January 15, 2024

Abstract

This case presentation describes and justifies the use of petrolatum gauze that is impregnated with 3%

bismuth tribromophenate (Xeroform) as a low-cost and effective alternative for synthetic skin grafts. Herein,

we discuss clinical trials that demonstrate the benefits of utilizing Xeroform for second-intention healing as

well as photographs of a case in which the authors used this method and followed a patient's wound-healing

process over time.

Categories: Dermatology, Medical Education, Healthcare Technology

Keywords: skin graft alternative, cost-effective, mohs syrgery, grafting, synthetic skin graft, xeroform, bolster

Introduction

Synthetic skin grafts such as porcine xenografts have been utilized for Mohs surgery defect repairs for many

years as they are thought to decrease healing time and infection rates as compared to second-intent healing

alone; however, they can be cost-prohibitive [1]. Petrolatum gauze that is impregnated with 3% bismuth

tribromophenate (Xeroform) is cheap and may be helpful as a possible alternative with similar benefits for

second intention healing of surgical defects. A head-to-head clinic trial comparing a porcine xenograft to

second-intent healing was registered on ClinicalTrials.gov in 2019 but was ultimately terminated as the

company manufacturing the xenograft discontinued production [2]. Numerous brands of porcine xenografts

have been removed from the market in recent years, and the remaining synthetic skin grafting materials

available have a high cost for the healthcare system and most patients [3]. Fortunately, Xeroform gauze may

be an inexpensive and widely available solution to this problem.

Case Presentation

An 85-year-old Caucasian male with a personal history of non-melanoma skin cancer in the setting of

chronically sun-damaged skin presented to the clinic for surgical evaluation and treatment of a biopsy

proven melanoma in situ involving the vertex scalp. After a discussion of treatment options, the decision

was made to proceed with staged excisions with en face margin evaluation (“slow Mohs”). The tumor was

cleared after two stages resulting in a 5.7 x 6.0 centimeter defect (Figure 1). The patient’s goals in repair

were minimizing the risk of infection and required wound care. The decision was made to sew into place

Xeroform gauze as a bolster (Figure 2). The bolster was removed after two weeks, and the patient followed up

four weeks after surgery for a wound check where he was found to have healthy granulation tissue at the site

of the wound (Figure 3).

Discussion

We have found that suturing Xeroform gauze into place as a wound dressing can be helpful with wound

healing in our Mohs patients. Xeroform has demonstrated rapid reepithelialization, while also being easy to

use, resistant to infection, and the most cost-effective material when compared to Opsite (polyurethane

film), Kaltostat (calcium sodium alginate), DuoDERM (hydrocolloid), Aquacel (hydrofiber), and Mepilex

(silicone foam) [4]. In a study that devised a scoring system evaluating percent reepithelialization,

inflammation, infection, ease of use, and cost for various materials, Xeroform tied for first rank with

DuoDERM. Xeroform was found to be slightly inferior to DuoDerm in terms of reepithelialization rate [4,5].

Additionally, as in the case presented here, Xeroform can be sutured into place. Thus, in areas where slower

rates of reepithelialization can be tolerated or there is a concern for the ability of the patient to care for the

wound, Xeroform may be the preferred wound care material.

Xeroform is commonly used to wrap pedicle flaps in Mohs repairs [6]. Additionally, the use of tie-over

bolsters with Xeroform has been described in the literature to promote second-intent healing [5]. As

illustrated with this case report, the authors have found wound healing by second intention following Mohs

surgery to be another potential beneficial application of Xeroform gauze. We removed the Xeroform bolster

after one to two weeks which ensured the granulation tissue did not adhere to the mesh.

Conclusions

Both effectivity and affordability should be considered when deciding what materials will be used for

second-intention healing. Xeroform gauze bolsters in place of synthetic skin grafts have been noted to be an

effective alternative to synthetic skin grafts. Dermatologic and Mohs surgeons should consider this simple

and affordable repair technique before pursuing more cost-prohibitive options.

1.Johnson, Kelsey L., Nicole Papac, and Jason M. Hirshburg. "Xeroform Gauze Bolster: A Cost-Effective Alternative to Synthetic Skin Grafts." Cureus 15.9 (2023).