INTRODUCTION
Burns are responsible for 180,000 deaths annually, which are mainly concentrated in
low and middle-income countries, a group in which Brazil is included. Besides, non-fatal
burns result in prolonged hospitalization, disfigurement, and disability, with subsequent
stigma and rejection1.
Nile tilapia (Oreochromis niloticus) is the most cultivated fish in Brazil and the
fourth most cultivated in the world2. In addition to the full availability and constituting a product that used to be
discarded, tilapia skin demonstrated, in previous studies, a non-infectious microbiota3, a morphological structure similar to human skin, even with higher amounts of collagen
type14.5, and excellent results when it was used as a xenograft to treat experimental burns
in rats6.
Phase II clinical studies, not yet published, comparing tilapia skin with 1% silver
sulfadiazine cream have shown promising results. In the protocols of these studies,
patients with burns in areas such as the face, genitals, neck, armpits, antecubital
fossa, and inguinal region were excluded. The presence of skin folds in these regions
generated the hypothesis that the biomaterial would not adhere properly, resulting
in a lower degree of healing.
OBJECTIVE
Report the case of a patient with deep second-degree burns involving genitalia and
inguinal region, among other areas, in which treatment was performed using tilapia
skin as a xenograft.
CASE REPORT
Female patient, 18 years old, without comorbidities, admitted to a burn unit after
thermal injury by direct contact with flames. Using the Lund and Browder table, an
involvement of 13.5% of the total body surface area (TBSA) was calculated, mostly
by deep second-degree burns and, less significantly, by superficial second-degree
burns (Figure 1). After hospitalization, the patient was resuscitated with intravenous fluids according
to Parkland’s formula and remained hemodynamically stable. Approval from the Research
Ethics Committee and written permission from the patient were obtained.
Figure 1 - Aspect of the burn before application of the tilapia skin.
Figure 1 - Aspect of the burn before application of the tilapia skin.
The method of processing, decontamination, and sterilization of tilapia skin for use
in burns was registered at the Instituto Nacional da Propriedade Industrial (INPI)
under number BR1020150214359 and is described in Lima Júnior et al., In 20176. Before use in the patient, the skin was washed in sterile 0.9% sodium chloride solution
for 5 minutes, a process that is repeated three times in a row. The coverage of at
least 1cm of healthy skin at the edges of the burned area and the overlapping of at
least 1cm between the pieces of skin are necessary procedures to ensure that an eventual
movement of patients in the first days of treatment does not lead to the exposure
of any segment of the lesion.
The patient underwent balneotherapy under anesthesia and analgesia with 100mg of ketamine,
2mg of midazolam, and 2000mg of dipyrone. After removing any necrotic tissue and cleaning
the lesion with drinking water and 2% chlorhexidine gluconate, the tilapia skin was
applied. In total, 11 tilapia skins were used, sometimes cut to fit the contour of
the burned area (Figure 2). Finally, the region was firmly covered with gauze and bandage.
Figure 2 - Aspect of the burn after application of tilapia skin.
Figure 2 - Aspect of the burn after application of tilapia skin.
On the fourth day of treatment, the patient was submitted to a new anesthetic bath,
in which the dressing was opened for the first time. It was observed good adhesion
of the tilapia skin in part of the burned surface; however, in some regions, the skin
did not adhere, having been removed together with the gauze or remaining in the burn
bed, but with softened consistency and excess of underlying secretion (Figure 3). In these regions, the tilapia skin was removed (Figure 4), and, after cleaning, the biomaterial was replaced (Figure 5), covering tightly with gauze and bandage. The same sequence of procedures was performed
on the seventh day of treatment, but with better adherence to the tilapia skin and
less presence of secretion (Figure 6).
Figure 3 - Aspect of the lesion on the fourth day of treatment, after dressing.
Figure 3 - Aspect of the lesion on the fourth day of treatment, after dressing.
Figure 4 - Aspect of the lesion on the fourth day of treatment, after removal of skins that did
not adhere.
Figure 4 - Aspect of the lesion on the fourth day of treatment, after removal of skins that did
not adhere.
Figure 5 - Aspect of the lesion on the fourth day of treatment, after tilapia skin replacement.
Figure 5 - Aspect of the lesion on the fourth day of treatment, after tilapia skin replacement.
Figure 6 - Aspect of the lesion on the seventh day of treatment, after dressing.
Figure 6 - Aspect of the lesion on the seventh day of treatment, after dressing.
On the 14th day of treatment, after opening the dressing, it was observed that several
of the pieces of tilapia skin previously adhered, now had a dry, hardened appearance
and had started to come off. These pieces were removed by digitally separating the
burn bed with the aid of petroleum jelly, exposing the underlying scarred skin (Figure 7). The rest of the tilapia skin was removed in the following 48 hours, and the patient
was discharged, totaling 16 days of treatment.
Figure 7 - Healing status after removing the tilapia skin on the fourteenth day of treatment.
Figure 7 - Healing status after removing the tilapia skin on the fourteenth day of treatment.
DISCUSSION
In the search for new therapeutic alternatives for the treatment of burns, biocompatible
or biological dressings have been highlighted. Since allografts are challenging to
obtain and have low availability, xenografts can be a viable alternative due to their
greater safety and reduced price7. Although frog skin has been used as a treatment for burns in Brazil8, it has never been registered by the Agência Nacional de Vigilância Sanitária (ANVISA)
and is no longer in use. Therefore, the tilapia skin promises to be an innovative
product, easy to apply, and highly available, which can become the first animal skin
nationally studied and registered by ANVISA for use in the treatment of burns, in
addition to be the first aquatic animal skin in the world used for this purpose.
With the use of standard treatments, it is expected about three weeks for complete
healing of deep second degree burns9. Therefore, the 16-day period required for reepithelialization of this patient’s
burn and the absence of side effects suggested the effectiveness of tilapia skin as
a flexible and adherent xenograft, with no antigenicity and toxicity, and the ability
to conserve moisture and avoid the entry of microorganisms, characteristics of an
ideal dressing for burns10. Besides, this case report contributes to reducing the limitations concerning the
anatomical areas appropriate for the application of tilapia skin, since, even with
the need for skin replacement, good results were obtained, including in the inguinal
and genital regions. The decrease in the number of dressing changes is an essential
factor in reducing pain in these patients, decreasing teamwork and hospital costs.
REFERENCES
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1. Instituto Dr. José Frota, Centro de Tratamento de Queimados, Fortaleza, CE, Brazil.
2. Universidade Federal do Ceará, Núcleo de Pesquisa e Desenvolvimento de Medicamentos,
Unidade de Farmacologia Clínica, Fortaleza, CE, Brazil.
Corresponding author: Edmar Maciel Lima Júnior Instituto Dr. José Frota (IJF), Rua Barão do Rio Branco, 1816, Centro, Fortaleza,
CE, Brazil. Zip Code: 60025-061 E-mail: edmarmaciel@gmail.com
Article received: March 12, 2019.
Article accepted: April 21, 2019.
Conflicts of interest: none.