Phototherapy improves healing of chronic venous ulcers

Treatment with a red-laser-based wound therapy device exerts positive effects in models of delayed keratinocyte and fibroblast wound healing

BACKGROUND

Light therapy is widely used in medicine. Specifically, photobiomodulation has been shown to exert beneficial effects in wound healing disorders, which present a major challenge in health care. The study's aim was providing information on the effect of a novel, red-laser-based wound therapy device (WTD) on keratinocytes and fibroblasts during wound healing under optimal and non-optimal conditions.

METHODS

The scratch wound assay was employed as a wound healing model for mechanical damage with readjustment of specific cell milieus, explicitly chronic TH1 inflammation and TH2-dominant conditions. Furthermore, gene expression analysis of pro-inflammatory cytokines (IL1A, IL6, CXCL8), growth factors (TGFB1, PDGFC), transcription factors (NFKB1, TP53) and heat shock proteins (HSP90AA1, HSPA1A, HSPD1) as well as desmogleins (DSG1, DSG3) in keratinocytes and collagen (COL1A1, COL3A1) in fibroblasts was performed after WTD treatment.

RESULTS

It was shown that WTD treatment is biocompatible and supports scratch wound closure under non-optimal conditions. A distinct enhancement of desmoglein and collagen gene expression as well as induction of early growth factor gene expression was observed under chronic inflammatory conditions. Moreover, WTD increased HSPD1 transcript levels in keratinocytes and augmented collagen expression in fibroblasts during wound healing under TH2 conditions. WTD treatment also alleviated the inflammatory response in keratinocytes and induced early growth factor gene expression in fibroblasts under physiological conditions.

CONCLUSION

Positive effects described for wound treatment with WTD could be replicated in vitro and seem to be to be conferred by a direct influence on cellular processes taking place in keratinocytes and fibroblasts during wound healing.

EFEITOS DO LED AZUL NA CICATRIZAÇÃO DE ÚLCERA VENOSA EM DIABÉTICOS

Úlceras em pacientes com Diabetes Mellitus são frequentes e consideradas uma das complicações de maior relevância durante a evolução clínica da doença. Analisar a aplicação do light-emitting diode (LED) azul no reparo tecidual de úlcera venosa de membro inferior. Consistiu na aplicação de LED azul, com comprimento de onda em torno de 680 THz e 620 THz no local da ferida, durante 10 minutos, 2 vezes por semana, durante 5 semanas. Foram utilizados instrumentos avaliativos de dor e sintomas neuropáticos, testes de sensibilidade, registro fotográfico diário, mensuração do tamanho das úlceras e índice do tempo de fechamento completo da ferida. Foi observada melhora no reparo tecidual das feridas, atingindo fechamento total em ambos os lados e redução da intensidade de dor referida. O LED como tratamento curativo de úlceras diabéticas crônicas mostrou efetividade na taxa de fechamento total da ferida e melhora de sintomas neuropáticos.

Development and Evaluation of Virola oleifera Formulation for Cutaneous Wound Healing

In regions adjacent to the Brazilian Atlantic Forest, Virola oleifera (VO) resin extract has been popularly used for decades as a skin and mucosal healing agent. However, this antioxidant-rich resin has not yet been investigated in wound healing, whose physiological process might also be aggravated by oxidative stress-related diseases (e.g., hypertension/diabetes). Our aim, therefore, was to investigate whether VO resin presents healing effects through an innovative cream for topical applications. For this, adult male Wistar rats were divided into four groups. Then, four 15 mm excisions were performed on the shaved skin. All treatments were applied topically to the wound area daily. At the end of experiments (0, 3rd, and 10th days) macroscopic analysis of wound tissue contraction and histological analysis of inflammatory cell parameters were performed. The group treated with VO cream showed the best wound contraction (15%, p < 0.05) and reduced levels of lipid peroxidation and protein oxidation (118% and 110%, p < 0.05, respectively) compared to the control group. Our results demonstrated the healing capacity of a new formulation prepared with VO, which could be, at least in part, justified by antioxidant mechanisms that contribute to re-epithelialization, becoming a promising dermo-cosmetic for the treatment of wound healing.

In Vivo Characterization of a Red Light-Activated Vasodilation: A Photobiomodulation Study

Nitric oxide dependent vasodilation is an effective mechanism for restoring blood flow to ischemic tissues. Previously, we established an ex vivo murine model whereby red light (670 nm) facilitates vasodilation via an endothelium derived vasoactive species which contains a functional group that can be reduced to nitric oxide. In the present study we investigated this vasodilator in vivo by measuring blood flow with Laser Doppler Perfusion imaging in mice. The vasodilatory nitric oxide precursor was analyzed in plasma and muscle with triiodide-dependent chemiluminescence. First, a 5–10 min irradiation of a 3 cm² area in the hind limb at 670 nm (50 mW/cm²) produced optimal vasodilation. The nitric oxide precursor in the irradiated quadriceps tissue decreased significantly from 123 ± 18 pmol/g tissue by both intensity and duration of light treatment to an average of 90 ± 17 pmol/g tissue, while stayed steady (137 ± 21 pmol/g tissue) in unexposed control hindlimb. Second, the blood flow remained elevated 30 min after termination of the light exposure. The nitric oxide precursor content significantly increased by 50% by irradiation then depleted in plasma, while remained stable in the hindlimb muscle. Third, to mimic human peripheral artery disease, an ameroid constrictor was inserted on the proximal femoral artery of mice and caused a significant reduction of flow. Repeated light treatment for 14 days achieved steady and significant increase of perfusion in the constricted limb. Our results strongly support 670 nm light can regulate dilation of conduit vessel by releasing a vasoactive nitric oxide precursor species and may offer a simple home-based therapy in the future to individuals with impaired blood flow in the leg.

Immune-modulating properties of blue light do not influence reepithelization in vitro

Phototherapy is gaining more attention in the treatment of various diseases. Especially, blue light seems to be a promising approach for wound healing promotion due to its antimicrobial and immune-modulating properties. Despite this, there is only little research focusing on the immune-modulating properties of blue light and its possible effects on wound healing. Therefore, we investigated the effects of blue light irradiation on peripheral blood mononuclear cells (PBMC) and the influence on reepithelization in vitro. PBMCs were irradiated with DermoDyne® (DermoDyne HealthCare, Berlin, Germany) and effects on cell viability, cytokine expression, and scratch wound closure were evaluated afterwards. Irradiated cells showed a higher Interleukin-γ concentration while irradiation reduced resazurin concentration in a time-dependent manner. No differences in reepithelization were detectable when keratinocytes were treated with the supernatant of these blue light irradiated PBMCs. Blue light-mediated ex vivo stimulation of PBMCs does not cause faster reepithelization in an in vitro setting. Further research is needed to investigate the wound healing effects of phototherapy with blue light.

Keratinocyte and Fibroblast Wound Healing In Vitro Is Repressed by Non-Optimal Conditions but the Reparative Potential Can Be Improved by Water-Filtered Infrared A

It is a general goal to improve wound healing, especially of chronic wounds. As light therapy has gained increasing attention, the positive influence on healing progression of water-filtered infrared A (wIRA), a special form of thermal radiation, has been investigated and compared to the detrimental effects of UV-B irradiation on wound closure in vitro. Models of keratinocyte and fibroblast scratches help to elucidate effects on epithelial and dermal healing. This study further used the simulation of non-optimal settings such as S. aureus infection, chronic inflammation, and anti-inflammatory conditions to determine how these affect scratch wound progression and whether wIRA treatment can improve healing. Gene expression analysis for cytokines (IL1A, IL6, CXCL8), growth (TGFB1, PDGFC) and transcription factors (NFKB1, TP53), heat shock proteins (HSP90AA1, HSPA1A, HSPD1), keratinocyte desmogleins (DSG1, DSG3), and fibroblast collagen (COL1A1, COL3A1) was performed. Keratinocyte and fibroblast wound healing under non-optimal conditions was found to be distinctly reduced in vitro. wIRA treatment could counteract the inflammatory response in infected keratinocytes as well as under chronic inflammatory conditions by decreasing pro-inflammatory cytokine gene expression and improve wound healing. In contrast, in the anti-inflammatory setting, wIRA radiation could re-initiate the acute inflammatory response necessary after injury to stimulate the regenerative processes and advance scratch closure.

Electromagnetic energy (670 nm) stimulates vasodilation through activation of the large conductance potassium channel (BKCa)

INTRODUCTION

Peripheral artery disease (PAD) is a highly morbid condition in which impaired blood flow to the limbs leads to pain and tissue loss. Previously we identified 670 nm electromagnetic energy (R/NIR) to increase nitric oxide levels in cells and tissue. NO elicits relaxation of smooth muscle (SMC) by stimulating potassium efflux and membrane hyperpolarization. The actions of energy on ion channel activity have yet to be explored. Here we hypothesized R/NIR stimulates vasodilation through activation of potassium channels in SMC.

METHODS

Femoral arteries or facial arteries from C57Bl/6 and Slo1-/- mice were isolated, pressurized to 60 mmHg, pre-constricted with U46619, and irradiated twice with energy R/NIR (10 mW/cm2 for 5 min) with a 10 min dark period between irradiations. Single-channel K+ currents were recorded at room temperature from cell-attached and excised inside-out membrane patches of freshly isolated mouse femoral arterial muscle cells using the patch-clamp technique.

RESULTS

R/NIR stimulated vasodilation requires functional activation of the large conductance potassium channels. There is a voltage dependent outward current in SMC with light stimulation, which is due to increases in the open state probability of channel opening. R/NIR modulation of channel opening is eliminated pharmacologically (paxilline) and genetically (BKca α subunit knockout). There is no direct action of light to modulate channel activity as excised patches did not increase the open state probability of channel opening.

CONCLUSION

R/NIR vasodilation requires indirect activation of the BKca channel.

Follow-up of pressure ulcer treatment with photodynamic therapy, low level laser therapy and cellulose membrane

OBJECTIVE

A pressure ulcer (PU) is an area of tissue trauma caused by continuous and prolonged pressure, often associated with hospitalised patients immobilised due to neurological problems, negatively affecting their quality of life, and burdening the public budget. The aim of this study was to report the follow-up, for 45 weeks, of three patients with neurological lesions due to trauma who subsequently developed PUs, and who were treated with a combination of photodynamic therapy (PDT), low level laser therapy (LLLT) and cellulose membrane (CM).

METHOD

PDT was mediated by the photosensitiser curcumin on a 1.5% emulsion base. Blue LED light at 450 nm was delivered continuously for 12 minutes at an irradiance of 30mW/cm² and total energy delivered to the tissue was 22J/cm². LLLT was performed with 660 nm laser, punctuated and continuous, twice a week with parameters: spot size 0.04cm², power of 40mW, 10 seconds per point, fluence of 10J/cm² and irradiance of 1000mW/cm².

RESULTS

All PUs had a significant reduction (range: 95.2-100%) of their area after 45 weeks of follow-up and two PUs had complete healing at 20 weeks and 30 weeks. All of the PUs showed a reduction in contamination with the PDT treatments in different proportions.

CONCLUSION

From the results obtained, we conclude that the combination of PDT, LLLT and CM is a promising treatment for PU healing.

Lightwave-reinforced stem cells with enhanced wound healing efficacy

Comprehensive research has led to significant preclinical outcomes in modified human adipose-derived mesenchymal stem cells (hADSCs). Photobiomodulation (PBM), a technique to enhance the cellular capacity of stem cells, has attracted considerable attention owing to its effectiveness and safety. Here, we suggest a red organic light-emitting diode (OLED)-based PBM strategy to augment the therapeutic efficacy of hADSCs. In vitro assessments revealed that hADSCs basked in red OLED light exhibited enhanced angiogenesis, cell adhesion, and migration compared to naïve hADSCs. We demonstrated that the enhancement of cellular capacity was due to an increased level of intracellular reactive oxygen species. Furthermore, accelerated healing and regulated inflammatory response was observed in mice transplanted with red light-basked hADSCs. Overall, our findings suggest that OLED-based PBM may be an easily accessible and attractive approach for tissue regeneration that can be applied to various clinical stem cell therapies.

Electromedical devices in wound healing management: a narrative review

Wound healing is the sum of physiological sequential steps, leading to skin restoration. However, in some conditions, such as diabetes, pressure ulcers (PU) and venous legs ulcers (VLU), healing is a major challenge and requires multiple strategies. In this context, some electromedical devices may accelerate and/or support wound healing, modulating the inflammatory, proliferation (granulation) and tissue-remodelling phases. This review describes some helpful electromedical devices including: ultrasonic-assisted wound debridement; electrotherapy; combined ultrasound and electric field stimulation; low-frequency pulsed electromagnetic fields; phototherapy (for example, laser therapy and light-emitting diode (LED) therapy); biophotonic therapies, and pressure therapies (for example, negative pressure wound therapy, and high pressure and intermittent pneumatic compression) The review focuses on the evidence-based medicine and adequate clinical trial design in relation to these devices.

Experimental models and methods for cutaneous wound healing assessment

Wound healing studies are intricate, mainly because of the multifaceted nature of the wound environment and the complexity of the healing process, which integrates a variety of cells and repair phases, including inflammation, proliferation, reepithelialization and remodelling. There are a variety of possible preclinical models, such as in mice, rabbits and pigs, which can be used to mimic acute or impaired for example, diabetic and nutrition-related wounds. These can be induced by many different techniques, with excision or incision being the most common. After determining a suitable model for a study, investigators need to select appropriate and reproducible methods that will allow the monitoring of the wound progression over time. The assessment can be performed by non-invasive protocols such as wound tracing, photographic documentation (including image analysis), biophysical techniques and/or by invasive protocols that will require wound biopsies. In this article, we provide an overview of some of the most often needed and used: (a) preclinical/animal models including incisional, excisional, burn and impaired wounds; (b) methods to evaluate the healing progression such as wound healing rate, wound analysis by image, biophysical assessment, histopathological, immunological and biochemical assays. The aim is to help researchers during the design and execution of their wound healing studies.

Successful Treatment of Digital Ischemia Following a Carbon Dioxide Laser and Tourniquet for a Digital Procedure With Adjuvant Low-Level Laser Therapy

A digital tourniquet with/without epinephrine is commonly used in local anesthetics when operating on digits. However, such a complication as digital ischemia could occur following tourniquet application. We reported an elderly patient with atherosclerotic risk factors and she subsequently underwent a digital tourniquet, partial nail plate removal, and a carbon dioxide laser treatment for subungual wart with digital gangrene development. The successful treatment consisted of wound-dressing, medication, and adjuvant low-level light therapy (LLLT) to enhance the wound healing process, thereby resulting in almost complete recovery of skin color and function of the digit in 3 months. In conclusion, the digital tourniquet should be cautiously applied, especially in elderly patients with atherothrombosis, under minimal pressure and appropriate length of time. Moreover, LLLT could be an effective adjuvant treatment to prevent the vascular complications of the digit.

Biomodulation induced by fluorescent light energy versus standard of care in venous leg ulcers: a retrospective study

Objective:

The recently completed EUREKA study confirmed the efficacy and safety profile of fluorescent light energy (FLE) in treating hard-to-heal wounds. To supplement the EUREKA prospective, observational, uncontrolled trial results, researchers selected one of the EUREKA clinical centres to conduct a retrospective analysis of matching wound care data for 46 venous leg ulcers (VLU) patients who had received standard wound care over a five-year period, compared with 10 EUREKA VLU subjects.

Method:

The study centre selected 46 patients with VLUs based on the matching criteria (wound age and size, patient's age and gender). They compared the healing rates of these matching VLUs with 10 VLU patients treated at the same centre during the EUREKA study.

Results:

The EUREKA patients had larger and significantly older wounds (p<0.05) and significantly more risk factors (p<0.05) than the matching wounds. However, they had better outcomes (EUREKA: 40% versus matching group: 7% for full wound closure by 16 weeks). No wound breakdown was observed at 16 weeks in the EUREKA group, compared with 25% in the matching group. No EUREKA patient developed infections requiring antibiotics, compared with 37% in the matching group. EUREKA wounds had a mean relative wound area regression (RWAR) of 32% at week six and 50% at week 16, compared with −3% at week six and −6% at week 16 for the matching group.

Conclusion:

These findings show that the system based on FLE was well-tolerated and efficacious, with better clinical outcome results compared with the wounds analysed in this retrospective matching study and treated with standard of care alone.

Photobiomodulation therapy (PBMT) in bone repair: A systematic review

BACKGROUND

Photobiomodulation therapy (PBMT) using low-level laser influences the release of several growth factors involved in the formation of epithelial cells, fibroblasts, collagen and vascular proliferation, besides accelerating the synthesis of bone matrix due to the increased vascularization and lower inflammatory response, with significant increase of osteocytes in the irradiated bone. Considering its properties, beneficial effects and clinical relevance, the aim of this review was to analyze the scientific literature regarding the use of PBMT in the process of bone defect repair.

METHODS

Electronic search was carried out in PubMed/MEDLINE^Ⓡ and Web of Science databases with combination of the descriptors low-level laser therapy AND bone repair, considering the period of publication until the year 2018.

RESULTS

The literature search identified 254 references in PubMed/MEDLINE and 204 in Web of Science, of which 33 and 4 were selected, respectively, in accordance with the eligibility requirements. The analysis of researches showed articles using PBMT in several places of experimentation in the subjects, different types of associated biomaterials, stimulatory effects on cell proliferation, besides variations in the parameters of use of laser therapy, mainly in relation to the wavelength and density of energy. Only four articles reported that the laser did not improve the osteogenic properties of a biomaterial.

CONCLUSIONS

Many studies have shown that PBMT has positive photobiostimulatory effects on bone regeneration, accelerating its process regardless of parameters and the use of biomaterials. However, standardization of its use is still imperfect and should be better studied to allow correct application concerning the utilization protocols.

Therapeutic efficacy of early photobiomodulation therapy on the zones of stasis in burns: An experimental rat model study

This study aimed to investigate the role of photobiomodulation therapy in preventing zones of stasis in burn wounds. We hypothesized that photobiomodulation therapy could promote tissue formation and release of nitric oxide (NO), and reduce inflammatory responses, thereby dilating local microvessels, reducing necrosis and apoptosis. Thirty rats were randomly divided into control group (CG) and laser group (LG). The zone of stasis was formed by applying a brass comb to the skin resulting in four rectangular burns separated by three unburned interspaces. The left side was laser wound (LW), while the right side was shielded wound (SW). The LW of LG was immediately subjected to photobiomodulation therapy, followed by once-daily 30-minutes photobiomodulation therapy sessions. Skin ultrasound and Doppler angiography analyses were used to evaluate the statuses of the zones of stasis at 1, 24, and 96 hours after injury. Harvested burn wound tissue was subjected to hematoxylin-eosin staining and HMGB1, caspase 3, and thrombomodulin immunohistochemistry, and the contents of NO and TNF-α were measured in stasis tissue. Thrombomodulin, HMGB1, and caspase 3 immunohistochemistry revealed significantly lower positive staining rates in the LW of LG rats relative to the others at 96 hours (p < 0.05), as well as a significantly higher skin blood flow relative to the others (p < 0.05). The NO content was significantly higher in the LW of LG, compared with other wounds, at 24 and 96 hours after injury (p < 0.05). The TNF-α level was significantly lower in the LW of LG than in other wounds at 96 hours (p < 0.05). Early, local photobiomodulation therapy can effectively ameliorate injury progression in the zone of stasis. However, these beneficial effects are limited to the directly irradiated sites.

A feasibility study of a novel low-level light therapy for digital ulcers in systemic sclerosis

Background: Locally acting, well-tolerated treatments for systemic sclerosis (SSc) digital ulcers (DUs) are needed.

Objectives: Our primary aim was to investigate the safety, feasibility, and tolerability of a novel low-level light therapy (LTTT). A secondary aim was to tentatively assess efficacy.

Methods: A custom-built device comprising infrared (850 nm), red (660 nm), and violet (405 nm) LEDs was utilized. DUs were irradiated with 10 J/cm² twice weekly for 3 weeks, with follow-up at weeks 4 and 8. Any safety concerns were documented. Patient opinion on time to deliver, feasibility, and pain visual analogue score (VAS; 0–100, 100 most severe) was collected. Patient and clinician DU global assessment VAS were documented. DUs were evaluated by laser Doppler perfusion imaging pre- and post-irradiation.

Results: In all, 14 DUs in eight patients received a total of 46 light exposures, with no safety concerns. All patients considered LTTT ‘took just the right amount of time’ and was ‘feasible’, with a low associated mean pain VAS of 1.6 (SD: 5.2). Patient and clinician global DC VAS improved during the study (mean change: –7.1 and –5.2, respectively, both p < .001). DU perfusion significantly increased post-irradiation.

Conclusions: LTTT for DUs is safe, feasible, and well tolerated. There was an early tentative suggestion of treatment efficacy.

The effect of Sebastiania hispida gel on wound model infected by methicillin resistant Staphylococcus aureus

Medicinal plants are an alternative for the treatment of infected wounds. The objective of this study was to evaluate the efficacy of Sebastiania hispida in an animal model with a wound infected by Staphylococcus aureus. The crude ethanol extract (Ext_EtOH) of S. hispida underwent phytochemical analysis, quantification of metabolites and antibacterial activity analysis performed using S. aureus. Wistar rats were used to test healing activity, and the groups evaluated comprised gels of Ext_EtOH at the concentrations 0.2 and 2% compared with control groups. Animals were inoculated with the bacteria S. aureus resistant to methicillin. The treatment periods were of 3 and 21 days. Macroscopic and microscopic analysis were conducted and data were submitted to analysis of variance (p < 0.05). Phytochemical and quantification analysis indicated that phenolic compounds and flavonoids are the major constituents, followed by tyterpenes. Ext_EtOH 0.2% was the most effective gel against the growth of strains of S. aureus. Histological wound and regression analysis showed that Ext_EtOH gels (0.2% and 2%) were similar and effective in promoting wound healing. In the quantification of collagen fibers, the animals from all groups showed a high amount of thick collagen fibers. Thus, Ext_EtOH gels based on the shoots of S. hispida can be used for the treatment of infected wounds as a complementary therapy for infected wound closure and further assays are required with other means. The healing effectiveness may be due to the high content of phenolics, flavonoids and triterpenes.

Dressings and topical agents for treating venous leg ulcers

BACKGROUND

Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decision-making challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents.

OBJECTIVES

To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality.

SEARCH METHODS

In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification.

SELECTION CRITERIA

We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, 'Risk of bias' assessment and data extraction. We conducted this NMA using frequentist meta-regression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole.

MAIN RESULTS

We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts.The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty.The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.The results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost.

Pressure ulcer healing with Plenusdermax® Calendula officinalis L. extract

RESUMO Objetivo: Avaliar os benefícios terapêuticos do extrato de bioativos de Calendula officinalis Plenusdermax® na cicatrização de úlceras de pressão. Métodos: estudo observacional de coorte realizado com quarenta e um pacientes com diagnóstico de úlcera por pressão com tamanho da ferida estável por mais de três meses. Os pacientes foram avaliados quinzenalmente durante 30 semanas, em relação a redução da área da lesão, controle de infecção, tipos de tecido e exsudato e microbiologia das úlceras. Resultados: a proporção de pacientes que cicatrizaram completamente após 15 e 30 semanas de tratamento foi 63% e 88%, respectivamente, sendo que a média de tempo de cicatrização foi de 12,5 ± 7,8 semanas. Não foram observados eventos adversos durante o tratamento. Conclusão: os resultados do estudo indicam que Plenusdermax® de bioativos de C. officinalis é um tratamento seguro que promove a cicatrização de úlceras de pressão.

A Double-Blind, Placebo-Controlled Randomized Evaluation of the Effect of Low-Level Laser Therapy on Venous Leg Ulcers

This study aimed to determine the effect of low-level laser therapy (LLLT) on chronic venous leg ulcers (VLUs). A double-blinded prospective randomized controlled trial was conducted to compare incidence of complete wound closure, ulcer size and pain reduction in patients randomized to 24 treatments of placebo or LLLT (635 nm) over 12 weeks. Patients presented with a 6-week history of VLUs ranging in size from 5 to 20 cm2. Venous origin was confirmed by Doppler ultrasound and an ankle brachial index of 0.8 or greater. Of 24 patients, 23% of the test group (n = 13) and 18% of placebo group (n = 11) achieved complete wound closure. At 12 weeks, patients in test and placebo groups had a mean surface area reduction of 6.26 cm2 ( P < .0001) and 6.72 cm2 ( P < .005), respectively, and a mean pain score decrease of 43.54 points ( P < .0001) and 25.73 points ( P = .002) respectively. Differences between groups was not statistically significant for wound closure ( P = 1.0) or ulcer size ( P = .80). Mean ulcer pain was significantly reduced from initiation of treatment compared with 4 weeks’ follow-up after 12 weeks with LLLT ( P < .01). Within the limitations of the study, LLLT may not have early effects as an adjunctive therapy to wound healing of VLUs, but LLLT may have delayed effects on VLU healing and associated pain, which requires further study.

Assessment of circular wound healing in rats after exposure to 808-nm laser pulses during specific healing phases

BACKGROUND AND OBJECTIVES

Low-level laser therapy (LLLT), is an important application modality for the advancement of wound healing processes. In this study, histological and morphometric analyses have been made to understand and compare effects of high-power 808-nm pulses on circular skin wounds among groups irradiated immediately after wounding and groups irradiated at specific stages of the healing period.

STUDY DESIGN

Experimental groups were as follows: Laser Therapy (LT) was received as three sessions of laser irradiation (6.38 J/cm2, 1.276 W/cm2, 808 nm) immediately after wounding (Inflammatory group, n = 12), 24 hours post-wounding (Proliferative group, n = 12), and 72 hours post-wounding (Remodeling group, n = 12); the Control group (n = 12) received no irradiation. Histological analyses were performed on the 3rd, 7th, and 14th days post-wounding.

RESULTS

Mean wound diameters were 5 mm for all groups. On Day 7, wound diameters were measured as 2.99 ± 0.17, 2.95 ± 0.3, 2.52 ± 0.11, and 2.41 ± 0.34 mm for the Control, Inflammatory, Proliferative, and Remodeling groups, respectively. At 2 weeks post-wounding, dermal tissue in the Inflammatory and Proliferative groups closed superficially, while 1.30 ± 0.1 mm and 1.30 ± 0.06 mm openings remained in the Control and Remodeling groups, respectively. Mean wound healing rates (WHR) for all treatment groups were found to differ significantly from the control group (P < 0.05). Upon comparing the Proliferative group with the other treatment groups, a significant difference was found. However, no significant difference was found between the Inflammatory and Remodeling groups, with the former having a slightly higher mean value.

CONCLUSION

Histological and morphometric results showed that high-power, low-energy application has the best effect when first applied 24 hours post-wounding (late inflammatory, early proliferative stage) as demonstrated by increases in granulation tissue, fibroblasts and collagen deposition, which lead to faster rates of wound contraction and thus accelerated healing.

Reduction of diabetic foot ulcer healing times through use of advanced treatment modalities

Diabetic wounds are a major health care problem associated with delayed healing and high amputation rates. This review systematically evaluated newer wound care therapies for the treatment of diabetic wounds. More recent means of approaching diabetic foot ulcers include various dressings, off-loading shoes, and bioengineered skin constructs and growth factors. Electrical stimulation, phototherapy, electromagnetic fields, and shockwave therapy have been further proposed as potential treatments. A brief overview of these treatments is presented using peer-reviewed evidenced-based literature. A review of the literature demonstrated that treatment of diabetic wounds has focused on either prevention of the wounds in the form of off-loading shoes or adequate protective dressings or on direct treatment of wounds with bioengineered skin constructs, growth factors, or medical devices that accelerate wound healing. The authors' conclusion, following extensive literature review, is that although excellent national and international guidelines exist regarding suggested approaches to the treatment of the diabetic foot ulcer, there is no definitive or universal consensus on the choice of specific treatment modalities. The importance of optimizing comorbidities and the disease state, hemodynamics, local and peripheral skin and wound care, and metabolic challenges while reducing biological and bacterial burden and minimizing trauma remain the primary approach, followed by choice of the most appropriate treatment material or product.

Phototherapy improves wound healing in rats subjected to high-fat diet

This study aimed to compare the phototherapy effects on wound healing in rats submitted to normal and high-fat diets. Thirty-six rats received normal lipidic diet (NL) and 36 high lipidic (HL) diet for 45 days. The nutritional status was measured by body mass, blood glucose, total cholesterol, and triglycerides levels. Four experimental groups were performed according light (L) therapy applied "on" or "off" (660 nm, 100 mW, 70 J/cm(2), 2 J) on 1.5-mm-punched dorsum skin wounds as NLL+, NLL-, HLL+, and HLL-. The wound healing rate (WHR) and oxidative stress markers were analyzed on 2nd, 7th, and 14th days. Despite no difference among body mass, the HL rats presented higher blood glucose, total cholesterol, and triglycerides levels than NL rats. Respectively, on the 2nd and 14th days, the HLL+ group presented the highest WHRs (0.38 ± 0.16/0.97 ± 0.02) among all groups, while the HLL- (-0.002 ± 0.12/0.81 ± 12.1) the lowest WHRs. Hydroxyproline level was lower in HLL- (6.41 ± 1.09 μg/mg) than HLL+ (7.71 ± 0.61 μg/mg) and also NLL+ (9.33 ± 0.84 μg/mg). HLL+ presented oxidative stress markers similar to normal control group (NLL-) during follow up and highest antioxidant defense on 7th day. The results showed phototherapy accelerated the cutaneous wound healing by modulating oxidative stress in rats with metabolic disorders under a high-fat diet.

Phototherapy promotes healing of cutaneous wounds in undernourished rats

BACKGROUND

Various studies have shown that phototherapy promotes the healing of cutaneous wounds.

OBJECTIVE

To investigate the effect of phototherapy on healing of cutaneous wounds in nourished and undernourished rats.

METHODS

Forty rats, 20 nourished plus 20 others rendered marasmus with undernourishment, were assigned to four equal groups: nourished sham, nourished Light Emitting Diode treated, undernourished sham and undernourished Light Emitting Diode treated. In the two treated groups, two 8-mm punch wounds made on the dorsum of each rat were irradiated three times per week with 3 J/cm2 sq cm of combined 660 and 890 nm light; wounds in the other groups were not irradiated. Wounds were evaluated with digital photography and image analysis, either on day 7 or day 14, with biopsies obtained on day 14 for histological studies.

RESULTS

Undernourishment retarded the mean healing rate of the undernourished sham wounds (p < 0.01), but not the undernourished Light emission diode treated wounds, which healed significantly faster (p < 0.001) and as fast as the two nourished groups. Histological analysis showed a smaller percentage of collagen in the undernourished sham group compared with the three other groups, thus confirming our photographic image analysis data.

CONCLUSION

Phototherapy reverses the adverse healing effects of undernourishment. Similar beneficial effects may be achieved in patients with poor nutritional status.

Development of lamellar gel phase emulsion containing marigold oil (Calendula officinalis) as a potential modern wound dressing

Appropriate therapeutics for wound treatments can be achieved by studying the pathophysiology of tissue repair. Here we develop formulations of lamellar gel phase (LGP) emulsions containing marigold (Calendula officinalis) oil, evaluating their stability and activity on experimental wound healing in rats. LGP emulsions were developed and evaluated based on a phase ternary diagram to select the best LGP emulsion, having a good amount of anisotropic structure and stability. The selected LGP formulation was analyzed according to the intrinsic and accelerated physical stability at different temperatures. In addition, in vitro and in vivo studies were carried out on wound healing rats as a model. The LGP emulsion (15.0% marigold oil; 10.0% of blend surfactants and 75.0% of purified water [w/w/w]) demonstrated good stability and high viscosity, suggesting longer contact of the formulation with the wound. No cytotoxic activity (50-1000 μg/mL) was observed in marigold oil. In the wound healing rat model, the LGP (15 mg/mL) showed an increase in the leukocyte recruitment to the wound at least on days 2 and 7, but reduced leukocyte recruitment after 14 and 21 days, as compared to the control. Additionally, collagen production was reduced in the LGP emulsion on days 2 and 7 and further accelerated the process of re-epithelialization of the wound itself. The methodology utilized in the present study has produced a potentially useful formulation for a stable LGP emulsion-containing marigold, which was able to improve the wound healing process.

Rehabilitation and physical therapy for the neurologic veterinary patient

A comprehensive physiotherapy plan for neurology patients manages pain, prevents secondary complications, and supports the health and function of musculoskeletal tissues during recovery. Neurologically impaired patients range in ability from complete immobility (tetraplegia/paraplegia), partial mobility (tetraparesis/paraparesis), mild ataxia, to pain only. Important considerations for the design of a physiotherapy program include access to the patient, level of staff support, and safety of staff, patient, and client during treatments. A thorough overview of the treatment plan and expected outcome should be discussed with the client at the onset of therapy and should be reviewed frequently, particularly as the patient's status changes.

Low level laser therapy for the treatment of diabetic foot ulcers: a critical survey

Diabetic foot ulcers as one of the most common complications of diabetes mellitus are defined as nonhealing or long-lasting chronic skin ulcers in diabetic patients. Multidisciplinary care for the diabetic foot is common, but treatment results are often unsatisfactory. Low level laser therapy (LLLT) on wound areas as well as on acupuncture points, as a noninvasive, pain-free method with minor side effects, has been considered as a possible treatment option for the diabetic foot syndrome. A systematic literature review identified 1764 articles on this topic. Finally, we adopted 22 eligible references; 8 of them were cell studies, 6 were animal studies, and 8 were clinical trials. Cell studies and animal studies gave evidence of cellular migration, viability, and proliferation of fibroblast cells, quicker reepithelization and reformed connective tissue, enhancement of microcirculation, and anti-inflammatory effects by inhibition of prostaglandine, interleukin, and cytokine as well as direct antibacterial effects by induction of reactive oxygen species (ROS). The transferral of these data into clinical medicine is under debate. The majority of clinical studies show a potential benefit of LLLT in wound healing of diabetic ulcers. But there are a lot of aspects in these studies limiting final evidence about the actual output of this kind of treatment method. In summary, all studies give enough evidence to continue research on laser therapy for diabetic ulcers, but clinical trials using human models do not provide sufficient evidence to establish the usefulness of LLLT as an effective tool in wound care regimes at present. Further well designed research trials are required to determine the true value of LLLT in routine wound care.

Overview of guidelines for the prevention and treatment of venous leg ulcers: a US perspective

Comprehensive care of chronic venous insufficiency and associated ulcers requires a multipronged and interprofessional approach to care. A comprehensive treatment approach includes exercise, nutritional assessment, compression therapy, vascular reconstruction, and advanced treatment modalities. National guidelines, meta-analyses, and original research studies provide evidence for the inclusion of these approaches in the patient plan of care. The purpose of this paper is to review present guidelines for prevention and treatment of venous leg ulcers as followed in the US. The paper further explores evidence-based yet pragmatic tools for the interprofessional team to use in the management of this complex disorder.

Shedding light on a new treatment for diabetic wound healing: a review on phototherapy

Impaired wound healing is a common complication associated with diabetes with complex pathophysiological underlying mechanisms and often necessitates amputation. With the advancement in laser technology, irradiation of these wounds with low-intensity laser irradiation (LILI) or phototherapy, has shown a vast improvement in wound healing. At the correct laser parameters, LILI has shown to increase migration, viability, and proliferation of diabetic cells in vitro; there is a stimulatory effect on the mitochondria with a resulting increase in adenosine triphosphate (ATP). In addition, LILI also has an anti-inflammatory and protective effect on these cells. In light of the ever present threat of diabetic foot ulcers, infection, and amputation, new improved therapies and the fortification of wound healing research deserves better prioritization. In this review we look at the complications associated with diabetic wound healing and the effect of laser irradiation both in vitro and in vivo in diabetic wound healing.

Effects of low intensity laser irradiation during healing of infected skin wounds in the rat

BACKGROUND AND OBJECTIVE

Low intensity laser irradiation remains a controversial treatment for non-healing wounds. This study examines the effect of low intensity light on healing of infected skin wounds in the rat.

MATERIALS AND METHODS

Wounds on the rat dorsum were inoculated with Pseudomonas aeruginosa. Wounds were irradiated or sham-irradiated three times weekly from day 1 to 19 using 635-nm or 808-nm diode lasers delivering continuous wave (CW) or intensity modulated (3800 Hz) laser radiation, all at radiant exposures of 1 and 20 J/cm². Wound area and bacterial growth on the wound surface were evaluated three times a week. Histological and immunohistochemical analyses were performed at day 8 and 19.

RESULTS

Wounds that were irradiated using a wavelength of 635 nm (1 and 20 J/cm²) or intensity modulated 808-nm laser light at 20 J/cm² were smaller in area at day 19 than the sham-irradiated controls (achieved significance level=0.0105-0.0208) and were similar to controls in respect of bacterial growth. The remaining light protocols had no effect on wound area at day 19 although they increased Staphylococcus aureus growth across the time line compared with controls (p<0.0001 to p<0.004). CW 808-nm light at 20 J/cm² significantly delayed half-heal time. Histological and immunohistochemical analyses supported wound closure findings: improved healing was associated with faster resolution of inflammation during the acute phase and increased signs of late repair at day 19. Significant inflammation was seen at day 19 in all irradiated groups regardless of radiant exposure, except when using 635 nm at 1 J/cm².

CONCLUSIONS

Red light improved healing of wounds. Only one 808-nm light protocol enhanced healing; lack of benefit using the remaining 808-nm light protocols may have been due to stimulatory effects of the light on S. aureus growth.

Analgesic Effect of Light-Emitting Diode (LED) Therapy at Wavelengths of 635 and 945 nm on Bothrops moojeni Venom-Induced Hyperalgesia

Envenoming induced by Bothrops snakes is characterized by drastic local tissue damage involving hemorrhage, myonecrosis and proeminent inflammatory and hyperalgesic response. The most effective treatment is antivenom therapy, which is ineffective in neutralizing the local response. Herein, it was evaluated the effectiveness of light-emitting diode (LED) at wavelengths of 635 and 945 nm in reducing inflammatory hyperalgesia induced by Bothrops moojeni venom (BmV) in mice, produced by an subplantar injection of BmV (1 μg). Mechanical hyperalgesia and allodynia were assessed by von Frey filaments at 1, 3, 6 and 24 h after venom injection. The site of BmV injection (1.2 cm(2) ) was irradiated by LEDs at 30 min and 3 h after venom inoculation. Both 635 nm (110 mW, fluence of 3.76 J/cm(2) and 41 s of irradiation time) and 945 nm (120 mW, fluence of 3.8 J/cm(2) and 38 s of irradiation time) LED inhibited mechanical allodynia and hyperalgesia of mice alone or in combination with antivenom treatment, even when the symptoms were already present. The effect of phototherapy in reducing local pain induced by BmV should be considered as a novel therapeutic tool for the treatment of local symptoms induced after bothropic snake bites.

Review and update on new horizon in the management of venous ulcers

Chronic venous ulcers (CVUs) contribute to functional deficits and are a source of significant morbidity among the affected population. In addition, they directly impact the quality of life of patients and are a significant economic burden on the health care system. In this review, we critically evaluate the current strategies for treating CVUs that have emerged within the last decade and outlined a suggested algorithm for treating patients with this difficult condition.