There may be intrinsic defects in ulcer healing in the diabetic patient. There is impairment of fibroblast function, deficiency in growth factors and abnormalities of the extracellular matrix. Initially it is important to try to achieve healing by standard techniques such as casting and debridement. However, an ulcer that does not heal is a risk for infection in the diabetic patient and advanced wound healing products should be considered. However, some of the products listed below are so expensive that the cost will be prohibitive for many practitioners.
• Dermagraft is bioengineered living human dermis manufactured by seeding dermal fibroblasts onto a three-dimensional bioabsorbable scaffold
• A randomized controlled multicentre study demonstrated that 50.8% of the Dermagraft group experienced complete wound closure which was significantly greater than in the controls, of whom 31.7% had complete closure
• Must be stored at -80°C. Prior to application it is thawed, warmed and rinsed with sterile saline.
• Apligraf is a bioengineered bilayered skin substitute consisting of human fibroblasts embedded in type 1 bovine collagen and covered by human keratinocytes
• A randomized controlled study demonstrated a healing rate of 56% for those who were treated by application of Apligraf and standard wound care; this was significantly greater than 39% healing rate for patients who received only standard wound care
• It is delivered in a ready-to-use form on nutrient agarose in a sealed plastic bag in a disposable, battery-powered incubator.
• This is platelet-derived growth factor which stimulates chemotaxis and mitogenesis of neutrophils, fibroblasts and monocytes
• A pivotal study in 382 patients demonstrated that Regranex gel 100 ng/g healed 50% of chronic diabetic ulcers which was significantly greater than 35% healed with placebo gel
• It presents as a tube of gel which is stored in a domestic refrigerator and applied every day.
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