The safety and effect of topically applied recombinant basic fibroblast growth factor on the healing of chronic pressure sores

Signal transduction in wound pharmacology

Growth factors such as TGF-beta, PDGF and FGF are thought to play important roles in wound healing. However, their biological activity and signal transduction during wound repair remain poorly understood. Growth factors are often ligands for receptor tyrosine kinase and receptor serine/threonine kinases. With recent advances in signal transduction by receptor kinases, we are beginning to understand the underlying mechanism of how growth factors may regulate cutaneous wound repair. In this paper, we will describe the pharmacological effects of growth factors on wound healing, and discuss the potential underlying signaling mechanisms. Thus, we hope to provide the basis for designing more specific therapeutics for wound healing in the near future.

Expression of receptors for basic fibroblast growth factor on human periodontal ligament cells

Basic fibroblast growth factor (FGF-2; bFGF) is a major mitogen for connective tissue cells, and participates in the healing process. It has already been reported that FGF-2 could be applicable to enhance periodontal regeneration. In the present study, we examined FGF receptor (FGFR) expression on human periodontal ligament (PDL) cells. The binding of [125I]-labeled FGF-2 to human PDL cells was studied by radioreceptor assay. The binding of [125I]-FGF-2 to PDL cells reached a plateau after 2.5 h incubation at 4 degrees C and was inhibited by the addition of unlabeled FGF-2 and acidic FGF (FGF-1; aFGF), but not insulin-like growth factor-I, platelet-derived growth factor and transforming growth factor-beta 1. Scatchard analysis revealed the presence of approximately 1.0 x 10(5) FGF-2 binding sites per cell with an apparent Kd of 1.2 x 10(-10) M. Interestingly, the binding of [125I]-FGF-2 on PDL cells reached its maximum at d 6 of the culture and then gradually decreased. Scatchard analysis also demonstrated that the number of FGFRs on a PDL cell was altered during the course of the culture, while the affinity between FGF-2 and its receptor was not. The responsiveness of PDL cells to FGF-2, which was monitored by the inhibitory effect on alkaline phosphatase activity, was reduced in proportion to the decrease in the number of FGFRs on the PDL cells. The present study suggests that PDL cells alter the responsiveness to FGF-2 during the course of the culture by changing the density of its receptor, and that the density of FGFR expression might be a marker of the cytodifferentiation of PDL cells into mineralized tissue forming cells.

Pressure ulcers

Pressure ulcers are localized areas of tissue necrosis that result from unrelieved pressure. They are graded or staged according to the degree of tissue damage observed. The main etiologic factors include pressure, shearing forces, friction, and moisture. The clinical course may be complicated by several conditions including infection, sepsis, osteomyelitis, fistulas, and carcinoma. Preventive measures in persons at risk can significantly reduce the incidence of pressure ulcers. Successful management should address the four etiologic factors as well as the general condition of the patient.

The effect of recombinant basic fibroblast growth factor (bFGF) in fibrin adhesive vehicle on the healing of ischaemic and normal incisional skin wounds

Normal and ischaemic incisional wounds in rats were treated with recombinant human basic fibroblast growth factor (rbFGF) in fibrin adhesive vehicle. After 10 days of healing the maximum load*S and stress*S (S denotes correction for shrinkage) of ischaemic wounds were increased by 45% and 39%, respectively, after treatment with 20 micrograms rbFGF and by 67% and 56% after treatment with 60 micrograms rbFGF. After 20 days only 20 micrograms rbFGF had any effect and increased maximum load*S by 31% and energy at maximum (load*S, stress*S) by 40%-48%. In normal wounds 0.6-20 micrograms and 60 micrograms rbFGF decreased the strength parameters by 19%-34% and 49%-52%, respectively, after 10 days. After 20 days there was no negative influence but 60 micrograms rbFGF increased the biomechanical properties by 15%-24%. Treatment with the fibrin adhesive vehicle alone decreased the biomechanical properties of ischaemic wounds after 20 days, and of normal wounds after both 10 and 20 days. In conclusion, rbFGF can improve the healing of ischaemic wounds and may be used in the treatment of ischaemic wounds in patients, but it can have negative effects on normal wound healing.

Beneficial effect of Aloe on wound healing in an excisional wound model

Recent evidence from in vitro and in vivo experiments suggests that topical antimicrobials may be toxic to fibroblasts and keratinocytes and retard wound healing. The purpose of this study was to determine the effects of Aloe, a potential wound-healing agent, on wound contraction in excisional wounds treated with topical antimicrobials. Sprague-Dawley rats were prepared with four 1.5 cm2 dorsal defects through the skin and panniculus. The animals were divided into five groups (n = 10 per group): (1) Aloe, (2) NaOCl solution (0.025%), (3) mafenide acetate, (4) mafenide acetate + Aloe, and (5) control. Wounds were treated topically for 14 days 3 times a day. Serial standard photographs and serial wound planimetry were performed weekly. Following healing, the breaking strength of each resultant scar was determined using an Instron tensiometer. Kruskal-Wallis, ANOVA, and multiple comparison methods were used for data analysis. Aloe and NaOCl solution significantly accelerated wound contraction (p < 0.05). In the mafenide acetate + Aloe group, contraction was similar to the control, whereas the mafenide acetate alone retarded wound healing. The addition of Aloe in combination and alone in wounds increased the breaking energy when compared to controls (p < 0.05). Aloe appears to expedite wound contraction and neutralize the wound retardant effect seen with the topical mafenide acetate alone. This effect appears to be due to an increased collagen activity, which is enhanced by a lectin, consequently improving the collagen matrix and enhancing the breaking strength.

Effects of basic fibroblast growth factor on human periodontal ligament cells

In order to clarify the regulatory mechanisms of periodontal regeneration by basic fibroblast growth factor (bFGF), effects of bFGF on proliferation, alkaline phosphatase activity, calcified nodule formation and extracellular matrix synthesis of human periodontal ligament (PDL) cells were examined in this study. bFGF enhanced the proliferative responses of PDL cells in a dose-dependent manner. The maximum mitogenic effect of bFGF on PDL cells was observed at the concentration of 10 ng/ml. In contrast, bFGF inhibited the induction of alkaline phosphatase activity and the mineralized nodule formation by PDL cells. Moreover, employing the reverse transcription-polymerase chain reaction (RT-PCR) technique, we observed that the levels of laminin mRNA of human PDL cells was specifically upregulated by bFGF stimulation, but that of type I collagen mRNA was downregulated. On the other hand, the expression of type III collagen and fibronectin mRNA were not altered even when the cells were activated by bFGF. These results suggest that suppressing cytodifferentiation of PDL cells into mineralized tissue forming cells, bFGF may play a role in wound healing by inducing growth of immature PDL cells and that in turn accelerates periodontal regeneration.

What is new in clinical research in wound healing

Treating the underlying pathophysiology of the wound remains of utmost importance. Several new treatment modalities may soon be available as adjunctive treatments. The efficacy of some remains to be established in well-controlled clinical studies.

Repair of Chronic Tympanic Membrane Perforations with Fibroblast Growth Factor

A number of angiogenic growth factors have been shown to accelerate wound healing. Previous work has demonstrated that topical application of epidermal growth factor is effective in healing chronic tympanic membrane perforations in an animal model. Theoretically, fibroblast growth factor may result in a superior healed membrane through preferential stimulation of the fibroblasts within the middle layer of the tympanic membrane. To test this hypothesis, the effects of exogenously applied fibroblast growth factor on the chronically perforated tympanic membrane were evaluated. A buffered solution of fibroblast growth factor (25 μl of fibroblast growth factor, 0.2 mg/ml) was administered to a Gelfoam pledget placed over chronic tympanic membrane perforations in chinchillas. Control ears were treated with Gelfoam and the buffer solution only. Complete closure of the tympanic membrane perforation was observed in 81% (13 of 16) of the fibroblast growth factor-treated ears, but in only 41% (7 of 17) of the controls ( p = 0.05). Healing took place gradually, requiring an average of 4 weeks for the fibroblast growth factor-treated and 6.5 weeks for the control ears that healed. The relatively high healing rate for the control group does not imply that the pretreatment perforations were not chronic, rather there appears to be some efficacy to the control protocol of repeated applications of Gelfoam and buffer. A histologic analysis of the fibroblast growth factor-healed eardrums immediately after closure demonstrated hypertrophy of the squamous and fibrous layers of the tympanic membrane. Over time, the eardrum thinned to reach proportions similar to those of the normal tympanic membrane, including the presence of a substantial middle fibrous layer. A screening ototoxicity study revealed no structural damage to the organ of Corti after growth factor treatment. To assess the potential for systemic toxicity, blood and peripheral tissues were analyzed for radioactivity at time points during a 48-hour period after application of 25 μl of 125l-fibroblast growth factor to the perforated tympanic membrane. More than 78% of the radioactivity remained at the application site. Given the tiny original dosage, the small fraction absorbed systemically is minuscule and highly unlikely to induce adverse effects in light of published toxicity data. On the basis of these promising safety and efficacy data in the chinchilla model, clinical trials of fibroblast growth factor in repair of chronic tympanic membrane perforations in human beings are being initiated.

The role of growth factors in wound healing

Growth factors have many activities that make them attractive agents for stimulating tissue repair. Growth factors attract cells into the wound, stimulate their proliferation, and have profound influence on extracellular matrix deposition. Since developing the ability to mass-produce these cytokines by recombinant techniques, hundreds of studies have demonstrated that growth factors can augment all aspects of tissue repair in normal and impaired healing models. After demonstrating that growth factors augment healing, investigators have started to detect and measure growth factors in wounds and have found that wounding initiates the expression of various growth factors. Impaired healing has also been linked to altered growth factor production. These findings have prompted great interest in the use of growth factors to augment clinical healing. Preliminary clinical trials have not produced the results expected. Growth factor treatment has occasionally led to statistically significant improvements in tissue repair, but whether the results are clinically significant can be debated. It appears that to be cost effective, clinical trials must focus on targeting growth factors for specific types of impaired healing. Although growth factors have not been the panacea that was originally expected, they have the potential for making significant clinical improvements when targeted for specific problem wounds.

Expression of interleukin-1alpha, interleukin-6, and basic fibroblast growth factor by cultured skin substitutes before and after grafting to full-thickness wounds in athymic mice

OBJECTIVES

Cultured skin substitutes (CSSs), consisting of human keratinocytes and human fibroblasts attached to collagen-glycosaminoglycan substrates, have been demonstrated to cover wounds, and may release detectable quantities of growth factors that promote wound healing.

MATERIALS AND METHODS

Basic fibroblast growth factor (bFGF), interleukin-1alpha (IL-1alpha), and interleukin-6 (IL-6) were assayed by enzyme linked immunosorbent assay and immunohistochemistry in CSSs in vitro and at days 1, 3, 7, 14, and 21 after grafting to full-thickness wounds in athymic mice.

MEASUREMENTS AND MAIN RESULTS

When isolated cells were tested, IL-1alpha was found to come primarily from the keratinocytes, whereas bFGF was from the fibroblasts. Combinations of both cell types in the CSSs resulted in a synergistic enhancement of IL-6 expression. Quantities of all three cytokines from CSSs were greater in vitro compared with in vivo levels at all time points after grafting. bFGF increased from day 1 to day 7, and then remained relatively constant until day 21. At day 3 maximal levels of IL-1alpha were observed. By day 7, IL-1alpha decreased to approximately 40% of maximal levels, and subsequently increased until day 21. IL-6 levels were highest at day 7 after grafting. All cytokines had reached elevated levels during the time of wound revascularization (days 3-7).

CONCLUSIONS

The sequence of cytokine synthesis in the wounds (i.e., rapid IL-1alpha increase followed by IL-6 expression) parallels serum levels reported after a septic challenge. These findings support the hypothesis that the wound is a source of systemic cytokines.

Growth factors in surgery

Surgical reconstruction of functional and aesthetic defects is often compromised by donor-tissue limitations and wound-healing constraints--problems that can potentially be overcome by peptide growth factor therapy. The effectiveness of growth factor therapy in animal models and in limited human clinical trials has been realized. Epidermal growth factor (EGF), fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), platelet-derived wound-healing formula (PDWHF), transforming growth factor (TGF), the bone morphogenetic proteins (BMPs), and general considerations of growth factor therapy are reviewed.

Pressure ulcers: prevention and management

OBJECTIVE

To describe important aspects of pressure ulcer prevention and management, especially in elderly patients.

DESIGN

We reviewed pertinent published material in the medical literature and summarized effective strategies in the overall management of the elderly population with pressure ulcers.

RESULTS

Pressure ulcers are commonly encountered in geriatric patients. The development of a pressure ulcer is associated with an increased risk of death. Certain well-recognized risk factors, such as immobility and incontinence, may predispose to the development of pressure ulcers; consequently, risk factor modification is an important aspect of prevention and treatment. For existing lesions, various innovative patient support surfaces and wound care products have been developed to alleviate pressure and to facilitate wound healing. The use of a particular product should be based on the clinical setting and the limited scientific evidence available. With treatment, most pressure ulcers eventually heal.

CONCLUSION

Pressure ulcers are often, but not always, preventable. The occurrence of such an ulcer signals the possible presence of chronic comorbid disease and should prompt a search for underlying risk factors in patients for whom ulcer treatment is considered appropriate.

A literature assessment of the use of miscellaneous topical agents, growth factors, and skin equivalents for the treatment of pressure ulcers

BACKGROUND

Agents reviewed for this manuscript were both rare and popular topical treatments for pressure ulcers.

OBJECTIVE

To review topical treatments for pressure ulcers and evaluate them based on available literature of controlled, blinded, and randomized trials.

METHODS

A MEDLARS database (1966-1993) search and a thorough review of reference article lists of key articles produced over 100 manuscripts. Studies were considered for review if they were conducted on humans with chronic stage II to IV pressure ulcers, in a properly controlled and randomized fashion.

RESULTS

The use of zinc acetate and aluminum hydroxide ointment, phenytoin, recombinant platelet-derived growth factor-BB (rPDGF-BB), and basic fibroblast growth factor (bFGF) have been evaluated in a controlled and blinded fashion. Many of the newer agents, cytokine growth factor (eg, rPDGF-BB and bFGF) and skin equivalents, are currently being scrutinized in clinical trials.

CONCLUSION

A paucity of data exist that adequately address the efficacy of any topical agent for the treatment of pressure ulcers.

Pharmacologic enhancement of wound healing

The field of pharmacologic modulation of soft tissue repair is in its infancy. Although the soluble, cellular, and insoluble mediators that govern repair have not been elucidated, the application of pharmacologic concentrations of purified polypeptide growth factors, cytokines, and matrix molecules has nonetheless resulted in the acceleration of normal repair and the reversal of deficient repair in a wide variety of dermal wound models in animals. However, early clinical results using these factors have been less than encouraging, and their potential roles in the armamentarium of chronic wound therapies remain to be established.

Effects of oxygen on wound responses to growth factors: Kaposi's FGF, but not basic FGF stimulates repair in ischemic wounds

Kaposi's fibroblast growth factor (K-FGF, FGF-4) is a newer member of FGF family with uncharacterized wound healing properties. Basic fibroblast growth factor (bFGF, FGF-2) has been well studied and accelerates repair in normal and impaired wound healing models. K-FGF and bFGF are known to have similar biological effects in tissue culture, and both stimulate fibroblast and endothelial cell proliferation. The rabbit dermal ulcer model was used to examine the effects of bFGF and K-FGF under ischemic and nonischemic conditions. We found bFGF was ineffective in stimulating healing under ischemic conditions even at high doses (30 micrograms/wound). However, when the ischemic wounds were treated with bFGF (5 micrograms/wound) plus hyperbaric oxygen therapy, it was highly effective again as previously found under nonischemic conditions (P < 0.05). In contrast K-FGF stimulated repair in both nonischemic and ischemic wounds (P < 0.05). These results suggest that wound oxygen content differentially regulates responsiveness to bFGF and that K-FGF is biologically active in hypoxic wounds.

Age-related changes in wound healing

Knowledge of the physiology of wound healing, in particular the recovery of the dermal and epidermal compartments and the co-ordination of these processes by the cytokine network, is of great importance to rational wound management. The individual components of the wound healing process have been studied using various in vitro and in vivo models, comparing young, adult and aged individuals. Many of the processes involved in wound healing are impaired in the elderly. However, in elderly patients not suffering from concomitant diseases, the rate of wound healing is normal or only slightly reduced. Various 'systemic factors' (endocrine and haematological diseases, nutritional deficiencies and medications) and 'regional disorders' (vascular and neural diseases) may impair wound healing. These complicating conditions occur more frequently in aged subjects. Failure of wound healing in the elderly is a chronic disabling condition, which occurs frequently in our society, requiring a major investment of medical care.

Growth factors and wound healing in otolaryngology

An immense amount of knowledge has been gained over the last decade in the realm of polypeptide growth factors. Only recently has this new information made an impact in otolaryngology. This article is a brief overview of peptide growth factors in relation to wound healing and otolaryngology.

Determination of endogenous cytokines in chronic wounds

OBJECTIVE

This study objectively characterized the microenvironment of indolent, chronic wounds by developing a method by which minute quantities of cytokines could be extracted from chronic wounds and separately identified.

SUMMARY BACKGROUND DATA

Recombinant DNA technology and the ability to clone compounds such as cytokines allow new management schemes for the treatment of acute and chronic wounds. Before treatment with an exogenous cytokine is started, it would be helpful to know the endogenous level of that cytokine in the wound. Although various methods of extracting cytokines from acute wounds have been reported, no techniques have existed to reliably measure endogenous levels of cytokines in chronic wounds.

METHODS

Porous, inert hydrophilic dextranomer beads were tested for their ability to absorb or adsorb protein and cytokines in vitro with either albumin or albumin laced with various known amounts of cytokines, and then from chronic human pressure ulcers. The Bradford protein assay was used to determine protein levels. Enzyme-linked immunosorbent assay (ELISA) techniques were used to determine levels of platelet-derived growth factor (PDGF)-AB, basic fibroblast growth factor (bFGF), epidermal growth factor (EGF), and transforming growth factor-Beta (TGF-beta) extracted by the beads.

RESULTS

Between 88% and 98% of known amounts of albumin could be recovered. Similarly, more than 90% of the laced cytokines could be recovered. In 20 grade III/IV pressure ulcers, although protein concentrations were remarkably similar, endogenous levels of cytokine growth factors varied tremendously. Platelet-derived growth factor-AB ranged from 49 to 867 pg/mL; bFGF from 47 to 697 pg/mL; and EGF from nondetectable to 247.5 pg/mL. TGF-B was not detected in 17 of the 20 pressure ulcers.

CONCLUSIONS

This new technique appears useful for measuring endogenous levels of cytokines. Levels of cytokines found in these chronic wounds are much lower than those reported from acute wounds. The marked variation found among the 20 wounds may help to explain the differences reported in recent wound healing trials with exogenous cytokines.

Wound therapy: growth factors as agents to promote healing

The development of recombinant growth factors for the treatment of nonhealing or badly healing wounds has reached the clinical-trial phase. These first studies in humans are yielding valuable information on the physiological role of growth factors in different types of wounds, their mode of action and their stability under in vivo conditions. Data from these early trials in humans can be interpreted in the light of the continuing scientific progress being made in wound-healing research, and thus lead to an improvement in the design of future studies. Growth-factor-based therapeutics are expected to enter the marketplace in the middle of this decade, and to become a highly profitable sector of the health-care industry by the turn of the century.

Surface area measurement of pressure sores using wound molds and computerized imaging

OBJECTIVE

To develop a method to measure wound surface area.

DESIGN

Validity study.

SETTING

Inpatient service.

PARTICIPANTS

Four patients with decubitus ulcers.

MEASUREMENTS

A new imaging process estimating wound surface area and volume by NMR spectroscopy of a mold of the pressure ulcer and a comparison measurement of volume of the mold by water displacement. Measurements made serially totalled 17.

RESULTS

Measurement of the volume of the mold by the computer system correlated strongly with measurement of the volume by water displacement. Surface area of the pressure sore mold correlated strongly with volume of the mold raised to the two-thirds power.

CONCLUSIONS

It is possible for the first time to measure surface area of decubitus ulcers. This may provide a way of determining accurately the dose of newly proposed topical treatments.