Preface

Wounds are common injuries that almost every human being experiences. They can vary in depth of tissue damage, etiology, location, contamination, lymphovascular integrity, and sensory neural function. They can be associated with diabetes, cardiovascular morbidity, hepatic and/or renal dysfunction, immunological status, malignancy, nutritional deficiencies, and so on. Wound healing is dependent on all these factors and many more.

Wounds that are limited to the epidermis and superficial layers of the dermis generally close and heal naturally. We now know the stages in this process and understand the role of multiple mediators, growth factors, cellular contributions, and the interaction between these components. However, there is no method by which we can control or modify this natural process of wound healing.

The situation is different when the wound involves full-thickness skin loss with or without loss of subcutaneous and deeper tissue. These wounds cannot achieve closure naturally, as both epidermal and dermal elements are lost. Without intervention, these wounds may remain as chronic, non-healing ulcers or they may close via wound contraction and formation of scar tissue causing functional limitations, deformities, and disfigurement. These scars may be unstable, leading to repeated breakdown, and are likely to develop Marjolin's ulcer, which is most often a squamous cell carcinoma of aggressive nature. Hence, a general recommendation is that wounds that do not close or that are not likely to close within 3–4 weeks of occurrence should be closed surgically with skin grafting or fasciocutaneous or myocutaneous flaps.

This book, *Skin Grafts for Successful Wound Closure*, focuses on various aspects related to free skin grafts; it does not address flaps. Skin autografts are necessary for providing permanent wound closure. While harvesting a split-thickness skin autograft from the appropriate donor area on the body of the patient, the surgeon is creating a partialthickness wound that needs care for healing. Justifying this new wound and the pain and scarring associated with its healing requires a successful skin graft. Optimal preparation of the recipient wound bed is essential for the success of the graft take.

Section I, "Wound Bed Preparation," includes three chapters that elaborate on the different methods of wound bed preparation. The simultaneous management of systemic factors is necessary but is not within the purview of this publication.

The knowledge and practice of wound care are mandatory for all surgeons and thus every surgical trainee should know the basics as well as keep up with advances in the field of wound bed preparation and skin grafting procedures. As such, Chapter 1, "Preparation for a Successful Skin Grafting," in Section I describes various established methods for wound bed preparation. Although relatively new, negative pressure wound therapy is already well accepted and its efficacy has been illustrated in photographs. However, there is always a search for newer, better, easily available, and affordable topical agents, dressing materials, and techniques. Everything new requires evaluation and established methods need to be revalidated. Chapter 2, "Experience of Wound Bed Preparation with Different Methods," describes the experience of the author in evaluating a new topical agent and foam dressing prepared using new technology. It also describes the experience of using skin allografts and xenografts in a setting where

the availability of both is uncommon. The chapter aims at providing stimulus for data collection, analysis, evaluation, and sharing of experiences about different methods of wound management. Chapter 3, "*Haruan* Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing," discusses a potential new method of wound healing using extract from Haruan, a carnivorous fish observed to have properties that are conducive to wound healing and pain relief. Research into the use of this extract is still in its infancy. The clinical trials described have not been designed to evaluate the effect of Haruan extract on wound healing or wound bed preparation. However, the extract's components and their actions suggest that this product has unevaluated promise in the field of wound bed preparation.

Once the recipient area is optimized to receive the skin autograft, the actual procedure needs to be performed with precision and planning. The planning process includes choice of the donor area, type of graft and its thickness, and processing and laying of the graft. Section II, "Skin Grafting," reviews the procedural aspects of skin grafting that are essential for the success of skin grafting procedures. Chapter 4, "Types of Skin Grafts," elaborates on the different types of skin grafts, provides guidance for choosing the correct graft, and discusses the procedure for skin graft harvesting and how to care for the donor site. It also gives information about methods of graft expansion and management of complications. This information is very valuable, particularly for surgeons undergoing training. Chapter 5, "Skin Graft Fixation and Methods," describes different methods of fixation of the skin graft over the wound bed. It is essential to maintain contact between these two surfaces, as hematoma, seroma, or movement of the graft over the wound bed can disturb nutrition to the graft in the initial period after the procedure. In the later phase of graft take, this can lead to poor uptake of the graft due to suboptimal vascularization of the applied skin graft thus compromising its survival. Chapter 6, "Procurement and Use of Cryopreserved Total Skin Allograft in Complex Wounds," describes a new concept of using a cryopreserved full-thickness skin allograft as an interim method in the process of achieving closure of complex wounds. In wounds with deep tissue loss over weight-bearing areas, a split-thickness skin graft may be inadequate in providing stable and robust wound closure due to a lack of adequate thickness of the dermis. Use of an acellular dermis or dermal regeneration template are other alternatives available in such a situation. Use of full-thickness allograft skin obtained from redundant skin excised during abdominoplasty and cryopreserved after complete defatting appears to be an effective alternative for providing neodermis over complex wounds. If more workers in the field of wound care start using this technique, it will allow for establishing the utility of this method in a more convincing way.

The opportunity to edit this book has given me the pleasure of acquainting myself with the contributions of other experts in the field of wound care. I enjoyed the experience thoroughly. I hope readers will find this book a useful resource and that its contents spur further interest and research in the field.

I wish to express my very special thanks to Author Service Manager Ms. Mia Vulovic at IntechOpen for all the support she provided throughout the editorial process. My very sincere thanks to the complete publishing team.

> **Dr. Madhuri Gore** Consultant Surgeon, Zen Hospital, Chembur, Mumbai, India

Section 1

## Wound Bed Preparation

#### **Chapter 1**

## Preparation for a Successful Skin Grafting

*Rahul Gorka*

#### **Abstract**

In this chapter, we shall look into the pre-requisites for a successful skin grafting. This includes patient selection, identifying various factors—patient related, environment related, treatment related, and optimizing them for a successful outcome. Avoiding/removing the adverse factors and improving the wound bed environment require knowledge, experience, and checklist to be followed, so as not to miss any of these pre-requisites. This would ensure complete take of the skin graft, with good reconstructive and esthetic outcome. Various factors include patients' general health, comorbidities, etiology of wound, duration and contamination, granulation tissue, local wound blood supply, wound sepsis, edema, vascular disease, wound bacteriology culture sensitivity, etc. The ultimate goal of improving success of skin grafting will lead to early recovery of patient, reducing hospital stay, burden on health infrastructure, and reduced loss of workdays, thereby reducing the socioeconomic impact of wound.

**Keywords:** skin grafting, optimizing, wound bed, graft-take, outcome

#### **1. Introduction**

Several factors have to be considered before planning a skin grafting. This ensures achievement of optimal tissue environment at the wound site. The quality of wound bed has to be enhanced so as to ensure a successful "take" of the skin graft. The donor site area skin color, thickness, and mechanical property should preferably match the recipient site skin quality. The causes of poor skin graft include multiple factors such as chronic or insufficiently debrided wounds, poorly vascularized wound bed, or high bacterial load.

#### **2. Recipient site considerations**

#### **2.1 Wound bed preparation**

Wound bed preparation is a valuable concept that attempts to systematize the approach to the treatment of chronic wounds [1]. The "take" of skin graft depends on a healthy well-vascularized wound bed. It is supported by an adequate quantity of blood vessels near the surface. Appropriate skin graft take is not allowed in ischemic, previously irradiated and scar tissues, bone, and tendon, as they have an insufficient blood supply.

Consistency of necrotic tissue also varies as tissue damage worsens/deepens:

We should assess the wound using a validated wound assessment tool such as the Bates-Jensen Wound Assessment tool [2]. Skin grafting can be done in the presence of well-vascularized peritendon and periosteum. Marginal wound re-epithelization is seen to occur in chronic wounds, which grows into the tissue and interrupts the lateral reconnections of the graft. Hence, it is advisable to do sharp excision of the margins with a blade before grafting.

Quantitatively, the bacterial level must be less than 105 bacteria per gram of tissue for a successful skin grafting. Clinically, the wound should be "clean" and debrided of all necrotic tissues. The chief aims of treatment should be the control of the infection and the promotion of the natural processes of healing [3]. The necrotic tissue debris physically impedes and chemically decelerates ingrowth of blood vessels into the skin graft. Necrotic tissue and slough are the key contributors to wound chronicity, and thus, debridement is necessary for wound healing [4]. Those wounds that are left open for many days contain heavy bacterial contamination and therefore need to be substantially debrided before skin grafting. Sharp debridement leads to the release of cytokines and mediators of inflammation [5]. The various debridement techniques [6] used to prepare the recipient site include the following:

Conservative Sharp Wound Debridement (CSWD) is a suitable method of debridement when there is dead necrotic tissue such as slough or eschar, callustissue around the wound, or hyperkeratosis (which is clearly demarcated from the healthy tissue, where other types of debridement may not give optimum result and/or where speed is essential) [2].

It has been understood that a "granulating" wound has better chances of skin graft take. Active bleeding of the wound bed can lead to hematoma collection under the graft, thereby inhibiting graft take. Adequate hemostasis can be performed using electrocautery and suture ligation.

Before skin grafting, the surrounding soft tissue can be adjusted to cover critical structures such as tendons or bones if they are exposed without peritendon or periosteum. A moist wound environment has been shown to accelerate wound healing by up to 50% compared with exposure to air [8]. Vacuum-assisted closure therapy or dermal substitutes can be used to prepare small areas of tendons and bones, by growing granulation tissue from the sides.

#### **2.2 Functional consideration**

An optimum skin graft can give a good functional and esthetic skin reconstruction. Particular attention should be given to the size of graft needed, the degree of wound contraction anticipated, the color and texture of the skin required, and the need for adnexal glands. More the amount of dermis in the skin graft, lesser is the amount of wound contraction.

Full-thickness grafts provide excellent cosmetic results since they include the complete epidermis and dermis and thereby have minimal contraction. Fullthickness skin grafts are commonly used for syndactyly release, nipple-areola reconstruction, or ectropion release. Full-thickness graft donor site is limited and can be increased by tissue expansion before harvesting.

The donor sites of very thin skin grafts like epidermal grafts heal quickly with minimal contraction, but do not resist the recipient wound contraction. This is desirable on areas such as large scalp wounds and abdominal wounds, where wound contraction leads to gradual pulling of the wound edges together, reducing the skin graft requirement. In a second stage surgery, the contracted skin graft can be excised and the wound can be primarily closed to get better functional and esthetic results. The skin thickness varies from upper eyelid (thin) to trunk and leg (thick).

#### **2.3 Esthetic considerations**

The final appearance of skin graft color is dependent upon skin texture, melanin pigmentation, and blood flow. According to Gillies' principles, like should replace like. So the replacement of tissue from a similar or surrounding site gives the best color match [9]. For face, full-thickness skin grafts are preferred from sites such as supraclavicular, posterior auricular, upper eyelid, or scalp [10]. For nipple-areola complex, skin grafts from the contralateral areola or genitalia may be used. Glabrous skin grafts from hypothenar area can be placed over palms and soles of feet.

#### **3. Conclusion**

Preparation for a successful skin grafting entails the optimization of patient factors including systemic and local tissue environment, in addition to

*Foreaarm Infected wound management by debridement followed by NPWT dressings and Skin grafting.*

**Figure 2.** *Abdominal wound management by debridment and NPWT dressing.*

*Preparation for a Successful Skin Grafting DOI: http://dx.doi.org/10.5772/intechopen.101375*

#### **Figure 3.**

*Thigh wound bed preparation by noormal saline dressings.*

**Figure 4.** *Forearm wound preparation by topical antibiotic ointments.*

**Figure 5.** *Diabetic foot wound bed preparation.*

#### **Figure 6.**

*Great toe raw area wound preparation by debridement and NPWT.*

consideration of functional and esthetic factors. The author has experienced that the simpler techniques of mechanical as well as sharp surgical debridement followed by negative pressure wound therapy in appropriately selected patients (as shown in **Figures 1**–**8**) fetch almost cent percent skin graft take results, with both functional and esthetic targets achieved.

#### *Preparation for a Successful Skin Grafting DOI: http://dx.doi.org/10.5772/intechopen.101375*

**Figure 7.** *NPWT dressing for pressure ulcers.*

**Figure 8.** *Diabetic foot ulcer- wound bed preparation by debridement and normal saline dressings.*

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Rahul Gorka Department of Burns, Plastic and Reconstructive Surgery, Government Medical College Jammu, India

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Preparation for a Successful Skin Grafting DOI: http://dx.doi.org/10.5772/intechopen.101375*

#### **References**

[1] Schultz G, Sibbald R, Falanga V, Ayello E, Dowsett C, Harding K, et al. Wound bed preparation: A systematic approach to wound management. Wound Repair and Regeneration: Official Publication of the Wound Healing Society [and] the European Tissue Repair Society. 2003;**11**(Suppl. 1): S1-S28

[2] Harris C, Coutts P, Raizman R, Grady N. Sharp wound debridement: Patient selection and perspectives. CWCMR. 2018;**6**:29-36

[3] Guo S, Dipietro LA. Factors affecting wound healing. Journal of Dental Research. 2010;**89**(3):219-229. DOI: 10.1177/0022034509359125

[4] Percival SL, Suleman L. Slough and biofilm: Removal of barriers to wound healing by desloughing. Journal of Wound Care. 2015;**24**(11):498-510

[5] Milne J. Wound-bed preparation: The importance of rapid and effective desloughing to promote healing. The British Journal of Nursing. 2015; **24**(Sup. 20):S52-S58

[6] Sibbald RG, Williamson D, Orsted HL, Campbell K, Keast D, Krasner D, et al. Preparing the wound bed--debridement, bacterial balance, and moisture balance. Ostomy/Wound Management. 2000;**46**(11):14-22. 24-8, 30-5; quiz 36-7

[7] Growth Effects of Phaenicia Sericata Larval Extracts on Fibroblasts: Mechanism for Wound Healing by Maggot Therapy - ScienceDirect [Internet]. [Cited 2021 October 15]. Available from: https://www. sciencedirect.com/science/article/abs/ pii/S0024320596006881?via%3Dihub

[8] Geronemus RG, Robins P. The effect of two new dressings on epidermal wound healing. The Journal of Dermatologic Surgery and Oncology. 1982;**8**(10):850-852

[9] Shimizu R, Kishi K. Skin Graft. Plastic Surgery International. 2012; **2012**:1-5

[10] Thornton JF. Skin grafts and skin substitutes. Selected Readings in Plastic Surgery. 2004;**10**(1):78

#### **Chapter 2**

## Experience of Wound Bed Preparation with Different Methods

*Madhuri Gore*

#### **Abstract**

The ultimate goal of wound care is to obtain wound closure either by natural process or by use of surgical technique and so all the steps need to be taken with a plan to reach the goal at the earliest. While performing skin grafting, closure of the existing wound is the aim, but the procedure also creates another wound (though superficial), causes pain, and may have healing issues. Optimal bed preparation is mandatory to obtain successful uptake of skin graft and to avoid loss of precious skin autograft. Every wound has its own unique needs and demands. Different agents and methods are often needed to meet these demands. It is essential to accrue experience and develop insight into the efficacy, utility, and advantages of different approaches for wound bed preparation. The availability, cost of the method, socioeconomic status of the patient, type of health care system, ease of access to facility, expertise—all these and many other factors play a role in deciding the choice of method for wound bed preparation. It is possible that different methods may be developed, evaluated, and found to be useful in different countries or different parts of the same country too. The author has evaluated methods spread over a wide spectrum including indigenously prepared topical agent, barrier foam dressing prepared using advanced technology, porcine xenografts which are not available in India, and skin allografts from the very first skin bank in India set up by the author and colleagues. The experience shared here looks at the ability of the method to control infection, inflammation, pain besides the time taken to achieve effective wound bed preparation and frequency of dressing change needed, along with ease of training.

**Keywords:** wound bed, topical agent, porcine xenografts, skin allografts, barrier foam dressing, control of infection, inflammation, skin autograft success, wound closure

#### **1. Introduction**

The aim of treating a patient with a wound is to correct the systemic factors and to achieve wound closure, either by natural processes or by using surgical techniques. To achieve this end concept of wound bed preparation was proposed by Dr. Falanga and Dr. Sibbald in the year 2000 [1] and updated thereafter. Besides controlling systemic aberrations such as cardiac failure, diabetes mellitus, liver or renal dysfunction, vascular insufficiency, etc., successful management of the wound environment

needs thorough understanding and assessment of multiple factors related to the wound. The components that need attention include the following [1].

The author has had a long association with wounds—burn and nonburn. Besides developing a simple, cheap, and easily available dressing for wounds [2], the author had the opportunity to conduct clinical trials to evaluate new topical agents, wound dressings and xenografts and skin allografts and their role in wound bed preparation. Some of these studies have been published and some are being shared here for the first time. It is hoped that this may provide a stimulus for research in the field of wound bed preparation.

A full-thickness wound that is not likely to achieve closure by natural process or secondary suturing, or is likely to cause esthetic/functional issues if left to heal on its own by secondary intention, needs skin grafting to achieve wound closure. Hence while assessing the efficacy of a new tool in achieving optimal wound bed preparation, it is essential to evaluate the following factors -

Observations such as relief of pain, ease, and conformability of dressing, frequency of dressing change, absence of toxicity, allergy; ease of training family members about the performance of wound care procedures are other important considerations.

Though it would be ideal to have a controlled trial, the presence of multiple variables affecting wound response, makes it very difficult to have absolutely comparable study and control groups. The study related to the topical agent being shared here, in brief, is unpublished data.

#### **2. Topical agent: Panchvalkal**

#### **2.1 The product**

It is hot ethanolic extract of barks of five trees added to liquefied petroleum jelly. The names of the trees are Ficus Bengalensis, Ficus Religiosa, Ficus Infectoria, Ficus Glomerata, and Azadirachta Indica.

It was shown to have broad-spectrum antimicrobial activity which included *Staphylococcus aureus*, *Pseudomonas Aeruginosa*, *Escherichia coli*, Proteus V, Streptococcous Pyo., anaerobes.

Studies related to mutagenicity, skin toxicity, oral toxicity, mucus membrane irritation revealed the product to be safe.

#### **2.2 The study**

To evaluate the efficacy and safety of Panchvalkal as topical agent for wound dressing.

After obtaining approval from the institutional ethics committee, an openlabeled clinical trial was conducted in 2003 enrolling 100 patients with wounds after obtaining informed consent.

Initial surgical debridement was performed when needed. The wound was cleaned with normal saline. The topical agent under evaluation was applied over the wound and covered with paraffin impregnated tulle gras. This was covered with secondary dressing of gamjee and fixed with appropriate method (bandage or tape). The dressing was changed every alternate day and the wound was evaluated for slough, exudate, pain, inflammation along with wound photograph at regular intervals. The time taken to reach endpoint was noted. The endpoint was readiness for skin grafting, secondary suturing, wound closure by contraction, and/or epithelization.

The results have been provided here in brief (unpublished data). There were 73 males and 27 females included in the study. The mean age of the patients was 39.71 years with range of 13 to 75 years. The most frequent cause of the wound was complex skin and soft tissue infection (CSSTI) (**Table 1**) including abscess, necrotizing fascitis. Surgical site infection or guillotine amputation stump, fresh burns were the causes of wounds in 23 patients.

In 43 out of 100 enrolled patients, the wounds were sterile at the time of entry in the trial and this included patients with fresh burns, postoperative wound gapes, and some bed sores. These wounds continued to remain sterile at the end of the study. In 57 patients wounds grew various pathogens at the time of entry in the study. *S. aureus* and *P. aeruginosa* were the most common isolates, followed by Klebsiella, Proteus, *E. coli*, and then Acinetobacter in a few. In 24 of 57 patients (42.1%) the wound became sterile before the endpoint was reached. The remaining wounds swab cultures grew *P. aeruginosa* and Klebsiella. None of the wounds grew Streptococci at any time in the study. Reduction of edema, wound discharge, slough, pain are all indicators of control of infection and related inflammation.

#### **Table 1.**

*Wound Etiology (topical agent).*

#### **Table 2.**

*Time taken to reach endpoint (topical agent).*

**Table 3.**

*Method of wound closure (topical agent).*

**Tables 2** and **3** provide the observations about the time taken to reach endpoint and methods used to achieve wound closure. Total 70 wounds out of 100 required split-thickness skin grafting (STSG) to achieve wound closure and 45 of these had reached the endpoint in less than 7 days and the remaining 31 were ready for STSG by 14 days. The graft take was complete in 66 of 70 (94.3%) wounds and in 4 cases partial graft loss was noted. This indicates good graft bed preparation.

#### **2.3 Conclusions**

**Figure 1.** *a. Necrotising fasciitis after surgical debridement. b. Wound at endpoint on day 14. c: After skin grafting.*

*Experience of Wound Bed Preparation with Different Methods DOI: http://dx.doi.org/10.5772/intechopen.102935*

**Figure 2.** *a. Diabetic foot ulcer. b. Ulcer at endpoint.*

4.No side effects, local reactions were noted and the topical agent was well tolerated by the patients.

This study led to commercial preparation (Treval) of this topical agent and the use could be continued. But due to the inadequate availability of appropriate quality barks of necessary trees, the preparation of the product had to be stopped in a year or two. We lost an indigenously prepared natural product with good efficacy for wound bed preparation.

#### **3. Porcine xenograft**

Porcine xenograft has been used for wound bed preparation with the hope of improving the take of skin autograft over burn and nonburn wounds [3, 4]. A recently published article [5] compared the use of porcine xenografts with no specific method for wound bed preparation and concluded that there was no difference in these two methods in terms of wound closure. But the author's experience differs from this study.

Though porcine xenografts are in use for wound management in many countries, these are not available in India for regular use. There is no published report from India about the use of porcine xenografts over different types of wounds. Hence, it is important to share this Indian experience about use of porcine xenografts.

A randomized controlled trial was conducted at LTM Medical college and general hospital by the author and colleagues in 2009–2010 after approval from the institutional ethics committee. The unpublished data of this clinical trial is being shared here. After randomization of the patients, the type of wound care the patient was to receive was explained to the patient in detail and informed consent was obtained. None of the patients enrolled in the study group refused to accept the porcine xenograft.

#### **3.1 Clinical trial—Comparison between Porcine Xenograft and usual wound dressing for wound bed preparation—A randomized controlled trial**

#### *3.1.1 Study design and protocol*

Patients with wounds on any part of the body were randomized to study (Porcine xenograft (PX)) or to control (usual dressing (UD)) group. The presence of diabetes mellitus was not an exclusion criterion.

Porcine xenograft is not commercially available in India. So, full-thickness porcine skin was procured from the abattoir after the pig was stunned and then skinned as is the usual procedure there. This skin was brought to the laboratory in the department and split-thickness skin grafts were taken with all aseptic precautions using Humby's handle and blade. The grafts were treated with antibiotics (Crystalline penicillin + Gentamycin) and then preserved in 85% Glycerol following the same method as used for skin allograft preservation. These porcine xenografts were used as required by washing them with normal saline till soft. Grafts were covered with paraffin impregnated gauze after application on the wound. Secondary dressing and fixation were with Gamgee and bandage or tape.

The control group received wound dressing with the application of topical agents such as povidone Iodine ointment or Framycetin cream covered by primary nonadherent (impregnated tulle gras) and secondary dressing and bandage or tape fixation.

#### **3.2 Results**

The wound parameters evaluated were same as described in the previous experience with Panchvalkal topical agent. The epidemiological data has been provided in **Table 4**. It reveals that the study and control groups were comparable in all aspects such as age and gender of patients, location of body parts involved, etiology of wounds, presence of exudate. The commonest comorbidity observed in both groups was diabetes mellitus. Other comorbid conditions observed in both groups were hypertension, ischemic heart disease, tuberculosis, addiction to smoking and these were comparable between the two groups. The difference in the duration of symptoms was not statistically significant.

The observations at the endpoint (which was the readiness of the wound to receive STSG) have been presented in **Table 5**. The difference observed in the reduction in wound size at the endpoint was not statistically significant. The wounds in the study group treated with porcine xenografts achieved better microbial clearance as compared to the control group. At the endpoint, 15 out of 30 wounds in PX group and 6 out of 30 wounds in the UD group did not grow any organisms on culture (**Table 6**). This difference was statistically significant. At enrollment, the isolates grown from the wounds in PX group were *E. coli*, MRSA, Pseudomonas, and Klebsiella. At the endpoint, no wounds in PX group had a

#### **Table 4.**

*Epidemiological data of study and control group (PX and UD).*

#### *Experience of Wound Bed Preparation with Different Methods DOI: http://dx.doi.org/10.5772/intechopen.102935*

#### **Table 5.**

*Presentation of observations at the endpoint (PX and UD).*

#### **Table 6.**

*Outcome of microbial culture at entry and endpoint (PX and UD).*

polymicrobial infection and the organism grown from 15 wounds were Proteus in 10 and Acinetobacter in 5. In UD group at enrollment 18 wounds and at endpoint 21 wounds showed growth of single isolates. These included Klebsiella, Pseudomonas, MSSA, *E. coli* at enrollment and Proteus, MRSA, Acinetobacter, and *E. coli* at the end point. No wound showed the presence of streptococci at endpoint. The initial pain score was comparable in both study (6.83) and control (6.66) group. But the reduction in pain score indicating relief of pain was statistically significant in the study (PX) group as compared to the control group. The mean number of days required to reach the endpoint were 8.66 in study group and 12.7 days in the control group (**Figure 3a** and **b**). This difference was statistically significant.

#### **3.3 Conclusion**

This study suggested that in comparison to the usual wound dressing the wound bed preparation was achieved earlier, with a significant reduction in pain and control of microbial load when porcine xenograft was applied over the wounds. An associated benefit was the reduction in the frequency of dressing change in the study group. The patients had to be admitted in the hospital or had to attend an outpatient clinic for a dressing change. Porcine xenografts were accepted by all patients randomized to study group.

In 86% of the patients in study group xenograft adherence to the wound bed was noted. But the xenograft uptake (vascularization) was not noted in any wound. Chiu and Burd [4] observed that adherence of porcine xenograft to the wound is related to its antimicrobial action. Adherence thus indicates the possibility of subsequent improvement in skin autograft take.

Raimer and colleagues [6] found porcine xenografts to be useful in the management of wounds following Mohs micrographic surgical procedures.

#### **Figure 3.**

*a. Wound after excision of carbuncle. b. Application of porcine xenografts. c. Wound bed preparation on day 5.*

Almost 40 years ago Ersek et al. [7] commented that porcine xenograft helps to maintain appropriate wound moisture and prevents cellular desiccation.

Though porcine xenograft was observed to be a useful temporary biological wound cover, it is not readily available in India. So, its use continues to require special efforts, and hence though feasible, it is not very common. This field is certainly open for a future venture in India.

#### **4. Cadaveric skin allograft**

Though the positive impact of cadaveric skin allografts has been well recognized for several decades, in India the first cadaver skin bank with the ability to procure, process, and store the allografts was established by the author and her supportive colleagues in April 2000 at LTM Medical College and General Hospital, Mumbai [8].

Burd [9] and others [10] associated mainly with burn management have noted that Allografts are more effective than Xenografts in achieving burn wound epithelization as well as wound bed preparation for subsequent wound closure with skin autograft. But the availability of cadaver skin allograft remains limited and hence alternative methods are essential.

The experience of the author in the utilization of skin allograft has been published [11] and is being shared here in brief with data updated to August 2010. Over about 10 years and 6 months cadaver skin allografts were used in 215 patients. *Experience of Wound Bed Preparation with Different Methods DOI: http://dx.doi.org/10.5772/intechopen.102935*

**Table 7.**

*Utilization of skin allografts.*

The majority of these were burned patients except for seven patients (four with nonburn trauma and three with necrotizing fasciitis) in whom the allografts were used for wound bed preparation. The different clinical situations that led to the utilization of skin allografts have been shown in **Table 7**. The allografts provided remarkable pain relief besides promotion of epithelization reducing the need for autograft. Excellent wound bed preparation was achieved by control of infection (**Figure 4a**–**c**), maintenance of moisture balance, improved wound vascularization, and control of protein loss from wound leading to improved general condition. The autograft take was observed to be 100%. These effects have been observed by many [9, 12, 13]. Nonburn wounds too showed control of slough formation and improved vascularity with the use of skin allografts (**Figure 5a** and **b**). In case of failure of autograft take, use of skin allograft salvaged the situation and re grafting could be

**Figure 4.**

*a. Burn wound unsuitable for skin autograft due to infection, poor granulation. b. Wound bed preparation after application of skin allografts. c. Wound closure with autograft in two sittings.*

#### **Figure 5.**

*a. Necrotising fasciitis wound post debridement. b. Wound improvement with skin allografts.*

**Figure 6.** *a. Loss of skin autograft. b. Salvage using skin allografts.*

**Figure 7.** *a. Intermingled skin allograft and autograft. b. Outcome of intermingled skin grafting.*

avoided (**Figure 6a** and **b**). Allograft was used for wound closure as intermingled grafting (**Figure 7a** and **b**).

Skin allografts are also effective as method of temporary wound closure for chronic nonhealing wounds such as venous ulcers and diabetic ulcers as allografts stimulate the release of growth factors and cause modification of the wound microenvironment [14, 15].

#### **4.1 Conclusion**

Skin allograft was found to be extremely effective in controlling infection, improving wound vascularity, reducing pain, promoting epithelization, improving general condition—all this with fewer dressing change procedures. Once again it was apparent that skin alone is the best replacement for lost skin. But the possibility of disease transmission, the immunogenicity of allograft, and the limited availability of allografts are the main hurdles in the use of skin allografts. Probably, tissue-engineered skin would provide an effective but certainly expensive answer to achieve wound closure for many [13].

#### **5. Barrier foam dressing**

Several types of wound dressings are available and the choice depends on the condition of the wound. The condition of a wound may vary from time to time depending on multiple factors such as infection, slough, discharge, and hence the choice of appropriate dressing should also change accordingly. Moist wound healing is a well-accepted concept, but excessive wound exudate is harmful for optimal wound bed preparation as it damages the extracellular matrix. Foam is an absorptive material that can be useful as a dressing for exuding wounds [1]. Foams impregnated with antimicrobials (most often Silver) have been in use for more than a decade and these are drug-eluting type of dressings. The antimicrobial action of these agents needs penetration through the cell wall of the organism. This mechanism itself is likely to lead to the development of resistant organisms [16]. Besides, sustained release of antimicrobial is likely to lead to cytotoxicity.

To overcome this issue barrier foam dressing has been prepared using NIMBUS technology [17]. This has polyurethane foam coated with poly diallyl-dimethyl ammonium chloride which is a quaternary ammonium compound—a surface-active agent. The technology is such that it does not permit leaching of the active agent from the foam and the antimicrobial action is due to contact with the microbial cell wall and not by entry inside the organism. This mechanism prevents the development of resistant organisms [17]. The study conducted by Tran et al. revealed that this barrier foam dressing effectively inhibits bacterial attachment and the formation of biofilm [18]. The dressing can be used as primary dressing without the application additional topical agent on the wound.

An open-labeled study was conducted by the author to evaluate the safety and efficacy of barrier foam dressing. The study details and the outcome has been published [19].

#### **5.1 Conclusion**

On completion of the study, the conclusion was that the foam dressing was effective in absorbing and reducing the wound exudate which reflects control of wound infection (**Figure 8a** and **b**). It aided the separation of necrotic tissue from the wound bed and hence good wound bed preparation was achieved

**Figure 8.** *a. Diabetic foot ulcer. b. Wound bed preparation at endpoint.*

**Figure 9.**

*a. Amputation stump. b. Wound bed preparation at endpoint.*

(**Figure 9a** and **b**). Dressing change was not painful. It was easy to train the relatives to do the wound dressing.

This barrier foam dressing is now available commercially.

#### **6. Discussion**

From the moment a wound occurs its journey towards closure begins. Besides the management of systemic factors, the role played by different components of wound care methods is extremely crucial in augmenting the process of wound closure. The components include wound cleaning agents, methods of wound debridement, topical agents, various dressing materials, skin and skin substitutes, and specific methods such as Negative Pressure Wound Therapy (NPWT), multilayered compression bandages. Some of these methods have been discussed in other chapters in this book.

Relatively simple modification like silver ion impregnation in porcine xenografts provides effective antimicrobial wound dressing for colonized chronic wounds according to Ersek [20]. This characteristic could be useful in wound bed preparation of significantly infected wounds with resistant organisms. A successful skin grafting procedure is life-saving for patients with large burns. Ersek has also reported significant improvement in the take of widely meshed skin autograft when covered with silver-impregnated porcine xenograft [21]. This modification would certainly increase the cost of the treatment but then our patient population does extend over a wide socioeconomic spectrum. The author has no personal experience of use of this product. New developments are always welcome but certainly, need appropriate evaluation and identification of indications for the use of new product or method.

*Experience of Wound Bed Preparation with Different Methods DOI: http://dx.doi.org/10.5772/intechopen.102935*

New technologies, new agents aiding debridement, new concepts related to temporary or permanent wound closure methods to aid wound bed preparation and wound closure will certainly continue to develop. Out of multiple methods available for wound bed preparation, the choice would continue to depend on the properties and quality of the method and the need of the wound at that point in time. The same method may not be appropriate for all wounds and hence thorough understanding of different methods is essential while working in the field of wound care. The choice of the method also depends on its availability, cost, affordability of the patient, access to the health care facility, the familiarity of the healthcare worker with the method, possible undesirable effects, and acceptance by the patient. Difficult access, financial constraints may make it necessary to train the family members of the patient to perform the wound care procedure. This situation would certainly have an impact on the choice of wound bed preparation method. Development of new methods will continue and consideration of all the abovementioned issues is essential while conducting proper evaluation of these methods.

#### **7. Conclusions**

Here, the author has shared her experience of evaluating different methods from topical agent, barrier foam dressing to xenografts and allografts. Each of these has its place in wound bed preparation. The topical agent, indigenously prepared was found to be effective in controlling infection, inflammation and led to good wound bed preparation. But it is no longer available. The barrier foam dressing uses a different technology and was found suitable for infected, exuding wounds with necrotic material along with ease of dressing change and easy training of family members. Though the study was not a controlled trial, the author would prefer barrier foam dressing over the conventional wet to dry dressing method which is painful and training of family member is difficult. Porcine xenografts were found to be effective in control of infection, pain and aided epithelization and wound bed preparation leading to successful graft take. But consistent and focused effort is needed to make it available in India as an indigenous product. Skin allografts played an excellent role not only in preparing the wound bed, reducing the need for skin autograft but also lead to remarkable improvement in the general condition of the patient, particularly with large burn wounds. But deceased donor skin donation is still a relatively new concept in India, the availability of skin allograft is limited.

It is hoped that this sharing of experiences would provide food for thought, the stimulus for development of newer products using indigenously available resources, blooming of new concepts adaptable for the patient population in given region or country. The appropriate evaluation of these innovations would identify the indications, make them cost-effective and affordable to the vast population of patients with wounds spread all over the world.

*Skin Grafts for Successful Wound Closure*

#### **Author details**

Madhuri Gore Zen Hospital, Mumbai, India

\*Address all correspondence to<EMAIL_ADDRESS>
© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Experience of Wound Bed Preparation with Different Methods DOI: http://dx.doi.org/10.5772/intechopen.102935*

#### **References**

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[2] Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness burn wounds. Burns. 2003;**29**(5):487-492. DOI: 10.1016/ s0305-4179(03)00050-0

[3] Halim AS, Khoo TL, Yussof SJM. Biologic and synthetic skin substitutes: An overview. Indian Journal of Plastic Surgery. 2010;**43**(Suppl):S23-S28. DOI: 10.4103/0970-0358.70712

[4] Chiu T, Burd A. "Xenograft" dressing in the treatment of burns. Clinics in Dermatology. 2005;**23**(4):419-423. DOI: 10.1016/j.clindermatol.2004.07.027

[5] Bekeny JC, Kennedy C, Turissini JD, et al. Utility of porcine-derived xenograft as an adjunct to split-thickness skin grafting in lower-extremity wounds. Journal of the American Podiatric Medical Association. 2021;**111**(3):1-8. DOI: 10.7547/20-058

[6] Raimer DW, Group AR, Petitt MS, Nosrati N, et al. Porcine xenograft biosynthetic wound dressings for the management of Mohs wounds. Dermatology Online Journal. 2011;**17**(9):1. DOI: 10.5070/ D37xp7m4cd

[7] Ersek RA, Hachen HJ. Porcine xenografts in the treatment of pressure ulcers. Annals of Plastic Surgery. 1980;**5**(6):464-470. DOI: 10.1097/ 00000637-198012000-00009

[8] Gore M. Cadaver skin donation and skin bank. Indian Journal of Burns. 2017;**25**(1):3. Available from: link.gale. com/apps/doc/A519525519/AONE?u=an on~ad9a29e5&sid=googleScholar&xi d=d20993ee

[9] Burd A, Chiu T. Allogenic skin in the treatment of burns. Clinics in Dermatology. 2005;**23**(4):376-387. DOI: 10.1016/j.clindermatol.2004.07.019

[10] Wang H-J, Yeap CL, Heimbach DM. Allograft vs xenograft in preparation of wound for autograft. Journal of Burn Care and Rehabilitation. 1984;**5**(2): 116-118. DOI: 10.1097/00004630- 198403000-00006

[11] Gore MA, De AS. Deceased donor skin allograft banking: Response and utilization. Indian Journal of Plastic Surgery. 2010;**43**(Suppl):S114-S120. DOI: 10.4103/0970-0358.70732

[12] Imahara SD, Klein MB. Skin grafts. In: Orgill D, Blanco C, editors. Woodhead Publishing Series in Biomaterials, Biomaterials for Treating Skin Loss. Woodhead Publishing; 2009. pp. 58-79. ISBN:<PHONE_NUMBER>633. DOI: 10.1533/9781845695545.1.58

[13] Sharma KS, Ralston D, Giblin V, MacNeil S. Engineering of accepted skin-equivalent tissue for tissue repair: Current state and perspectives. In: Reis RL, editor. Encyclopedia of Tissue Engineering and Regenerative Medicine. Academic Press; 2019. pp. 285-298. ISBN:<PHONE_NUMBER>000. DOI: 10.1016/B978- 0-12-801238-3.65568-X

[14] Snyder RJ. Treatment of nonhealing ulcers with allografts. Clinics in Dermatology. 2005;**23**(4):388-395. DOI: 10.1016/j.clindermatol.2004.07.020

[15] Kirsner RS, Margolis D, Masturzo A, et al. A real-world experience with the bioactive human split thickness skin allograft for venous leg ulcers; wound repair and regeneration. The International Journal of Tissue Repair and Regeneration. 2020;**28**(4):547-552

[16] Mikhaylova A, Liesenfeld B, Moore D, Toreki W, Vella J, et al. Preclinical evaluation of antimicrobial efficacy and biocompatibility of a novel bacterial barrier dressing. Wounds. 2011;**23**(2):24-31

[17] Murata H, Koepsel RR, Matyjaszewski K, Russell AJ.  Biomaterials. 2007;**28**:4870-4879

[18] Tran PL, Hamood AN, De souza A, Schultz G, Liesenfeld B, et al. A study on the ability of quaternary ammonium groups attached to a polyurethane foam wound dressing to inhibit bacterial attachment and biofilm formation. Wound Repair and Regeneration. 2015;**23**:74-81. DOI: 10.1111/wrr.12244

[19] Gore M, Jadhav S, Schultz G, Mehta D. Evaluation of safety and efficacy of barrier foam dressing in patients with exuding wounds. Biomedical Journal of Scientific & Technical Research. 2021;**33**(5):26292- 26297. ISSN: 2574-1241. DOI: 10.26717/ BJSTR.2021.33.005475

[20] Ersek RA, Navarro JA. Maximizing wound healing with silver-impregnated porcine xenograft. Today's OR Nurse. 1990;**12**(12):4-9

[21] Ersek RA, Denton DR. Silverimpregnated porcine xenografts for treatment of meshed autografts. Annals of Plastic Surgery. 1984;**13**(6): 482-487. DOI: 10.1097/00000637- 198412000-00004

#### **Chapter 3**

## *Haruan* Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing

*Ahmad Farouk Musa and Cheang Jia Min*

#### **Abstract**

Wound healing remains a major issue in surgery. None of the existing treatment modalities in caring for wounds can yet claim to be the holy grail of wound management. *Channa striatus*, locally known in Malaysia as *Haruan*, is a freshwater air-breathing carnivorous fish that is proven to influence the different phases of wound healing. As a medicinal fish, not only does *Haruan* have a high content of amino and fatty acids, which are essential in collagen fibre synthesis during wound recovery, it also abounds in arachidonic acid and polyunsaturated fatty acids that promote prostaglandin synthesis, a vital component of the healing process. Moreover, its antinociceptive effects could potentially reduce wound pain, an important factor in wound healing. Proteomic studies show that a quarter of the total protein detected in freeze- and spray-dried *C. striatus* extract are actin, myosin and tropomyosin – all molecules that play a role in the wound healing process. Proteomic profiling also reveals that *Haruan* possesses two types of collagen namely collagen type-I and type-II that confer tensile strength during the healing process. It is proven that collagen along with other components of the extracellular matrix form the granulation tissue which, when contracted, closes the wound and concomitantly aligns the collagen fibres in the extracellular matrix. Hence, it is inferred that *Haruan* promotes the maturation of granulation tissue, thereby expediting the wound healing process itself. Consequently, it could mediate a faster recovery from surgical wound coupled with a lower incidence of wound infection due to an improved and accelerated wound healing process. Additionally, *Haruan* has demonstrated its ability in promoting angiogenesis and cell proliferation in wound bed preparation for skin grafting. Furthermore, a *Haruan* aerosol concentrate can act as a wound dressing at the donor site thereby enhancing the healing process while simultaneously exhibiting some antinociceptive properties. *Haruan*'s exceptional ability in promoting wound healing together with its potential use in skin grafting would be instrumental in the field of surgery. In essence, the cumulated benefits from all the processes involved would translate into a significant reduction of hospitalisation cost; that would immensely benefit not only the patient, but also the government.

**Keywords:** *Haruan*, *Channa striatus*, wound healing, proteomic studies, skin grafting, economic burden

#### **1. Introduction**

A wound is a mechanical injury to the body leading to disruption of the normal anatomical structure and function. It can be classified into acute and chronic wounds. Acute wounds normally proceed through the reparative process in an orderly and timely manner to restore anatomical and functional integrity. Conversely, wounds that demonstrate signs of delayed and interrupted healing and fail to go through the normal healing process are termed chronic wounds [1–3].

Wound healing reflects a cascade of complex, highly regulated biological events to restore the body's anatomical function back to its pre-injured state. Unlike acute wounds that heal by primary intention where the edges of the wound are apposed and held together with minimal scarring, chronic wounds heal by secondary intention [4, 5]; they form granulation tissue which fills the wound defects.

#### **2. History of wound care and wound dressing**

Wound management involves providing an optimum environment to promote healing, control bleeding and prevent infection. The history of wound care traces its origin to the Sumerians, a civilisation believed to be older than 2,000 BC [6]. In their manuscript, three healing gestures – cleansing the wounds, making the plasters and bandaging the wounds – were identified [7].

The ancient Egyptians and Greeks also contributed to the evolution of wound management. The Egyptian medical papyri documented the principle of wound closure to aid healing and the utilisation of honey, grease and lint as the main constituents of the most common plaster. It was believed that lint, a derivative of vegetable fibre, serves an absorbent role; grease or animal fat forms a barrier against bacteria; and honey, the most frequently cited ingredient in multiple topical wound preparations, possesses various healing and antibacterial properties favourable for wound healing [8, 9].

Interestingly, the Greeks were the first to recognise the difference between infected and uninfected wounds, using terms such as "fresh" or "non-healing" to describe wounds [10, 11]. Galen of Pergamum (120–201 AD) is a Greek surgeon who made remarkable contributions to wound and haemorrhage management. He emphasised the maintenance of wound moisture and the application of styptics consisting of basic elements with antibiotic properties for optimum wound healing [12, 13]. Despite advances in modern technology, Galen's basic principles are still incorporated into the development of current wound dressings.

Additionally, the Hippocratic collection discussed the addition of wine to obstinate ulcer for maximal wound healing [13]. Indeed, in ancient times, a number of magical and mythological agents were utilised as wound dressings; they include honey, plaster, wine and milk. While some of them demonstrate significant pharmacological roles, others merely have ritualistic meanings [13].

In the modern era, a wide array of dressings and wound care products with their properties tailored to special wound care needs were invented. In fact, Winter's study [10–13], which concluded that moisturised wounds heal quicker than dry wounds, sparked an explosive burst in the evolution of wound Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

dressings. Thanks to modern technology, novel techniques such as the adoption of growth factors, bioengineered tissue, negative pressure therapy and hyperbaric oxygen therapy are nowadays implemented in wound management. Nonetheless, none of the existing modalities can claim to be the holy grail of wound management.

Alongside the cosmetic advancement in the past decades, skin grafting – a source of epithelium for both acute and chronic wounds – has become increasingly prevalent [14, 15]. However, quite surprisingly, skin grafting is not a new concept; for the past 3500 years, it has been extensively practised by a string of renowned physicians. These include Aulus Cornelius Celsus (25 BC - 50 AD), the Roman author of the first systematic treatise on Medicine; Claudius Gelenus (129 AD - 210 AD) popularly known as Galen, a prominent Greek physician; Jaques-Louis Reverdin (1842–1929), the Swiss surgeon who performed the first "fresh skin" allograft; and George David Pollock (1817–1897), a British surgeon known as a pioneer of skin grafts [16–24]. Throughout the years, the roles and functions of skin grafting have expanded. Nowadays, skin graft is an indispensable therapy in burn reconstruction, major traumatic injuries and surgical defects [25, 26]. Nonetheless, it still suffers from major drawbacks such as compromised skin grafts, skin graft rejection and skin graft contractions particularly in elderly patients, immunocompromised individuals and those on immunosuppressant medications [27–35].

Meanwhile, TIME – a concept that stands for Tissue, Infection or Inflammation, Moisture, and Epithelial edge advancement – is a new framework of wound bed preparation initiated by Schultz and his team in 2003 to achieve optimal wound healing [36, 37]. As the freshwater fish *Haruan* is naturally gifted with numerous antinociceptive and antimicrobial capabilities, high water content and ample amounts of amino acids and polyunsaturated fatty acids essential for granulation tissues formation and epithelialisation, it fits the components of Tissue, Infection and Moisture in the TIME framework. Therefore, we can postulate that *Haruan* fish also has the potential to function as an effective wound dressing.

#### **3. Stages of wound healing**

The phases of wound healing is a continuum that encompasses homeostasis, inflammatory, proliferative and maturation phases under stringent regulation of growth factors, cytokines, and chemokines [38]. Admittedly, the various phases of the wound healing process can overlap and go awry anytime. The inflammatory phase is the shortest of all phases and, if arrested, wound healing will be delayed and fibrosed tissue may be formed. Meanwhile, in the proliferative phase, the wound is shrunken in size until the maturation phase. Despite the surface of the wounds being closed completely, full tensile strength might take up to twelve months to develop [3, 4, 38–40]. **Table 1** below describes the different stages, mechanisms and molecules at interplay during the wound healing process.

Unfortunately, despite the enormous efforts made in skin repair, a wound can never achieve the maximum tensile strength of a normal skin. Additionally, owing to its tight regulation by a multitude of factors, proper wound healing can be easily impeded. Indeed, chronic non-healing wounds are a common phenomenon. **Figure 1** describes both the intrinsic and extrinsic factors that affect wound healing.

#### **Table 1.**

*Stages of wound healing [3, 4, 38–40].*

#### **Figure 1.**

*Factors that affect wound healing.*

#### **4. What is** *Haruan*

*Channa striatus* or snakehead murrel, commonly known as *Haruan* or *Gabus* in the Southeast Asian region, originates from the family *Channidae* or *Ophiocephalidae* [41]. It is a tropical, aerobic, carnivorous freshwater species measuring around 100 cm. It is sexually active at 30 cm, with a dark dorsal surface and Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

sides, and mottled with a combination of black and ochre; it also has a white belly, a large head resembling a snake and a fully-toothed mouth with large scales. It preys on smaller fishes and frogs for survival. Since *C. striatus* is an obligate air-breather, it survives by burrowing in muds of lakes, rivers or canals, keeping its skin and air-breathing apparatus moist while surviving on stored fats [42, 43]. Wild *Haruan* lives a solitary life except in the spawning season. **Figure 2** shows a solitary *Haruan* in an aquarium with a glass reflection showing its white belly.

**Figure 2.** *Wild Haruan - Channa striatus - in an aquarium.*

Pairs breed during most months of the year, laying hundreds of ambercoloured eggs. The eggs, guarded by both parents, are non-adhesive and they hatch within one to three days. The adults have compact muscles and a less bony structure which give them the desirable characteristics of a predatory fish [43]. Besides, they are highly aggressive predators with the ability to travel overland to exploit new bodies of water [42]. **Figure 3** describes the characteristics of *Channa striatus* or *Haruan*.

**Figure 3.** *Summary of the characteristics of Haruan species [41–43].*

*Haruan* fish can be farmed though it is considered a pest or predatory species in Europe, North America and Australia, being a voracious predator and a competitor of native fish species [44, 45]. When it is reared in a controlled habitat, the parameters of the aquatic environment such as the pH, temperature and water depth should be kept as close to its natural habitat as possible. For its diet, *Haruan* fish can be fed with a wide range of food products including formulated food [46–48].

However, compared to other species such as *Keli* or *Tilapia* fish, *Haruan* fish farming is not popular for two reasons: firstly, being a predator, it can easily eat up the surrounding aquatic animals and small terrestrial rodents; secondly, its commercial benefits have not been extensively publicised to receive enough attention [49, 50].

In Malaysia, *Haruan* fish is cherished as a wholesome delicacy; it is served in a multitude of preparations ranging from steamed, grilled, spiced, fried, roasted, in the form of soup to even raw [51]. According to a study [52] conducted by Haemamalar and his team in Krau Wildlife Reserve, *Haruan* fish was reported to be one of the sources of freshwater fish among the Orang Asli (aboriginal people) tribunates.

Additionally, *Haruan* serves as a natural remedy for the local population. The National Health and Morbidity Survey carried out in 2014 [53], which looked at the prevalence of food supplements and the reasons for their intake, demonstrated that of the 0.68% of Malaysians consuming *Haruan* as a dietary supplement, 90.82% did so based on its alleged health benefits.

Thanks to the Chinese and Malay communities, *Haruan* has acquired a reputation for wound healing for the past several decades [54]. Poh *et al* did a research [55] involving a total of 134 Chinese mothers during the months of childbirth; they found out that *Haruan* fish was reported by a quarter of the participating women as either a necessary or a recommended food owing to its wound healing property [56]. Nonetheless, the wound healing effect of *Haruan* was merely anecdotal until two recently published clinical trials [57, 58] scientifically confirmed this common belief.

#### **5. Preparation of** *Haruan*

#### **5.1 Cooking**

Different cooking methods of *Haruan* fish can generate different outcomes. For instance, *Haruan* fish fillets preserve their nutritional value when grilled but absorb too much oil when fried, which can be detrimental to health [59]. Meanwhile, when prepared in soup, the time and heat utilised have to be properly adjusted for the snakehead fish to retain its nutritional value [60].

Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

#### **5.2 Topical agent**

*Haruan* fish can also be converted into a topical agent in the form of spray or cream. This preparation involves the addition of a propellant (spray) or aqua cream (cream) to the *Haruan* extract [61, 62]. When *Haruan* is formulated into aerosol concentrate and sprayed on a wound, it will form a thin layer of dressing that acts as a protective barrier against the outside environment [63]. This minimises the physical pain as well as the mental suffering associated with dressing application and removal [64].

#### **5.3 Haruan capsules**

The principal author of this chapter worked collaboratively with the School of Pharmacy, Universiti Sains Malaysia, to process *Haruan* capsules for his research work together with fellow surgeons at the National Heart Institute, Kuala Lumpur, several years ago. Admittedly, oral *Haruan* supplement has a higher amount of concentrate which is believed to yield more merits compared to eating the flesh itself. Besides, for surgical or major traumatic wounds that involve multiple tissue layers, oral administration of *Haruan* extract is deemed superior to topical application [65, 66]. The detailed steps in the preparation of *Haruan* capsules are described in **Figure 4**.

*Preparation of Haruan capsules [57].*

#### **6. Laboratory works**

#### **6.1 Chemical properties**

*Haruan* is considered a crucial source of protein (78.32 ± 0.23%), lipid (2.08 ± 0.08%) and vitamin A (0.265 ± 0.013 mg) [49, 67, 68]. A proximate analysis of *Haruan* revealed that the ratio of crude protein, crude fat to crude ash in *Haruan* is 23:5.7:1.8 [67, 68]. In fact, *Haruan* is rich in amino acids and fatty acids, particularly glycine and arginine, which help minimise protein losses and enhance collagen synthesis essential for wound healing [56, 69, 70].

Interestingly, *Haruan* also synthesises polyunsaturated fatty acids, which accelerate wound healing via the mediation of prostaglandin and thromboxane synthesis [49, 68, 71–73]. Furthermore, apart from the major fatty acids such as stearic acid and linoleic acid [56, 74], *Haruan* possesses an unusually high profile of arachidonic acid (AA) and docosahexaenoic acid (DHA) which lower the risk of coronary artery disease [56, 67, 68, 75–77]. In terms of dietary nutritional elements, micronutrients such as magnesium, copper, zinc, iron, calcium and manganese and trace amounts of nickel and lead are also present in *Haruan* [78–80].

#### **6.2 Antimicrobial effects**

Exposed to an aquatic environment full of microbiota, fish usually develop their own immunity to safeguard against pathogens [81–83]. As a front-liner and paramount component of the innate immune system, fish mucus possesses a broad array of proteins and enzymes such as lysozyme, immunoglobulin, complement proteins, lectins and proteolytic enzymes that can phagocytose and digest microorganisms [84–90]. Furthermore, it constantly secretes and sloughs off the skin to avoid adherence and prolonged colonisation by parasites [84–89]. Hence, fish skin mucus is regarded as a potential antibacterial therapeutic agent [91, 92]. The multiple roles of *Haruan* mucus are described in **Figure 5**.

#### **Figure 5.**

*Roles of the fish mucus [91, 92].*

In recent years, extensive work has been conducted to analyse the antibacterial effects of the mucus of fish species [93–97], including the *Channa* species. Several research studies [48, 98–104] were performed over the years to evaluate the antibacterial and antifungal activities of *Haruan*. Most of the studies [99–104] revealed that *Haruan* displays some antimicrobial activities, except two studies [98, 99] which detected negligible inhibitory effects against *Staphylococcus aureus* and *Escherichia coli* strains respectively. As wound infection and dehiscence – two disastrous yet frequent complications of surgical wounds – are the common factors of delayed wound healing, the antimicrobial activity of *Haruan* is an added merit for wound dressing [105–107].

#### **6.3 Antinociceptive properties**

Pain can have a deleterious impact on wound healing [108, 109]. Coupled with chronic inflammation, prolonged pain can trigger a vicious cycle that hinders wound healing [110]. Fortunately, appropriate wound dressings with sufficient pain control can enormously improve wound healing outcomes, with accelerated wound healing and, consequently, a shorter hospital stay [111].

The antinociceptive effects of *Haruan* in postoperative and traumatic patients have long been discussed and reported. For instance, an earlier *Haruan* study [112] conducted abdominal constriction and tail flick test on mice and found that *Haruan* not only possesses peripherally-acting antinociceptive activity, but its

Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

extracts could also act synergistically with other painkillers such as morphine to relieve postoperative pain and discomfort. These findings are supported by another study conducted by Solihah *et al* [113] who presented a similar positive result. The underlying mechanism is thought to be attributed to the presence of fatty acids and amino acids, particularly arginine, glycine and arachidonic acid, in addition to the involvement of the L-arginine-nitric oxide-cGMP pathway [42, 114]. In fact, the antinociceptive effects *Haruan* remain relatively stable in a wide range of temperature and pH; this allows the essence to be extracted and processed safely for future use [115].

#### **6.4 Wound healing capabilities**

Freshwater fish constitute 60–70% of the animal protein intake in Malaysia [116]. Previous studies demonstrated that *Haruan* contains a high content of albumin which promotes the formation of collagen [117–119]. Moreover, it has a considerable amount of copper and zinc that can help accelerate wound healing by maintaining cell stability, besides promoting wound remodelling and the formation of blood vessels and fibrosis or scar [119–124]. Additionally, the presence of elements such as hydroxyproline, glycine, arachidonic acid and arginine in *Haruan* is another essential source of collagen [124–126].

It is therefore no surprise that the collagen content in *Haruan* is relatively high. Indeed, collagen plays a determining role in expediting wound healing via various mechanisms. According to Kwan *et al* who performed proteometric profiling of *Haruan*, two types of collagen, namely type I and type II collagen, were detected [127, 128]. Both of them increase the tensile strength [129]. In fact, when the increased tensile strength and glycosaminoglycan of *Haruan* was examined and compared to cetrimide, it was reported that *Haruan* is superior to cetrimide in improving wound contraction and the fibroblastic phase of wound healing [61, 130, 131]. Furthermore, it was found that the collagen in *Haruan* can help promote the maturation of granulation tissue which accelerates wound healing. *Haruan* can act in synchrony with the other components of the extracellular matrix to form a granulation tissue which subsequently contracts and seals the wound. Concurrently, it aligns the collagen fibres in the extracellular matrix. If the area of involvement is wide enough, the granulation tissue could be reserved for split skin grafting. The various steps of collagen involvement in wound healing are described in **Figure 6**.

**Figure 6.** *Wound healing effects of collagen [132–135].*

According to the researchers [128] who performed proteomic profiling of *Haruan* extract at the Analytical Biochemistry Research Centre, Universiti Sains Malaysia, the proportion of actin, myosin and tropomyosin to the total protein in freeze-dried and spray-dried *Haruan* water extract are 25% and 26% respectively. While it is known that these three structures play a significant role in muscle contraction in the sliding filament theory, many were unaware that that they also work hand-in-hand in the wound healing process. Tropomyosin can help control cell functioning of actin while actin can regulate vital cellular functions during re-epithelisation involving cell division, cytokinesis and cell signalling, seal the embryonic wound as well as interact with myosin in the regulation of cell motility [132–134]. The functions of actin, myosin, and tropomyosin during the wound healing process are diagrammatically summarised in **Figure 7**.

**Figure 7.** *Functions of actin, myosin, and tropomyosin in wound healing [57, 128].*

#### **7. Clinical trials on** *Haruan*

To the best of our knowledge, only two clinical trials have reported the effects of *Haruan* in wound healing to date.

One study [57] was conducted by the principal author of this chapter. The researchers performed a double-blinded, randomised, controlled trial in 2018 at the National Heart Institute to look at the effects of *Haruan* fish extracts on the chest and leg surgical wounds of 253 patients after they have undergone coronary artery bypass surgery (CABG). Noting the detrimental impact of wound pain on wound healing and the interplay between wound pain, morbidity, quality of life and hospital stay [135–137], parameters such as wound pain and healing, mobilisation and quality of life were specifically evaluated. It was found that the wound scoring system favoured those patients who received *Haruan* capsules instead of placebo at day-6, six-weeks and three months postoperatively. They also discovered that *Haruan* extracts could alleviate wound pain, and improve quality of life with respect to energy, pain, emotion, sleep and physical level except social level based on the Nottingham Health Profile questionnaire that assesses the quality of life [57]. Therefore, *Haruan* extract is considered a cost-effective solution in wound healing because it decreases the percentage of wound infection thereby reducing the cost of hospitalisation. Moreover, with the patient's surgical recovery hastened, it can tremendously reduce the economic burden not only to the hospital but to the country as well.

Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

Meanwhile, a similar study [58] conducted by Wahab *et al* targeted 76 post-lower segment Caesarean Section women, a study population which are the dominant consumers of *Haruan* in Malaysia due to old beliefs and food taboos [55, 56]. The study concluded that *Haruan* could improve the wound's cosmetic appearance and, accordingly, patient's satisfaction. These findings are in line with a randomised controlled trial [138] which reported that *Haruan* extract consumers harboured a remarkably higher rate of uterine involution than the placebo group. Conversely, in the same study, the outcomes of wound healing and pain were noted to be comparable; this can be attributed to the interval used for the pain score assessment and the concomitant use of analgesics.

#### **8. Potential role of** *Haruan* **in skin grafting**

Skin grafting is the transfer of cutaneous tissue to cover large wounds. It can take two forms: split skin grafting, which involves the epidermis and a portion of the dermis, and full-thickness skin grafting which involves the epidermis and the entire dermis [139]. While deliberating on the pros and cons of split skin grafting as compared to full thickness skin grafting is beyond the scope of this paper, it is noteworthy that a split skin graft does not have its own blood supply; it relies on the wound bed. This is where *Haruan* might play an important role. In their seminal work on the bioactive proteins in *C. striatus*, Kwan *et al* [140] have shown that the fish proteins promote angiogenesis and cell proliferation. The stable, healthy and well-vascularised wound bed potentiated by *Haruan* action allows for skin grafts to be well taken.

The main challenge to ensure that *Haruan* play its magical role in promoting angiogenesis and cell proliferation lies in the wound bed preparation before skin grafting. To ensure that the wound bed is healthy, wound debridement is of utmost importance. This could be done in several ways: via a scalpel, a dermatome, or even by using a hydro-surgery device until the wound bed is really clean and healthy with some bleeding at the wound bed [141]. It has to be stressed here that without a clean and healthy wound bed, and wound edges cleared from any necrotic or purulent tissue, the added value of *Haruan* would be lost and the skin graft will not have a proper healing.

When the wound bed is well prepared, skin grafts will normally go through three different stages as follows:

After undergoing these stages, the skin grafts will usually need another five to seven days to adhere to the wound bed followed by the process of maturation that could last from several months to years; this includes pigmentation changes, softening and flattening [139]. As described earlier, *Haruan* abounds in amino acids in such as glycine, lysine and arginine, and fatty acids such as arachidonic acid, palmitic acid and docosahexaenoic acid – they all help to enhance wound healing through the initiation of several pathways including the remodelling of collagen that gives the strength to the wound, besides stimulating wound contraction [145].

Having discussed at length regarding the recipient site, we should also look at whether *Haruan* plays any role in wound healing at the donor site. Theoretically, the donor site requires wound care only in terms of wound dressing. Since the wound edges are not approximated at the donor site and are left to heal via secondary intention, they will be filled by granulation tissue matrix [146] and can be covered by a simple dressing only. Presumably this is another area in skin grafting where *Haruan* dressing might play a role. An aerosol concentrate containing *Haruan* water extract was formulated in an aerosol system to produce a thin film over the wound bed and serve as a dressing at the donor site [147]. The aerosol concentrate that would form a thin layer of dressing over the wound could enhance the healing process at the donor site as proven in an animal model [148], besides showing pronounced antinociceptive properties [149].

#### **9. Other usages of** *Haruan*

Apart from its aforementioned desirable features, *Haruan* has also been reported to confer feasible outcomes in a myriad of diseases.

Osteoarthritis is a degenerative joint disease characterised by synovial inflammation and articular cartilage degradation that leads to chronic pain and inflammation [150, 151]. In osteoarthritis, a wide variety of inflammatory mediators are secreted and activated [140]. After several previous studies which demonstrated the antiinflammatory capabilities of *Haruan*, the role of *Haruan* in osteoarthritis has been extensively explored [152–154]. Few scientific reports on the efficacy of *Haruan* in osteoarthritic patients revealed promising outcomes where *Haruan* was shown to be superior in reducing inflammatory changes in the synovial membrane, improving the pain, symptoms and quality of life of osteoarthritic sufferers while maintaining the structure of the cartilage of the control group [155–159]. As osteoarthritis is a common complication of major traumatic wound injury, which necessitates skin grafting owing to the disfigurement and disabling condition, oral administration of *Haruan* can exert a double action, improving both wound healing and osteoarthritis.

Other functions of *Haruan* mentioned in the medical literature include its usage in allergic rhinitis [160, 161], dermatitis [162, 163], gastric ulcer [164, 165], cancer [166, 167], hypertension [168, 169] and depression [170, 171]. Unfortunately, due to the paucity of studies to date, further high-powered studies are warranted to clarify and define the role of *Haruan* in these diseases.

#### **10. Discussion**

Hong *et al* [65] did a scoping review on the effectiveness of *Haruan* extracts on wound healing; they concluded that current evidence favours the use of *Haruan* extracts to expedite wound healing. Indeed, optimal wound bed preparation and proper wound closure are the two fundamental goals of skin grafting regardless of the graft type [172–174]. With its extraordinary antimicrobial, antinociceptive and anti-inflammatory properties, *Haruan* is undeniably a handy tool for skin grafting. From a psychological perspective, *Haruan* can minimise post-operative pain and discomfort, achieve satisfactory aesthetic wound effect and improve patient postoperative quality of life. For skin grafting that covers a wound area only partially, *Haruan* can promote wound closure since it encourages the epithelialisation of wound. When a wound recovery is sped up with less wound infection, the duration of hospital stay will also be shortened. Consequently, expenses related to skin grafting will be cut down.

#### Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

It is still inconclusive which particular biomolecules play a role in the wound healing property. However, with the advancement of technology especially in the field of proteomics, we have managed to conduct a more comprehensive protein profiling [175, 176]. Although proteomics helps us to understand the interactions between the proteins in the fish and the wound, the previous protein profiling [177] were not as accurate as the new one due to the lower sensitivity of the old equipment. Conversely, the current work using Gel Elution Liquid Fractionation Entrapment Electrophoresis (GELFREE) system can maximise protein profiling [127]. The researchers at the Analytical Biochemistry Research Centre of the Universiti Sains Malaysia [127, 128] also looked at the post-translational modifications (PTMs) of proteins which might be involved in the wound healing process to complement the protein profiling results. PTMs, as the name suggests, occurs following the translation of amino acids in the later part of the protein biosynthesis. They play an important role in protein regulation and are also involved in the regulation of a number of physiological functions. This helps us to appreciate how the consumption of *Haruan* contributes to the wound healing mechanism.

It is a known fact that structural proteins such as actin, myosin and tropomyosin are vital in the formation of muscle tissue within an organism. From the protein profiling, it was shown that 37% of all the proteins detected in the fish meat are structural proteins which play a specific role in enhancing wound healing. For example, actin gives rise to the formation of myofibroblasts which differentiated from fibroblasts containing bundles of actin microfilaments with contractile proteins such as non-muscle myosin [178–180]. On the one hand, both fibroblasts and myofibroblasts regulate traction force and coordinate contraction during wound closure [181]. On the other hand, tropomyosin, has been reported to regulate cell migration, particularly fibroblast and myofibroblasts [182]. This results in the promotion of rapid wound healing whenever tropomyosin is manipulated in the wound area [183, 184]. Hence, the abundant presence of structural proteins in the fish meat could be a key reason why it helps in the wound healing process.

Apart from structural proteins, *Haruan* meat also possesses numerous enzymes including trypsin. Trypsin has been shown to enhance the healing process by potentiating fibrocyte differentiation [185]. Trypsin has also been used as a biomedicine for treating wound [186]. A clinical study conducted by Gudmunssdsdóttir *et al* [175] showed that native-proteins were digested by cold-adapted cod trypsin and produced an encouraging effect on the wound. These findings supported the idea that the abundant level of trypsin in *Haruan* meat helps in facilitating the wound healing process.

Collagen, which is essential for wound healing, is also present in the *Channa striatus* meat with Collagen Type-I being the most abundant [127]. Collagen is required in the different stages of wound healing including the binding process to fibronectin that helps in platelet aggregation [187], triggering angiogenesis by transforming myocytes into macrophages [188], in addition to giving support to budding capillaries [189]. A recent study by Helary *et al* [190] has also shown that apoptosis was prevented during chronic wound treatment by the use of concentrated collagen hydrogel that promotes cell proliferation and protects fibroblasts. Recently, mammalian collagen has been replaced by fish collagen [191] which is considered a regenerative medicine [192], a sign that the abundant collagen found in fish meat does help to advance the wound healing process.

Results from the proteomic study [127] also show that *C. striatus* meat is rich in calcium related proteins such as calmodulin and parvalbumin. We are aware that calcium (Ca2+) plays a major role in maintaining homeostasis of the skin and is considered a key signalling molecule during wound healing [193, 194]. Ca2+ binding proteins are also known to assist in Ca2+ signalling and skin intracellular trafficking, which includes calmodulin and calmodulin-like proteins [195]. It is also known that

Calmodulin assists in keratinocytes maturation [196], proving its significant role in the wound healing process. The important role played by both calmodulin and parvalbumin in the wound healing cascade deserves to be highlighted. Expression of parvalbumin in ependymal cells has been shown to assist in tissue remodelling and wound closure [197]. Hence, it is clear that both parvalbumin and calmodulin help to transfer Ca2+ to the affected area, thereby promoting wound healing.

Proteomic profiling also revealed that more than 50% of the total proteins detected in *C. striatus* are uncharacterised proteins [128]. The functions of these proteins are still unknown due to the paucity of research. These proteins have been labelled as such due to the absence of any detectable homology to those proteins of known functions at both the sequence and structural level [198]. However, it is possible that one or more of the uncharacterised proteins found in *Haruan* play a role in the wound healing process. Indeed, the high quantity of uncharacterised proteins detected via proteomics, that is, the proteome database for *C. striatus*, is far from complete. At this point in time, we can safely say that while existing data have given us an insight into the proteins of *Haruan,* more rigorous effort must be made into the research of the uncharacterised proteins that might be involved in accelerating the wound healing process – the indisputable characteristic of *C. striatus* or *Haruan.*

#### **11. Conclusion**

As a wound cosmetic enhancer as well as an antimicrobial, anti-inflammatory and antinociceptive agent, *Haruan* fish is a promising medicinal food product for wound healing. Current evidence has illustrated the effectiveness of *Haruan* in wound healing, particularly in postoperative patients. This book chapter has highlighted the wonders of *Haruan* in wound healing associated with skin grafting. Unfortunately, in spite of the emerging role and increasing popularity of *Haruan* in wound healing, the use of *Haruan* extracts in skin grafting remains insufficient. When its merits have been fully explored, *Haruan* extracts could become a viable alternative to the current wound dressing regimen in skin grafting in the near future.

#### **Acknowledgements**

The authors would like to express their gratitude to Nageeb Gounjaria for proofreading and editing the manuscript.

#### **Author details**

Ahmad Farouk Musa\* and Cheang Jia Min Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Malaysia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Haruan *Extract (*Channa striatus*) as an Effective Mediator in Promoting Wound Healing DOI: http://dx.doi.org/10.5772/intechopen.99207*

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