Biology of Dermal Wound Repair

Molecular balance of capillary tube formation versus regression in wound repair: role of matrix metalloproteinases and their inhibitors

In this review, we discuss the identification of distinct matrix metalloproteinases (MMPs) and their inhibitors that differentially control the processes of capillary tube formation (morphogenesis) versus capillary tube regression in three-dimensional (3D) collagen matrices. This work directly relates to both granulation tissue formation and regression during wound repair. The membrane metalloproteinase, MT1-MMP (MMP-14), is required for endothelial cell (EC) tube formation using in vitro assays that mimic vasculogenesis or angiogenic sprouting in 3D collagen matrices. These events are markedly blocked by small interfering RNA (siRNA) suppression of MT1-MMP in ECs or by addition of tissue inhibitor of metalloproteinases (TIMPs)-2,-3, and -4 but not TIMP-1. In contrast, MMP-1 and MMP-10 are strongly induced during EC tube formation to regulate the process of tube regression (following activation by serine proteases) rather than formation. TIMP-1, which selectively inhibits soluble MMPs, blocks tube regression by inhibiting MMP-1 and MMP-10 while having no influence on EC tube formation. siRNA suppression of MMP-1 and MMP-10 markedly blocks tube regression without affecting tube formation. Furthermore, we discuss that pericyte-induced stabilization of EC tube networks in our model system appears to occur through EC-derived TIMP-2 and pericyte-derived TIMP-3 to block both the capillary tube formation and regression pathways.

Stable suppression of tumorigenicity by Pin1-targeted RNA interference in prostate cancer

PURPOSE

The peptidyl-prolyl isomrase Pin1 plays a catalytic role in oncogenesis in solid cancers, including prostate cancer. In the present study, we sought to determine the potential of Pin1-targeted gene silencing in inhibiting cellular growth and tumorigenicity in prostate cancer.

EXPERIMENTAL DESIGN

A retrovirus-mediated RNA interference targeting Pin1 was expressed in PC3 and LNCaP cells, and cell growth and several transformed properties were investigated.

RESULTS

The stable expression of Pin1-specific small interfering RNA constructs in PC3 and LNCaP cells significantly reduced cellular proliferation, colony formation, migration, and invasion but strongly enhanced the apoptotic response induced by serum depletion or treatment with anticancer agents. Furthermore, Pin1 depletion significantly suppressed tumorigenic potential in athymic mice, resulting in the inhibition of both tumor growth and angiogeneisis.

CONCLUSIONS

These results strongly suggest that Pin1 plays an important role not only in tumorigenesis but also in the maintenance of the transformed phenotype in prostate cancer cells. Hence, Pin1 may serve as a promising therapeutic target, particularly for recurrent prostate tumors.

How the cornea heals: cornea-specific repair mechanisms affecting surgical outcomes

In mammals, penetrating injuries typically heal by deposition of fibrotic "repair tissue" that fills and seals wounds but does not restore normal function. Excessive deposition of fibrotic repair tissue can lead to pathologies involving excessive scarring and contracture. In the cornea, fibrotic repair presents special challenges affecting both clarity and shape of the cornea. With the increasing popularity of surgical techniques that alter corneal refractive errors, understanding of cornea repair mechanisms has acquired new significance. The cornea has unique anatomic, cellular, molecular, and functional features that lead to important mechanistic differences in the process of repair in comparison with what occurs in skin and other organs. Moreover, corneal function calls for special outcomes. This review addresses these features from the viewpoint of the authors' research on factors of importance to understanding and improving surgical outcomes.

A Randomized, Controlled Trial to Determine the Efficacy of Paper Tape in Preventing Hypertrophic Scar Formation in Surgical Incisions that Traverse Langer??s Skin Tension Lines

BACKGROUND

How a scar is managed postoperatively influences its cosmetic outcome. After suture removal, scars are susceptible to skin tension, which may be the trigger for hypertrophic scarring. Paper tape to support the scar may reduce multidirectional forces and prevent hypertrophic scarring.

METHODS

Seventy patients who had undergone cesarean section at the Royal Brisbane and Women's Hospital were randomized to treatment and control groups. Patients in the control group received no postoperative intervention. Patients in the treatment group applied paper tape to their scars for 12 weeks. Scars were assessed at 6 weeks, 12 weeks, and 6 months after surgery using ultrasound to measure intradermal scar volume. Scars were also assessed using the International Clinical Recommendations.

RESULTS

Paper tape significantly decreased scar volume by a mean of 0.16 cm3, (95 percent confidence interval, 0.00 to 0.29 cm3). At 12 weeks after surgery, 41 percent of the control group developed hypertrophic scars compared with none in the treatment group (exact test, p = 0.003). In the treatment group, one patient developed a hypertrophic scar and four developed stretched scars only after the tape was removed. The odds of developing a hypertrophic scar were 13.6 times greater in the control than in the treatment group (95 percent confidence interval, 3.6 to 66.9). Of the 70 patients randomized, 39 completed the study. Four patients in the treatment group developed a localized red rash beneath the tape. These reactions were minor and transient and resolved without medical intervention.

CONCLUSIONS

The development of hypertrophic and stretched scars in the treatment group only after the tape was removed suggests that tension acting on a scar is the trigger for hypertrophic scarring. Paper tape is likely to be an effective modality for the prevention of hypertrophic scarring through its ability to eliminate scar tension.

Does the use of low-level laser influence wound healing in chronic venous leg ulcers?

OBJECTIVE

Venous leg ulcer treatment often requires months or years of regular wound care by trained staff. It has been suggested that low-level laser irradiation has a biostimulative and wound healing effect, but this has not been clinically verified by controlled studies. This study aimed to compare the effectiveness of low-level laser irradiation with that of a placebo 'light source'.

METHOD

Forty-four patients were assigned to two treatment groups (laser and placebo) or a third group (standardised treatment only) to quantify the effect of the laser therapy. Patients in all three groups received standardised wound care (disinfection, a hydrofibre dressing and compression bandaging). Ulcer size was measured at baseline (day 1), at the end of therapy (day 28) and then two months later (day 90). The relative difference in wound size was evaluated.

RESULTS

The difference in the reduction in wound size was not statistically significant in all three groups. A positive effect of using the non-laser device (placebo effect) was demonstrated in some patients.

CONCLUSION

These study results suggest that low-level laser does not stimulate wound healing in venous leg ulcers. Further controlled studies are needed to clarify the efficacy of low-level laser treatment as a wound-healing stimulant.

Force microscopy studies of fibronectin adsorption and subsequent cellular adhesion to substrates with well-defined surface chemistries

Molecular force spectroscopy was used to study the mechanical behavior of plasma fibronectin (FN) on mica, gold, poly(ethylene glycol), and -CH(3), -OH, and -COOH terminated alkanethiol self-assembled monolayers. Proteins were examined at two concentrations, one resulting in a saturated surface with multiple intermolecular interactions referred to as the aggregate state and another resulting in a semiaggregate state where the proteins were neither completely isolated nor completely aggregated. Modeling of the force-extension data using two different theories resulted in similar trends for the fitted thermodynamic parameters from which insight into the protein's binding state could be obtained. Aggregated proteins adsorbed on hydrophobic surfaces adopted more rigid conformations apparently as a result of increased surface denaturation and tighter binding while looser conformations were observed on more hydrophilic surfaces. Studies of FN in a semiaggregate state showed heterogeneity in the model's thermodynamic parameters suggesting that, in the early stages of nonspecific adsorption, multiple protein conformations exist, each having bound irreversibly to the substrate. Proteins in this state all demonstrated a more rigid conformation than in the corresponding aggregate studies due to the greater number of substrate contacts available to the protein. Finally, the force spectroscopy experiments were examined for any biocompatibility correlation by seeding substrates with human umbilical vascular endothelial cells. As predicted from the models used in this work, surfaces with aggregated FN promoted cellular deposition while surfaces with FN in a semiaggregate state appeared to hinder cellular deposition and growth. The atomic force microscope's use as a means for projecting surface biocompatibility, although requiring additional testing, does look promising.

Second-intention repair in the horse and pony and management of exuberant granulation tissue

Second-intention repair is faster in ponies than in horses and faster in body wounds than in limb wounds. To a large extent, the differences between horses and ponies can be explained by differences in the local inflammatory response, which are a result of the functional capacity of leukocytes. In ponies, leukocytes produce more inflammatory mediators,resulting in better local defense, faster cellular debridement, and a faster transition to the repair phases, with more wound contraction. In horses,leukocytes produce fewer mediators, initiating a weak inflammatory response, which becomes chronic. This inhibits wound contraction and gives rise to the formation of exuberant granulation tissue. The anatomic environment that influences the inflammatory response and wound contraction most probably determines the differences between body and limb wounds. In body wounds, better perfusion results in faster initiation of the inflammatory phase. The weaker local resistance results in a greater degree of contraction. In limb wounds, particularly of horses, the initial inflammatory response is weak and wound contraction is restricted. Both factors give rise to chronic inflammation, which further inhibits wound contraction and promotes exuberant granulation tissue. The high incidence of exuberant granulation tissue in limb wounds of horses can thus be explained by the chronicity of the inflammatory response as well as by the common use of bandages during treatment. Chronic inflammation is often not recognized as a cause of exuberant granulation tissue. It must be prevented and treated to promote the healing process. Bandages and casts stimulate the formation of exuberant granulation tissue; however, they are advantageous in many respects and play an important role in support of the overall healing process.

Diffusible factors released by fibroblasts support epidermal morphogenesis and deposition of basement membrane components

Epithelial-mesenchymal interactions play an important role in controlling epidermal morphogenesis and homeostasis but little is known about the mechanisms of these interactions. To examine whether diffusible factors produced by fibroblasts and/or keratinocytes support epidermal morphogenesis and basement membrane formation, organotypic keratinocyte monocultures were established in media collected either from organotypic fibroblast or keratinocyte-monocultures or from keratinocyte-fibroblast cocultures, and the expression of keratin 10, 16, and 17 and basement membrane components (types IV and VII collagen, laminin 5, nidogen, BP 180, LAD-1) were examined. We found that diffusible factors released by keratinocytes were not sufficient to support the establishment of normalized epidermal phenotype and deposition of basement membrane components in contrast to fibroblast- or keratinocyte/fibroblast-derived factors. Keratinocytes appear to affect the spectrum of secreted soluble factors, as keratinocyte/fibroblast-derived factors were more effective to accomplish continuous linear deposition of laminin 5 and of nidogen. The finding that released amounts of keratinocyte growth factor and granulocyte macrophage colony stimulating factor were not sufficient to fully support epidermal morphogenesis and deposition of basement membrane components is suggestive for the involvement of other released diffusible factors. Generation of organotypic keratinocyte monocultures in the presence of fibroblast- or keratinocyte/fibroblast-derived soluble factors resulted in enhanced expression of keratins K16 and K17 and the absence of type IV collagen. This observation indicates that next to paracrine acting factors, epidermal homeostasis is controlled by mutual keratinocyte-fibroblast interaction.

HB-EGF is a potent inducer of tumor growth and angiogenesis

Heparin-binding epidermal growth factor-like growth factor (HB-EGF) has been shown to stimulate the growth of a variety of cells in an autocrine or paracrine manner. Although HB-EGF is widely expressed in tumors compared with normal tissue, its contribution to tumorigenicity is unknown. HB-EGF can be produced as a membrane-anchored form (pro-HB-EGF) and later processed to a soluble form (s-HB-EGF), although a significant amount of pro-HB-EGF remains uncleaved on the cell surface. To understand the roles of two forms of HB-EGF in promoting tumor growth, we have studied the effects of HB-EGF expression in the process of tumorigenesis using in vitro and in vivo systems. We demonstrate here that in EJ human bladder cancer cells containing a tetracycline-regulatable s-HB-EGF or pro-HB-EGF expression system, s-HB-EGF expression increased their transformed phenotypes, including growth rate, colony-forming ability, and activation of cyclin D1 promoter, as well as induction of vascular endothelial growth factor in vitro. Moreover, s-HB-EGF or wild-type HB-EGF induced the expression and activities of the metalloproteases, MMP-9 and MMP-3, leading to enhanced cell migration. In vivo studies also demonstrated that tumor cells expressing s-HB-EGF or wild-type HB-EGF significantly enhanced tumorigenic potential in athymic nude mice and exerted an angiogenic effect, increasing the density and size of tumor blood vessels. However, cells expressing solely pro-HB-EGF did not exhibit any significant tumorigenic potential. These findings establish s-HB-EGF as a potent inducer of tumor growth and angiogenesis and suggest that therapeutic intervention aimed at the inhibition of s-HB-EGF functions may be useful in cancer treatment.

Cytokines and wound healing: the role of cytokine and anticytokine therapy in the repair response

Wound healing is an integrated and complex process involving a large number of regulatory molecules, including proinflammatory cytokines and growth factors, and an orchestrated tissue response. Dysregulation in cytokine or growth factor expression dramatically alters the normal wound healing process, and blocking the inappropriate production of specific proinflammatory cytokines or supplementing the milieu with increased quantities of growth factors has demonstrated the central role played by these mediators. Both protein-based and DNA-based (gene transfer) therapies are currently under clinical development as tools to improve the healing process. Although there has been some success with these approaches in both experimental models and in patients, only through a better understanding of the complexity and diversity of the wound healing process, as well as an improved comprehension of the time-dependent and concentration-dependent responses to individual proinflammatory cytokines or growth factors, will further development in the therapeutic treatment of healing wounds be attained.

Fibroblasts facilitate re-epithelialization in wounded human skin equivalents

The re-epithelialization of the wound involves the migration of keratinocytes from the edges of the wound. During this process, keratinocyte migration and proliferation will depend on the interaction of keratinocytes with dermal fibroblasts and the extracellular matrix. The present study aimed to investigate (1) the role of fibroblasts in the re-epithelialization process and on the reconstitution of the dermal-epidermal junction (DEJ) and (2) differential protein expression during re-epithelialization. For both purposes, three-dimensional human skin equivalents (HSE) were used. A full-thickness wound in HSE was introduced by freezing with liquid nitrogen and a superficial wound by linear incision with a scalpel. The closure of the wound in the absence or presence of exogenous growth factors was followed by monitoring the rate of re-epithelialization and regeneration of the DEJ. The results obtained in this study demonstrate that fibroblasts facilitate wound closure, but they differentially affected the deposition of various basement membrane components. The deposition of laminin 5 at the DEJ was delayed in superficial wounds as compared to the full-thickness wounds. During freeze injury, some basement membrane (BM) components remain associated with the dermal compartment and probably facilitate the BM reconstitution. The re-epithelialization process in full-thickness but not in superficial wounds was accelerated by the presence of keratinocyte growth factor and especially by epidermal growth factor. In addition, we have examined the deposition of various basement membrane components and the differences in protein expression in a laterally expanding epidermis in uninjured HSE. Laminin 5, type IV and VII collagen deposition was decreased in the laterally expanding epidermis, indicating that the presence of these proteins is not required for keratinocyte migration to occur in vitro. Using two-dimensional polyacrylamide gel electrophoresis, we have identified DJ-1, a protein not earlier reported to be differently expressed during the epithelialization process of the skin.

Fucoidan Modulates the Effect of Transforming Growth Factor (TGF)-.BETA.1 on Fibroblast Proliferation and Wound Repopulation in in Vitro Models of Dermal Wound Repair

Aberrant wound healing, either causing scarring or chronic wounds, is a significant cause of morbidity. There is therefore, considerable interest in agents which can modulate certain aspects of the wound healing process. Fucoidans, sulphated polyfucose polysaccharides which may be extracted from Fucus spp., have been shown to modulate the effects of a variety of growth factors through mechanisms thought to be similar to the action of heparin. We investigated the interaction between two commercial preparations of fucoidan and transforming growth factor (TGF)-beta(1). These preparations of fucoidan, as well as heparin, inhibited fibroblast proliferation at concentrations from 0.01 to 100 mg/ml. The anti-proliferative effects of 1 ng/ml TGF-beta(1) on dermal fibroblasts were abrogated by fucoidan preparation F7 when used at concentrations over 1 mg/ml. In a three dimensional in vitro model of wound repair, the fibroblast populated collagen lattice or "dermal equivalent", TGF-beta(1) reduced the rate of fibroblast repopulation of a wound defect created by punch biopsy. Addition of fucoidan to the model in the presence of TGF-beta(1) increased the rate of fibroblast repopulation of the wound and at 10 mg/ml of fucoidan the number of cells which had migrated into the wounded defect was similar to that of control cultures. These data suggest that fucoidan has properties which may be beneficial in the treatment of wound healing.

Tracking angiogenesis induced by skin wounding and contact hypersensitivity using a Vegfr2-luciferase transgenic mouse

The vascular endothelial growth factor-2 (VEGFR2) gene is transcriptionally regulated during angiogenesis. The ability to monitor and quantify VEGFR2 expression in vivo may facilitate a better understanding of the role of VEGFR2 in different states. Here we describe a transgenic mouse, Vegfr2-luc, in which a luciferase reporter is under control of the murine VEGFR2 promoter. In adult mice, luciferase activity was highest in lung and uterus, intermediate in heart, skin, and kidney, and lower in other tissues. Luciferase expression in these tissues correlated with endogenous VEGFR2 mRNA expression. In a cutaneous wound-healing model, Vegfr2-luc expression was induced in the wound tissue. Histologic and immunohistochemical studies showed significant macrophage infiltration into the wound and induction of Vegfr2-luc expression in endothelial and stromal cells. Dexamethasone significantly suppressed Vegfr2-luc expression and macrophage infiltration into the wound, resulting in delayed healing and impaired angiogenesis. In a skin hypersensitivity reaction produced by treatment with oxazolone, Vegfr2-luc expression was induced in the ear. Treatment by dexamethasone markedly suppressed Vegfr2-luc expression and leukocyte infiltration in the ear and was correlated with reduced dermal edema and epidermal hyperplasia. The Vegfr2-luc model will be valuable in monitoring the ability of drugs to affect angiogenesis in vivo.

Proliferative scarring

Proliferative scarring in all organ systems is an enigma. Treatment has been difficult to impossible because the pathobiology of exuberant scarring and fibrosis was unclear. With the concept that proliferative scarring can be viewed on the healing trajectory and dissected into variations of the normal wound healing cellular processes mediated by soluble cytokine messengers, one can begin to understand how excessive scar formation occurs. Realizing that overexpression or dysregulated activity of the fibrogenic isoforms of TGF-beta and its attendant effect on apoptosis may be responsible for proliferative scarring opens the route to propose rational molecular manipulations that can be tested for the prevention or treatment of this enigmatic condition.

Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids

BACKGROUND

Hypertrophic scars affect 1.5% to 4.5% of the general population and remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with treatment. Pulsed dye laser (PDL) treatment and intralesional corticosteroids have individually been reported to be effective in reducing hypertrophic scar bulk and symptoms.

OBJECTIVE

To determine whether combination PDL and intralesional corticosteroid treatment produces better hypertrophic scar improvement than PDL treatment alone.

METHODS

Bilateral hypertrophic inframammary scars in 22 females were randomly assigned to receive treatment with 585-nm PDL alone or in combination with intralesional corticosteroid. Clinical evaluations and scar pliability scores were determined before each of the two treatment sessions and 6 weeks after the final treatment. Histologic evaluation of skin biopsies obtained before and after treatment was performed in four patients.

RESULTS

All scars showed clinical improvement with increased pliability and decreased symptoms (pruritus) after each of the two treatments. Clinical improvement scores were not significantly better with the concomitant use of corticosteroids. Side effects were limited to mild purpura and transient hyperpigmentation. Decreased sclerosis was seen in scars after PDL treatment (with or without concomitant corticosteroids).

CONCLUSIONS

Treatment of hypertrophic inframammary scars with 585-nm PDL irradiation alone effected substantial clinical and histologic improvement. The adjunctive use of intralesional corticosteroids did not significantly enhance clinical outcome except in those scars that were most symptomatic.

Cytokine manipulation of the wound

Most individuals expect that healing is an inevitable outcome; wound healing is taken for granted. Although wound healing is perceived as inevitable, it can be fraught with problems and altered at many points. In the past, optimization of wound healing focused on minimizing contamination, accurate tissue approximation, and providing protection. With the advent of recombinant technology, optimization can now include manipulation of the molecular and cellular wound environment. Although the exact manipulative scheme has not yet evolved, it is clear from the multiple attempts reported in this article that understanding and progress is being made.

A novel controlled drug-delivery system for growth hormone applied to healing skin wounds in diabetic rats

Controlled release systems for drugs, hormones and growth factors can be particularly useful in tissue repair processes. These systems act as a biodegradable support containing the substance to be delivered, allowing their gradual release. In the past years, the local application of growth factors has acquired special relevance as a therapeutic option for use in subjects who show deficient tissue scarring, the hormone dose being the limiting factor for its success. In this study, the in vitro biocompatibility of a copolymer formed by vinylpyrrolidone and 2-hydroxyethyl methacrylate, used as an administration vehicle for hGH, was evaluated. The system was then tested in vivo in terms of its capacity for healing incisional wounds in healthy and diabetic rats. For the in vitro studies, polymer and hormone degradation rates were determined, and polymer biocompatibility was evaluated in fibroblast cultures. In the in vivo experiments, an incision was made in the back of the animals, and polymers discs with/without hGH, were introduced in the aperture. Morphological, immunohistochemical and morphometric evaluations were performed on wound tissue specimens 3-10 days after surgery. In vitro, the polymer was found to be biodegradable and showed no toxic effects on fibroblasts, the hormone being slowly released to the culture medium. In untreated diabetic rats, a delayed skin scarring and cell response were observed, compared to that noted in healthy animals. Skin closure, keratinisation and fibrosis occurred earlier in the presence of the polymer-hGH system. The use of this co-polymer as an administration vehicle for hGH improves the wound scarring process in the pathological setting of diabetes.

Biophysics of nonablative dermal remodeling

This article explores the physics of nonablative skin remodeling as well as the histologic sequelae. Although there have been several studies of nonablative skin remodeling, the exact mechanisms of action and thus the optimum device-specific parameters are not yet known. The article is divided into a discussion of the physics of laser-tissue interactions, followed by a review of the types of devices used for nonablative skin remodeling, and the histologic findings that follow treatment.

Adenovirus-mediated VEGF(165) gene transfer enhances wound healing by promoting angiogenesis in CD1 diabetic mice

It has been previously shown that vascular endothelial growth factor (VEGF) plays a central role in promoting angiogenesis during wound repair and that healing-impaired diabetic mice show decreased VEGF expression levels. In order to investigate the potential benefits of gene therapy with growth factors on wound repair, a replication-deficient recombinant adenovirus vector carrying the human VEGF(165) gene (AdCMV.VEGF(165)) was topically applied on excisional wounds of streptozotocin-induced diabetic mice. Treatment with AdCMV.VEGF(165) significantly accelerated wound closure when compared with AdCMV.LacZ-treated, as well as saline-treated control mice, by promoting angiogenesis at the site of injury. Our findings suggest that AdCMV.VEGF(165) may be regarded as a therapeutic tool for the treatment of diabetic ulcers.

Effect of fibrin sealant composition on human neutrophil chemotaxis

The use of fibrin sealants offers one of the most physiologically compatible approaches to preventing postoperative adhesions. Although a number of fibrin sealant formulations have been developed, little is known about how the various components of these preparations affect the wound-healing process. Because one of the key steps in wound healing is the migration of phagocytic leukocytes, such as neutrophils, into the site of injury, we performed studies to characterize systematically the effects of various fibrin sealant components on neutrophil chemotaxis. Using a transwell chemotaxis assay, we found that increasing fibrin concentration resulted in an inhibition of the ability of the cells to migrate through the clots in a dose-dependent manner, and at fibrin clot concentrations >2.0 mg/mL chemotaxis was completely blocked. Factor XIII crosslinking of the clots also had a significant impact on neutrophil chemotaxis, and sealant preparations deficient in Factor XIII allowed neutrophil migration at much higher fibrin concentrations. The presence of various other fibrin sealant components such as plasminogen and fibrinolysis inhibitors (aprotinin and tranexamic acid) did not have any significant effects on the ability of neutrophils to migrate through fibrin clots as compared to control clots without these components. Overall, these studies show that the composition of fibrin sealant preparations can significantly affect neutrophil migration into the site of injury, which could possibly influence the wound healing process.

The identification of novel wound-healing genes through differential display

Effective methods to identify novel genes in complicated dynamic tissue processes are needed in molecular biology research. Traditional techniques primarily target known genes and are inefficient in the pursuit of unknown genes. Here we describe the use of a modified differential display polymerase chain reaction (DD-PCR) protocol for the identification of genes differentially expressed in wound healing. Full-thickness dorsal wounds were made on 35 adult rats, followed by wound harvest at 12 hours, 24 hours, 3 days, 5 days, 7 days, 10 days, and 14 days after injury. Modified DD-PCR was performed and gene fragments displaying definite changes during wound healing were cloned and sequenced. Gene fragments from DD-PCR were compared with available gene bank database sequences. Specific primer PCR was used to confirm DD-PCR expression patterns. As a result, over 1000 gene fragments were amplified by DD-PCR, 35 of which demonstrated distinct differences during repair. Cloning and sequencing of 13 of these gene fragments revealed that some were homologous to several characterized genes with previously unsuspected roles in repair, whereas others were completely novel genes with no known function. Specific primer PCR further confirmed expression of six of these 13 gene fragments. Only one of the 13 cloned fragments, later identified as interleukin-1beta, had well-recognized associations with tissue injury. Other fragments corresponded to various genes involved in cellular processes such as differentiation, proliferation, exocytosis, and myofibril assembly. No prior studies have linked them to wound healing. We have demonstrated that modified DD-PCR can be used to effectively identify novel genes differentially expressed during repair. Because DD-PCR allows for the simultaneous amplification of multiple arbitrary transcripts, it is a powerful genetic screening tool for complicated dynamic tissue processes, particularly when multiple, limited-sized samples are involved.

Inflammation. 1: Its role in the healing of acute wounds

The inflammatory response is an essential part of the wound-healing process. This article discusses inflammation in acute wounds and the part played by the migration of cells including neutrophils, macrophages and T-lymphocytes.

An ex vivo assay to assess the potential of skin keratinocytes for wound epithelialization

Wound closure following injury to the skin is a complex process involving both dermal contraction and keratinocyte migration. Murine models of wound healing are potentially useful because of the ability to determine protein function through gene manipulation. Owing to the dominant role of dermal contraction, the technical difficulties in preparing the wound site for morphologic studies, and the postnatal phenotypes altering the properties of transgenic skin, there are difficulties in assessing the epithelial contribution to wound closure in mouse skin. We describe a simple ex vivo assay utilizing explant culture that enables a quantitative assessment of the potential of mouse keratinocytes for wound epithelialization. In this assay, the behavior and properties of skin keratinocytes mimic well those that occur at the edge of skin wounds in situ, including a dependence upon connective tissue element(s), proliferation, and migration. The epithelial cell outgrowths emerging from skin explants can be studied in real-time or examined at specific time-points for markers of interest in the epithelialization process. The assay is quantitative and can successfully detect increases or decreases in epithelialization potential, and can be useful in the characterization of transgenic mouse models.

Curcumin differentially regulates TGF-beta1, its receptors and nitric oxide synthase during impaired wound healing

Wound healing is a highly ordered process, requiring complex and coordinated interactions involving peptide growth factors of which transforming growth factor-beta (TGF-beta) is one of the most important. Nitric oxide is also an important factor in healing and its production is regulated by inducible nitric oxide synthase (iNOS). We have earlier shown that curcumin (diferuloylmethane), a natural product obtained from the plant Curcuma longa, enhances cutaneous wound healing in normal and diabetic rats. In this study, we have investigated the effect of curcumin treatment by topical application in dexamethasone-impaired cutaneous healing in a full thickness punch wound model in rats. We assessed healing in terms of histology, morphometry, and collagenization on the fourth and seventh days post-wounding and analyzed the regulation of TGF-beta1, its receptors type I (tIrc) and type II (tIIrc) and iNOS. Curcumin significantly accelerated healing of wounds with or without dexamethasone treatment as revealed by a reduction in the wound width and gap length compared to controls. Curcumin treatment resulted in the enhanced expression of TGF-beta1 and TGF-beta tIIrc in both normal and impaired healing wounds as revealed by immunohistochemistry. Macrophages in the wound bed showed an enhanced expression of TGF-beta1 mRNA in curcumin treated wounds as evidenced by in situ hybridization. However, enhanced expression of TGF-beta tIrc by curcumin treatment observed only in dexamethasone-impaired wounds at the 7th day post-wounding. iNOS levels were increased following curcumin treatment in unimpaired wounds, but not so in the dexamethasone-impaired wounds. The study indicates an enhancement in dexamethasone impaired wound repair by topical curcumin and its differential regulatory effect on TGF-beta1, it's receptors and iNOS in this cutaneous wound-healing model.

Fibrosin: a novel lymphokine in wound healing

Several growth factors are actively synthesized during wound repair and function to stimulate different cell types involved in the process of healing. Fibrosin is a novel fibrogenic lymphokine that stimulates several biological activities that relate to in vivo scarring. To investigate the role of fibrosin, we used "punch biopsy" and linear wounding procedures in a murine model of wound healing. Histological examination showed that recombinant fibrosin stimulated epithelialization of wounds and accelerated healing of both punch biopsy and linear wounds. Fibrosin enhanced healing of linear wounds by reducing the time for healing by approximately 30-40%. From our data we estimated the healing time of control wounds to be 22-24 days; wounds treated with fibrosin appeared to heal in 14-16 days. Our observations suggest that fibrosin enhances wound healing and may be involved in accelerating epithelialization, collagen matrix formation, and also remodeling of the extracellular matrix in vivo. Thus fibrosin may function during different phases of wound healing and act as a potent inducer of scar formation and wound healing. This finding may have direct clinical applications.

The mast cell in wound healing

This review describes the role of the mast cell in the pathobiology of skin healing. After illustrating its main morphofunctional characteristics, with special reference to the dog and cat, we consider the involvement of the mast cell in the various phases of skin repair. With the aid of a wide array of newly formed or preformed mediators released by degranulation, the activated mast cell controls the key events of the healing phases: triggering and modulation of the inflammatory stage, proliferation of connective cellular elements and final remodelling of the newly formed connective tissue matrix. The importance of the mast cell in regulating healing processes is also demonstrated by the fact that a surplus or deficit of degranulated biological mediators causes impaired repair, with the formation of exuberant granulation tissue (e.g. keloids and hypertrophic scars), delayed closure (dehiscence) and chronicity of the inflammatory stage.

Delayed wound repair and impaired angiogenesis in mice lacking syndecan-4

The syndecans make up a family of transmembrane heparan sulfate proteoglycans that act as coreceptors with integrins and growth factor tyrosine kinase receptors. Syndecan-4 is upregulated in skin dermis after wounding, and, in cultured fibroblasts adherent to the ECM protein fibronectin, this proteoglycan signals cooperatively with beta1 integrins. In this study, we generated mice in which the syndecan-4 gene was disrupted by homologous recombination in embryonic stem cells to test the hypothesis that syndecan-4 contributes to wound repair. Mice heterozygous or homozygous for the disrupted syndecan-4 gene are viable, fertile, and macroscopically indistinguishable from wild-type littermates. Compared with wild-type littermates, mice heterozygous or homozygous for the disrupted gene have statistically significant delayed healing of skin wounds and impaired angiogenesis in the granulation tissue. These results indicate that syndecan-4 is an important cell-surface receptor in wound healing and angiogenesis and that syndecan-4 is haplo-insufficient in these processes.

Laser treatment of hypertrophic scars, keloids, and striae

The successful use of the 585-nm pulsed dye laser for the treatment of hypertrophic scars has been well established over the past decade. Although 5 years ago this treatment option might have been considered as a viable choice only after all other methods failed, it is now generally recognized as an excellent first-line treatment option. Early scar treatment with pulsed dye laser irradiation effectively prevents scar formation or worsening and yields a better and more prolonged clinical improvement. The concomitant use of corticosteroids, 5-fluorouracil, or other treatments is proving to be of particular importance in reducing scar bulk and symptoms of more proliferative scars. Although optimal management for keloids and striae has yet to be determined, pulsed dye laser irradiation will no doubt continue to play a role in their treatment.

Regulated cutaneous gene delivery: the skin as a bioreactor

Epidermal keratinocytes can secrete polypeptides into the bloodstream, and they can be easily expanded in culture and genetically modified. It is thus possible to use epidermal keratinocytes for the systemic delivery of transgene products. Here we review the development of epidermal secretory systems, from cultured keratinocytes to skin grafts and transgenic mouse models. We also discuss a gene-switch approach for regulated cutaneous gene delivery.

Stimulatory effect of 660 nm low level laser energy on hypertrophic scar-derived fibroblasts: possible mechanisms for increase in cell counts

BACKGROUND AND OBJECTIVE

Varying effects of red light wavelengths on in vitro cells have been reported. Low level lasers (LLL) are employed to assist wound healing especially for indolent ulcers. On healing, burn wounds may become hypertrophic, resulting in excessive wound contraction, poor cosmesis, and functional impairment. This study enquired whether 660 nm LLL affected hypertrophic scar-derived fibroblasts.

STUDY DESIGN/MATERIALS AND METHODS

The experiments investigated the effect of a 660 nm, 17 mW laser diode at dosages of 2.4 J/cm2 and 4 J/cm2 on cell counts of two human fibroblast cell lines, derived from hypertrophic scar tissue (HSF) and normal dermal (NDF) tissue explants, respectively. The protocol avoided transfer of postirradiated cells. Estimation of fibroblasts utilized the methylene blue bioassay.

RESULTS/CONCLUSION

The post-660 nm-irradiated HSFs exhibited very significantly higher cell counts than controls P < 0.01 on days 1-4 (Mann-Whitney U-test), and P < 0.01 on days 1-3 for similarly irradiated NDFs.

Second intention healing after Mohs micrographic surgery

BACKGROUND

Although second intention healing has been used for many years in Mohs micrographic surgery, it has lost popularity. This is due to the long process and functional alteration of important anatomical units if certain wound healing factors are not carefully taken into consideration.

OBJECTIVE

To review indications, contraindications, complications, advantages, disadvantages, as well as basic concepts of the wound healing process, wound care and antibiotic prophylaxis in the management of open wounds after Mohs surgery.

METHODS

A short but comprehensive review of studies published in the literature dealing with second intention healing as a reconstruction alternative option in certain situations.

CONCLUSIONS

Second intention healing is a simple and cost-effective method for reconstruction after Mohs micrographic surgery in well-defined cases. It allows adequate tumoral control with good to excellent functional and cosmetic results.

Alterations in rat's brain capillaries in a model of focal cerebral necrosis

Focal brain compression causes cerebral tissue damage. In this study we followed alterations in capillary ultrastructure in the rat cortex and neurohypophysis caused by 40 mm Hg compression for 15 minutes. One day after experiment we observed clogging of capillaries, accumulation of collagen fibrills under the basement membrane and necrosis or apoptosis of endothelial cells. Four days after it the basement membrane was multiplicated, blurred and thickened. In the neurohypophysis the formation of vessels lined with the atypical continuous endothelium was seen. There was also evidence for the migration of pericytes through the blurred basement membrane and the differentiation of pericytes into endothelial cells. Thus, vascular injury in the compressed brain is followed by a highly ordered sequence of processes in the basement membrane and perivascular cells leading to capillary repair.

Prolonged clinical and histologic effects from CO2 laser resurfacing of atrophic acne scars

BACKGROUND

The recent development of high-energy pulsed CO2 lasers that minimize thermal injury to uninvolved adjacent structures has revolutionized the manner in which atrophic facial scars are recontoured. Significant improvement of atrophic scars with laser resurfacing has clearly been demonstrated; however, the exact timing for assessment of skin for further treatment has varied due to the unknown amount of time needed after laser scar resurfacing to effect maximal collagen formation and remodeling.

OBJECTIVE

The aim of this study was to determine the immediate and long-term (12-18 months) histologic and clinical effects of atrophic acne scars after CO2 laser resurfacing in order to provide physician guidelines for postoperative clinical assessment for retreatment.

METHODS

Sixty patients (50 women, 10 men, mean age 38 years, skin types I-V) with moderate to severe atrophic facial scars were evaluated. Nineteen patients received regional cheek treatment and 41 patients received full-face resurfacing with a high-energy pulsed CO2 laser. Independent clinical assessments of treated scars were performed at 1, 6, 12, and 18 months and blinded histologic analyses were made of skin biopsies immediately prior to and after laser resurfacing, and at 1, 6, 12, and 18 months postoperatively in six patients.

RESULTS

Significant immediate and prolonged clinical improvement in skin tone, texture, and appearance of CO2 laser-irradiated scars was seen in all patients. Average clinical improvement scores were 2.22 (69%) at 1 month, 2.1 (67%) at 6 months, 2.37 (73%) at 12 months, and 2.5 (75%) at 18 months. Continued collagenesis and subsequent dermal remodeling were observed on histologic examination of biopsied tissue up to 18 months after surgery.

CONCLUSION

Continued clinical improvement was observed as long as 18 months after CO2 laser resurfacing of atrophic scars, with an 11% increase in improvement observed between 6 and 18 months postoperatively. We propose that a longer postoperative interval (12-18 months) prior to assessment for re-treatment be advocated in order to permit optimal tissue recovery and an opportunity for collagen remodeling.

Accelerated wound healing in mice with a disruption of the thrombospondin 2 gene

Mice that lack the extracellular matrix protein thrombospondin 2 have, among several abnormalities, an increase in vascular density, abnormal collagen fibrils, and dermal fibroblasts that are defective in adhesion. These findings suggested that responses involving these processes, such as wound healing, might be altered. To investigate the healing process, excisional wounds were made with the aid of a biopsy punch. Such wounds, observed over a 14 d period, appeared to heal at an accelerated rate and with less scarring in thrombospondin 2-null mice. Histologic analysis of thrombospondin 2-null wound sites revealed the presence of an irregularly organized and highly vascularized granulation tissue. In addition, thrombospondin 2-null wounds retained a higher total cellular content, than control wounds. No differences in wound re-epithelization rates were observed, but thrombospondin 2-null epithelia formed rete pegs and were thicker than control epithelia. By immunohistochemistry, we detected elevated levels and an irregular deposition pattern for fibronectin in thrombospondin 2-null wounds, observations that correlated with the abnormal collagen organization in the granulation tissue. Immunostaining for thrombospondin 2 in control wounds showed that the protein is present in both early and late wounds, in a scattered cell-associated pattern or widely distributed cell- and matrix-associated pattern, respectively. Our results suggest that thrombospondin 2 plays a crucial part in the organization and vascularization of the granulation tissue during healing, possibly by modulating fibroblast-matrix interactions in early wounds and regulating the extent of angiogenesis in late wounds.

Involucrin-positive keratinocytes demonstrate decreased migration speed but sustained directional migration in a DC electric field

When skin is wounded, keratinocytes from the cut edges of the epidermis migrate over the wounded area to re-epithelialize the wound. It is not clear which cells of the epidermis have the capacity to migrate and contribute to this re-epithelialization: the less differentiated cells of the basal layer, or the more differentiated, involucrin-positive suprabasilar cells. Here we demonstrate that both involucrin-negative and involucrin-positive cells are able to respond to a directional cue for migration with sustained directional migration. When cultured keratinocytes are exposed to a physiologic DC electric field of 100 mV per mm as a cue to guide migration (galvanotaxis) they migrate toward the cathode with equivalent directionality. The involucrin-positive cells, however, display mean migration speeds approximately one half (23.6 microm per h) of the mean rate achieved by involucrin-negative cells (46.5 microm per h). Despite their decreased migration rates, involucrin-positive cells appear to possess an intact mechanism for sensing a directional signal, transducing that signal, and responding with sustained directional migration. Because electric fields are endogenous in skin wounds, it is likely that both the basal, involucrin-negative cells and the involucrin-positive suprabasilar cells respond to this cue with directional migration. The new observation that involucrin-positive cells can indeed migrate suggests that these cells may also contribute to wound re-epithelialization in vivo.

Arnebin-1 accelerates normal and hydrocortisone-induced impaired wound healing

Wound healing involves inflammation, cell proliferation, matrix deposition, and tissue remodeling. Interaction of different cells, extracellular matrix proteins, and their receptors are mediated by cytokines and growth factors during wound healing. In this study, we have evaluated the effect of arnebin-1, a natural product isolated from Arnebia nobilis, on normal and impaired wound healing in cutaneous punch wound model. Arnebin-1 was applied topically daily on wounds of hydrocortisone-treated or untreated animals. Arnebin-1 significantly accelerated healing of wounds with or without hydrocortisone treatment as revealed by a reduction in the wound width and gap length compared with controls. Arnebin-1 treatment promoted the cell proliferation, migration, and vessel formation to form a thick granulation tissue and re-epithelialization of the wounds. An increase in the synthesis of collagen, fibronectin and transforming growth factor-beta1 was seen in arnebin-1-treated wounds compared with the untreated control. As transforming growth factor-beta1 is known to enhance wound healing, and associated with the wound healing defect in hydrocortisone-treated wounds, the enhanced expression of transforming growth factor-beta1 at both translational and transcriptional level by arnebin-1 may be responsible for the enhancement of wound healing during normal and impaired wound repair. These studies suggest that arnebin-1 could be developed as a potent therapeutic agent for wound healing in steroid-impaired wounds.

Tissue transglutaminase is expressed, active, and directly involved in rat dermal wound healing and angiogenesis

Tissue transglutaminase (TG) is an enzyme that stabilizes the structure of tissues by covalently ligating extracellular matrix molecules. Expression and localization of TG are not well established during wound healing. We performed punch biopsy wounds on anesthetized rats and monitored the wound healing process by histological and immunohistochemical methods. The TG antigen and activity are expressed at sites of neovascularization in the provisional fibrin matrix within 24 h of wounding. Endothelial cells, macrophages, and skeletal muscle cells expressed TG throughout the healing process. The TG antigen within the wound was active in vivo based on the detection of isopeptide bonds. The TG antigen increased four- to fivefold by day 3 postwounding and was proteolytically degraded. TG expression occurred in association with TGF-beta, TNF-alpha, IL-6, and VEGF production in the wound. Recombinant TG increased vessel length density (a measure of angiogenesis) when applied topically in rat dorsal skin flap window chambers. We have established that TG is an important tissue stabilizing enzyme that is active during wound healing and can function to promote angiogenesis.

Acute inflammatory responses to mechanical lesions in the CNS: differences between brain and spinal cord

Lesion-induced inflammatory responses in both brain and spinal cord have recently become a topic of active investigation. Using C57BL/6J mice, we compared the tissue reaction in these two central nervous system (CNS) compartments with mechanical lesions of similar size involving both grey and white matter. This evaluation included the quantitative assessment of neutrophils, lymphocytes and activated macrophages/microglia, as well as astrocyte activation, upregulation of vascular cell adhesion molecules (ICAM-1, VCAM-1, PECAM) and the extent of blood-brain barrier (BBB) breakdown. Time points analysed post-lesioning included 1, 2, 4 and 7 days (as well as 10 and 14 days for the BBB). We found clear evidence that the acute inflammatory response to traumatic injury is significantly greater in the spinal cord than in the cerebral cortex. The numbers of both neutrophils and macrophages recruited to the lesion site were significantly higher in the spinal cord than in the brain, and the recruitment of these cells into the surrounding parenchyma was also more widespread in the cord. The area of BBB breakdown was substantially larger in the spinal cord and vascular damage persisted for a longer period. In the brain, as in spinal cord, the area to which neutrophils were recruited correlated well with the area of BBB breakdown. It will be of interest to determine the extent to which the infiltration of inflammatory cells contributes, either directly or indirectly, to the vascular permeability and secondary tissue damage or, conversely, to local tissue repair in the brain and the spinal cord.

Plasma fibronectin: three steps to purification and stability

Large amounts of soluble fibronectin were easily purified from cryoprecipitated or fresh citrated human blood plasma by a three-step combination of gelatin and heparin-cellufine affinity chromatography. The elution conditions were optimized to obtain a homogeneous fraction on SDS-PAGE and Western blot under reducing condition. No proteolytic activities were detected by zymography at acidic or neutral pH. Furthermore, the fibronectin preparation was stable over time up to 456 h at 37 degrees C in the presence of calcium, zinc, or mercury. This preparation of very stable fibronectin, called highly purified fibronectin (hpFN), gave a yield of 7.00 +/- 0.77 mg of fibronectin per gram of cryoprecipitated plasma and 0.16 mg of fibronectin per milliliter of fresh citrated, giving a yield of 32 to 53% (from presumed fibronectin concentration). This preparation may be useful for cellular tests and interaction analysis.

Curcumin enhances wound healing in streptozotocin induced diabetic rats and genetically diabetic mice

Tissue repair and wound healing are complex processes that involve inflammation, granulation and tissue remodeling. Interactions of different cells, extracellular matrix proteins and their receptors are involved in wound healing, and are mediated by cytokines and growth factors. Previous studies from our laboratory have shown that curcumin (diferuloylmethane), a natural product obtained from the rhizomes of Curcuma longa, enhanced cutaneous wound healing in rats and guinea pigs. In this study, we have evaluated the efficacy of curcumin treatment by oral and topical applications on impaired wound healing in diabetic rats and genetically diabetic mice using a full thickness cutaneous punch wound model. Wounds of animals treated with curcumin showed earlier re-epithelialization, improved neovascularization, increased migration of various cells including dermal myofibroblasts, fibroblasts, and macrophages into the wound bed, and a higher collagen content. Immunohistochemical localization showed an increase in transforming growth factor-beta1 in curcumin-treated wounds compared to controls. Enhanced transforming growth factor-beta1 mRNA expression in treated wounds was confirmed by in situ hybridization, and laser scan cytometry. A delay in the apoptosis patterns was seen in diabetic wounds compared to curcumin treated wounds as shown by terminal deoxynucleotidyl transferase-mediated deoxyuridyl triphosphate nick end labeling analysis. Curcumin was effective both orally and topically. These results show that curcumin enhanced wound repair in diabetic impaired healing, and could be developed as a pharmacological agent in such clinical settings.

Systemic replacement therapy from genetically modified epidermal keratinocytes

Epidermal keratinocytes are a potential vehicle for gene transfer and systemic delivery. We review data showing that epidermis-secreted protein does indeed reach the circulation, and we discuss factors that bear upon the issue of how much protein epidermal keratinocytes can deliver to the circulation.