Skin Grafting procedure to treat burns and other wounds began as early as 800 B.C. Modern organ transplant procedures began in the early 1900s. In 1936, an Ukranian doctor Yu Yu Voronoy transplanted the first human kidney, using an organ from a deceased donor. The transplant was successful but Voronoy’s patient died shortly after as a result of organ rejection which was the cause for many failures in the early years of transplant technology.

The first successful kidney transplant by surgeons at Boston’s Peter Bent Brigham Hospital in 1954 worked because the recipient and donor were genetically identical twins. In 1960, British immunologist Peter Medawar won the Nobel Prize for his studies in acquired immune tolerance that lead to the development of anti-rejection drugs, allowing patients to receive organs from non-identical donors. The awareness for organ transplants like Kidney, Liver, Pancreas and eye has lead to the increased number of such transplants. Apart from blood and these organs , banked human tissues include:

1. Bone- frozen, freeze-dried, and de-mineralized

2. Corneas

3. Heart valves

4. Tendons

5. Skin

6. Hematopoietic tissues, bone marrow and cord blood.

7. Dura mater, ear ossicles, and cartilage.

Importance of skin donation:

The skin is the largest organ in the body. The functions of skin are

1. Skin acts as a barrier to bacterial invasion.

2. Prevents loss of body proteins and fluids

3. As an organ in temperature regulation.

Early burn wound closure is crucial for survival of patients with large burn wounds. Burn wound infection leading to systemic sepsis is the single most major cause of death in burn patients. Burn wound is a devastating trauma that affects the patients physically, psychologically, socially and economically. Patients with burn size up to 40-50% of total body surface area (TBSA) can usually be treated with auto grafts obtained from the unburnt areas of the patient. Auto graft will be insufficient in larger burn size or in patients without available donor areas. Hence the skin donors are very  essential to save the lives of burn injury patients.

Skin Autograft donors can be : Living or Cadaver

1 .Living skin donation has the following features:

1. The donor has to undergo investigations for preoperative evaluation.

2. A surgical procedure under suitable anesthesia for harvest of graft.

3. Hospitalization is required for at least 2 days.

4. Donor site healing time and wound site pain of about 10-14 days.

5.  Only 15 to 20% of total body surface can be harvested at a time.

6. The other alternative is to procure split thickness skin grafts from a cadaver donor and preserve them for use in future.

2 .Cadaver skin donation:

The concept of skin donation after death is not new and the first skin bank was established in USA around 1950. The  benefits of use of autograft  on full thickness burn wounds are

1. Effective control of protein and fluid loss from wounds.

2. Reversal of hyper metabolic state with improvement in nutritional status.

3. Augmentation of immunological response.

4. Control of wound infection and improvement in the wound bed making it ready for acceptance of precious skin auto grafts.

5. Immediate pain relief and general feeling of well being.

6. Excellent biological wound cover till the auto graft donor sites become ready for taking of skin again.

7. Important information regarding skin donation

8. Only a thin layer of skin from thighs and back is taken.

9. No disfigurement! No bleeding!

10. No blood matching is required.

11. Can donate skin up to 24 hrs following death of a person.

12. Helpline numbers are available.

13. Hospital’s doctor’s team will come within 2 hours of your call.

14. Skin will be harvested in about 45 minutes.

Who can donate skin?

A person above 18 yrs of age, not having transmissible diseases like hepatitis, HIV, skin cancer or skin diseases can donate skin. Even an old person with wrinkled skin can also donate. Skin can be harvested up to 12 hours and with precautions even up to 24 hours after death if the body is kept in a cold storage. The skin quality must be good.

Who cannot donate skin?

Persons harboring transmissible infections such as Hepatitis B, Hepatitis C and HIV cannot donate skin. Skin from people suffering from skin cancer, persons who died of septicemia with damaged skin e.g. scleroderma, pemphigus should not be taken. The skin must be free of tattoos.

Why skin donation?

Skin is usually donated to patients suffering from burn injuries, diabetic wounds and to trauma patients requiring coverage of raw areas. It covers the exposed body and prevents the entry of bacteria. Controls the loss of protein, heat and fluid from the body. Gives the patient enough time to develop his own skin available for covering the wounds. The applied skin acts as a biological dressing for the patient.

Stored Donor skin graft is useful in the following clinical situations

Poor general condition of patient with high risk for surgical procedures. Insufficient auto graft donor sites especially in patients with major burn injuries. Risk of increase in the size of wound due to addition of donor site wound to the actual burn area and its associated complications unhealthy recipient bed and general status of the patient when skin graft procedure may be associated with graft loss. When the expected duration for harvesting skin graft from the same donor sites is more than 3 weeks.

Legal requirements:

1. Death certificate from the competent authority

2. Consent form signed by the next of kin.

Xenografts (from other species e.g. pig-skin) are not commercially available in many countries. Biosynthetic skin substitutes (artificial skin) are extremely expensive and unaffordable for most of the burnt patients in developing countries. Their availability is also uncertain. The only cost effective and definite alternative is skin allograft obtained from a human donor and stored in Skin Banks. The efficacy of skin allograft in the management of burn wound was realized in 1881.

These skin substitutes provide temporary but long term wound closure, with potential to save life of patients with large burn. The skin allograft transplant differs from organ transplantation as the skin grafts are used to provide temporary long term protection and are not expected to survive in the recipient permanently as transplanted organ. This means that neither ABO blood group nor HLA matching is required for allograft skin transplantation. So any human being can be a donor for anyone else.

Organization of a Skin Bank:

Permission for establishing a skin bank with procurement of deceased donor skin allograft has to be obtained from appropriate authority of the government. Though skin is an organ, split thickness skin graft (STSG) is considered as a tissue. The following protocols are prepared.

1. Defining the eligibility criteria.

2. Communication and response details.

3. Readiness of equipment and response team.

4. Skin procurement protocol.

5. Transport equipment & protocol.

6. Deposition and information routine.

7. Homograft and serological processing protocol.

8. Storage method and quality control.

9. Procedure for requisition and disbursement of homograft.

10. Record keeping.

Protocol preparation in relation to the following criteria

1. Response to donation call

2. Procurement of deceased donor skin allograft with consent of the next-of-kin.

3. Microbiological studies.

4. Viability testing of donated skin.

5. Preservation methods.

6. Awareness campaign

An ongoing awareness program is essential for success of the skin donation campaign. Brochures, posters, flip charts and power point presentations, educational films, articles in print media, television interviews and radio talks, guest lectures in social service organizations and in educational Institutions on a regular basis will create an awareness among the public. Development of burn survivor community and their interaction with the public will be more effective.

The skin bank team consists of: counselor, contact person,response team including surgeon, assistant, helper, supervising consultant, Microbiologist or biochemist, record keeper

Skin graft procurement:

Standard protocol for graft harvesting methods has to be followed. With shortest delay possible after death (it can be procured up to 24 hours after death if the body is preserved in cold storage) skin should be harvested. Prolonged delay may cause bacterial and fungal colonization of the donor skin.

1. The procedure takes about one hour and conducted with aseptic precautions in operation theater.

2. Skin is harvested from both thighs and back of the deceased person.

3. There is no bleeding as blood circulation stops at death.

4. The thighs are covered with dressing before handing over the body to relatives.

5. About 10 cc of blood of the deceased is collected at the same time for serological testing.

6. The grafts are transported to the skin bank in Phosphate buffered saline in glass containers placed in ice box along-with blood sample for serology and the microbiologist is informed.

7. Counseling responsibility is by the consultants and residents of department of surgery.

8. Extend the counseling outside the hospital in the community as well.

9. Participation of voluntary organizations may be useful in skin donation awareness.

Microbiological analysis:

1. Microbiological analysis of deceased donor skin allograft is carried out on regular basis

2. Appropriate protocols must be followed in the donor area cleaning.

3. Protocol for graft harvesting techniques.

Equipment required:

1. Instruments for skin graft procurement including dermatome.

2. Refrigerator and Incubator.

3. Ultra-cool refrigerator for -70 degree C temperature.

4. Laminar flow cabinet with air conditioners.

5. Universal power supply.

6. Laboratory articles, reagents, chemicals, furniture.

7. The cost of consumables for procuring skin donation including the cost of serological testing has to be worked up.

Storage and disbursement of homograft:

Initially the harvested skin is stored in 50% Glycerol for two hours at 4-6  degrees C for 2 hours. Then it is checked for any infection and the put in 85% Glycerol for 3 hours at 33 degrees C in a shaking incubator. Then the skin is kept in a freezer at 8 degrees C for 4-6 weeks until the serological reports are available. After 4-6 weeks the graft is transferred to a bio-safety cabinet and made into smaller uniform strips. The skin is then preserved in 85 per cent glycerol in a temperature of 4 degrees and it is ready for use. The treated cadaveric skin has a shelf-life of four to five years. The stored graft is checked every 3 months for bacterial or fungal infections. The stored graft is used for treating patients with damaged skin due to burns or injuries.

The future of Skin banking:

1. Augment the awareness in the medical fraternity regarding skin donation.

2. Participation of teaching institutions, peripheral hospitals and private hospitals for counseling

3. Participation of voluntary organizations in the awareness campaign.

4. The facility for skin banking should ideally be available in every medical college hospital

5. Several collection centers can be affiliated to each skin bank facility.

6. Training in standardized graft procurement protocol can be provided to available personnel.

7. Establishment of Tissue Bank Association to ensure the quality in functioning of skin banks.

Further research to improve the quality of skin  is necessary. Recently introduced Glyaderm (preserved acellular dermal substitute), a science of Bi-layered skin restoration technology will benefit the patients in future.

Also Read: ORGAN DONATION-INDIA STRUGGLING WITH SHORTAGE OF ORGANS FOR TRANSPLANTATION

Dr.N.Mariappan- Chennai.
Consultant Plastic surgeon
Mob:9901043568

The post Skin donation and skin banking- it has high benefit to the mankind. appeared first on Health Vision.

Acne is the most common skin problem especially in young adults, though it is more common in females, males are not spared either.

Acne is a chronic, inflammatory skin condition that causes spots and pimples. Acne typically appears on face, forehead, chest, upper back and shoulders because these areas of skin have the most number of oil (sebaceous) glands. Hair follicles are connected to oil glands.

It commonly occurs during puberty and adolescence, when the sebaceous glands (oil secreting glands of skin), are the most active, but it can occur at any age. Though not dangerous, it may leave behind skin scars.

A recent data says that 80% of people in the age group of 11-30 years have acne out break at least once. This doesn’t mean that adults may not get acne; they are also prone to it. Some women who do not get acne in their teens may get it in their adult hood.

Acne symptoms

Acne signs and symptoms vary depending on the severity of the condition:

• Whiteheads (closed plugged pores)
• Blackheads (open plugged pores)
• Small red, tender bumps (papules)
• Pimples (pustules), which are papules with pus at their tips
• Large, solid, painful lumps beneath the surface of the skin (nodules)
• Painful, pus-filled lumps beneath the surface of the skin (cystic lesions)

Types of Acne

• Acne Vulgaris: Acne Vulgaris is the medical name for common acne – the presence of blackheads, whiteheads, and other types of pimples on the skin. The most common spots for breakouts are the face, chest, shoulders, and back.
• Comedones: A comedo, or basic acne lesion, is a hair follicle that has become clogged with oil and dead skin cells. Comedones (the plural of comedo) can develop into bumps called whiteheads and blackheads. Products that may trigger comedones are called “comedogenic.” Makeup labeled “noncomedogenic” is less likely to clog pores and contribute to acne.
• Blackheads: Blackheads are comedones that are open at the surface of the skin. They are filled with excess oil and dead skin cells. It’s not dirt that causes the comedone to turn black. The black hue results from the irregular reflection of light coming from clogged hair follicles.
• Whiteheads: Comedones that stay closed at the surface of the skin are called whiteheads. This happens when oil and skin cells prevent a clogged hair follicle from opening. Many of the same over-the-counter medicines that treat blackheads are also effective against whiteheads.
• Papules: Papules are comedones that become inflamed, forming small red or pink bumps on the skin. This type of pimple may be sensitive to the touch. Picking or squeezing can make the inflammation worse and may lead to scarring. A large number of papules may indicate moderate to severe acne.
• Pustules: Pustules are another kind of inflamed pimple. They resemble a whitehead with a red ring around the bump. The bump is typically filled with white or yellow pus. Avoid picking or squeezing pustules. Picking can cause scars or dark spots to develop on the skin.
• Nodules: Nodules are large, inflamed bumps that feel firm to the touch. They develop deep within the skin and are often painful.
• Cysts: Cysts are large, pus-filled lesions that look similar to boils. Like nodules, cysts can be painful and should be treated by a dermatologist. People who develop nodules and cysts are usually considered to have a more severe form of acne.

What causes Acne?

Four main factors cause acne:
• Excess oil production
• Hair follicles clogged by oil and dead skin cells
• Bacteria
• Excess activity of hormone (androgens)

Acne typically appears on your face, forehead, chest, upper back and shoulders because these areas of skin have the most oil (sebaceous) glands. Hair follicles are connected to oil glands.

The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually the pore is filled with bacteria and oil, which turns brown when exposed to the air.

Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation that develop deep inside hair follicles produce cyst like lumps beneath the surface of the skin. Other pores in your skin, which are the openings of the sweat glands, aren’t usually involved in acne.

Factors that may worsen acne

These factors can trigger or aggravate acne:

• Hormones. Androgens are hormones that increase in boys and girls during puberty and cause the sebaceous glands to enlarge and produce more sebum. Hormonal changes related to pregnancy and the use of oral contraceptives also can affect sebum production. Low amounts of androgens circulating in the blood of women and can worsen acne.
• Ovarian Cysts. In females, acne can occur as one of the key manifestations of polycystic ovarian syndrome (PCOS) along with facial hair growth, weight gain, irregular menstrual cycle etc.
• Certain medications. Examples include drugs containing corticosteroids, testosterone or lithium.
• Diet. Studies indicate that certain dietary factors, including skim milk and carbohydrate-rich foods — such as bread, bagels and chips — may worsen acne. Chocolate has long been suspected of making acne worse.
• Dandruff. People suffering from dandruff tend to develop acne especially on shoulders, chest & fore head.
• Cosmetics. Creams, lotions, oil based make up products can cause acne cosmetica
• Stress. Stress can make acne worse.

Risk factors

Risk factors for acne include:

• Age. People of all ages can get acne, but it’s most common in teenagers.
• Hormonal changes. Such changes are common in teenagers, women and girls, and people using certain medications, including those containing corticosteroids, androgens or lithium.
• Family history. Genetics plays a role in acne. If both parents had acne, child is likely to develop it, too.
• Greasy or oily substances. You may develop acne where your skin comes into contact with oily lotions and creams or with grease in a work area, such as a kitchen with fry vats.
• Friction or pressure on your skin. This can be caused by items such as telephones, cell phones, helmets, tight collars and backpacks.
• Stress. Stress doesn’t cause acne, but if you have acne already, it may make it worse.

Acne Treatment
Homeopathy Treatment for Acne
Homeopathy has proven to be very good and effective in the treatment of acne. Rightly chosen homeo remedies along with changes in patient’s life style can provide a better solution for acne. Acne is not just considered as a mere skin ailment, the causes lie much deeper.

There are hundreds of homeo remedies indicated in acne few examples are given below to emphasize the holistic approach through homeopathy in the treatment of acne

• Pulsatilla is remedy in treating acne in girls during puberty, acne with irregular menstrual cycle, useful in people in whom acne is triggered by eating fat rich, oil rich foods like condiments, bakery foods etc. other points in selecting this remedy is that the person needing this remedy is usually sensitive emotionally, mild natured.
• Nat.Mur: Is very effective remedy in people having acne with itching & oily skin. Other points being increased thirst, excessive sweating, and intolerance to heat of sun.
• Silicea is indicated when there is acne filled with pus & cystic acne. Acne in people who also suffer with constipation, their wound and injuries suppurate (pus formation) easily and don’t heal fast. Other points on which this remedy is prescribed are where the person is very sensitive to cold weather, has profuse sweating etc..:
• Kali.Brom. is the remedy for acne in puberty, acne having reddish appearance and for acne leaving ugly scars.
• Ant.crud. is prescribed when acne either due to or associated with gastric problems, like indigestion, eating sour foods, like pickles etc.
• Sulphur is very effective in acne with lot of itching. It is also good for people with acne who have dry, dirty looking skin & their skin complaints become worse by bathing or washing.

There are many such effective Homeo remedies which if properly chosen can tackle any kind of acne without causing any harm to the patient, it helps not only in curing acne but also prevents its recurrence.

Dr Tejaswi K P
Reader, Dept of Surgery
Bhagwan Buddha Homeo Medical College,
Mallathalli, Bengaluru
Consultant – Surabhi Homeo Clinic
Vidyaranyapura, Bengaluru 560097
Mob: 9731133819

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