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Published on May 09, 2017

Codfish Skin Helps Heal Chronic Wounds, Reduces Pain Levels

Karl R. Stark, MD, FACS

Karl R. Stark, MD, FACS

Dr. Stark earned his medical degree from the University of Missouri-Kansas City School of Medicine. He completed his residency in general surgery at Truman Medical Center in Kansas City, MO, and a fellowship in vascular surgery at Robert Wood Johnson University Hospital in New Brunswick, NJ.

An innovative wound treatment using fish skin is bringing dramatic healing, a reduction in pain and cost savings to patients at North Kansas City Hospital.

Karl R. Stark, MD, FACS, vascular surgeon, president of Midwest Aortic and Vascular Institute and director of NKCH’s Wound Healing Center, and his colleagues are the Northland’s only physicians using codfish skin to treat chronic wounds, including foot and leg wounds caused by diabetes.

Natural Scaffold

Thanks to naturally occurring and beneficial alpha omega fatty acids, the fish skin acellular dermal matrix works like a scaffold. When grafted onto damaged human tissue, the material vascularizes and recruits a patient’s own cells, ultimately reducing inflammation and converting into living tissue. The U.S. Food and Drug Administration approved the product in 2013.

“The fish skin has no risk of disease transmission, so the manufacturer doesn’t have to prepare it in the same way it would mammalian tissue,” Dr. Stark said. “That allows the tissue to be more normal in structure and to integrate better into human tissue, causing the cells to advance quickly through the structure. The alpha omega fatty acids also work as an anti-inflammatory agent to improve pain levels.

He was drawn to this patient population in need of wound care early in his career. “It was sort of natural for me,” he said. “I saw how much I could improve lives by taking good care of people’s wounds. A lot of people brushed them aside, and some of them were left ashamed and depressed by their wounds. There is a huge level of satisfaction in the physician-patient relationship of wound care because it’s hands on, and the patients are so appreciative.”

Percentage of Wounds Healed:

Fish Skin Acellular Dermal Matrix Versus Porcine Small-intestine Submucosa Extracellular Matrix

Fish Skin ADM Porcine SIS ECM
21 Days 72.5% 56%
25 Days 77.5% 65%
28 Days 95% 96.3%
Source: “Healing Rate and Autoimmune Safety of Full-thickness Wounds Treated With Fish Skin Acellular Dermal Matrix Versus Porcine Small-Intestine Submucosa,” The International Journal of Lower Extremity Wounds, Vol. 14, No. 1, March 9, 2015.


Patients typically undergo weekly outpatient fish skin applications as part of their wound care management, and Dr. Stark has witnessed dramatically fast wound healing, including in patients who have diabetes and are on dialysis.

“Their wounds are some of the most challenging to close because people on dialysis have chronic protein loss,” Dr. Stark said. “We expect less than 10% of these wounds to ever close, but we have had some close. That is impressive, and these patients get a new lease on life.”

The fish skin is 1 mm thick and can be used on large – 10-15 cm – wounds, that are too large for treatment with bovine and porcine products because of cost.


This electron microscopy image shows the highly
porous nature of the fish skin. The fish originates
off the northwest coast of Iceland in the pristine
waters of the North Atlantic Ocean.

Multiple clinical trials have shown fish skin to heal wounds faster than mammalian skin substitutes.

A prospective randomized, double-blind trial compared the fish skin acellular dermal matrix to a porcine small intestinal submucosa extracellular matrix. Participants had two 4-mm adjacent punch wounds made on their nondominant arms. Forty had their wounds dressed with fish skin, and 41 had their wounds covered with porcine (see table).

Not a Panacea

Part and parcel to chronic wound treatment is adherence to the basics of wound care. These patients need:

  • Adequate arterial flow
  • Diabetes management
  • Infection and edema control
  • Proper nutrition

“This is not a panacea. It’s another tool we have in the algorithm of getting wounds to heal, so it doesn’t replace all the other good aspects of wound care,” Dr. Stark said. For deep wounds, he first uses a negative pressure device to build up some of the tissue at the base of the wound before applying fish skin.

“All of these components come together to keep the pressure off their wounds,” Dr. Stark said. “Then, when a patient reaches a certain point, we can then use fish skin to accelerate their wound closing.”

Insurance Coverage

Dr. Stark said insurance companies cover patients who undergo fish skin applications. If an insurance company is unfamiliar with the product, his clinic makes them aware of its applications and cost-savings.

“We don’t use fish skin unless the patient’s insurance company covers the treatment,” he said. “It’s cost-efficient, which is a big benefit.”