Consensus Recommendations for Intact Fish Skin Graft in the Management of Burn Injury

Background: Intact fish skin graft (IFSG) derived from North Atlantic cod emerged as a treatment for burns in 2019. This consensus paper presents the best to date evidence and experience-based recommendations from eight U.S. burn care experts regarding optimal use of IFSG across different burn depths and wound types. Methods: Eight U.S. burn specialists with routine IFSG experience conducted a two cycle modified Nominal Focus Group. A systematic literature search (through April 2024) was conducted, followed by informed discussion, and the generation of consensus statements. Consensus was defined as ≥80 % agreement on a 5 point Likert scale. Results: Full or strong consensus (≥80 %) was reached on 12/15 statements. IFSG is recommended for: mid-dermal & deep-dermal partial-thickness burns (as definitive treatment), full thickness traumatic & burn wounds (in a 2-stage procedure before split-thickness skin graft). IFSG is not routinely recommended for purely epidermal burns. Based on recommendations from panelists, IFSG should be applied immediately after thorough debridement except in traumatic wounds when IFSG application should be delayed until clear demarcation and resolution of any infection. Reapplication is rarely required and, if needed, should occur 6–10 days after the initial graft. For wounds >100 cm², negative pressure wound therapy (NPWT) is the preferred bolster. The panel agreed IFSG accelerates readiness for STSG, decreases procedural pain, and can reduce nursing burden and overall cost of care. Recommendations: Clinicians should reserve IFSG for deep-dermal or full thickness burns and traumatic wounds and should pair IFSG with NPWT for large areas. IFSG is not needed in superficial burns that heal adequately with standard care. Prospective trials in deep-dermal partial thickness and full thickness burns remain a priority.