Mechanism of action of retinyl compounds on wound healing. I. Structural relationship of retinyl compounds and wound healing

Retinoids and Wound Healing

BACKGROUND

Retinoids are widely used in dermatology and may play a role in wound healing. The exact role of retinoids in wounds is confusing and controversial, however. Systemic retinoids are presumed to be detrimental to wound healing; however, this standard is based on isolated reports.

OBJECTIVE

The objective was to provide a critical review of the available literature regarding the role of both topical and systemic retinoids in various aspects of wound healing.

CONCLUSIONS

Pretreatment with retinoids likely promotes wound healing after facial resurfacing procedures and full- or partial-thickness wounds. While the evidence is mixed regarding the effects of retinoids applied to fresh and healing wounds, the majority of the evidence available shows favorable wound-healing properties in this setting. The medical-legal standard regarding the avoidance of facial resurfacing and surgical procedures in patients on or recently completing a course of systemic retinoids was likely prematurely established.

Pretreatment of photoaged forearm skin with topical tretinoin accelerates healing of full-thickness wounds

Pretreatment of skin with all-trans retinoic acid (tretinoin) has been shown to enhance wound healing. Previous studies have mainly used animal models to demonstrate this effect. We wanted to determine whether pretreatment could promote wound healing in severely photoaged dorsal forearm skin. Four elderly men with severely actinically damaged forearms were treated daily for 16 weeks. One arm was treated with 0.05-0.1% tretinoin cream (Retin A, Ortho), and the other with Purpose cream (Ortho) as a vehicle control. Four-millimetre punch biopsies were taken from both dorsal forearms prior to treatment. After 16 weeks, full-thickness 2-mm punch biopsies were taken from both sides. Serial photographs were taken, and healing of the wounds quantitatively assessed by image analysis. On the 11th day, the wounds were excised using a 4-mm biopsy punch. Biopsies were processed for light microscopy. After 16 weeks, the tretinoin-treated forearms showed moderate erythema and scaling. Polarized light photographs revealed multiple, red, vascularized foci and/or a diffuse network of small vessels. The histological effects were typical for tretinoin, i.e. compaction of the stratum corneum, epidermal acanthosis with correction of atypia, an increase in small vessels, and increased cellularity in the upper dermis. Purpose cream had no effect, either clinically or histologically. On the tretinoin-treated side, the wound areas were 35-37% smaller on days 1 and 4, and 47-50% smaller on days 6, 8, 11, compared with the controls. Clinically and histologically, reepithelialization occurred more rapidly. Thus tretinoin dramatically accelerated wound healing in photodamaged skin.

Vitamin A and wound healing

Retinoids have long been associated with wound healing, but objective data, until recently, have been scarce. Vitamin A deficiency retards repair. Secondly, retinoids restore steroid-retarded repair toward normal. Because vitamin A tends to suppress fibroblasts in cell culture and stimulate steroid-treated macrophages to initiate reparative behavior in tissue, we favor the hypothesis that retinoids are particularly important in macrophagic inflammation, which plays a central role in the control of wound healing. Probably all patients who take anti-inflammatory steroids should control their retinoid intake, but how they should control it is as yet unknown.

Cancer resistance, carcinogenesis and ground substance viscosity

Tumor host resistance and promotion are multiple complex simultaneous phenomena. This paper relates only to the effect of ground substance viscosity on tumor host interaction. Tar, anthralin, ultraviolet light, x-ray and arsenic have been widely used to treat inflammatory skin disorders such as psoriasis. They are also well known carcinogens. It is proposed that both the anti-inflammatory effect and part of the carcinogenic effect could occur by decreasing ground substance viscosity and suppressing fibroblasts. Streptococcal infections, chloroquine and pyridoxine deficiency increase inflammatory skin disorders and are known to be beneficial to tumor resistance. It is proposed that both effects could occur because of their effect of increasing ground substance viscosity and, at least with streptococcal infections, by stimulating fibroblasts. Within certain limits, vitamin C has a stimulant effect on fibroblast and ground substance viscosity. Beta carotene is active in stimulating wound healing. Localized edema of the dermal papillae precedes granulocytic inflammation in disorders like psoriasis. Anything that decreases ground substance viscosity will prevent dilution of tissue fluids by decreasing localized edema and thus decrease formation of some mediators of inflammation. Anything that increases ground substance and its viscosity will promote local dilution of tissue fluid. Increasing dilution of tissue fluids promotes the formation of some mediators of inflammation. Tumors commonly secrete hyaluronidase. It is proposed that substances that decrease ground substance viscosity (hyaluronidase-like activity) encourage tumors and substances that increase ground substance viscosity (anti-hyaluronidase-like effect) increase resistance to tumors.