Suitability of natural fish skin for UK burn wound treatment: a systematic review and narrative synthesis
Authors: Omar Nadir , Powell Richard A. , Williams Allison , Antonacci Grazia , Moses Michael , Harris Matthew 
Published: February 2025

Introduction:
Bioengineered acellular fish skin matrix (BAM) is a highly engineered derivation of natural fish skin (NFS) and is occasionally used in the United Kingdom (UK) National Health Service (NHS) to treat severe thermal burns and other wounds that are refractive to therapies. However, NFS, with its collagenous and regenerative properties, has been used successfully in Brazil and other low- and middle-income countries as a material for skin grafts and occlusive dressings in partial thickness burns, and also as a skin replacement graft in some clinical scenarios (e.g. vaginoplasty). Given their common derivation, and potential use in similar clinical settings, this review is a comparative analysis of the health outcomes and costs of both BAM and NFS, and discusses NFS’s potential suitability for the NHS.

Method:
A systematic search was conducted using six databases to identify peer-reviewed literature on NFS and BAM use in burn therapy. Two independent reviewers employed Covidence for research selection and data extraction. The Cochrane Risk of Bias Tool was used to assess research quality and bias risk. A narrative synthesis approach was employed due to the varied outcomes examined.

Results:
Despite studies using different outcome measures on different burn types, 14 studies investigating the use of NFS and/or fish-skin derived BAM for burn treatment were included. Studies utilizing NFS demonstrated favorable outcomes for pain reduction, re-epithelialization time, and healing time, and these were comparable to fish skin-derived BAM. Moreover, NFS exhibited significantly lower costs, approximately $11 per patient, making it a potentially cost-effective alternative to BAM, which is several hundred times more expensive.

Discussion:
NFS shows promise as a viable option for partial thickness burn treatments in the UK, presenting comparable outcomes to fish skin-derived BAM. The significantly lower cost of NFS suggests potential economic benefits for implementation within the NHS. Although fish skin-derived BAM is used predominantly for full-thickness burns, NFS offers significantly greater cost-benefit profile for partial thickness burns, with even some evidence for full thickness burn treatment given its recent application in vaginoplasty, i.e. as a dermal replacement. However, further research, including comparator trials, feasibility studies, and assessments of acceptability, is necessary to explore the full potential of NFS in UK healthcare settings. Whether or not NFS is considered a xenotransplant in the UK will need further examination as well as a clear pathway to regulatory approval, beginning with well evaluated pilot studies in the UK within appropriate Research Ethics Committee approvals.

Conclusion:
NFS demonstrates promise as a viable burns treatment option, offering substantial economic savings compared to current treatments. Further research is warranted to evaluate its effectiveness and acceptability.