Successful and safe use of 2 min cold atmospheric argon plasma in chronic wounds: results of a randomized controlled trial

The topical application of low-temperature argon plasma enhances the anti-inflammatory effect of Jaun-ointment on DNCB-induced NC/Nga mice

BACKGROUND

Jaun-ointment (JO), also known as Shiunko in Japan, is one of the most popular medicinal formulae used in Korean traditional medicine for the external treatment of skin wound and inflammatory skin conditions. Since JO is composed of crude mixture of two herbal extracts (radix of Lithospermum erythrorhizon Siebold & Zucc and Angelica gigas Nakai), those been proved its anti-inflammatory activities in-vitro and in-vivo, JO has been expected as a good alternative treatment option for atopic dermatitis (AD). However, due to the lack of strategies for the penetrating methods of JO's various anti-inflammatory elements into the skin, an effective and safe transdermal drug delivery system needs to be determined. Here, low-temperature argon plasma (LTAP) was adopted as an ancillary partner of topically applied JO in a mice model of AD and the effectiveness was examined.

METHODS

Dorsal skins of NC/Nga mice were challenged with DNCB (2,4-dinitrochlorobenzene) to induce AD. AD-like skin lesions were treated with JO alone, or in combination with LTAP. Inflammatory activity in the skin tissues was evaluated by histological analysis and several molecular biological tests.

RESULTS

LTAP enhanced the effect of JO on AD-like skin lesion. Topical application of JO partially inhibited the development of DNCB-induced AD, shown by the moderate reduction of eosinophil homing and pro-inflammatory cytokine level. Combined treatment of JO and LTAP dramatically inhibited AD phenotypes. Interestingly, treatment with JO alone did not affect the activity of nuclear factor (NF)κB/RelA in the skin, but combined treatment of LTAP-JO blocked DCNB-mediated NFκB/RelA activation.

CONCLUSIONS

LTAP markedly enhanced the anti-inflammatory activity of JO on AD-like skin lesions. The effect of LTAP may be attributed to enhancement of drug penetration and regulation of NFκB activity. Therefore, the combination treatment of JO and LTAP could be a potential strategy for the treatment of AD.

Genotoxicity and cytotoxicity of the plasma jet-treated medium on lymphoblastoid WIL2-NS cell line using the cytokinesis block micronucleus cytome assay

Despite growing interest in the application of atmospheric plasma jets as medical treatment strategies, there has been comparatively little research on the potential genotoxic and cytotoxic effects of plasma jet treatment. In this study, we have employed the cytokinesis block micronucleus cytome (CBMN-Cyt) assay with WIL2-NS B lymphoblastoid cells to test the potential genotoxicity, as well as the cytotoxicity, of toxic species generated in cell culture media by an argon (Ar) plasma jet. Elevated levels of cell death (necrosis) and occurrence of chromosomal damage (micronuclei MN, nculeoplasmic bridge NPBs and nuclear bus, Nbuds) were observed when cells were exposed to plasma jet-treated media. These results provide a first insight into how we might measure the genotoxic and cytotoxic effect of plasma jet treatments (both indirect and direct) in dividing human cells.

Electrostatic Debye layer formed at a plasma-liquid interface

We construct an analytic model for the electrostatic Debye layer formed at a plasma-liquid interface by combining the Gouy-Chapman theory for the liquid with a simple parabolic band model for the plasma sheath. The model predicts a nonlinear scaling between the plasma current density and the solution ionic strength, and we confirmed this behavior with measurements using a liquid-anode plasma. Plots of the measured current density as a function of ionic strength collapse the data and curve fits yield a plasma electron density of ∼10^{19}m^{-3} and an electric field of ∼10^{4}V/m on the liquid side of the interface. Because our theory is based firmly on fundamental physics, we believe it can be widely applied to many emerging technologies involving the interaction of low-temperature, nonequilibrium plasma with aqueous media, including plasma medicine and various plasma chemical synthesis techniques.

One Year Follow-Up Risk Assessment in SKH-1 Mice and Wounds Treated with an Argon Plasma Jet

Multiple evidence in animal models and in humans suggest a beneficial role of cold physical plasma in wound treatment. Yet, risk assessment studies are important to further foster therapeutic advancement and acceptance of cold plasma in clinics. Accordingly, we investigated the longterm side effects of repetitive plasma treatment over 14 consecutive days in a rodent full-thickness ear wound model. Subsequently, animals were housed for 350 days and sacrificed thereafter. In blood, systemic changes of the proinflammatory cytokines interleukin 1β and tumor necrosis factor α were absent. Similarly, tumor marker levels of α-fetoprotein and calcitonin remained unchanged. Using quantitative PCR, the expression levels of several cytokines and tumor markers in liver, lung, and skin were found to be similar in the control and treatment group as well. Likewise, histological and immunohistochemical analysis failed to detect abnormal morphological changes and the presence of tumor markers such as carcinoembryonic antigen, α-fetoprotein, or the neighbor of Punc11. Absence of neoplastic lesions was confirmed by non-invasive imaging methods such as anatomical magnetic resonance imaging and positron emission tomography-computed tomography. Our results suggest that the beneficial effects of cold plasma in wound healing come without apparent side effects including tumor formation or chronic inflammation.

Investigation of toxicity and mutagenicity of cold atmospheric argon plasma

Cold atmospheric argon plasma is recognized as a new contact free approach for the decrease of bacterial load on chronic wounds in patients. So far very limited data are available on its toxicity and mutagenicity on eukaryotic cells. Thus, the toxic/mutagenic potential of cold atmospheric argon plasma using the MicroPlaSter β^® , which has been used efficiently in humans treating chronic and acute wounds, was investigated using the XTT assay in keratinocytes and fibroblasts and the HGPRT (hypoxanthine guanine phosphoribosyl transferase) assay with V79 Chinese hamster cells. The tested clinical parameter of a 2 min cold atmospheric argon plasma treatment revealed no relevant toxicity on keratinocytes (viability: 76% ± 0.17%) and on fibroblasts (viability: 81.8 ± 0.10) after 72 hr as compared to the untreated controls. No mutagenicity was detected in the HGPRT assay with V79 cells even after repetitive CAP treatments of 2-10 min every 24 hr for up to 5 days. In contrast, UV-C irradiation of V79 cells, used as a positive control in the HGPRT test, led to DNA damage and mutagenic effects. Our findings indicate that cold atmospheric plasma using the MicroPlaSter β^® shows negligible effects on keratinocytes and fibroblasts but no mutagenic potential in the HGPRT assay, indicating a new contact free safe technology. Environ. Mol. Mutagen. 58:172-177, 2017. © 2017 Wiley Periodicals, Inc.

Non-thermal air plasma promotes the healing of acute skin wounds in rats

Non-thermal plasma (NTP) has nonspecific antibacterial effects, and can be applied as an effective tool for the treatment of chronic wounds and other skin pathologies. In this study we analysed the effect of NTP on the healing of the full-thickness acute skin wound model in rats. We utilised a single jet NTP system generating atmospheric pressure air plasma, with ion volume density 5 · 10¹⁷ m^-3 and gas temperature 30-35 °C. The skin wounds were exposed to three daily plasma treatments for 1 or 2 minutes and were evaluated 3, 7 and 14 days after the wounding by histological and gene expression analysis. NTP treatment significantly enhanced epithelization and wound contraction on day 7 when compared to the untreated wounds. Macrophage infiltration into the wound area was not affected by the NTP treatment. Gene expression analysis did not indicate an increased inflammatory reaction or a disruption of the wound healing process; transient enhancement of inflammatory marker upregulation was found after NTP treatment on day 7. In summary, NTP treatment had improved the healing efficacy of acute skin wounds without noticeable side effects and concomitant activation of pro-inflammatory signalling. The obtained results highlight the favourability of plasma applications for wound therapy in clinics.

Plasma cell treatment device Plasma-on-Chip: Monitoring plasma-generated reactive species in microwells

We have developed a plasma cell treatment device called Plasma-on-Chip that enables the real-time monitoring of a single cell culture during plasma treatment. The device consists of three parts: 1) microwells for cell culture, 2) a microplasma device for generating reactive oxygen and nitrogen species (RONS) for use in cell treatment, and 3) through-holes (microchannels) that connect each microwell with the microplasma region for RONS delivery. Here, we analysed the delivery of the RONS to the liquid culture medium stored in the microwells. We developed a simple experimental set-up using a microdevice and applied in situ ultraviolet absorption spectroscopy with high sensitivity for detecting RONS in liquid. The plasma-generated RONS were delivered into the liquid culture medium via the through-holes fabricated into the microdevice. The RONS concentrations were on the order of 10–100 μM depending on the size of the through-holes. In contrast, we found that the amount of dissolved oxygen was almost constant. To investigate the process of RONS generation, we numerically analysed the gas flow in the through-holes. We suggest that the circulating gas flow in the through-holes promotes the interaction between the plasma (ionised gas) and the liquid, resulting in enhanced RONS concentrations.

Cytoprotective effects of mild plasma-activated medium against oxidative stress in human skin fibroblasts

Non-thermal atmospheric pressure plasma (NTAPP) has recently been applied to living cells and tissues and has emerged as a novel technology for medical applications. NTAPP affects cells not only directly, but also indirectly with previously prepared plasma-activated medium (PAM). The objective of this study was to demonstrate the preconditioning effects of “mild PAM” which was prepared under relatively mild conditions, on fibroblasts against cellular injury generated by a high dose of hydrogen peroxide (H₂O₂). We observed the preconditioning effects of mild PAM containing approximately 50 μM H₂O₂. Hydrogen peroxide needs to be the main active species in mild PAM for it to exert preconditioning effects because the addition of catalase to mild PAM eliminated these effects. The nuclear translocation and recruitment of nuclear factor erythroid 2-related factor 2 (Nrf2) to antioxidant response elements (ARE) in heme oxygenase 1 (HO-1) promoters and the up-regulation of HO-1 were detected in fibroblasts treated with mild PAM. The addition of ZnPP, a HO-1-specific inhibitor, or the knockdown of Nrf2 completely abrogated the preconditioning effects. Our results demonstrate that mild PAM protects fibroblasts from oxidative stress by up-regulating HO-1, and the H₂O₂-induced activation of the Nrf2-ARE pathway needs to be involved in this reaction.

Hydrogen Peroxide: A Potential Wound Therapeutic Target?

Hydrogen peroxide (H2O2) is a topical antiseptic used in wound cleaning which kills pathogens through oxidation burst and local oxygen production. H2O2 has been reported to be a reactive biochemical molecule synthesized by various cells that influences biological behavior through multiple mechanisms: alterations of membrane potential, generation of new molecules, and changing intracellular redox balance, which results in activation or inactivation of different signaling transduction pathways. Contrary to the traditional viewpoint that H2O2 probably impairs tissue through its high oxidative property, a proper level of H2O2 is considered an important requirement for normal wound healing. Although the present clinical use of H2O2 is still limited to the elimination of microbial contamination and sometimes hemostasis, better understanding towards the sterilization ability and cell behavior regulatory function of H2O2 within wounds will enhance the potential to exogenously augment and manipulate healing.

Gas-liquid interfacial plasmas producing reactive species for cell membrane permeabilization

Gas-liquid interfacial atmospheric-pressure plasma jets (GLI-APPJ) are used medically for plasma-induced cell-membrane permeabilization. In an attempt to identify the dominant factors induced by GLI-APPJ responsible for enhancing cell-membrane permeability, the concentration and distribution of plasma-produced reactive species in the gas and liquid phase regions are measured. These reactive species are classified in terms of their life-span: long-lived (e.g., H₂O₂), short-lived (e.g., O₂^•−), and extremely-short-lived (e.g., ^•OH). The concentration of plasma-produced ^•OH_aq in the liquid phase region decreases with an increase in solution thickness (<1 mm), and plasma-induced cell-membrane permeabilization is found to decay markedly as the thickness of the solution increases. Furthermore, the horizontally center-localized distribution of ^•OH_aq, resulting from the center-peaked distribution of ^•OH in the gas phase region, corresponds with the distribution of the permeabilized cells upon APPJ irradiation, whereas the overall plasma-produced oxidizing species such as H₂O_2aq in solution exhibit a doughnut-shaped horizontal distribution. These results suggest that ^•OH_aq is likely one of the dominant factors responsible for plasma-induced cell-membrane permeabilization.

Low temperature plasma equipment applied on surgical hemostasis and wound healings

Low temperature plasma (LTP) coagulation equipment, which avoids causing burn injuries to patients, has been introducing into minimally invasive surgery. The mechanism by which this equipment stops bleeding is to directly occupy the injury with the formed blood clots, and different from the mechanism of the common electrical hemostatic devices that cauterize the tissues around the bleeding to stem the blood flow. A noteworthy point is that LTP treatment with our equipment is not confined only to the blood coagulation system, but it has significant effects on the other blood components to form clots with or without hemolysis, and that there is a plasma current threshold that determines whether the treatment makes stable clots. In this review, we introduce the clinical benefits of LTP current and describe the clot formation it facilitates.

Dose- and Time-Dependent Cellular Effects of Cold Atmospheric Pressure Plasma Evaluated in 3D Skin Models

BACKGROUND

Application of cold atmospheric pressure plasmas (CAPs) in or on the human body was termed 'plasma medicine'. So far, plasmas were utilized for sterilization of implants, other heat-sensitive products, or employed for chemical surface modifications. By now, CAPs are further used effectively for wound treatment. The present study analyses the effect of a plasma jet with air or nitrogen as process gas, previously evaluated for antimicrobial efficacy, on human cells using a 3D skin model.

METHODS

CAP treatment of 3D skin models consisting of a keratinocyte-containing epidermal layer and a fibroblast/collagen dermal matrix was performed using the Tigres plasma MEF technology. To evaluate the effects on the 3D skin models, the following plasma parameters were varied: process gas, input power, and treatment time.

RESULTS

Low CAP doses exhibited good cell compatibility. Increasing input power or elongating treatment intervals led to detrimental effects on 3D skin model morphology as well as to release of inflammatory cytokines. It was further observed that air as process gas was more damaging compared to nitrogen.

CONCLUSIONS

Treatment of 3D skin models with the plasma MEF nozzle using air or nitrogen is reported. A clearly dose- and time-dependent effect of CAPs could be observed in which the CAP based on nitrogen exhibited higher cell compatibility than the CAP generated from air. These settings might be recommended for medical in vivo applications such as wound decontamination.

Spatial Dependence of DNA Damage in Bacteria due to Low-Temperature Plasma Application as Assessed at the Single Cell Level

Low temperature plasmas (LTPs) generate a cocktail of reactive nitrogen and oxygen species (RNOS) with bactericidal activity. The RNOS however are spatially unevenly distributed in the plasma. Here we test the hypothesis that this distribution will affect the mechanisms underpinning plasma bactericidal activity focussing on the level of DNA damage in situ. For the first time, a quantitative, single cell approach was applied to assess the level of DNA damage in bacteria as a function of the radial distance from the centre of the plasma jet. Salmonella enterica on a solid, dry surface was treated with two types of LTP: an atmospheric-pressure dielectric barrier discharge plasma jet (charged and neutral species) and a radio-frequency atmospheric-pressure plasma jet (neutral species). In both cases, there was an inverse correlation between the degree of DNA damage and the radial distance from the centre of the plasma, with the highest DNA damage occurring directly under the plasma. This trend was also observed with Staphylococcus aureus. LTP-generated UV radiation was eliminated as a contributing factor. Thus valuable mechanistic information can be obtained from assays on biological material, which can inform the development of LTP as a complementary or alternative therapy for (topical) bacterial infections.

The Healing Effect of Low-Temperature Atmospheric-Pressure Plasma in Pressure Ulcer: A Randomized Controlled Trial

Pressure ulcers are difficult to treat. Recent reports of low-temperature atmospheric-pressure plasma (LTAPP) indicated its safe and effectiveness in chronic wound care management. It has been shown both in vitro and vivo studies that LTAPP not only helps facilitate wound healing but also has antimicrobial efficacy due to its composition of ion and electron, free radicals, and ultraviolet ray. We studied the beneficial effect of LTAPP specifically on pressure ulcers. In a prospective randomized study, 50 patients with pressure ulcers were divided into 2 groups: Control group received standard wound care and the study group was treated with LTAPP once every week for 8 consecutive weeks in addition to standard wound care. We found that the group treated with LTAPP had significantly better PUSH (Pressure Ulcer Scale for Healing) scores and exudate amount after 1 week of treatment. There was also a reduction in bacterial load after 1 treatment regardless of the species of bacteria identified.

Plasma-activated medium selectively eliminates undifferentiated human induced pluripotent stem cells

Human pluripotent stem cells, including human induced pluripotent stem cells (hiPSCs), are promising materials for regenerative medicine and cell transplantation therapy. However, tumorigenic potential of residual undifferentiated stem cells hampers their use in these therapies. Therefore, it is important to develop methods that selectively eliminate undifferentiated stem cells from a population of differentiated cells before their transplantation. In the present study, we investigated whether plasma-activated medium (PAM) selectively eliminated undifferentiated hiPSCs by inducing external oxidative stress. PAM was prepared by irradiating cell culture medium with non-thermal atmospheric pressure plasma. We observed that PAM selectively and efficiently killed undifferentiated hiPSCs cocultured with normal human dermal fibroblasts (NHDFs), which were used as differentiated cells. We also observed that undifferentiated hiPSCs were more sensitive to PAM than hiPSC-derived differentiated cells. Gene expression analysis suggested that lower expression of oxidative stress-related genes, including those encoding enzymes involved in hydrogen peroxide (H₂O₂) degradation, in undifferentiated hiPSCs was one of the mechanisms underlying PAM-induced selective cell death. PAM killed undifferentiated hiPSCs more efficiently than a medium containing the same concentration of H₂O₂ as that in PAM, suggesting that H₂O₂ and various reactive oxygen/nitrogen species in PAM selectively eliminated undifferentiated hiPSCs. Thus, our results indicate that PAM has a great potential to eliminate tumorigenic hiPSCs from a population of differentiated cells and that it may be a very useful tool in regenerative medicine and cell transplantation therapy.

[Plasma medicine in dermatology: Mechanisms of action and clinical applications]

Plasma medicine has developed into an innovative field of research showing high potential. Since the establishment of cold atmospheric plasma, new, multifaceted medical treatment opportunities have become available. Within a short time a multidisciplinary special interest group of medical scientists, physicists, and biologists was created, aiming to understand plasma medicine and answer clinical as well as scientific questions. In dermatology, new horizons are being opened for wound healing, tissue regeneration, treatment of skin infections, and tumor therapy. A major task will be the introduction of plasma into clinical medicine and, simultaneously, the further investigation of the mechanisms of action of plasma at the cellular level. Only then can the safety of plasma treatment in patients be assured.

Visible tumor surface response to physical plasma and apoptotic cell kill in head and neck cancer

The aim of the study was to learn, whether clinical application of cold atmospheric pressure plasma (CAP) is able to cause (i) visible tumor surface effects and (ii) apoptotic cell kill in squamous cell carcinoma and (iii) whether CAP-induced visible tumor surface response occurs as often as CAP-induced apoptotic cell kill. Twelve patients with advanced head and neck cancer and infected ulcerations received locally CAP followed by palliative treatment. Four of them revealed tumor surface response appearing 2 weeks after intervention. The tumor surface response expressed as a flat area with vascular stimulation (type 1) or a contraction of tumor ulceration rims forming recesses covered with scabs, in each case surrounded by tumor tissue in visible progress (type 2). In parallel, 9 patients with the same kind of cancer received CAP before radical tumor resection. Tissue specimens were analyzed for apoptotic cells. Apoptotic cells were detectable and occurred more frequently in tissue areas previously treated with CAP than in untreated areas. Bringing together both findings and placing side by side the frequency of clinical tumor surface response and the frequency of analytically proven apoptotic cell kill, detection of apoptotic cells is as common as clinical tumor surface response. There was no patient showing signs of an enhanced or stimulated tumor growth under influence of CAP. CAP was made applicable by a plasma jet, kINPen(®) MED (neoplas tools GmbH, Greifswald, Germany).

Inhibition of inflammatory reactions in 2,4-Dinitrochlorobenzene induced Nc/Nga atopic dermatitis mice by non-thermal plasma

Non-thermal plasma (NTP) has recently been introduced and reported as a novel tool with a range of medicinal and biological roles. Although many studies using NTP have been performed, none has investigated the direct relationship between NTP and immune responses yet. Especially, the effects of NTP on atopic dermatitis (AD) were not been explored. Here, NTP was tested whether it controls immune reactions of AD. NTP treatment was administered to pro-inflammatory cytokine-stimulated keratinocytes and DNCB (2,4-Dinitrochlorobenzene)-induced atopic dermatitis mice, then the immune reactions of cells and skin tissues were monitored. Cells treated with NTP showed decreased expression levels of CCL11, CCL13, and CCL17 along with down-regulation of NF-κB activity. Repeated administration of NTP to AD-induced mice reduced the numbers of mast cells and eosinophils, IgE, CCL17, IFNγ levels, and inhibited NF-κB activity in the skin lesion. Furthermore, combined treatment with NTP and 1% hydrocortisone cream significantly decreased the immune responses of AD than that with either of these two treatments individually. Overall, this study revealed that NTP significantly inhibits several immune reactions of AD by regulating NF-κB activity. Therefore, NTP could be useful to suppress the exaggerated immune reactions in severe skin inflammatory diseases such as AD.

Clinical and Biological Principles of Cold Atmospheric Plasma Application in Skin Cancer

Plasma-based electrosurgical devices have long been employed for tissue coagulation, cutting, desiccation, and cauterizing. Despite their clinical benefits, these technologies involve tissue heating and their effects are primarily heat-mediated. Recently, there have been significant developments in cold atmospheric pressure plasma (CAP) science and engineering. New sources of CAP with well-controlled temperatures below 40 °C have been designed, permitting safe plasma application on animal and human bodies. In the last decade, a new innovative field, often referred to as plasma medicine, which combines plasma physics, life science, and clinical medicine has emerged. This field aims to exploit effects of mild plasma by controlling the interactions between plasma components (and other secondary species that can be formed from these components) with specific structural elements and functionalities of living cells. Recent studies showed that CAP can exert beneficial effects when applied selectively in certain pathologies with minimal toxicity to normal tissues. The rapid increase in new investigations and development of various devices for CAP application suggest early adoption of cold plasma as a new tool in the biomedical field. This review explores the latest major achievements in the field, focusing on the biological effects, mechanisms of action, and clinical evidence of CAP applications in areas such as skin disinfection, tissue regeneration, chronic wounds, and cancer treatment. This information may serve as a foundation for the design of future clinical trials to assess the efficacy and safety of CAP as an adjuvant therapy for skin cancer.

The repetitive use of non-thermal dielectric barrier discharge plasma boosts cutaneous microcirculatory effects

BACKGROUND

Non-thermal atmospheric plasma has proven its benefits in sterilization, cauterization and even in cancer reduction. Furthermore, physical plasma generated by dielectric barrier discharge (DBD) promotes wound healing in vivo and angiogenesis in vitro. Moreover, cutaneous blood flow and oxygen saturation can be improved in human skin. These effects are mostly explained by reactive oxygen species (ROS), but electric fields, currents and ultraviolet radiation may also have an impact on cells in the treated area. Usually, single session application is used. The aim of this study was to evaluate the effects of the repetitive use of cold atmospheric plasma (rCAP) on cutaneous microcirculation.

HYPOTHESIS

The repetitive use of non-thermal atmospheric plasma boosts cutaneous microcirculation effects.

METHODS

Microcirculatory data was assessed at a defined skin area of the radial forearm of 20 healthy volunteers (17 males, 3 females; mean age 39.1±14.8years; BMI 26.4±4.6kg/m(2)). Microcirculatory measurements were performed under standardized conditions using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90s and cutaneous microcirculation was assessed for 10min. Afterwards, a second session of CAP application was performed and microcirculation was measured for another 10min. Then, the third application was made and another 20min of microcirculatory parameters were assessed.

RESULTS

Tissue oxygen saturation and postcapillary venous filling pressure significantly increased after the first application and returned to baseline values within 10min after treatment. After the second and third applications, both parameters increased significantly vs. baseline until the end of the 40-minute measuring period. Cutaneous blood flow was significantly enhanced for 1min after the first application, with no significant differences found during the remainder of the observation period. The second application improved and prolonged the effect significantly until 7min and the third application until 13min.

CONCLUSION

These data indicate that the repetitive use of non-thermal atmospheric plasma boosts and prolongs cutaneous microcirculation and might therefore be a potential tool to promote wound healing.

Investigation on the effects of the atmospheric pressure plasma on wound healing in diabetic rats

It is estimated that 15 percent of individuals with diabetes mellitus suffer from diabetic ulcers worldwide. The aim of this study is to present a non-thermal atmospheric plasma treatment as a novel therapy for diabetic wounds. The plasma consists of ionized helium gas that is produced by a high-voltage (8 kV) and high-frequency (6 kHz) power supply. Diabetes was induced in rats via an intravascular injection of streptozotocin. The plasma was then introduced to artificial xerograph wounds in the rats for 10 minutes. Immunohistochemistry assays was performed to determine the level of transforming growth factor (TGF-β1) cytokine. The results showed a low healing rate in the diabetic wounds compared with the wound-healing rate in non-diabetic animals (P < 0.05). Moreover, the results noted that plasma enhanced the wound-healing rate in the non-diabetic rats (P < 0.05), and significant wound contraction occurred after the plasma treatment compared with untreated diabetic wounds (P < 0.05). Histological analyses revealed the formation of an epidermis layer, neovascularization and cell proliferation. The plasma treatment also resulted in the release of TGF-β1 cytokine from cells in the tissue medium. The findings of this study demonstrate the effect of plasma treatment for wound healing in diabetic rats.

Non-thermal plasma inhibits human cervical cancer HeLa cells invasiveness by suppressing the MAPK pathway and decreasing matrix metalloproteinase-9 expression

Non-thermal plasma (NTP) has been proposed as a novel therapeutic method for anticancer treatment. However, the mechanism underlying its biological effects remains unclear. In this study, we investigated the inhibitory effect of NTP on the invasion of HeLa cells, and explored the possible mechanism. Our results showed that NTP exposure for 20 or 40 s significantly suppressed the migration and invasion of HeLa cells on the basis of matrigel invasion assay and wound healing assay, respectively. Moreover, NTP reduced the activity and protein expression of the matrix metalloproteinase (MMP)-9 enzyme. Western blot analysis indicated that NTP exposure effectively decreased phosphorylation level of both ERK1/2 and JNK, but not p38 MAPK. Furthermore, treatment with MAPK signal pathway inhibitors or NTP all exhibited significant depression of HeLa cells migration and MMP-9 expression. The result showed that NTP synergistically suppressed migration and MMP-9 expression in the presence of ERK1/2 inhibitor and JNK inhibitor, but not p38 MAPK inhibitor. Taken together, these findings suggested that NTP exposure inhibited the migration and invasion of HeLa cells via down-regulating MMP-9 expression in ERK1/2 and JNK signaling pathways dependent manner. These findings provide hints to the potential clinical research and therapy of NTP on cervical cancer metastasis.

Towards the understanding of non-thermal air plasma action: effects on bacteria and fibroblasts

Non-thermal plasma research has put a growing focus on the bacteria inactivation problem. Here we show how non-thermal plasma destroys Gram-positive and Gram-negative bacteria and discuss the mechanisms of plasma bactericidal effects.

Improvement of cutaneous microcirculation by cold atmospheric plasma (CAP): Results of a controlled, prospective cohort study

BACKGROUND

Cold atmospheric plasma (CAP) has proven its benefits in the reduction of various bacteria and fungi in both in vitro and in vivo studies. Moreover, CAP generated by dielectric barrier discharge (DBD) promoted wound healing in vivo. Charged particles, chemically reactive species (such as O3, OH, H2O2, O, NxOy), ultraviolet radiation (UV-A and UV-B), strong oscillating electric fields as well as weak electric currents are produced by DBD operated in air. However, wound healing is a complex process, depending on nutrient and oxygen supply via cutaneous blood circulation. Therefore, this study examined the effects of CAP on cutaneous microcirculation in a prospective cohort setting.

HYPOTHESIS

Cold atmospheric plasma application enhances cutaneous microcirculation.

METHODS

Microcirculatory data of 20 healthy subjects (11 males, 9 females; mean age 35.2 ± 13.8 years; BMI 24.3 ± 3.1 kg/m(2)) were recorded continuously at a defined skin area at the radial forearm. Under standardized conditions, microcirculatory measurements were performed using a combined laser Doppler and photospectrometry system. After baseline measurement, CAP was applied by a DBD plasma device for 90 s to the same defined skin area of 22.5 cm(2). Immediately after the application cutaneous microcirculation was assessed for 30 min at the same site.

RESULTS

After CAP application, tissue oxygen saturation immediately increased by 24% (63.8 ± 13.8% from 51.4 ± 13.2% at baseline, p<0.001) and stayed significantly elevated for 8 min. Cutaneous blood flow increased by 73% (41.0 ± 31.2 AU from 23.7 ± 20.8 AU at baseline, p<0.001) and remained upregulated for 11 min. Furthermore, cutaneous blood flow showed two peaks at 14 (29.8 ± 25.0 AU, p=0.049) and 19 min (29.8 ± 22.6 AU, p=0.048) after treatment. Postcapillary venous filling pressure continuously increased, but showed no significant change vs. baseline in the non-specific BMI group. Subgroup analysis revealed that tissue oxygen saturation, postcapillary venous filling pressure and blood flow increased more in case of a lower BMI.

CONCLUSION

CAP increases cutaneous tissue oxygen saturation and capillary blood flow at the radial forearm of healthy volunteers. These results support recently published data on wound healing after CAP treatment. However, further studies are needed to determine if this treatment can improve the reduced microcirculation in diabetic foot ulcers. Moreover, repetitive application protocols have to be compared with a single session treatment approach.

Cold Atmospheric Plasma: A Promising Complementary Therapy for Squamous Head and Neck Cancer

Head and neck squamous cell cancer (HNSCC) is the 7th most common cancer worldwide. Despite the development of new therapeutic agents such as monoclonal antibodies, prognosis did not change for the last decades. Cold atmospheric plasma (CAP) presents the most promising new technology in cancer treatment. In this study the efficacy of a surface micro discharging (SMD) plasma device against two head and neck cancer cell lines was proved. Effects on the cell viability, DNA fragmentation and apoptosis induction were evaluated with the MTT assay, alkaline microgel electrophoresis (comet assay) and Annexin-V/PI staining. MTT assay revealed that the CAP treatment markedly decreases the cell viability for all tested treatment times (30, 60, 90, 120 and 180 s). IC 50 was reached within maximal 120 seconds of CAP treatment. Comet assay analysis showed a dose dependent high DNA fragmentation being one of the key players in anti-cancer activity of CAP. Annexin-V/PI staining revealed induction of apoptosis in CAP treated HNSCC cell lines but no significant dose dependency was seen. Thus, we confirmed that SMD Plasma technology is definitely a promising new approach on cancer treatment.

Nanomechanical and surface properties of rMSCs post-exposure to CAP treated UHMWPE wear particles

Wear debris generated by ultra-high molecular weight polyethylene (UHMWPE) used in joint replacement devices has been of concern due to reductions of the implant longevity. Cold atmospheric plasma (CAP) has been used to improve the wear performance of UHMWPE. Our aim was to investigate the elastic and adhesive properties of rat mesenchymal stem cells (rMSCs), through AFM, after exposure to UHMWPE wear debris pre- and post-CAP treatment. The results indicated that the main changes in cell elasticity and spring constant of MSC exposed to wear particles occurred in the first 24 h of contact and the particle concentration from 0.5 to 50 mg/l did not play a significant role. For UHMWPE treated for 7.5 min, with progression of the wear simulation the results of the CAP treated samples were getting closer to the result of untreated samples; while with longer CAP treatment this was not observed.

From the Clinical Editor

Joint replacements are now common clinical practice. However, the use of ultra-high molecular weight polyethylene (UHMWPE) still poses a concern, due to the presence of wear debris. The authors here investigated the effects of wear debris after cold atmospheric plasma treatment on rat mesenchymal stem cells. The positive results provided new strategies in future design of joint replacement materials.

Proteomic Changes of Tissue-Tolerable Plasma Treated Airway Epithelial Cells and Their Relation to Wound Healing

Background. The worldwide increasing number of patients suffering from nonhealing wounds requires the development of new safe strategies for wound repair. Recent studies suggest the possibility of nonthermal (cold) plasma application for the acceleration of wound closure. Methods. An in vitro wound healing model with upper airway S9 epithelial cells was established to determine the macroscopically optimal dosage of tissue-tolerable plasma (TTP) for wound regeneration, while a 2D-difference gel electrophoresis (2D-DIGE) approach was used to quantify the proteomic changes in a hypothesis-free manner and to evaluate the balance of beneficial and adverse effects due to TTP application. Results. Plasma doses from 30 s up to 360 s were tested in relation to wound closure after 24 h, 48 h, 72 h, 96 h, and 120 h, in which lower doses (30, 60, and 120 s) resulted in dose-dependent improved wound healing rate compared to untreated cells. Thereby, the 120 s dose caused significantly the best wound healing properties after 96 and 120 h. The proteome analysis combined with IPA revealed that a lot of affected stress adaptation responses are linked to oxidative stress response emphasizing oxidative stress as a possible key event in the regeneration process of epithelial cells as well as in the adaptation to plasma exposure. Further cellular and molecular functions like proliferation and apoptosis were significantly up- or downregulated by all TTP treatments but mostly by the 120 s dose. Conclusions. For the first time, we were able to show plasma effects on cellular adaptation of upper airway epithelial S9 cells improving wound healing. This is of particular interest for plasma application, for example, in the surgery field of otorhinolaryngology or internal medicine.

Atmospheric-Pressure Cold Plasma Induces Transcriptional Changes in Ex Vivo Human Corneas

Background

Atmospheric pressure cold plasma (APCP) might be considered a novel tool for tissue disinfection in medicine since the active chemical species produced by low plasma doses, generated by ionizing helium gas in air, induces reactive oxygen species (ROS) that kill microorganisms without substantially affecting human cells.

Objectives

In this study, we evaluated morphological and functional changes in human corneas exposed for 2 minutes (min) to APCP and tested if the antioxidant n-acetyl l-cysteine (NAC) was able to inhibit or prevent damage and cell death.

Results

Immunohistochemistry and western blotting analyses of corneal tissues collected at 6 hours (h) post-APCP treatment demonstrated no morphological tissue changes, but a transient increased expression of OGG1 glycosylase that returned to control levels in 24 h. Transcriptome sequencing and quantitative real time PCR performed on different corneas revealed in the treated corneas many differentially expressed genes: namely, 256 and 304 genes showing expression changes greater than ± 2 folds in the absence and presence of NAC, respectively. At 6 h post-treatment, the most over-expressed gene categories suggested an active or enhanced cell functioning, with only a minority of genes specifically concerning oxidative DNA damage and repair showing slight over-expression values (<2 folds). Moreover, time-related expression analysis of eight genes up-regulated in the APCP-treated corneas overall demonstrated the return to control expression levels after 24 h.

Conclusions

These findings of transient oxidative stress accompanied by wide-range transcriptome adjustments support the further development of APCP as an ocular disinfectant.

Clinical use of cold atmospheric pressure argon plasma in chronic leg ulcers: A pilot study

OBJECTIVE

In the age of multiresistant microbes and the increasing lack of efficient antibiotics, conventional antiseptics play a critical role in the prevention and therapy of wound infections. Recent studies have demonstrated the antiseptic effects of cold atmospheric pressure plasma (APP). In this pilot, study we investigate the overall suitability of one of the first APP sources for wound treatment focusing on its potential antimicrobial effects.

METHOD

The wound closure rate and the bacterial colonisation of the wounds were investigated. Patients suffering from chronic leg ulcers were treated in a clinical controlled monocentric trial with either APP or octenidine (OCT). In patients who presented with more than one ulceration in different locations, one was treated with APP and the other one with OCT. Each group was treated three times a week over a period of two weeks. The antimicrobial efficacy was evaluated immediately after and following two weeks of treatment.

RESULTS

Wounds treated with OCT showed a significantly higher microbial reduction (64%) compared to wounds treated with APP (47%) immediately after the treatment. Over two weeks of antiseptic treatment the bacterial density was reduced within the OCT group (-35%) compared to a slight increase in bacterial density in the APP-treated group (+12%). Clinically, there were no signs of delayed wound healing observed in either group and both treatments were well tolerated.

CONCLUSION

The immediate antimicrobial effects of the APP prototype source were almost comparable to OCT without any signs of cytotoxicity. This pilot study is limited by current configurations of the plasma source, where the narrow plasma beam made it difficult to cover larger wound surface areas and in order to avoid untreated areas of the wound bed, smaller wounds were assigned to the APP-treatment group. This limits the significance of AAP-related effects on the wound healing dynamics, as smaller wounds tend to heal faster than larger wounds. However, clinical wound healing studies on a larger scale now seem justifiable. A more advanced plasma source prototype allowing the treatment of larger wounds will address APP's influence on healing dynamics, synergetic treatment with current antiseptics and effects on multiresistant bacteria.

On the history of plasma treatment and comparison of microbiostatic efficacy of a historical high-frequency plasma device with two modern devices

Background: Cold atmospheric pressure plasma (CAP) with its many bioactive properties has defined a new medical field: the plasma medicine. However, in the related form of high-frequency therapy, CAP was even used briefly a century ago. The aim of this study was to review historic CAP treatments and to obtain data regarding the antimicrobial efficacy of a historical high-frequency plasma device.

Methods: First, historic literature regarding the history of CAP treatment was evaluated, because in the modern literature no data were available. Second, the susceptibility of 5 different bacterial wound isolates, cultured on agar, to a historic plasma source (violet wand [VW]) and two modern devices (atmospheric pressure plasma jet [APPJ] and Dielectric Barrier Discharge [DBD]) was analyzed . The obtained inhibition areas (IA) were compared.

Results: First, the most convenient popular historical electromedical treatments produced a so-called effluvia by using glass electrodes, related to today’s CAP. Second, all three tested plasma sources showed complete eradication of all tested microbial strains in the treated area. The “historical” cold VW plasma showed antimicrobial effects similar to those of modern APPJ and DBD regarding the diameter of the IA.

Conclusion: Some retrograde evidence may be deducted from this, especially for treatment of infectious diseases with historical plasma devices. The underlying technology may serve as model for construction of modern sucessive devices.

Combined antibacterial effects of tissue-tolerable plasma and a modern conventional liquid antiseptic on chronic wound treatment

Potential antimicrobial effects of sequential applications of tissue-tolerable plasma (TTP) and the conventional liquid antiseptic octenidine dihydrochloride (ODC) were investigated. 34 patients with chronic leg ulcers were treated with TTP, ODC or a combination of both. The bacterial colonization was measured semi-quantitatively before and immediately after treatment and changes in the microbial strains' compositions before and after antiseptic treatments were analyzed. All antiseptic procedures reduced the bacterial counts significantly. The sequential application of TTP and ODC displayed the highest antimicrobial efficacy. Me combined use of TTP and conventional antiseptics might represent the most efficient strategy for antiseptic treatment of chronic wounds.

Effect of cold plasma on glial cell morphology studied by atomic force microscopy

The atomic force microscope (AFM) is broadly used to study the morphology of cells. The morphological characteristics and differences of the cell membrane between normal human astrocytes and glial tumor cells are not well explored. Following treatment with cold atmospheric plasma, evaluation of the selective effect of plasma on cell viability of tumor cells is poorly understood and requires further evaluation. Using AFM we imaged morphology of glial cells before and after cold atmospheric plasma treatment. To look more closely at the effect of plasma on cell membrane, high resolution imaging was used. We report the differences between normal human astrocytes and human glioblastoma cells by considering the membrane surface details. Our data, obtained for the first time on these cells using atomic force microscopy, argue for an architectural feature on the cell membrane, i.e. brush layers, different in normal human astrocytes as compared to glioblastoma cells. The brush layer disappears from the cell membrane surface of normal E6/E7 cells and is maintained in the glioblastoma U87 cells after plasma treatment.

Effects of cold atmospheric plasma (CAP) on ß-defensins, inflammatory cytokines, and apoptosis-related molecules in keratinocytes in vitro and in vivo

Cold atmospheric plasma (CAP) has been gaining increasing interest as a new approach for the treatment of skin diseases or wounds. Although this approach has demonstrated promising antibacterial activity, its exact mechanism of action remains unclear. This study explored in vitro and in vivo whether CAP influences gene expression and molecular mechanisms in keratinocytes. Our results revealed that a 2 min CAP treatment using the MicroPlaSter ß in analogy to the performed clinical studies for wound treatment induces expression of IL-8, TGF-ß1, and TGF-ß2. In vitro and in vivo assays indicated that keratinocyte proliferation, migration, and apoptotic mechanisms were not affected by the CAP treatment under the applied conditions. Further, we observed that antimicrobial peptides of the ß-defensin family are upregulated after CAP treatment. In summary, our results suggest that a 2 min application of CAP induces gene expression of key regulators important for inflammation and wound healing without causing proliferation, migration or cell death in keratinocytes. The induction of ß-defensins in keratinocytes describes an absolutely new plasma strategy. Activation of antimicrobial peptides supports the well-known antibacterial effect of CAP treatment, whereas the mechanism of ß-defensin activation by CAP is not investigated so far.

Antimicrobial Efficacy of a Historical High-Frequency Plasma Apparatus in Comparison With 2 Modern, Cold Atmospheric Pressure Plasma Devices

BACKGROUND

Today, highly sophisticated devices deliver cold atmospheric pressure plasma (CAPP) with a multitude of bioactive properties, opening the window to a new medical field: plasma medicine. Different techniques to create the optimal plasma device for different medical indications are currently being explored. However, even a 100 years ago, CAPP was briefly used in the related form of high-frequency therapy. The objective of our study was to compare historic with modern techniques regarding antimicrobial efficacy.

METHODS

First, 26 different clinical isolates of relevant wound pathogens were treated in vitro with a historic violet wand (VW) and 2 modern plasma sources (kINPen 09 and dielectric barrier discharge [DBD]) and the obtained inhibition areas (IAs) were compared. Second, a biofilm model was used to compare biofilm inactivation by VW, DBD, ethanol, and polyhexanide treatment.

RESULTS

DBD with the largest electrode produced the largest IAs. VW showed results similar to 2 different modes of the kINPen 09. IAs of VW were enlargeable by attaching a larger electrode. Against biofilms, VW was less effective than DBD but more effective than ethanol 70% and polyhexanide.

CONCLUSION

The proven antimicrobial efficacy of VW may encourage the development of new, potent plasma devices based on the very simple and inexpensive technique of the historic high-frequency apparatus.