Wound Healing

It is a pleasure to serve as the guest editor for this special issue of the Archives dedicated to wound healing. This issue provides the opportunity to appreciate the special relationship dermatologists have with wound healing and to highlight dermatology and dermatologists' role in advancing the science of wound healing and wound care. In addition, on the 50th anniversary of the Department of Dermatology and Cutaneous Surgery at the University of Miami, Miami, Florida, it provides an opportunity to recognize the outstanding contributions of the department's chairman emeritus, William H. Eaglstein, MD, to the field of wound healing.

Wounds and wound healing intersect medical, surgical, and cosmetic dermatology. Medical conditions as diverse as pemphigus vulgaris, primary syphilis, lupus erythematosus, and sarcoidosis all either have or can have wounds as part of their initial presentation. Dermatologists create more wounds through surgical procedures and biopsies than any other specialty.^{1 - 2} Often, wounds are treated with surgical procedures such as debridement or grafting.³ Finally, with regard to cosmetic dermatology, its goals and the goals of wound healing are often the same: to fill a defect or contour, to provide dermal support, and to normalize epithelialization.

In 2006, the American Academy of Dermatology, in collaboration with the Society of Investigative Dermatology, published the results of a joint effort evaluating the burden of skin disease in the United States.⁴ The results are that skin care is costly, with the 5 conditions most expensive to treat combined costing Americans over $16 billion annually. Second, the conditions that are by far the most expensive to treat are wounds and ulcers. Therefore, wounds are common, extremely costly to the American health care system, and created to a greater extent by dermatologists than by any other specialty; therefore, they should be of interest to all dermatologists.

This issue allows the Archives to celebrate dermatology's role in advancing the science of wound care. This issue also coincides with the 50th anniversary of the Department of Dermatology and Cutaneous Surgery at the University of Miami. In March of this year, the department held a 3½-day academic and social event commemorating scientific and academic advances of the department and its alumni, faculty, and residents. Among the activities was a full day to honor the accomplishments of Dr Eaglstein in the field of wound healing. He was the second of only 3 chairmen that the department, founded by Harvey Blank, MD, has had in its illustrious 50-year history. Having trained under Dr Blank, as a resident and faculty member, Dr Eaglstein returned to Miami in 1986 to assume the chairmanship after serving as chairman of the Department of Dermatology at the University of Pittsburgh, Pittsburgh, Pennsylvania, for 6 years. He led the department at the University of Miami for 17 years, through 2003.

A founding member of the Wound Healing Society who was recently awarded the prestigious John Boswick Award for Lifetime Achievement in Wound Care, Dr Eaglstein has made seminal contributions to wound care. Working with colleagues, he has made many contributions, some of which include the development of the porcine model for wound healing,⁵ and the use of this model to study the effect of steroids on healing,^{5 - 6} to study the role of occlusion on healing,^{5 ,7 - 10} and to study the effect of antimicrobial agents on healing.^{11 - 12} He, with others, developed the growth factor trap hypothesis to explain venous ulcer pathophysiologic characteristics,¹³ put forth the idea that skin grafts do not act solely as a tissue replacement but as pharmacologic agents in healing,¹⁴ and influenced his department's faculty to develop the concept that biofilms play a role in chronic wound healing.¹⁵ This and other work has led to or popularized the use of occlusive dressings,^{16 - 18} tissue-engineered skin,^{19 - 23} and cyanoacrylate dressings.^{24 - 25} Equally important to his scientific contributions has been Dr Eaglstein's mentorship of members of his departments and of the field. His mentees, like wound healing itself, cross interests and include dermatologic surgeons, scientists interested in wounds, and medical and cosmetic dermatologists. Dr Eaglstein is currently chairman emeritus in the department headed by Lawrence Schachner, MD. This issue of the Archives celebrates Dr Eaglstein's influence on the entire field of wound healing.

Also in this special issue of the Archives, we provide a wide variety of articles, both in terms of types of wounds addressed and the aspects of wound healing discussed. Two articles in the issue explore wound assessment techniques. Pressley et al²⁶ present data from a recent randomized control trial demonstrating the benefit from a digital analysis system, and Romanelli et al²⁷ provide rationale for an easy-to-use 3-dimensional laser system for wound assessment. Skin biopsy still remains an important diagnostic and assessment tool. Wahie and Lawrence²⁸ studied patients undergoing diagnostic biopsies in the inpatient setting and found a high complication rate (29%), most commonly from infection. Their data suggest that a biopsy site located below the waist, a biopsy performed bedside (vs in a operating suite), comorbid conditions (eg, diabetes mellitus), and lack of subcutaneous sutures were associated risk factors for wound infection.

Also in this issue, 2 articles are presented that discuss the pathophysiologic characteristics of nonhealing venous ulcers. Heinen et al,²⁹ from the Netherlands, studied cases of patients with venous leg ulcers from 12 dermatology department–run wound clinics. The standard of care is multilayered compression dressing, but Heinen et al²⁹ found that only slightly more than one-third of patients used the compression dressings. Interestingly, exercise levels were low in patients with venous leg ulcers. Thirty-five percent of patients with venous leg ulcers walked less than 10 minutes per day. These data are especially interesting in light of an article by Pieper et al,³⁰ who describe a distinct group of patients who have venous disease: those who inject drugs into their legs. Pieper et al³⁰ review the literature and present data from their ongoing study, funded by the National Institutes of Health, evaluating venous disease, mobility, gait, and balance among this subset of injection drug users compared with drug users who do not inject and those who inject into locations other than the legs. It becomes apparent that these patients with venous disease, perhaps representative of all patients with venous disease, have changes in gait, mobility, ankle range of motion, and balance. These 2 articles, taken together, suggest the importance of mobility and the ongoing role of physical therapy for patients with venous disease.

A third article in this issue related to venous ulcers presents new epidemiologic information. Margolis et al³¹ study the relationship between β-adrenergic receptor agonists and antagonist use and the likelihood of developing venous ulcers. Using a general practice database from the United Kingdom, they demonstrate that patients taking β-adrenergic receptor agonists were less likely to develop venous ulcers. Interestingly, using complex analysis called propensity analysis, they also demonstrate that some subsets of those taking β-adrenergic receptor antagonists were also less like to develop venous ulcers. Taking into account laboratory studies that suggest a role of β-adrenergic receptors in wound repair, this provides a rationale for considering these types of agents in clinical trials for the treatment of venous leg ulcers.

It has been a great privilege to serve as the guest editor for this issue. It has been a pleasure to have worked with June K. Robinson, MD, and the editorial staff of the Archives. Finally, it is an exceptional and singular honor to pay tribute to William H. Eaglstein, MD, who has had a profound influence on my career.

Correspondence: Dr Kirsner, Department of Dermatology, University of Miami, PO Box 016250 (R250), Miami, FL 33101 (RKirsner@med.miami.edu).

Financial Disclosure: None reported.