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Introduction Nexobrid®, a bromelain-based type of enzymatic debridement, has become more prevalent in recent years. We present the recommendations on enzymatic debridement (Nexobrid®)’s role based on the practice knowledge of expert Italian users. Methods The Italian recommendations, endorsed by SIUST (Italian Society of Burn Surgery), on using enzymatic debridement to remove eschars for burn treatment were defined. The definition followed a process to evaluate the level of agreement (a measure of consensus) among selected experts, representing Italian burn centers, concerning defined clinical aspects of enzymatic debridement. The consensus involved a multi-phase process based on the Delphi method. Results The consensus panel included experts from Italy with a combined experience of 1068 burn patients treated with enzymatic debridement. At the end of round 3 of the Delphi method, the panel reached 100% consensus on 26 out of 27 statements. The panel achieved full, strong consensus (all respondents strongly agreed on the statement) on 24 out of 27 statements. Discussion The statements provided by the Italian consensus panel represent a “ready to use” set of recommendations for enzymatic debridement in burn surgery that both draw from and complete the existing scientific literature on the topic. These recommendations are specific to the Italian experience and are neither static nor definitive. As such, they will be updated periodically as further quality evidence becomes available.

The main objective of this book is to present a thorough update on stem cell research and the potential therapeutic applications of stem cells. The text is structured following a path that starts from the molecular basics and the biological properties of pluripotent, embryonic or reprogrammed stem cells, and it compares the different degrees of stemness, while describing the adult stem populations residing in the various tissues and organs of the human body. Starting from basic research, the book discusses examples of regenerative medicine that translate the experimental findings into clinical applications of cell therapy. Finally, the book reviews how stem cells represent a model to understand not only the physiological mechanisms that control their fate, but also the pathological mechanisms involved in the aberrant biology of cancer stem cells. Each chapter has been conceived by distinguished researchers in the field who provide detailed and updated contributions that distill knowledge in a very readable text. Laura Bonsi is Associate Professor of Histology at the Department of Experimental, Diagnostic and Specialty Medicine of the University of Bologna. Francesco Alviano is Assistant Professor of Histology at the Department of Experimental, Diagnostic and Specialty Medicine of the University of Bologna. Prof. Bonsi and Dr. Alviano are authors of numerous scientific papers published in international journals. They coordinate the Biotechnology Laboratory of Human Stem Cells at the University of Bologna, that is focused on the study of stem cells isolated from different sources, above all from extraembryonic tissues such as the placenta, the umbilical cord, and the fetal membranes. They are longterm members of the International Placenta Stem Cell Society (IPLASS).

Darier disease is an autosomal dominant skin disorder characterized by keratotic papules. After their appearance, these lesions tend to grow over time, producing large and exudative plaques that compromise the general condition of the affected patient's skin. The authors report the clinical case of a patient affected by Darier disease with superinfected de-epithelialized areas over 30% of his body. In addition to antibiotic and antifungal therapy, providers used allograft skin to cover the injured areas and stimulate their progressive re-epithelialization with complete healing after 2 months. To the authors' knowledge, this is the first clinical case of treating Darier disease with allograft skin on an extensively damaged area. The effectiveness of this treatment may lead clinicians to consider allograft skin tissue a new, alternative dressing to treat Darier disease when this pathologic condition manifests with extensive eroded skin.

The rapid eschar removal by surgical debridement is currently considered the standard of care for the treatment of burned patients. However, the excision of viable dermal residues can frequently occur when this procedure is applied affecting, in turn, the possible spontaneous re-epithelialization of the lesion area and increasing the amount of autologous skin grafts required for its treatment. To overcome these problems, the use of enzymatic debridement by proteolytic enzymes enriched in Bromelain has aroused great interest in the clinical field as a valid alternative to surgical procedure for the treatment of burns when they appear of indeterminate depth. With the aim to evaluate the effectiveness of this new approach in comparison with a surgical procedure for the treatment of these types of burns we performed a retrospective data analysis taking into account patients hospitalized in our Burn Center from 2014 to 2017. The results obtained show a significant reduction in the time frame to perform debridement when an enzymatic approach is chosen, with the maintenance of viable dermal tissue on the superficial areas of the wounds, their spontaneous re-epithelialization, and a reduction of the bleeding time in the treated patients. A reduced amount of autologous skin grafts is also used when enzymatic treatment is applied. The length of stay of the patients treated with enzymatic debridement did not show significant differences compared to that treated with surgery, with excellent aesthetic results after 1 to 3 years.

Our purpose was accelerating the physiologic wound healing, stimulating tissue regeneration and the reparative tissue processes in resistant skin ulcers as in a case of an erosive lichen planus of the soles and after a surgical treatment as for severe Darier disease. The challenge was to establish an effective therapy to enhance tissue healing by the injection of a mixture of peripheral blood mononuclear cells (PB-MNCs) and platelet-rich plasma (PRP) into a skin autograft area. This new perioperative biotechnological approach enriches PRP with the effects of PB-MNCs. It offers a novel advanced strategy that could become an ideal biologic blood-derived therapy, whose components are entirely autologous and produced by a protocol independent by the operator.

Full-thickness skin wounds occur in many different clinical cases and the use of biological acellular dermal matrices (ADMs) to reconstruct the damaged area is increasing in the field of plastic and reconstructive surgery. In particular, the ability of ADMs to maintain the structural properties of extracellular matrix as well as to provide a suitable environment for cell growth makes their use suitable for the improvement of wound healing and the reduction of side effects deriving from contracture and scar tissue formation. In this study, we describe the clinical use of a recently developed human dermal matrix (HDM) in combination with graft skin as an alternative reconstructive solution for the treatment of full-thickness skin wounds. The HDM was applied in combination with autologous graft skin on three different clinical cases in which full-thickness skin wounds occurred. The clinical outcomes were evaluated in the patients during their follow-up. Histological as well as ultra-structural analysis were also performed on skin biopsy of the clinical case 3 one year after the treatment with HDM. The use of HDM stimulates the wound healing process in all clinical cases of full-thickness skin wounds here described with a functional and aesthetic rescue of the damaged area. Histological and ultra-structural analysis show a regenerative healing of the wound area with well-organized/oriented connective tissue in which cellular infiltration as well as blood vessels are evident. Our results support the clinical use of HDM as a permanent dermal replacement for the treatment of full-thickness skin wounds.

Interest is increasing in biological scaffolds for tissue regeneration such as extracellular matrix membranes, developed through soft tissue decellularization. Extracellular matrix membranes were developed to heal different tendon and soft tissue lesions that are very frequent in the general population with high health-care costs and patient morbidity. The aim of this research was to evaluate a human dermal matrix (HDM) decellularized by a chemico-physical method. A primary culture of rat tenocytes was performed: tenocytes were seeded on HDM samples and on polystyrene wells as controls (CTR). Cell viability and synthetic activity were evaluated at 3 and 7 days. An in vitro microwound model was used to evaluate HDM bioactivity: after tenocyte expansion, artificial wounds were created, HDM extracts were added, and closure time and decorin synthesis were monitored histomorphometrically at 1, 4, 24, and 72 hr. A significant higher amount of collagen I was observed when cells were cultured on HDM in comparison with that on CTR (3 days: p < 0.0001; 7 days: p < 0.05). In HDM group, fibronectin synthesis was significantly higher at both experimental times (p < 0.0001). At 3 days, proteoglycans and transforming growth factor-β1 releases were significantly higher on HDM (p < 0.0001 and p < 0.005, respectively). The artificial microwound closure time and decorin expression were significantly enhanced by the addition of 50% HDM extract (p < 0.05). In vitro data showed that the decellularization technique enabled the development of a matrix with adequate biological and biomechanical properties.

Background and design Although acute or chronic hair loss in psoriasis of the scalp can be a symptom of the disease, until now there has been no agreement as to whether or not it is only restricted to erythrodermic, generalized pustular and scalp plaque psoriasis. The purpose of this study was to evaluate patients with chronic scalp psoriasis and alopecia and to determine if the alopecia was of the scarring type. Results We report four cases of psoriatic scarring alopecia and describe the clinical and histologic features of these patients. The diagnosis was made by scalp biopsies (vertical and transverse sections) and other causes of scarring alopecia were excluded. Conclusions Psoriasis can cause scarring alopecia.