Peace Chukwu is a medical writer and fourth-year medical student at the University of Nigeria. She also serves as the national Editor-in-Chief for SCORA, a magazine published by the Nigerian Medical Students Association. She tweets @Makuopeace.
Nile tilapia, wikipedia commons
As a medical student, watching the episode on Grey’s Anatomy where fish skin was used on a man with severe burns piqued my interest in this possibility. Now this was a long time ago and back then using fish skin as a biological dressing was more speculative than clinical.
However, when scientists from Nanyang Technological University (NTU), Singapore, established that fish skin contains collagen that could be very effective in wound healing, and various other biomedical applications, I became invested in the research and its latest development. I’ve made some interesting discoveries that I would love to share with you.
For one, the scientific research implicating fish skin in wound healing dates as far back as 2015, in China, where Zhou et al experimented on extracting collagen from the skin of the tilapia fish to construct a nanofiber matrix referred to as a collagen “sponge,” which was found to be stable under fluctuating environmental conditions due to its high denaturation temperature. Its ability to retain its unique triple helix shape meant it could stay in place on skin and adapt to different skin positions and movement. This research is really important as it suggests that fish skin can be used in topical applications and formulations.
But what makes fish skin so special in this regard?
Introducing fish skin for wound healing
Fish skin contains a special type of collagen and omega 3 polyunsaturated fatty acids, together with proteins and other lipids and skin elements that differ from other biologic products. Collagen in general has always been known for promoting skin regeneration as it is one of the structural proteins found in connective tissues all over the human body.
Associate Professor Andrew Tan, from the NTU School of Biological Sciences, said: “Collagen is commonly used for wound dressing material due to its favourable biological properties. Applying collagen dressings to a wound to stimulate tissue growth can provide relief for a wide variety of injuries. Collagen dressings come in all shapes and sizes — gels, pastes, powders and pads. It can potentially treat wounds of all dimensions.” However, most collagen products that are available commercially are mammalian-derived collagen from sources such as pigs, sheep and cows. This presents a problem in clinical application due to the risks of zoonotic diseases. The treatment to avoid this is harsh and strips it of important lipids that aid healing, leaving behind the connective tissue only. The same is true of human skin grafts, which is the current norm for treating deep skin wounds.
Fish skin, on the other hand, does not contain infectious microbiota and is a cheap and readily available material. Its versatility, due to its triple helix shape, allows it to adapt to the human body for easy and smooth movement. Important to note is the fact that it promotes the growth of in vitro keratinocytes, a group of cells with very important roles in wound healing and immune response. Tilapia collagen invokes no noticeable immune response when applied, and has been tested to this regard by Zhou et al. This is in contrast to bovine skin that evokes a hypersensitivity reaction on the human skin, as well as raising antibody levels. This, along with many other factors, makes fish skin invaluable.
What is the clinical evidence of the success of fish skin use in wound healing?
Results of experimental studies in animals
Following positive outcomes in the treatment of experimental burns in smaller animals like rats, fish skin therapy has been confirmed to work on larger mammals too. A study was conducted on donkeys using Oreochromis niloticus skin (Nile tilapia) as a wound dressing for a full thickness cutaneous metacarpal wound. Results showed accelerated wound healing, decrease in wound size and microbial activity inhibition. There were no negative effects and no dressing changes were required.
In the U.S., fish skin has been successfully used to treat third degree burns on two bears and a five-month-old mountain lion that were victims of the California wildfires.
Human clinical trials
Fish skin has been recorded for use in pediatric burn treatment for a three year old at a burn treatment centre in Fortaleza, Brazil, with burn wounds covering 18 per cent of total body surface including scalds on the left side of the face, neck, abdomen, anterior thorax and left arm. No adverse effects were noted during treatment, and complete re-epithelialization of his superficial partial thickness burn was noted in 10 days before discharge.
Another real life application was for a 23-year-old burn victim of a gunpowder explosion. His right upper limb had superficial partial thickness burns, whereas his left upper limb, face and thorax had deep partial thickness burns, all amounting to 16 per cent total body surface involvement. The lesions were covered with tilapia skin, and resulted in full re-epithelialization after 12 and 17 days of therapy, respectively. No negative effects were recorded and no frequent dressings were needed (i.e. reduced high maintenance care). Also, the need for pain medication was greatly reduced.
Future directions
The use of fish skin for wound healing and regeneration has shown great potential in various animal and human clinical trials. All that is needed is to fully explore the potential of fish skin in wound healing in different forms, such as fish skin bandages and band aids. Currently Kerecis, an Icelandic company, has a patented fish-skin graft and this is increasingly being used to treat wounds of various etiologies. It is marketed in the U.S., Europe, and Southeast Asia and has been cleared by the U.S. Food and Drug Administration (FDA). We await its full implementation in Canadian health care.
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