Acellular Fish Skin Graft use for Diabetic Lower Extremity Wound Healing

A Retrospective Study of 58 Ulcerations and a Literature Review

Shannon Michael, DPM; Christopher Winters, DPM; Maliha Khan, DPM


Wounds. 2019;31(10):262-268. 

In This Article


The current standard of care for DFUs includes glucose control, adequate extremity perfusion, debridement of nonviable tissue, offloading, infection control, local wound care, and patient education.[2] Despite an extensive and thorough standard care regimen, about 30% of DFUs heal at 20 weeks.[3] In order to expedite healing, physicians have added biologics into the treatment regimen of DFUs. Unlike other biologics on the market (eg, human, porcine, ovine, bovine, equine), fish graft is able to retain its natural fat source of omega-3 polyunsaturated fatty acids, EPA and DHA. These lipids have been shown to reduce inflammatory responses and advance proinflammatory cytokines in wounds; therefore, enabling the DFU to transition from a chronic inflammatory state into an acute wound.[10] Baldursson et al[14] compared acellular fish skin graft with porcine grafts in a double-blind, randomized, controlled clinical trial. The results[14] indicated 77.5% of wounds treated with fish graft healed compared with 65% of wounds healed at 3.5 weeks with porcine graft. Those results[14] support faster wound healing with fish graft compared with porcine grafts.

In comparison with amnion/chorion membrane products, the acellular fish skin graft structure is porous rather than dense. This porous structure facilitates 3D wound cell ingrowth.[15] Additional prospective controlled studies are necessary to compare wound healing with acellular fish skin graft to healing with other allografts.

Although the quantity of current research is limited on strictly lower extremity ulcerations treated with fish graft, the results and conclusions agree that improved wound healing is noted. At 4 weeks, studies have reported a decrease in wound surface area by 40% to 50%.[10,13] The current results are similar and indicate a 64% reduction in wound area at 4 weeks. The findings of this retrospective study support current evidence that fish graft encourages the progression of healing from a chronic to an acute wound.

To the best of the authors' knowledge, this is the largest and longest retrospective study on acellular fish graft for DFUs.