elevated in the medium from CSS 645 and 647 versus the controls, CSS 644 and 648. Western blots, and casein zymography demonstrated the presence of the latent and active forms of MMP-1 in the HF and CSS media, respectively.

CONCLUSION

MMP-1 was significantly higher in the media from two of the four HF strains and CSS after a 24 h incubation period. Elevated MMP-1 coincided with premature degradation of the dermal substitute in vitro, and reduced numbers of CSS that met quality assurance standards for clinical transplantation.

Preservation of phenotype in an organotypic cell culture model of a recessive keratinization defect of Norfolk terrier dogs

The purpose of this study is to reproduce in vitro a recessive keratinization defect of Norfolk terrier dogs characterized by a lack of keratin 10 (K10) production. Keratinocytes from skin biopsy samples of four normal dogs and two affected dogs were cultured organotypically with growth factor-supplemented media in order to stimulate cornification. The cultured epidermis from the normal dogs closely resembled the normal epidermis in vivo and cornified. The cultured epidermis from the affected dogs displayed many phenotypic alterations identified in skin biopsies from dogs with this heritable defect. Immunohistochemistry and immunoblotting showed a marked decrease in K10 from the cultures of the affected keratinocytes, compared to that in K10 from the cultures of the normal keratinocytes. Real-time reverse transcription polymerase chain reaction quantitation showed a 31-fold decrease in K10, a 1.75-fold increase in K1 and a 136-fold increase in K2e between the affected and the normal epidermis. Organotypic keratinocytes showed a 241-fold decrease in K10, a 31-fold decrease in K1 and a 1467-fold decrease in K2e between the affected and normal cultures. Although in vitro keratin expression did not precisely simulate in vivo, the morphology of the normal and the affected epidermis was largely preserved; thus, this culture system may provide an alternative to in vivo investigations for cutaneous research involving cornification.

Directing stem cells into the keratinocyte lineage in vitro

A major area of research in regenerative medicine is the potential application of stem cells in skin grafting and tissue engineering. This would require well defined and efficient protocols for directing the commitment and differentiation of stem cells into the keratinocyte lineage, together with their selective purification and proliferation in vitro. The development of such protocols would reduce the likelihood of spontaneous differentiation of stem cells into divergent lineages upon transplantation, as well as reduce the risk of teratoma formation in the case of embryonic stem cells. Additionally, such protocols could provide useful in vitro models for studying skin tissue biology, as well as facilitate the genetic manipulation of stem cells for therapeutic applications. The development of pharmacokinetic and cytotoxicity/genotoxicity screening tests for skin-related biomaterials and drugs could also utilize protocols developed for the commitment and differentiation of stem cells into the keratinocyte lineage. Hence, this review critically examines the various strategies that could be employed to direct the commitment and differentiation of stem cells into the keratinocyte lineage in vitro.

Human dermal microvascular endothelial cells form vascular analogs in cultured skin substitutes after grafting to athymic mice

Cultured skin substitutes (CSS) consisting of autologous fibroblasts and keratinocytes combined with biopolymers are an adjunctive treatment for large excised burns. CSS containing two cell types are limited by anatomical deficiencies, including lack of a vascular plexus, leading to slower vascularization after grafting than split-thickness autograft. To address this limitation, CSS were prepared containing human keratinocytes, fibroblasts, and dermal microvascular endothelial cells (HDMEC) isolated from a single skin sample. After 16 days in culture, control CSS and CSS containing HDMEC (CSS+EC) were grafted to full-thickness wounds in athymic mice. In CSS+EC in vitro, HDMEC persisted in the dermal substitutes and formed multicellular aggregates. One wk after grafting, HDMEC in CSS+EC organized into multicellular structures, some containing lumens. By 4 wk after grafting, HDMEC were found in linear and circular organizations resembling vascular analogs associated with basement membrane deposition. In some cases, colocalization of HDMEC with mouse perivascular cells was observed. The results demonstrate HDMEC transplantation in a clinically relevant cultured skin model, persistence of HDMEC after grafting, and HDMEC organization into vascular analogs in vitro and in vivo. All cells were derived from the same donor tissue, indicating the feasibility of preparing CSS containing autologous HDMEC for grafting to patients.

Vitamin C regulates keratinocyte viability, epidermal barrier, and basement membrane in vitro, and reduces wound contraction after grafting of cultured skin substitutes

Cultured skin substitutes have become useful as adjunctive treatments for excised, full-thickness burns, but no skin substitutes have the anatomy and physiology of native skin. Hypothetically, deficiencies of structure and function may result, in part, from nutritional deficiencies in culture media. To address this hypothesis, vitamin C was titrated at 0.0, 0.01, 0.1, and 1.0 mM in a cultured skin substitute model on filter inserts. Cultured skin substitute inserts were evaluated at 2 and 5 wk for viability by incorporation of 5-bromo-2'-deoxyuridine (BrdU) and by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) conversion. Subsequently, cultured skin substitute grafts consisting of cultured human keratinocytes and fibroblasts attached to collagen-glycosaminoglycan substrates were incubated for 5 wk in media containing 0.0 mM or 0.1 mM vitamin C, and then grafted to athymic mice. Cultured skin substitutes (n = 3 per group) were evaluated in vitro at 2 wk of incubation for collagen IV, collagen VII, and laminin 5, and through 5 wk for epidermal barrier by surface electrical capacitance. Cultured skin substitutes were grafted to full-thickness wounds in athymic mice (n = 8 per group), evaluated for surface electrical capacitance through 6 wk, and scored for percentage original wound area through 8 wk and for HLA-ABC-positive wounds at 8 wk after grafting. The data show that incubation of cultured skin substitutes in medium containing vitamin C results in greater viability (higher BrdU and MTT), more complete basement membrane development at 2 wk, and better epidermal barrier (lower surface electrical capacitance) at 5 wk in vitro. After grafting, cultured skin substitutes with vitamin C developed functional epidermal barrier earlier, had less wound contraction, and had more HLA-positive wounds at 8 wk than without vitamin C. These results suggest that incubation of cultured skin substitutes in medium containing vitamin C extends cellular viability, promotes formation of epidermal barrier in vitro, and promotes engraftment. Improved anatomy and physiology of cultured skin substitutes that result from nutritional factors in culture media may be expected to improve efficacy in treatment of full-thickness skin wounds.

Storage media and temperature maintain normal anatomy of cadaveric human skin for transplantation to full-thickness skin wounds

Cadaveric human skin provides an optimal temporary cover after early excision of full-thickness burns; however, engraftment is reduced greatly by cryopreservation. Refrigerated skin is generally preferred because of its rapid revascularization, presumably caused by its greater viability. In this study, the effects of storage solutions, temperature, and the changing of the storage media on skin graft anatomy were evaluated as an indicator of graft viability. Split-thickness human skin grafts (0.012-0.015 mm) were retrieved from cadaveric donors and grafted to circumferential, full-thickness skin wounds on athymic mice. After clinical determination of engraftment 3 months after grafting, 6-mm punch biopsy samples of the human skin were harvested and separated into two groups. Biopsy samples were stored in either saline or Eagle's minimal essential medium. Media were not changed or were changed every 3 days. All groups were stored at either 4 degrees C or room temperature (RT). After 5, 10, and 21 days of storage, biopsy samples were grafted onto athymic mice for 20 days. The biopsy grafts were then collected and prepared for histologic scoring on a scale of +4 (normal anatomy) to 0 (no epithelial cells). Significant differences in histologic scores were found by the nonparametric Kruskal-Wallis test followed by Wilcoxon pairwise comparison. Skin stored in media maintained better histologic anatomy than skin in saline, suggesting better maintenance of viability. There was also better preservation of anatomy after storage at RT for 21 days with media changes every 3 days when compared to unchanged media and all conditions at 4 degrees C. These results support the hypothesis that increased availability of nutrients and increased storage temperature maintain higher viability of cadaveric human skin for transplantation to full-thickness cutaneous wounds.

Biomedical applications of collagen

Collagen is regarded as one of the most useful biomaterials. The excellent biocompatibility and safety due to its biological characteristics, such as biodegradability and weak antigenecity, made collagen the primary resource in medical applications. The main applications of collagen as drug delivery systems are collagen shields in ophthalmology, sponges for burns/wounds, mini-pellets and tablets for protein delivery, gel formulation in combination with liposomes for sustained drug delivery, as controlling material for transdermal delivery, and nanoparticles for gene delivery and basic matrices for cell culture systems. It was also used for tissue engineering including skin replacement, bone substitutes, and artificial blood vessels and valves. This article reviews biomedical applications of collagen including the collagen film, which we have developed as a matrix system for evaluation of tissue calcification and for the embedding of a single cell suspension for tumorigenic study. The advantages and disadvantages of each system are also discussed.

Expression of Insulin-Like Growth Factor I by Cultured Skin Substitutes Does Not Replace the Physiologic Requirement for Insulin In Vitro

Clinical efficacy of cultured skin substitutes may be increased if their carbohydrate metabolism is optimized by understanding whether endogenous insulin-like growth factor I can substitute for exogenous insulin. Cultured skin substitutes were prepared and incubated at the air-liquid interface for 4 wk in media containing 0.5 or 5 microg per ml insulin, 10 or 50 ng per ml insulin-like growth factor I, or 0 insulin and 0 insulin-like growth factor I (negative control). In situ hybridization showed that the epidermal and dermal cultured skin substitute components express insulin-like growth factor I mRNA throughout the 28 d interval. Immunohistochemistry confirmed the expression of insulin-like growth factor I protein by the human keratinocytes and fibroblasts in cultured skin substitutes. Insulin-like growth factor I at 10 or 30 ng per ml could partially replace insulin in a clonal assay of keratinocyte growth. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assays showed significantly higher values in cultured skin substitutes incubated with insulin at incubation days 14 and 28 compared to negative control or the 10 ng per ml insulin-like growth factor I condition. Cultured skin substitutes incubated in 50 ng per ml insulin-like growth factor I had MTT values similar to the insulin-treated cultured skin substitutes at day 14, but were significantly lower by day 28. Light microscopy agreed with MTT data showing that cultured skin substitutes grown with insulin media had multiple layers of nucleated keratinocytes and stratum corneum at days 14 and 28. The negative control and 10 ng per ml insulin-like growth factor I exhibited poor cultured skin substitute epidermal morphology throughout the experiment. In contrast, the cultured skin substitutes in 50 ng per ml insulin-like growth factor I were similar to the insulin-treated cultured skin substitutes at day 14, but by day 28 had deteriorated to resemble the negative control. Bromodeoxyuridine incorporation at day 28 was significantly higher for 5 microg per ml insulin cultured skin substitutes versus all other treatment groups. These data suggest that medium containing 5 microg per ml insulin supports greater physiologic stability in cultured skin substitutes over time, and that expression of insulin- like growth factor I by keratinocytes and fibroblasts in cultured skin substitutes is not sufficient to fully replace the requirement for exogenous insulin in vitro.

Adhesives and emollients in the preterm infant

This chapter focuses on recent advances in preterm infant skin care related to skin adhesion and skin emolliency. Different types of adhesives and hydrating agents are reviewed. Clinical applications are best guided by understanding the biology of epidermal barrier development. The role of xeric stress in accelerating formation of the stratum corneum is discussed along with the effects of occlusive agents and emollients on wound healing and epidermal barrier repair. The principles of skin moisturization are introduced. The concept is advanced that programmatic changes in skin adhesion and water handling occur during the normal ontogeny of superficial biofilms (sebum, sweat, acid mantle).