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Kim JH, Song JW, Kim YH, Kim HJ, Kim RH, Park YH, Nam HS, Kang DO, Yoo H, Park K, Kim JW. Multimodal Imaging-Assisted Intravascular Theranostic Photoactivation on Atherosclerotic Plaque. Circ Res 2024; 135:e114-e132. [PMID: 38989585 DOI: 10.1161/circresaha.123.323970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Atherosclerosis is a chronic inflammatory disease causing a fatal plaque rupture, and its key aspect is a failure to resolve inflammation. We hypothesize that macrophage-targeted near-infrared fluorescence emitting photoactivation could simultaneously assess macrophage/lipid-rich plaques in vivo and facilitate inflammation resolution. METHODS We fabricated a Dectin-1-targeted photoactivatable theranostic agent through the chemical conjugation of the near-infrared fluorescence-emitting photosensitizer chlorin e6 and the Dectin-1 ligand laminarin (laminarin-chlorin e6 [LAM-Ce6]). Intravascular photoactivation by a customized fiber-based diffuser after administration of LAM-Ce6 effectively reduced inflammation in the targeted plaques of atherosclerotic rabbits in vivo as serially assessed by dual-modal optical coherence tomography-near-infrared fluorescence structural-molecular catheter imaging after 4 weeks. RESULTS The number of apoptotic macrophages peaked at 1 day after laser irradiation and then resolved until 4 weeks. Autophagy was strongly augmented 1 hour after the light therapy, with the formation of autophagolysosomes. LAM-Ce6 photoactivation increased the terminal deoxynucleotidyl transferase dUTP (deoxyuridine triphosphate) nick end labeling/RAM11 (rabbit monocyte/macrophage antibody)- and MerTK (c-Mer tyrosine kinase)-positive cells in the plaques, suggesting enhanced efferocytosis. In line with inflammation resolution, photoactivation reduced the plaque burden through fibrotic replacement via the TGF (transforming growth factor)-β/CTGF (connective tissue growth factor) pathway. CONCLUSIONS Optical coherence tomography-near-infrared fluorescence imaging-guided macrophage Dectin-1-targetable photoactivation could induce the transition of macrophage/lipid-rich plaques into collagen-rich lesions through autophagy-mediated inflammation resolution and TGF-β-dependent fibrotic replacement. This novel strategy offers a new opportunity for the catheter-based theranostic strategy.
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Affiliation(s)
- Jin Hyuk Kim
- BK21 Graduate Program, Department of Biomedical Sciences, Korea University College of Medicine, Seoul, Korea (J.H.K., J.W.K.)
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Joon Woo Song
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Yeon Hoon Kim
- Department of Mechanical Engineering, KAIST, Daejeon, Korea (Y.H.K., H.S.N., H.Y.)
| | - Hyun Jung Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Ryeong Hyun Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Ye Hee Park
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Hyeong Soo Nam
- Department of Mechanical Engineering, KAIST, Daejeon, Korea (Y.H.K., H.S.N., H.Y.)
| | - Dong Oh Kang
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
| | - Hongki Yoo
- Department of Mechanical Engineering, KAIST, Daejeon, Korea (Y.H.K., H.S.N., H.Y.)
| | - Kyeongsoon Park
- Department of Systems Biotechnology, Chung-Ang University, Anseong, Gyeonggi, Korea (K.P.)
| | - Jin Won Kim
- BK21 Graduate Program, Department of Biomedical Sciences, Korea University College of Medicine, Seoul, Korea (J.H.K., J.W.K.)
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital (J.H.K., J.W.S., H.J.K., R.H.K., Y.H.P., D.O.K., J.W.K.)
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Chen Y, Guo P, Chen L, He D. 5-aminolevulinic acid induced photodynamic reactions in diagnosis and therapy for female lower genital tract diseases. Front Med (Lausanne) 2024; 11:1370396. [PMID: 39076768 PMCID: PMC11284047 DOI: 10.3389/fmed.2024.1370396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/13/2024] [Indexed: 07/31/2024] Open
Abstract
Since the patients suffering from female lower genital tract diseases are getting younger and younger and the human papilloma virus (HPV) infection is becoming more widespread, the novel non-invasive precise modalities of diagnosis and therapy are required to remain structures of the organ and tissue, and fertility as well, by which the less damage to normal tissue and fewer adverse effects are able to be achieved. In all nucleated mammalian cells, 5-Aminolevulinic acid (5-ALA) is an amino acid that occurs spontaneously, which further synthesizes in the heme biosynthetic pathway into protoporphyrin IX (PpIX) as a porphyrin precursor and photosensitizing agent. Exogenous 5-ALA avoids the rate-limiting step in the process, causing PpIX buildup in tumor tissues. This tumor-selective PpIX distribution after 5-ALA application has been used successfully for tumor photodynamic diagnosis (PDD) and photodynamic therapy (PDT). Several ALA-based drugs have been used for ALA-PDD and ALA-PDT in treating many (pre)cancerous diseases, including the female lower genital tract diseases, yet the ALA-induced fluorescent theranostics is needed to be explored further. In this paper, we are going to review the studies of the mechanisms and applications mainly on ALA-mediated photodynamic reactions and its effectiveness in treating female lower genital tract diseases.
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Affiliation(s)
- Yuqing Chen
- Department of Urology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, Shaanxi, China
| | - Peng Guo
- Department of Urology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, Shaanxi, China
| | - Lihong Chen
- Department of Obstetrics and Gynecology, Shaanxi Provincial People’s Hospital, Xi'an, Shaanxi, China
| | - Dalin He
- Department of Urology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi'an, Shaanxi, China
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Nardini P, Notari L, Magazzini M, Mariani B, Rossi F, Rossi S, Van Aardt E, Marszalek K, Grandi V, Corsi A, Pimpinelli N, Bacci S. Neuroimmunomodulatory effect of Nitric Oxide on chronic wound healing after photodynamic therapy. Photodiagnosis Photodyn Ther 2024; 47:104078. [PMID: 38588874 DOI: 10.1016/j.pdpdt.2024.104078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
Neuroimmunomodulation is the capacity of the nervous system to regulate immune processes. The existence of neurotransmitter receptors in immune cells enables this phenomenon to take place. Neuronal mediators possess the capacity to direct and control several occurrences during the wound healing process. Nitric oxide (NO) functions as a neuromodulator, playing a crucial role in the regulation of vascular tone and blood pressure with antimicrobial properties. Photodynamic therapy has been shown to augment the function of immune cells involved in the healing process of venous leg ulcers. Nitric oxide can be secreted into the extracellular environment by these cells. In lesions treated with PDT, the synthesis of iNOs (the enzyme that releases NO) increased, as demonstrated by the experimental results. Therefore the significance of PDT in enhancing the clinical condition of the lesion is thus highlighted.
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Affiliation(s)
- Patrizia Nardini
- Department of Clinical and Experimental Medicine, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Lorenzo Notari
- Department of Clinical and Experimental Medicine, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Miriam Magazzini
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Bianca Mariani
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Federico Rossi
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Sofia Rossi
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy
| | - Elisabeth Van Aardt
- School of Pharmacy and Biomedical Sciences, Faculty of Science and Health, University of Portsmouth, Portsmouth, United Kingdom
| | - Katarzyna Marszalek
- School of Pharmacy and Biomedical Sciences, Faculty of Science and Health, University of Portsmouth, Portsmouth, United Kingdom
| | - Vieri Grandi
- Department of Health Sciences, Division of Dermatology, University of Florence, 50121, Firenze, Italy
| | | | - Nicola Pimpinelli
- Department of Health Sciences, Division of Dermatology, University of Florence, 50121, Firenze, Italy
| | - Stefano Bacci
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, 50121, Firenze, Italy.
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Hernández-Bule ML, Naharro-Rodríguez J, Bacci S, Fernández-Guarino M. Unlocking the Power of Light on the Skin: A Comprehensive Review on Photobiomodulation. Int J Mol Sci 2024; 25:4483. [PMID: 38674067 PMCID: PMC11049838 DOI: 10.3390/ijms25084483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Photobiomodulation (PBM) is a procedure that uses light to modulate cellular functions and biological processes. Over the past decades, PBM has gained considerable attention for its potential in various medical applications due to its non-invasive nature and minimal side effects. We conducted a narrative review including articles about photobiomodulation, LED light therapy or low-level laser therapy and their applications on dermatology published over the last 6 years, encompassing research studies, clinical trials, and technological developments. This review highlights the mechanisms of action underlying PBM, including the interaction with cellular chromophores and the activation of intracellular signaling pathways. The evidence from clinical trials and experimental studies to evaluate the efficacy of PBM in clinical practice is summarized with a special emphasis on dermatology. Furthermore, advancements in PBM technology, such as novel light sources and treatment protocols, are discussed in the context of optimizing therapeutic outcomes and improving patient care. This narrative review underscores the promising role of PBM as a non-invasive therapeutic approach with broad clinical applicability. Despite the need for further research to develop standard protocols, PBM holds great potential for addressing a wide range of medical conditions and enhancing patient outcomes in modern healthcare practice.
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Affiliation(s)
| | | | - Stefano Bacci
- Research Unit of Histology and Embriology, Department of Biology, University of Florence, 50139 Florence, Italy;
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Chen P, Zou Y, Liu Y, Han W, Zhang M, Wu Y, Yin R. Low-level photodynamic therapy in chronic wounds. Photodiagnosis Photodyn Ther 2024; 46:104085. [PMID: 38614272 DOI: 10.1016/j.pdpdt.2024.104085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Chronic wounds refer to those that can't reconstruct anatomical and physical functional integrity, and are usually associated with signs of microbial infection. Current therapies include debridement and dressing change, local or systemic application of antibiotics, and medical dressing care, which are not ideal for the healing of chronic wounds. OBJECTIVE To explore the efficacy and safety of photodynamic therapy (ALA-PDT) for the treatment of chronic infectious wounds. MATERIALS AND METHODS ALA-PDT was used in ten patients with persistent wound infections and systemic complications who did not respond to conventional treatment. 5 % ALA solution was applied to the wound surface after debridement, incubated for 3 h with light protection, and then irradiated with red light for 20 min. This procedure was repeated every two weeks, and any adverse reactions were recorded. After the end of three treatments, the patients were followed up for 3 months. RESULTS Patients who exhibit resistance to traditional therapies demonstrate a favorable therapeutic outcome with ALA-PDT, although complications may impede wound healing. All participants successfully underwent ALA-PDT treatment and subsequent monitoring, with 90 % achieving complete healing. Common adverse reactions to ALA-PDT encompass treatment-related pain, temporary erythema, and swelling, all of which are well-tolerated by patients without enduring severe consequences. CONCLUSIONS ALA-PDT proves to be an efficacious intervention for managing chronic wounds, irrespective of the presence of localized infections or systemic complications.
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Affiliation(s)
- Pan Chen
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yongzhen Zou
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yueling Liu
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Weidong Han
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Mingwang Zhang
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yaguang Wu
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Rui Yin
- Department of Dermatology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China; Department of Dermatology, Southwest Hospital Jiangbei Area (The 958th Hospital of Chinese People's Liberation Army), Chongqing, 400020, China.
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Zhao H, Sun J, Yang Y. Research Progress of Photodynamic Therapy in Wound Healing: A Literature Review. J Burn Care Res 2023; 44:1327-1333. [PMID: 37747820 DOI: 10.1093/jbcr/irad146] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Indexed: 09/27/2023]
Abstract
Light is an efficient technique that has a significant influence on contemporary medicine. Photodynamic therapy (PDT), which involves the combined action of photosensitizers (PSs), oxygen, and light, has emerged as a therapeutically promising method for treating a broad variety of solid tumors and infectious diseases. Photodynamic therapy is minimally invasive, has few side effects, lightens scars, and reduces tissue loss while preserving organ structure and function. In particular, PDT has a high healing potential for wounds (PDT stimulates wound healing by enhancing re-epithelialization, promoting angiogenesis as well as modulating skin homeostasis). Wound healing involves interactions between many different processes, including coagulation, inflammation, angiogenesis, cellular migration, and proliferation. Poor wound healing with diabetes or extensive burns remains a difficult challenge. This review emphasizes PDT as a potential research field and summarizes PDT's role in wound healing, including normal wounds, chronic wounds, and aging wounds.
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Affiliation(s)
- Hongqing Zhao
- Nanbu County People's Hospital, Nanchong City, Sichuan Province 637300, China
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, 51 Fucheng Road, Haidian District, Beijing 100048, China
- Jinzhou Medical University, No. 40 Songpo Road, Taihe District, Jinzhou City, Liaoning Province 121001, China
| | - Jiachen Sun
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, 51 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yuguang Yang
- Department of Dermatology, Fourth Medical Center of Chinese PLA General Hospital, 51 Fucheng Road, Haidian District, Beijing 100048, China
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Chin JD, Zhao L, Mayberry TG, Cowan BC, Wakefield MR, Fang Y. Photodynamic Therapy, Probiotics, Acetic Acid, and Essential Oil in the Treatment of Chronic Wounds Infected with Pseudomonas aeruginosa. Pharmaceutics 2023; 15:1721. [PMID: 37376169 PMCID: PMC10301549 DOI: 10.3390/pharmaceutics15061721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/05/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
As a prevalent medical problem that burdens millions of patients across the world, chronic wounds pose a challenge to the healthcare system. These wounds, often existing as a comorbidity, are vulnerable to infections. Consequently, infections hinder the healing process and complicate clinical management and treatment. While antibiotic drugs remain a popular treatment for infected chronic wounds, the recent rise of antibiotic-resistant strains has hastened the need for alternative treatments. Future impacts of chronic wounds are likely to increase with aging populations and growing obesity rates. With the need for more effective novel treatments, promising research into various wound therapies has seen an increased demand. This review summarizes photodynamic therapy, probiotics, acetic acid, and essential oil studies as developing antibiotic-free treatments for chronic wounds infected with Pseudomonas aeruginosa. Clinicians may find this review informative by gaining a better understanding of the state of current research into various antibiotic-free treatments. Furthermore. this review provides clinical significance, as clinicians may seek to implement photodynamic therapy, probiotics, acetic acid, or essential oils into their own practice.
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Affiliation(s)
- Jaeson D. Chin
- Department of Microbiology, Immunology & Pathology, Des Moines University, Des Moines, IA 50312, USA
| | - Lei Zhao
- The Department of Respiratory Medicine, The Second People’s Hospital of Hefei and Hefei Hospital Affiliated to Anhui Medical University, Hefei 230002, China
| | - Trenton G. Mayberry
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Braydon C. Cowan
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA
| | - Mark R. Wakefield
- Department of Surgery, University of Missouri School of Medicine, Columbia, MO 65212, USA
- Ellis Fischel Cancer Center, University of Missouri, Columbia, MO 65212, USA
| | - Yujiang Fang
- Department of Microbiology, Immunology & Pathology, Des Moines University, Des Moines, IA 50312, USA
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Howley R, Chandratre S, Chen B. 5-Aminolevulinic Acid as a Theranostic Agent for Tumor Fluorescence Imaging and Photodynamic Therapy. Bioengineering (Basel) 2023; 10:bioengineering10040496. [PMID: 37106683 PMCID: PMC10136048 DOI: 10.3390/bioengineering10040496] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
5-Aminolevulinic acid (ALA) is a naturally occurring amino acid synthesized in all nucleated mammalian cells. As a porphyrin precursor, ALA is metabolized in the heme biosynthetic pathway to produce protoporphyrin IX (PpIX), a fluorophore and photosensitizing agent. ALA administered exogenously bypasses the rate-limit step in the pathway, resulting in PpIX accumulation in tumor tissues. Such tumor-selective PpIX disposition following ALA administration has been exploited for tumor fluorescence diagnosis and photodynamic therapy (PDT) with much success. Five ALA-based drugs have now received worldwide approval and are being used for managing very common human (pre)cancerous diseases such as actinic keratosis and basal cell carcinoma or guiding the surgery of bladder cancer and high-grade gliomas, making it the most successful drug discovery and development endeavor in PDT and photodiagnosis. The potential of ALA-induced PpIX as a fluorescent theranostic agent is, however, yet to be fully fulfilled. In this review, we would like to describe the heme biosynthesis pathway in which PpIX is produced from ALA and its derivatives, summarize current clinical applications of ALA-based drugs, and discuss strategies for enhancing ALA-induced PpIX fluorescence and PDT response. Our goal is two-fold: to highlight the successes of ALA-based drugs in clinical practice, and to stimulate the multidisciplinary collaboration that has brought the current success and will continue to usher in more landmark advances.
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Affiliation(s)
- Richard Howley
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Sharayu Chandratre
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
| | - Bin Chen
- Department of Pharmaceutical Sciences, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA 19104, USA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Zhang Y, Liu W, Wang Q. Positive effects of low-dose photodynamic therapy with aminolevulinic acid or its methyl ester in skin rejuvenation and wound healing: An update. JOURNAL OF BIOPHOTONICS 2023; 16:e202200293. [PMID: 36602479 DOI: 10.1002/jbio.202200293] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/28/2022] [Accepted: 01/02/2023] [Indexed: 06/17/2023]
Abstract
In dermatology, photodynamic therapy (PDT) is widely used in skin tumors, infections, etc., because of the killing effect triggered by toxic reactive oxygen species (ROS). However, the ROS concentration is determined by various photosensitizer concentrations and formulations, as well as various irradiation parameters. Low-dose PDT leads to sufficiently low ROS level, which results in biological effects that are the exact opposite of the killing potency. Therefore, in recent years, low-dose PDT has been exploited in improving aging and wound. Low-dose ALA/MAL PDT might improve aging through promoting the proliferation of fibroblasts, blocking DNA damage, counteracting oxidative stress, inhibiting melanogenesis, and remodeling lymphatic vessels in aged skin. Promoting fibroblasts and epidermal stem cells proliferation and migration, promoting granulation tissue formation and angiogenesis and regulating the inflammatory process might be the mechanisms of low-dose ALA/MAL PDT in wound healing. Nevertheless, the positive effects of low-dose PDT have not been thoroughly investigated in dermatology, and high-quality studies are still needed to fill the relevant vacancy.
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Affiliation(s)
- YuWei Zhang
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Liu
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Qian Wang
- The Institute of Dermatology and Venereology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
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Khorsandi K, Hosseinzadeh R, Esfahani H, Zandsalimi K, Shahidi FK, Abrahamse H. Accelerating skin regeneration and wound healing by controlled ROS from photodynamic treatment. Inflamm Regen 2022; 42:40. [PMID: 36192814 PMCID: PMC9529607 DOI: 10.1186/s41232-022-00226-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/16/2022] [Indexed: 11/24/2022] Open
Abstract
Cellular metabolisms produce reactive oxygen species (ROS) which are essential for cellular signaling pathways and physiological functions. Nevertheless, ROS act as “double-edged swords” that have an unstable redox balance between ROS production and removal. A little raise of ROS results in cell proliferation enhancement, survival, and soft immune responses, while a high level of ROS could lead to cellular damage consequently protein, nucleic acid, and lipid damages and finally cell death. ROS play an important role in various pathological circumstances. On the contrary, ROS can show selective toxicity which is used against cancer cells and pathogens. Photodynamic therapy (PDT) is based on three important components including a photosensitizer (PS), oxygen, and light. Upon excitation of the PS at a specific wavelength, the PDT process begins which leads to ROS generation. ROS produced during PDT could induce two different pathways. If PDT produces control and low ROS, it can lead to cell proliferation and differentiation. However, excess production of ROS by PDT causes cellular photo damage which is the main mechanism used in cancer treatment. This review summarizes the functions of ROS in living systems and describes role of PDT in production of controllable ROS and finally a special focus on current ROS-generating therapeutic protocols for regeneration and wound healing.
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Affiliation(s)
- Khatereh Khorsandi
- Department of Photodynamic, Medical Laser Research Center, Yara Institute, ACECR, Tehran, Iran. .,Department of Biochemistry and Molecular Medicine, School of Medicine and Health Sciences, The George Washington University, Washington, DC, 20037, USA.
| | - Reza Hosseinzadeh
- Department of Photodynamic, Medical Laser Research Center, Yara Institute, ACECR, Tehran, Iran.,Academic center for education, culture and research, Urmia, Iran
| | - HomaSadat Esfahani
- Department of Photodynamic, Medical Laser Research Center, Yara Institute, ACECR, Tehran, Iran
| | - Kavosh Zandsalimi
- Department of Photodynamic, Medical Laser Research Center, Yara Institute, ACECR, Tehran, Iran
| | - Fedora Khatibi Shahidi
- Department of Photodynamic, Medical Laser Research Center, Yara Institute, ACECR, Tehran, Iran
| | - Heidi Abrahamse
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, P.O. Box 17011, Doornfontein, Johannesburg, 2028, South Africa
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Ning X, He G, Zeng W, Xia Y. The photosensitizer-based therapies enhance the repairing of skin wounds. Front Med (Lausanne) 2022; 9:915548. [PMID: 36035433 PMCID: PMC9403269 DOI: 10.3389/fmed.2022.915548] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/26/2022] [Indexed: 11/29/2022] Open
Abstract
Wound repair remains a clinical challenge and bacterial infection is a common complication that may significantly delay healing. Therefore, proper and effective wound management is essential. The photosensitizer-based therapies mainly stimulate the photosensitizer to generate reactive oxygen species through appropriate excitation source irradiation, thereby killing pathogenic microorganisms. Moreover, they initiate local immune responses by inducing the recruitment of immune cells as well as the production of proinflammatory cytokines. In addition, these therapies can stimulate the proliferation, migration and differentiation of skin resident cells, and improve the deposition of extracellular matrix; subsequently, they promote the re-epithelialization, angiogenesis, and tissue remodeling. Studies in multiple animal models and human skin wounds have proved that the superior sterilization property and biological effects of photosensitizer-based therapies during different stages of wound repair. In this review, we summarize the recent advances in photosensitizer-based therapies for enhancing tissue regeneration, and suggest more effective therapeutics for patients with skin wounds.
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Affiliation(s)
- Xiaoying Ning
- Department of Dermatology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Gang He
- State Key Laboratory for Strength and Vibration of Mechanical Structures, Frontier Institute of Science and Technology, Xi’an Jiaotong University, Xi’an, China
- Xi’an Key Laboratory of Sustainable Energy Materials Chemistry, Frontier Institute of Science and Technology, Xi’an Jiaotong University, Xi’an, China
| | - Weihui Zeng
- Department of Dermatology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yumin Xia
- Department of Dermatology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Yumin Xia,
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Cellular Mechanisms in Acute and Chronic Wounds after PDT Therapy: An Update. Biomedicines 2022; 10:biomedicines10071624. [PMID: 35884929 PMCID: PMC9313247 DOI: 10.3390/biomedicines10071624] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 12/17/2022] Open
Abstract
PDT is a two-stage treatment that combines light energy with a photosensitizer designed to destroy cancerous and precancerous cells after light activation. Photosensitizers are activated by a specific wavelength of light energy, usually from a laser. The photosensitizer is nontoxic until it is activated by light. However, after light activation, the photosensitizer becomes toxic to the targeted tissue. Among sensitizers, the topical use of ALA, a natural precursor of protoporphyrin IX, a precursor of the heme group, and a powerful photosensitizing agent, represents a turning point for PDT in the dermatological field, as it easily absorbable by the skin. Wound healing requires a complex interaction and coordination of different cells and molecules. Any alteration in these highly coordinated events can lead to either delayed or excessive healing. The goal of this review is to elucidate the cellular mechanisms involved, upon treatment with ALA-PDT, in chronic wounds, which are often associated with social isolation and high costs in terms of care.
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Cytokines and Venous Leg Ulcer Healing-A Systematic Review. Int J Mol Sci 2022; 23:ijms23126526. [PMID: 35742965 PMCID: PMC9224200 DOI: 10.3390/ijms23126526] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 01/01/2023] Open
Abstract
Venous leg ulcers (VLUs) are the most common type of leg ulcers with a significant socioeconomic burden due to slow healing. Cytokines may be involved in the pathogenesis of VLUs. In this systematic review, our objective was to investigate the association between cytokine levels, including growth factors, with the healing of VLUs. PubMed, Embase, Web of Science and Cochrane Library were searched from their inception to August 2021. We retrieved 28 articles investigating 38 different cytokines in 790 patients. Cytokines were most commonly investigated in wound fluid and less frequently in biopsies and serum. The studies were judged as having a moderate to high risk of bias, and the results were often inconsistent and sometimes conflicting. A meta-analysis was not performed due to clinical and methodological heterogeneities. We found weak evidence for elevated IL-1α, IL-6, IL-8, TNF-α and VEGF levels in non-healing VLUs, an elevation that declined with healing. TGF-β1 levels tended to increase with VLU healing. Other cytokines warranting further investigations include EGF, FGF-2, GM-CSF, IL-1β, IL-1Ra and PDGF-AA/PDGF-BB. We conclude that non-healing VLUs may be associated with an elevation of a palette of pro-inflammatory cytokines, possibly reflecting activated innate immunity in these wounds. There is a paucity of reliable longitudinal studies monitoring the dynamic changes in cytokine levels during wound healing.
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Efficacy and safety of ALA-PDT in treatment of diabetic foot ulcer with infection. Photodiagnosis Photodyn Ther 2022; 38:102822. [PMID: 35331957 DOI: 10.1016/j.pdpdt.2022.102822] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/28/2022] [Accepted: 03/17/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) with infection is a major clinical issue, as the infection not only potentially devastate the wound healing, but also is the factor that most often leads to amputation. Nevertheless, traditional antibiotic treatment is often insufficient to clear the infection, which could lead to side effects. Photodynamic therapy (PDT) has broad-spectral antibacterial activity. Meanwhile, it is difficult to induce antibiotic resistance. Here, we aim to evaluate the safety and efficacy of 5-aminolevulinic acid photodynamic therapy (ALA-PDT) in the treatment of DFUs with infection. METHODS In our study, 5 diabetic patients with infectious DFUs were diagnosed by pathological examination and the depth of wound was examined by X-Ray. All patients' wounds were firstly irradiated with 20% ALA-PDT (635 nm, 100 J/cm2, 80 mW/cm2) using the red LED to control the infection. Treatment will be combined with debridement if there is granulation necrosis or secretion on the wound surface. PDT sessions were performed weekly in all patients until healing was achieved. All patients were followed up for 0.6-1.2 years after treatment. RESULTS In 5 patients, the DFUs with infection was completely controlled by ALA-PDT. There was no recurrence of DFUs in the follow-up of 0.9 years (range, 0.6-1.2 years) after the treatment. CONCLUSIONS ALA-PDT treatment for DFUs with infection show successful outcomes and might ultimately avoid amputation.
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Songsantiphap C, Vanichanan J, Chatsuwan T, Asawanonda P, Boontaveeyuwat E. Methylene Blue-Mediated Antimicrobial Photodynamic Therapy Against Clinical Isolates of Extensively Drug Resistant Gram-Negative Bacteria Causing Nosocomial Infections in Thailand, An In Vitro Study. Front Cell Infect Microbiol 2022; 12:929242. [PMID: 35846758 PMCID: PMC9283779 DOI: 10.3389/fcimb.2022.929242] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/31/2022] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND/PURPOSE Some multidrug-resistant gram-negative bacteria as a global threat have been recently prioritized for research and development of new treatments. We studied the efficacy of methylene blue-mediated antimicrobial photodynamic therapy (MB-aPDT) for the reduction of extensively drug-resistant Acinetobacter baumannii (XDR-AB) and Pseudomonas aeruginosa (XDR-PS) and multidrug-resistant Klebsiella pneumoniae (MDR-KP) isolated in a university hospital setting in Thailand. METHOD Two isolates of each selected bacterium were collected, XDR-AB1 and AB2, XDR- PS1 and PS2, and MDR-KP1 and KP2. Three triplicate experiments using various MB concentrations alone, various red light fluences alone, as well as the selected non-toxic doses of MB and fluences of red light combined as MB-aPDT were applied on each selected isolate. The colonies were counted [colony forming units (CFU)/ml]. Estimation of the lethal treatment dose defined as reduction of > 2 log10 in CFU/ml compared with untreated bacteria. RESULT There were generally negligible changes in the viable counts of the bacterial suspensions treated with all the MB concentrations (p > 0.05). In the second experiment with the only red light treatments, at fluences higher than 2 J/cm, reduction trend in viable counts across all the isolates was observed. Only for MDR-KP1, however, the lethal dose was achieved with the highest fluence of red light (80 J/cm). With the concentration of MB, 50 and 150 mg/L in the third experiment (MB-aPDT), the greater bacterial reduction was observed in all clinical isolates leading to their lethal viable cell reduction when escalating the light fluence to 80 J/cm. CONCLUSIONS MB-aPDT evidently killed the selected XDR and MDR-gram negative bacteria. In highly drug-resistant crisis era, MB-aPDT could be a promising option, particularly for local infections and infection complicating chronic wounds.
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Affiliation(s)
- Chankiat Songsantiphap
- Photodermatology Unit, Division of Dermatology, Department of Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jakapat Vanichanan
- Division of Infectious Diseases, Department of Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tanittha Chatsuwan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Antimicrobial Resistance and Stewardship Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pravit Asawanonda
- Photodermatology Unit, Division of Dermatology, Department of Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Einapak Boontaveeyuwat
- Photodermatology Unit, Division of Dermatology, Department of Medicine, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- *Correspondence: Einapak Boontaveeyuwat,
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Grandi V, Paroli G, Puliti E, Bacci S, Pimpinelli N. Single ALA-PDT irradiation induces increase in mast cells degranulation and neuropeptide acute response in chronic venous ulcers: A pilot study. Photodiagnosis Photodyn Ther 2021; 34:102222. [PMID: 33601002 DOI: 10.1016/j.pdpdt.2021.102222] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/14/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The behavior of mast cells, their interaction with neuronal cells or nerve fibers, the expression of neuropeptides and the distribution of skin neuronal cells or nerve fibers after ALA-PDT treated vs untreated chronic wounds were investigated. METHODS Nineteen patients suffering from chronic venous ulcers (CVU) were enrolled in this study. Skin samples from wound bed before and after irradiation with ALA-PDT were taken. All specimens were anonymized and analyzed by immunohistochemistry. RESULTS After completion of ALA-PDT, mast cells showed an increase of degranulation index and expression of NGF and VIP. Amongst all the neuronal mediators tested, all except for SP showed an increase of cellular expression after ALA-PDT therapy. CONCLUSION Our study shows preliminary evidences that ALA-PDT induces rapid recruitment of mast cells around dermal fibers in chronic venous ulcers. This finding is also associated with increase in expression of multiple peripheral neuropeptides except SP by skin neuronal cells. ALA-PDT may promote healing of chronic venous ulcers via stimulation of quiescent peripheral nerves, possibly after release of inflammatory molecules by degranulating mast cells.
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Affiliation(s)
- Vieri Grandi
- Department of Health Sciences, Division of Dermatology, University of Florence, Italy; St John's Institute of Dermatology, GSTT NHS Foundation Trust, London, United Kingdom
| | - Gaia Paroli
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, Italy
| | - Elisa Puliti
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, Italy
| | - Stefano Bacci
- Department of Biology, Research Unit of Histology and Embriology, University of Florence, Italy.
| | - Nicola Pimpinelli
- Department of Health Sciences, Division of Dermatology, University of Florence, Italy
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Zhang Y, Cheung YK, Ng DKP, Fong WP. Enhancement of innate and adaptive anti-tumor immunity by serum obtained from vascular photodynamic therapy-cured BALB/c mouse. Cancer Immunol Immunother 2021; 70:3217-3233. [PMID: 33821298 DOI: 10.1007/s00262-021-02917-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 03/14/2021] [Indexed: 02/03/2023]
Abstract
Photodynamic therapy (PDT) is a clinically approved treatment for various types of cancer. Besides killing the tumor cells directly, PDT has also been reported to trigger anti-tumor immunity. In our previous study, BAM-SiPc-based PDT was shown to induce immunogenic cell death on CT26 murine colon tumor cells in vitro. Using the BALB/c mouse animal model and a vascular-PDT (VPDT) approach, it could also eradicate tumor in ∼ 70% of tumor-bearing mice and elicit an anti-tumor immune response. In the present study, the serum obtained from the VPDT-cured mice was studied and found to possess various immunomodulatory properties. In in vitro studies, it stimulated cytokine secretions of IL-6 and C-X-C motif chemokine ligands 1-3 in CT26 cells through the NF-κB and MAPK pathways. The complement protein C5a boosted in the serum was shown to be involved in the process. The serum also induced calreticulin exposure on CT26 cells and activated dendritic cells. It contained CT26-targeting antibodies which, through the Fc region, induced macrophage engulfment of the tumor cells. In in vivo studies, inoculation of the serum-treated CT26 cells to mice demonstrated a retarded tumor growth with leukocytes, particularly T cells, attracted to the tumor site. In addition, the VPDT-cured mice showed different degrees of resistance against challenge of other types of murine tumor cells, for example, the breast tumor 4T1 and EMT6 cells.
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Affiliation(s)
- Ying Zhang
- School of Life Sciences, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China
| | - Ying-Kit Cheung
- School of Life Sciences, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China
| | - Dennis K P Ng
- Department of Chemistry, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China
| | - Wing-Ping Fong
- School of Life Sciences, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong, China.
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Geisler AN, Taylor N. Venous Stasis Ulcers: an Update on Diagnosis and Management. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sun Y, Tosa M, Takada H, Ogawa R. Photodynamic Therapy Delays Cutaneous Wound Healing in Mice. J NIPPON MED SCH 2020; 87:110-117. [PMID: 32655090 DOI: 10.1272/jnms.jnms.2020_87-301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cutaneous wound healing is a complex, dynamic physiological process. Traditional methods of promoting wound healing are not always effective. Consequently, alternative modalities, such as photodynamic therapy (PDT), are needed. We examined the effectiveness and underlying mechanisms of PDT in a murine model of acute wound healing. METHODS Two excisional wounds were produced, one on each side of the midline, in C57bL/6J mice. Methyl 5-aminolevulinate hydrochloride (MAL) was applied to the right-side wound. After 1 to 3 hours of incubation, the wound was irradiated with red light. The left-side wound was not treated with MAL or red light. On Day 14, the wounds were excised and subjected to histological and immunohistochemical analysis. RESULTS During the first week, no difference was seen between the two sides. However, at week 2, PDT-treated wounds exhibited delayed re-epithelialization. On Day 14, hematoxylin and eosin (HE) staining showed a continuous epithelial lining in untreated wounds. In contrast, PDT-treated wounds partially lacked epithelium in the wound bed. Masson's Trichrome (MTC) staining showed a thicker dermis and more collagen fibers and inflammatory cells in PDT-treated wounds than in untreated wounds. Immunohistochemical analyses showed significantly fewer CD31+ blood vessels and greater collagen III density in PDT-treated wounds than in untreated wounds. However, treated and untreated wounds did not differ in collagen I density. CONCLUSIONS PDT delayed acute wound healing in a murine model of secondary intention wound healing.
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Affiliation(s)
- Yan Sun
- Department of Dermatology, The First Hospital of China Medical University.,Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| | - Mamiko Tosa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| | - Hiroya Takada
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
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Sun Y, Ogawa R, Xiao BH, Feng YX, Wu Y, Chen LH, Gao XH, Chen HD. Antimicrobial photodynamic therapy in skin wound healing: A systematic review of animal studies. Int Wound J 2019; 17:285-299. [PMID: 31724831 DOI: 10.1111/iwj.13269] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 01/08/2023] Open
Abstract
Bacterial infection is a common wound complication that can significantly delay healing. Classical local therapies for infected wounds are expensive and are frequently ineffective. One alternative therapy is photodynamic therapy (PDT). We conducted a systematic review to clarify whether PDT is useful for bacteria-infected wounds in animal models. PubMed and Medline were searched for articles on PDT in infected skin wounds in animals. The language was limited to English. Nineteen articles met the inclusion criteria. The overall study methodological quality was moderate, with a low-moderate risk of bias. The animal models were mice and rats. The wounds were excisional, burn, and abrasion wounds. Wound size ranged from 6 mm in diameter to 1.5 × 1.5 cm2 . Most studies inoculated the wounds with Pseudomonas aeruginosa or methicillin-resistant Staphylococcus aureus. Eleven and 17 studies showed that the PDT of infected wounds significantly decreased wound size and bacterial counts, respectively. Six, four, and two studies examined the effect of PDT on infected wound-cytokine levels, wound-healing time, and body weight, respectively. Most indicated that PDT had beneficial effects on these variables. PDT accelerated bacteria-infected wound healing in animals by promoting wound closure and killing bacteria.
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Affiliation(s)
- Yan Sun
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Bi-Huan Xiao
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
| | - Yu-Xin Feng
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
| | - Yan Wu
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
| | - Liang-Hong Chen
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xing-Hua Gao
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
| | - Hong-Duo Chen
- Department of Dermatology, The First Hospital of China Medical University, Shenyang, China
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