1. Introduction
Burn
• Tissue disruption due contact to source: thermal
The use of Stem cells (burn/scald), chemical, electrical (lightning), radiation.
in burn care • Problems encountered:
– Acute phase
• Deterioration of airway, breathing and circulation
• Systemic Inflammatory Response Syndrome
Yefta Moenadjat (SIRS) & Multi-system Organ Dysfunction
Syndrome (MODS)
– Late phase
• Wound healing
Introduction Superficial burn
Burn • Epidermal layer disruption
• Intact dermal
• Tissue disruption: wound classification
• Painful
• Spontaneous healing 5-7
Type of wound days
1 Superficial burn 1o • Treatment:
2 Partial thickness burn 2o • Moisturizer cream
• Common analgesic
• superficial partial 2o superf
thickness
• deep partial thickness
2o deep
(full thickness)
3 Deep burn 3o
Partial thickness Partial thickness
burn burn
1. Superficial 2. Deep (full thickness)
• Epidermal layer disruption • Epidermal layer disruption
• 1/3 superficial dermal layer • 2/3 superficial dermal layer
• Blister formation • Blister formation (+/─)
• Painful • Thin eschar
• Intact dermis > • Painful
Spontaneous healing 10-14 • Intact skin appendices
days Spontaneous healing up to 21
• Treatment: days
• Moisturizer cream • Treatment:
• Blister management • Moist dressing
• Common analgesic • Blister management
• Common analgesic

2. Débridement:
Deep burn Surgical Non surgical
• Epidermal layer, dermal layer Concept changes:
and deeper layer (subcutaneous • Total excision Second place
& adipose tissue, muscles, • Tangential excision
bones) • Total excision
• Eschar Rapid Slow
• No sensation Complication: No bleeding
• Intact dermis & skin appendices Surgical bleeding complication
(─) Method:
Spontaneous healing impossible • Conventional (Humby Method:
• Treatment: knife) • Autolytic
• Debridement (escharectomy) • Electric dermatome • Enzymatic
• Skin grafting • Hydropressure
Debris removal referred to source control
The wound closure Wound healing: Review
Phases of Wound healing
• Problems encountered in burn wound closure
Homeostasis &
inflammation
Maturation
• Degree of severity
Fibroplasia
– Damaged tissue → deteriorated circulation→ non
vital tissue → inflammatory response ▲
– Burn exhaustion [metabolic changes,
inflammation]
– Prolonged phases of wound healing
• Impaired – non healing wound 0 2 4 6 8 365
Days after injury
Injury
Phase of proliferative [fibroplasias, fibro-proliferative]
Phase of Fibroplasias
• Template formation
– Proliferation of fibrin cells [collagen matrix ] replaces the
clot
• Angiogenesis
– Proliferation of endothelial cells [new vessels formation]
►Granulation tissue
• Epithelialization
– Proliferation of epithelial cells from wound edges and 1. Fibrin proliferation
skin appendices early

3. Phase of Fibroplasias
1. Fibrin proliferation
early
Phase of Fibroplasias Phase of Fibroplasias
1. Fibrin proliferation 1. Fibrin proliferation
early late
Phase of Fibroplasias Phase of Fibroplasias
1. Fibrin proliferation 2. Angiogenesis
late early

4. Phase of Fibroplasias Phase of Fibroplasias
2. Angiogenesis 2. Angiogenesis
early late
Phase of Fibroplasias Phase of Fibroplasias
Granulation: Fibrin proliferation + Angiogenesis Granulation: Fibrin proliferation + Angiogenesis
Phase of Fibroplasias Phase of Fibroplasias
Wound: contraction 3. Epithelialization
early

5. Epithelialization:
Phase of Fibroplasias Epithelization is start from the wound edges
Basal membrane
3. Epithelialization
complete
Epithelialization:
Epithelization is not always start from the wound edges
Sweat gland
Sebaseous gland
Hair follicle
Phase of remodeling [phase of maturation] Conditions of fibroplasias
• Collagen deposition [early, 2 mo]
– Indurative tissue
• Healthy granulation
• Collagen resorption [late, up to 8-12 mo] tissues
– Soften tissue – Adequate collagen
• Regression of vessels matrix
– Tissue becomes pale – Angiogenesis
►Firm and pale tissue
►Scar tissue Granulation tissue

6. Conditions of fibroplasias
• Healthy granulation
tissues
– Adequate collagen
matrix
– Angiogenesis
►excessive granulation tissue
Granulation tissue
Influencing factors
• Structural component or scaffolding
• Biologically active component stimulating all phases of
healing
• Collagen (protein)
– Scaffold for cell migration and matrix deposition
– Cell guidance
• Elastin (protein)
– Tissue elasticity
• Fibronectin (protein)
– Cell to cell adherence
– Contact orientation for cells
– Increases epithelial cell division, migration
– Chemo attractant for fibroblasts, macrophages
Influencing factors
• Growth Factors (proteins)
• Stimulate all phases of wound healing
• Glycosaminoglycan (glycosylated protein)
– Cell adherence properties
– Conduit for healing factors
– Deactivator of proteases
– Scaffold or foundation for dermal elements
• Hyaluronic Acid (complex carbohydrate)
– Maintaining matrix hydrated
– Decreases inflammation
– Stimulates healing
– Proper cell alignment

7. Temporary Skin Substitute
• Injury
SIRS and MODS Product Company
Tissue of
Origin
Layers Category Uses
How
supplied
• Inflammation
• Inadequate blood flow Temporary
Frozen in
Split coverage of
• Ischemia-reperfusion injury
Ischemia- Human Human Epidermis and rolls of
Skin bank thickness large
allograft cadaver dermis varying
• Infection skin excised
size
burns
Temporary
coverage
Brennan
Autolysis Pig dermis Dermis Dermis of partial Frozen or
Toxins Infection Healing Pig skin Medical St.
thickness refrigerated
Inflammation Xenograft Louis, Mo
and in rolls
excised
burns
Epidermis
↑ demand for ↑ demand for ↑ demand for Human On site
Placenta
Amniotic
Dermis
Same as Refrigerato
amnion procurement membrane above r
Inflammatory cells Immune modulation Mesenchymal stem cells
Room T°
Extracellular Superficial
Healthpoint Bioactive storage
Oasis® Xenograft wound matrix burns Skin
↑ demand on LTD San
from small
Dermal like
graft donor
Multiple
Marrow suppression Antonio, Tx Matrix sizes
Bone Marrow support intestine sites
3x3.5cm
submucosa Chronic
7x20cm
wounds
Marrow Exhaustion
Temporary Skin Substitute Permanent Skin Substitute
Tissue of How AVAILABLE PERMANENT SKIN SUBSTITUTES
Product Company Layers Category Uses
Origin supplied Tissue of How
Product Company Layers Category Uses
Origin supplied
Superficial
Synthetic Room T° Chronic
Dow Bilayer Synthetic partial
Biobrane® with added storage Composite wounds,
Hickam/Bertek product outer epidermis thickness Collagen matrix 7.5cm
denatured 15x20inch Organogenesis : often used
Pharmaceutica silicone Inner and dermis burns,Temp seeded with diameter
bovine 10x15cm Inc and Novartis Allogenic Epidermis with thin
ls nylon mesh orary cover Apligraf human neonatal disc
collagen 5x15inch Pharmaceuticals Composite and STSG
with added of excised keratinocytes 1/pack
5x5 inch Corp Dermis Excised
collagen burns and fibroblasts
deep burn
Superficial
Bioactive to mid- Composite
Bilayer Collagen sponge Skin graft
Smith & Dermal Partial Ortec : 6x6cm
Transcyte® Allogenic product Outer Frozen in OrCel Allogenic seeded with donor site,
Nephew Matrix thickness International Epidermis sheets
Dermis silicone Inner 5x7.5 inch Composite human neonatal chronic
Wound Components burns Inc. and
nylon seeded sheets keratinocytes wounds
Management on Synthetic Temporary Dermis
with neonatal and fibroblasts
Largo, FL dermis and coverage of
fibroblasts Deep
epidermis excised
burns partial and
50cm2
Cultured full
Genzyme Tissue Autogenous Epidermis sheets in
Epicel* autologous thickness
Repair Corp keratinocytes Only culture
keratinocytes burns
medium
>30%
TBSA
1. Used mainly in burns
Permanent Skin Substitute
AVAILABLE PERMANENT SKIN SUBSTITUTES
Tissue of How
Product Company Layers Category Uses
Origin supplied
Deep
partial and
full
A cellular
thickness
Allogenic Dermis Dermis 1x2cm to
Alloderm Life Cell burns, Soft
dermis (processed only 4x12cm
tissue
allograft)
replacemen
t, Tissue
patches
Full
The Role of Stem Cells
thickness 2x2 inch
Silicone outer soft tissue 4x10
Integra Life layer on Biosyntheti defects inch
Integra* Synthetic
Science Corp collagen GAG c Dermis definitive 8x10
dermal matrix “closure” inch
requires 5/pack
skin graft
1. Used mainly in burns

8. R. John Davenport
editor of Science’s SAGE KE
1 July 2005 Vol 309 SCIENCE www.sciencemag.org
Published by AAAS Hematopoietic and stromal stem cell differentiation
Br J Dermatol. 2005 Jul;153(1):29-36. Related
Articles, Links
Human mesenchymal stem cells
successfully improve skin-
substitute wound healing.
Nakagawa H, Akita S, Fukui M, Fujii T, Akino K.
Division of Plastic and Reconstructive Surgery, Department of
Developmental and Reconstructive Medicine, Nagasaki University,
Graduate School of Medical and Dental Sciences, 1-7-1 Sakamoto,
Nagasaki 8528501, Japan.
Plasticity of adult
stem cells
About Stem Cells Research About Stem Cells Research
• Human and Social Costs
Severe Burns
According to the Sandia National Laboratories, there are over 100,000 burn victims
annually in the U.S., receiving a total of almost one million in-hospital days spent in
Severe burns are devastating injuries, burn treatment. This represents approximately $2 billion in annual health care costs.
Potential for Stem Cell Therapies and Cures
requiring long and painful recovery, and Potential for Stem Cell Therapies and Cures
often resulting in significant scaring, Scientists have established that skin progenitor stem cellsprogenitor stem
Scientists
have established that skin (called keratinocyte
disfigurement and disability. Although cellsprogenitors) inItadult human skin haveto use embryonic stemfor growth and tissue-
(called keratinocyte progenitors) in adult human
regeneration. may also be possible
a significant capacity
cells to generate large
progress has been made with skin grafting skin numbers of healthy new epidermal or dermal skin cells.
have a significant capacity for growth and tissue- tissue-
and artificial skin technologies, scientists regeneration. Italso benefit from the stem cell therapy technique called somatic
Burn victims could may also be possible to use embryonic
believe that stem cells could provide better stem cells to generateUsing SCNT scientists can makethe original donor.
cell nuclear transfer, or SCNT.
large numbers of healthy new
“patient specific” cells, meaning the cells’ DNA matches that of
large numbers of
ways to regenerate functional skin epidermal coulddermalcommon cells. and grafts without the risk of the
Such cells or generate healthy new skin tissue
immune-rejection problems
skin to tissue organ transplants.
following burns. Information obtained from the California Research and Cures Act.
For more information on burns, visit:
• California Medical Association -- http://www.cmanet.org/
• American Nurses Association of California -- http://www.anacalifornia.org/

9. Mesenchymal Bone Marrow Stem
Cells More Effectively Stimulate
Regeneration of Deep Burn
Wounds than Embryonic
Fibroblasts
V. I. Shumakov1, N. A. Onishchenko1, M. F. Rasulov1, Structure of regenerative
M. E. Krasheninnikov1 and V. A. Zaidenov1 epidermal-dermal equivalents
based on EDC-collagen after
(1) Institute of Transplantology and Artificial Organs, Ministry of
one week (original
Health of Russian Federation, Moscow
magnification 200x, H&E
Volume 136, Number 2 / August, 2003 staining). hMSCs promote
Available in website: http://www.springerlink.com/content/1wlqwjpqleqt/ stratification ( ) and proliferation
of keratinocytes and result in a
fully differentiated multilayered
epidermis with organisation of
rete ridge-like structures ( ).
Conclusion
Structure of regenerative
epidermal-dermal equivalents The approach to skin modelling reported here
based on EDC-collagen after
one week (original
showed that non-skin-localized hMSC can
magnification 200x, H&E promote skin regeneration. The work suggests
staining). Keratinocytes
seeded alone on the collagen
that direct intercellular contact is required for a
matrix invaded into skin-specific morphology. Co-cultures of
the spongy structure ( ) and
formed only a thin, irregular
hMSCs and keratinocytes may improve the
epidermal layer. performance of composite skin grafts in clinical
applications
COLLOQUIUM PAPERS
Stem cells of the skin epithelium
Laura Alonso, and Elaine Fuchs *
Howard Hughes Medical Institute, Laboratory of Mammalian Cell Biology and Development, The
Rockefeller University, New York, NY 10021
Tissue stem cells form the cellular base for organ homeostasis and repair. Stem cells
have the unusual ability to renew themselves over the lifetime of the organ while
producing daughter cells that differentiate into one or multiple lineages. Difficult to
identify and characterize in any tissue, these cells are nonetheless hotly pursued
because they hold the potential promise of therapeutic reprogramming to grow human
tissue in vitro, for the treatment of human disease. The mammalian skin epithelium
exhibits remarkable turnover, punctuated by periods of even more rapid production
after injury due to burn or wounding. The stem cells responsible for supplying this
tissue with cellular substrate are not yet easily distinguishable from neighboring cells.
However, in recent years a significant body of work has begun to characterize the skin
epithelial stem cells, both in tissue culture and in mouse and human skin. Some
epithelial cells cultured from skin exhibit prodigious proliferative potential; in fact, for
>20 years now, cultured human skin has been used as a source of new skin to engraft
onto damaged areas of burn patients, representing one of the first therapeutic uses of
stem cells. Cell fate choices, including both self-renewal and differentiation, are crucial
biological features of stem cells that are still poorly understood. Skin epithelial stem
cells represent a ripe target for research into the fundamental mechanisms underlying
these important processes.

10. Columnar organization
of the epidermis
Cornified layers
Suprabasal layers
Basal layers
Dermis
From Gambardella and Barrandon. Curr opin cell biol 200
Ex vivo expansion of adult autologous epidermal stem cells
1-5 cm2
1 m2
Fro Howard Green and colleagues
(Rheinwald and Green, 1975. Gallico et al., N. Engl. J. Med, 1984)
Normal skin
Spontaneous healing
Epidermis generated
from transplanted
Stem cells

11. Regeneration of epidermis
•Normal keratinized epithelium
•Presence of holoclones
Regeneration of superficial
dermis
•Undulated dermo-epidermal junction
• Presence of subepidermal vascular
arcades
•Presence of elastic fibers
•Observed in fetal wound healing
•Never observed in post natal wound
healing
Absence of epidermal
appendages
•Sweat glands, sebaceous glands,
hair follicle
Why no epidermal appendages ?
1. Absence of multipotent epidermal stem cells
• No multipotent stem cells in adult skin
• Multipotent stem cells do not survive in culture
• Current culture conditions favor epidermal
differentiation
2. Absence of inductive signal(s)
The information remain scanty
• Difficulties to conduct experiment in human
– Obvious ethical reasons
– Regulatory rules (GMP)
– Cost
• Difficulties regarding patient follow up
• Poor communication between basic and medical
research laboratories
• Difficulties to assay stemness
• No control of stem cell engraftment
• Necessity of a reliable and predictable animal model

12. Therapeutic use of skin stem cells Challenges