State of the Art in Topical Wound-Healing Products:

Polycaprolactone/cress seed mucilage based bilayer antibacterial films containing ZnO nanoparticles with superabsorbent property for the treatment of exuding wounds

In this research, a novel double-layer film based on polycaprolactone and cress seed mucilage containing zinc oxide nanoparticles (0.5-2 %) was synthesized using solution casting technique, as an interactive multi-functional wound dressing. The bilayer films were characterized by measuring moisture content, contact angle parameter, porosity, water vapor transmission rate (WVTR), color attributes and opacity, swelling, degradation, mechanical properties, cell viability, and antimicrobial activity, as well as using scanning electron microscopy (SEM), Fourier transform infrared spectroscopy (FTIR) and X-ray diffraction (XRD). The results indicated that the film containing 1.5 % zinc oxide nanoparticles had the best performance, with high swelling ability (3600 %) and 25 % degradation within 24 h of placement in a wound simulator solution. Its mechanical properties, including tensile strength and elongation at break, were 9 MPa and 5.53 %, respectively. In investigating the antimicrobial activity of the optimal film against Escherichia coli and Staphylococcus aureus, the diameter of the inhibition zone was observed to be 39.33 and 42 mm, respectively. Moreover, increasing the number of ZnO-NPs hindered the growth of NIH/3T3 cells, but the 1.5 % ZnO-NP loaded film showed a high percentage of cell viability in 1 day (90 %) and 3 days (93 %), which is suitable for biomedical applications.

SA/G hydrogel containing NRF2-engineered HEK-293-derived CM improves wound healing efficacy of WJ-MSCs in a rat model of excision injury

AIM OF THE STUDY

Skin wounds are a major public health issue due to the lack of real effective remedies. Mesenchymal stem cells (MSCs) are considered as a promising therapeutic strategy for wound injuries; however, low survival rate following transplantation limited their application. In an attempt to introduce a novel potential wound dressing and improve wound healing properties, the current study was conducted.

MATERIAL AND METHODS

we prepared conditioned medium (CM) harvested from HEK-293 cells overexpressing nuclear factor erythroid 2-related factor 2 (NRF2), a master regulator of antioxidant genes expression. Then, the CM was loaded in a biodegradable hydrogel. Next, in an animal model of full-thickness excision wound, wharton's jelly derived-mesenchymal stem cells (WJ-MSCs) were transplanted at the margins of the wound followed by application of the hydrogel on injury site. Finally, wound healing characteristics were evaluated by proper methods.

RESULTS

Our findings revealed that, the NRF2-CM protected the WJ-MSCs against H₂O₂-induced toxicity in vitro. Furthermore, in vivo results showed that, SA/G hydrogel containing NRF2-CM significantly (P < 0.01) promoted WJ-MSCs survival, increased angiogenesis, accelerated wound contraction, and promoted wound healing compared to other groups.

CONCLUSION

Though further preclinical and clinical studies regarding mechanisms behind the protection and also safety of the strategy are needed, our findings strongly suggest that the prepared wound dressing enhanced the efficacy of therapeutic potential of WJ-MSCs by providing an enriched/antioxidant niche support.

Benefits of sucrose octasulfate (TLC-NOSF) dressings in the treatment of chronic wounds: a systematic review

OBJECTIVE

Management of chronic wounds remains one of the major challenges for health professionals and patients. An evidence-based decision is important to ensure that patients are receiving the best treatment proven to reduce healing time and improve outcomes, including economic benefits and patients' health-related quality of life (HRQoL). Due to recent restrictions because of the COVID-19 pandemic, including closure of wound care centres within hospitals and a drop in patient volume, chronic wound management needs simple-to-use dressings which are still effective and evidence-based solutions. This systematic review was conducted to identify the clinical evidence available on a sucrose octasulfate dressing (TLC-NOSF, UrgoStart dressing range, Laboratoires Urgo, France) to explore its efficacy in the management of chronic wounds, particularly lower limb ulcers, diabetic foot ulcers and pressure ulcers.

METHOD

A literature search of PubMed, Cochrane Library and Google Scholar was conducted based on the PICO model (patient/population, intervention, comparison and outcomes) to retrieve publications of different levels of evidence in order to evaluate outcomes of the use of TLC-NOSF dressings.

RESULTS

A total of 21 publications of different levels, ranging from double-blind randomised control trials to case reports, involving over 12,000 patients, were identified through PubMed, with a further eight publications through Google Scholar and two publications through Cochrane Library. A total of seven results were omitted due to the lack of relevance or repetition.

CONCLUSION

All the evidence provided suggest that these dressings provide clinicians with an evidence-based option for the management of chronic wounds; that the TLC-NOSF dressings are beneficial in promoting the healing process, reducing healing times, enhancing patients' HRQoL, and in allowing a more cost-effective procedure.

Stem cells and growth factors-based delivery approaches for chronic wound repair and regeneration: A promise to heal from within

The sophisticated chain of cellular and molecular episodes during wound healing includes cell migration, cell proliferation, deposition of extracellular matrix, and remodelling and are onerous to replicate. Encapsulation of growth factors (GFs) and Stem cell-based (SCs) has been proclaimed to accelerate healing by transforming every phase associated with wound healing to enhance skin regeneration. Therapeutic application of mesenchymal stem cells (MSCs), embryonic stem cells (ESCs) and induced pluripotent stem cells (PSCs) provides aid in wound fixing, tissue integrity restoration and function of impaired tissue. Several scientific studies have established the essential role GFs in wound healing and their reduced degree in the chronic wound. The overall limitation includes half-life, unfriendly microhabitat abundant with protease, and inadequate delivery approaches results in decreased delivery of effective amounts in a suitable time-based fashion. Advancements in the area of reformative medicine as well as tissue engineering have offered techniques competent of dispensing SCs and GFs in site-oriented manner. The progress in nanotechnology-based approaches attracts researcher to study and evaluate the potential of this SCs and GFs based therapy in chronic wounds. These techniques embrace the polymeric regime viz., nano-formulations, hydrogels, liposomes, scaffolds, nanofibers, metallic nanoparticles, lipid-based nanoparticles and dendrimers that have established better retort through targeting tissues when GFs and SCs are transported via these humans made devices. Assumed the current problems, improvements in delivery approaches and difficulties offered by chronic wounds, we hope to show that encapsulation of SCs and GFs loaded nanoformulations therapies is the rational next step in improving wound care.

Wound healing cream formulated with Kalanchoe pinnata major flavonoid is as effective as the aqueous leaf extract cream in a rat model of excisional wound

Leaves of Kalanchoe pinnata are used worldwide for healing skin wounds. This study aimed to develop and compare two creams containing a leaf aqueous extract of K. pinnata (KP; 6%) and its major flavonoid [quercetin 3-O-α-L-arabinopyranosyl-(1→2)-α-L-rhamnopyranoside] (0.15%). Both creams were topically evaluated in a rat excision model for 15 days. On the 12^th day, groups treated with KP leaf-extract and KP major flavonoid creams exhibited 95.3 ± 1.2% and 97.5 ± 0.8% of healing, respectively (positive control = 96.7 ± 0.8%; negative control = 76.1 ± 3.8%). Both resulted in better re-epithelialization and denser collagen fibres. Flavonol glycosides are the main phenolics in KP leaf-extract according to HPLC-ESI-MS/MS analysis. KP major flavonoid plays a fundamental role in the wound healing. The similar results found for both creams indicate that the use of KP crude extract should be more profitable than the isolated compound.

Electrospun Composite Nanofibrous Materials Based on (Poly)-Phenol-Polysaccharide Formulations for Potential Wound Treatment

In this paper, we focus on the preparation of electrospun composite nanofibrous materials based on (poly)-phenol-polysaccharide formulation. The prepared composite nanofibres are ideally suited as a controlled drug delivery system, especially for local treatment of different wounds, owing to their high surface and volume porosity and small fibre diameter. To evaluate the formulations, catechin and resveratrol were used as antioxidants. Both substances were embedded into chitosan particles, and further subjected to electrospinning. Formulations were characterized by determination of the particle size, encapsulation efficiency, as well as antioxidant and antimicrobial properties. The electrospinning process was optimised through fine-tuning of the electrospinning solution and the electrospinning parameters. Scanning electron microscopy was used to evaluate the (nano)fibrous structure, while the successful incorporation of bio substances was assessed by X-ray Photoelectron Spectroscopy and Fourier transform infrared spectroscopy. The bioactive properties of the formed nanofibre -mats were evaluated by measuring the antioxidative efficiency and antimicrobial properties, followed by in vitro substance release tests. The prepared materials are bioactive, have antimicrobial and antioxidative properties and at the same time allow the release of the incorporated substances, which assures a promising use in medical applications, especially in wound care.

In vitro evaluation of the association of medicinal larvae (Insecta, Diptera, Calliphoridae) and topical agents conventionally used for the treatment of wounds

Wound healing is a complex process involving multiple biochemical and cellular events and represents a neglected public health issue. As a consequence, millions of people worldwide suffer from chronic wounds. The search for new treatment alternatives is therefore an important issue. In the context of wound healing, Maggot Debridement Therapy (MDT) is an inexpensive treatment with few contraindications and very promising results. This study aimed to evaluate the in vitro feasibility and implications of larvae (= MDT) use when combined with topical agents as a strategy to identify additive or synergistic combinations. The weight and survival rate of Cochliomyia macellaria (Fabricius) (Insecta, Diptera, Calliphoridae) larvae reared in an in vitro wound with either honey, hydrogel, 10% papain gel, essential fatty acids (EFA), collagenase, or silver sulfadiazine were evaluated after 24, 48 and 72 h. Hydrogel (for weight: 24 and 72 h; for survival: 24 h) and 10% papain gel (for weight: 48 h; for survival: 48 and 72 h) demonstrated the least interference in larval weight gain and survival rate, when compared to the control group. The results obtained in this study showed that the combined use of larvae and hydrogel or 10% papain gel may be promising to maximize the tissue repair. Honey, EFA and collagenase could be used to prepare the bed of the dry wounds to receive the MDT.

Recent advances in inorganic nanomaterials for wound-healing applications

The emergence of inorganic nanoparticles has generated considerable expectation for solving various biomedical issues including wound healing and tissue regeneration. This review article highlights the role and recent advancements of inorganic nanoparticles for wound healing and tissue regeneration along with their advantages, clinical status, challenges and future directions.

CCN1 accelerates re-epithelialization by promoting keratinocyte migration and proliferation during cutaneous wound healing

Re-epithelialization is an essential part of wound healing and has a prominent influence on the prognosis. CCN family member 1 (CCN1 or Cysteine-rich 61, CYR61), a matricellular protein, has a potential role in the wound healing process. However, its role in re-epithelialization remains unclear. The aim of this study was to determine the expression of CCN1 in the epidermis and its effect on keratinocytes during re-epithelialization. CCN1 expression in the wounded skin was analyzed using microarray data from GEO database and detected by immunofluorescence. The results showed upregulated CCN1 during the early stages of wound healing. Human primary keratinocytes were treated with recombinant human CCN1. The results showed that CCN1 promoted keratinocyte migration and proliferation. Moreover, a full-thickness mouse skin wound model and a superficial second-degree burn mouse model treated intracutaneously with CCN1 were used for in vivo studies. Topical treatment with CCN1 protein accelerated wound closure and re-epithelialization. Additionally, longer newly-formed epithelium tongue and elevated expression of PCNA and Ki67 were detected in the CCN1-treated group 4 days post-burn. These results indicate that CCN1 accelerates re-epithelialization by promoting keratinocyte migration and proliferation, and may serve as a novel target to promote re-epithelialization.

A wet dressing for male genital surgery: A phase II clinical trial

Purpose:

This study was to confirm the safety and efficacy of BC dressing when used in surgical male wound healing at the urogenital area.

Methods:

Open, non-controlled clinical study of phase II. A total of 141 patients, among those children, adolescents and adults with hypospadias (112), epispadias (04), phymosis (13) and Peyronie's disease (12) that had a BC dressing applied over the operated area after surgery. A written informed consent was obtained from all participants. Study exclusion criteria were patients with other alternative treatment indications due to the severity, extent of the injury or the underlying disease. The outcomes evaluated were efficacy, safe and complete healing. The costs were discussed.

Results:

In 68% patients, the BC dressing fell off spontaneously. The BC was removed without complications in 13% of patients at the outpatient clinic during the follow-up visit and 17% not reported the time of removal. In 3% of the cases, the dressing fell off early. Complete healing was observed between 8th and 10th days after surgery. The BC dressings have shown a good tolerance by all the patients and there were no reports of serious adverse events.

Conclusion:

The bacterial cellulose dressings have shown efficacy, safety and that can be considered as a satisfactory alternative for postoperative wound healing in urogenital area and with low cost.

Granzyme B inhibits keratinocyte migration by disrupting epidermal growth factor receptor (EGFR)-mediated signaling

Chronic non-healing wounds including diabetic, venous, and decubitus skin ulcers are currently lacking effective therapies. Non-healing diabetic ulcers can lead to amputations as progress into a highly chronic state before detection and existing treatments for these wounds often fail. Granzyme B (GzmB) is a serine protease that was, until recently, believed to function exclusively in cytotoxic lymphocyte-mediated apoptosis. However, during excessive or chronic inflammation, GzmB can accumulate in the extracellular milieu, retain its activity, and cleave a number of important extracellular proteins. Epidermal growth factor receptor (EGFR) is a transmembrane receptor involved in cellular processes such as proliferation and migration. EGFR signaling is integral to the wound healing process. The present study investigated the effects of GzmB on keratinocyte cell migration using HaCaT cell line. Using electric cell-substrate impedance sensing and scratch assays, the present study demonstrates that GzmB inhibits keratinocyte migration by interfering with the EGFR pathway. GzmB limited cell transition into a migratory morphology and was found to reduce ligand-induced EGFR phosphorylation. Inhibition of GzmB reversed the aforementioned effects. In summary, data from the present study suggest key role for GzmB in the pathogenesis of impaired wound healing through the impairment of EGFR signaling and cell migration.

The role of bone marrow mesenchymal stromal cell derivatives in skin wound healing in diabetic mice

Mesenchymal stromal cells (MSCs) have shown to be a promising tool in cell therapies to treat different conditions. Several pre-clinical and clinical studies have proved that the transplantation of MSCs improves wound healing. Here, we compare the beneficial effects of mouse bone marrow-derived allogeneic MSCs (allo-mBM-MSCs) and their acelullar derivatives (allo-acd-mMSCs) on skin wound healing in Non-Obese Diabetic (NOD) mice. One dose of allo-mBM-MSCs (1×106 cells) or one dose of allo-acd-mMSCs (1X) were intradermally injected around wounds in 8-10 week old female NOD mice. Wound healing was evaluated macroscopically (wound closure) every two days, and microscopically (reepithelialization, dermoepidermal junction, skin appendage regeneration, leukocyte infiltration, vascularization, granulation tissue formation, and density of collagen fibers in the dermis) after 16 days of MSC injection. In addition, we measured growth factors and specific proteins that were present in the allo-acd-mMSCs. Results showed significant differences in the wound healing kinetics of lesions that received allo-acd-mMSCs compared to lesions that received vehicle or allo-mBM-MSCs. In particular, mice treated with allo-acd-mMSCs reached significantly higher percentages of wound closure at day 4, 6 and 8, relative to the allo-mBM-MSCs and vehicle groups (p < 0.05), while wound closure percentages could not be statistically distinguished between the allo-mBM-MSCs and vehicle groups. Also, allo-acd-mMSCs had a greater influence in the skin would healing process. Specifically, they caused a less pronounced inflammatory severe response (p < 0.0001), more granulation tissue formation at an advanced stage (p < 0.0001), and higher density of collagen fibers (p < 0.05) compared to the other groups. Nevertheless, at day 16, both allo-mBM-MSCs and allo-acd-mMSCs revealed a higher effect on the recovery of the quality skin (continuous epidermis; regular dermoepidermal junction and skin appendages) relative to untreated lesions (p < 0.0001), but not between them. On the other hand, ELISA analyses indicated that the allo-acd-mMSCs contained growth factors and proteins relevant to wound healing such as IGF-1, KGF, HGF, VEGF, ANG-2, MMP-1, CoL-1 and PGE2. Compared to allo-acd-mMSCs, the administration of allo-mBM-MSCs is insufficient for wound healing in diabetic mice and delays the therapeutic effect, which maybe explained by the fact that trophic factors secreted by MSCs are critical for skin regeneration, and not the cells per se, suggesting that MSCs may require some time to secrete these factors after their administration.

Nanotechnology-Driven Therapeutic Interventions in Wound Healing: Potential Uses and Applications

The chronic nature and associated complications of nonhealing wounds have led to the emergence of nanotechnology-based therapies that aim at facilitating the healing process and ultimately repairing the injured tissue. A number of engineered nanotechnologies have been proposed demonstrating unique properties and multiple functions that address specific problems associated with wound repair mechanisms. In this outlook, we highlight the most recently developed nanotechnology-based therapeutic agents and assess the viability and efficacy of each treatment, with emphasis on chronic cutaneous wounds. Herein we explore the unmet needs and future directions of current technologies, while discussing promising strategies that can advance the wound-healing field.

Continuous Aspirin Use Does Not Increase Bleeding Risk of Split-Thickness Skin Transplantation Repair to Chronic Wounds

BACKGROUND

Discontinuation of aspirin therapy before cutaneous surgery may cause serious complications.

OBJECTIVES

The aim of this prospective study was to evaluate the bleeding risk of split-thickness skin transplantation repair to chronic wounds in patients on aspirin therapy.

METHODS

A total of 97 patients who underwent split-thickness skin transplantation surgery of chronic wounds during a 2-year period were enrolled. They were categorized on the basis of aspirin therapies. The primary outcome was postoperative bleeding and bleeding complications. Univariate analysis was performed to examine the association between aspirin and bleeding complications. Among the 26 patients taking aspirin continuously in group A, there were 5 bleeding complications (19.23%). Among the 55 nonusers in group B, there were 10 bleeding complications (18.18%). Among the 16 discontinuous patients in group C, there were 3 bleeding complications (18.75%). No statistical differences were found among the groups ( P = .956). Univariate analysis showed that continuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.933; 95% confidence interval, 0.283-3.074; P = .910 in the aspirin and control groups) and that discontinuous aspirin use was not significantly associated with bleeding complications (odds ratio, 0.963; 95% confidence interval, 0.230-4.025; P = .959 in the aspirin and control groups; odds ratio, 0.969; 95% confidence interval, 0.198-4.752; P = .969 in the aspirin and discontinuous groups).

CONCLUSIONS

Continuous aspirin use does not produce an additional bleeding risk in patients who undergo split-thickness skin transplantation repair of chronic wounds.

Efficacy of bacterial cellulose membrane for the treatment of lower limbs chronic varicose ulcers: a randomized and controlled trial

ABSTRACT Objective: to evaluate the efficacy of Bacterial Cellulose (BC) membrane dressings in the treatment of lower limb venous ulcers. Methods: we carried out a prospective, randomized, controlled study of 25 patients with chronic venous ulcer disease in the lower limbs from the Angiology and Vascular Surgery Service of the Federal University of Pernambuco Hospital and from the Salgado Polyclinic of the County Health Department, Caruaru, Pernambuco. We randomly assigned patients to two groups: control group, receiving dressings with triglyceride oil (11 patients) and experimental group, treated with BC membrane (14 patients). We followed the patients for a period of 120 days. Results: There was a reduction in the wound area in both groups. There were no infections or reactions to the product in any of the groups. Patients in the BC group showed decreased pain and earlier discontinuation of analgesic use. Conclusion: BC membrane can be used as a dressing for the treatment of varicose ulcers of the lower limbs.

Biochemical and Biophysical Cues in Matrix Design for Chronic and Diabetic Wound Treatment

Progress in biomaterial science and engineering and increasing knowledge in cell biology have enabled us to develop functional biomaterials providing appropriate biochemical and biophysical cues for tissue regeneration applications. Tissue regeneration is particularly important to treat chronic wounds of people with diabetes. Understanding and controlling the cellular microenvironment of the wound tissue are important to improve the wound healing process. In this study, we review different biochemical (e.g., growth factors, peptides, DNA, and RNA) and biophysical (e.g., topographical guidance, pressure, electrical stimulation, and pulsed electromagnetic field) cues providing a functional and instructive acellular matrix to heal diabetic chronic wounds. The biochemical and biophysical signals generally regulate cell-matrix interactions and cell behavior and function inducing the tissue regeneration for chronic wounds. Some technologies and devices have already been developed and used in the clinic employing biochemical and biophysical cues for wound healing applications. These technologies can be integrated with smart biomaterials to deliver therapeutic agents to the wound tissue in a precise and controllable manner. This review provides useful guidance in understanding molecular mechanisms and signals in the healing of diabetic chronic wounds and in designing instructive biomaterials to treat them.

Human fibrocyte-derived exosomes accelerate wound healing in genetically diabetic mice

Diabetic ulcers represent a substantial societal and healthcare burden worldwide and scarcely respond to current treatment strategies. This study was addressed to evaluate the therapeutic potential of exosomes secreted by human circulating fibrocytes, a population of mesenchymal progenitors involved in normal wound healing via paracrine signaling. The exosomes released from cells sequentially stimulated with platelet-derived growth factor-BB and transforming growth factor-β1, in the presence of fibroblast growth factor 2, did not show potential immunogenicity. These exosomes exhibited in-vitro proangiogenic properties, activated diabetic dermal fibroblasts, induced the migration and proliferation of diabetic keratinocytes, and accelerated wound closure in diabetic mice in vivo. Important components of the exosomal cargo were heat shock protein-90α, total and activated signal transducer and activator of transcription 3, proangiogenic (miR-126, miR-130a, miR-132) and anti-inflammatory (miR124a, miR-125b) microRNAs, and a microRNA regulating collagen deposition (miR-21). This proof-of-concept study demonstrates the feasibility of the use of fibrocytes-derived exosomes for the treatment of diabetic ulcers.

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.

The Effect of Bone Marrow-Derived Mesenchymal Stem Cells and Their Conditioned Media Topically Delivered in Fibrin Glue on Chronic Wound Healing in Rats

Bone marrow-derived mesenchymal stem cells (BM-MSCs) represent a modern approach for management of chronic skin injuries. In this work, we describe BM-MSCs application versus their conditioned media (CM) when delivered topically admixed with fibrin glue to enhance the healing of chronic excisional wounds in rats. Fifty-two adult male rats were classified into four groups after induction of large-sized full-thickness skin wound: control group (CG), fibrin only group (FG), fibrin + MSCs group (FG + SCs), and fibrin + CM group (FG + CM). Healing wounds were evaluated functionally and microscopically. Eight days after injury, number of CD68+ macrophages infiltrating granulation tissue was considerably higher in the latter two groups. Although--later--none of the groups depicted a substantially different healing rate, the quality of regenerated skin was significantly boosted by the application of either BM-MSCs or their CM both (1) structurally as demonstrated by the obviously increased mean area percent of collagen fibers in Masson's trichrome-stained skin biopsies and (2) functionally as supported by the interestingly improved epidermal barrier as well as dermal tensile strength. Thus, we conclude that topically applied BM-MSCs and their CM-via fibrin vehicle--could effectively improve the quality of healed skin in chronic excisional wounds in rats, albeit without true acceleration of wound closure.

Randomized clinical trial of autologous skin cell suspension combined with skin grafting for chronic wounds

BACKGROUND

Treatment of chronic wounds using traditional surgical procedures is challenging because of the low graft take rates. This study investigated the combination approach of split-thickness autografts with harvested skin cell suspension for chronic wound treatment.

METHODS

This randomized clinical trial enrolled patients with chronic wounds between March 2012 and December 2013. Patients who were assigned randomly to the active treatment received a split-thickness autograft combined with harvested skin cell suspension. Control patients received the split-thickness autograft alone. The primary outcome was the rate of complete wound closure by postoperative day 28. Analysis was by intention to treat. Patients who achieved wound closure were followed up for a minimum of 6 months to evaluate the quality of healing.

RESULTS

A total of 88 patients were included, 44 in each group. More patients achieved complete wound closure in the skin cell group than in the control group (41 versus 34 patients; P = 0·035). Complete wound closure was observed at a median of 14 (95 per cent c.i. 12·0 to 16·0) days in the skin cell group and 20 (15·7 to 24·3) days in the control group (P = 0·001). The skin cell group had significantly fewer complications (4 versus 11 patients; P = 0·047). The autografted sites displayed better physical attributes and a reduced tendency for wound recurrence in the skin cell group.

CONCLUSION

Complementary split-thickness autologous skin grafting with autologous skin cells harvested using ReCell® (Avita Medical, Cambridge, UK) technology improved the healing rate of chronic wounds.

REGISTRATION NUMBER

UMIN000011966 (http://www.umin.ac.jp/ctr).

The Roles of Growth Factors in Keratinocyte Migration

Significance: The re-epithelialization of wounded skin requires the rapid and coordinated migration of keratinocytes (KC) into the wound bed. Almost immediately after wounding, cells present at or attracted to the wound site begin to secrete a complex milieu of growth factors. These growth factors exert mitogenic and motogenic effects on KCs, inducing the rapid proliferation and migration of KCs at the wound edge. Recent Advances: New roles for growth factors in KC biology are currently being discovered and investigated. This review will highlight the growth factors, particularly transforming growth factor-α (TGF-α), heparin-binding epidermal growth factor (HB-EGF), insulin-like growth factor 1 (IGF-1), fibroblast growth factor 7 (FGF-7), FGF-10, and hepatocyte growth factor (HGF), which have conclusively been shown to be the most motogenic for KCs. Critical Issues: The cellular and molecular heterogeneity of wounded tissue makes establishing direct relationships between specific growth factors and KC migration difficult in situ. The absence of this complexity in simplified in vitro experimental models of migration makes the clinical relevance of the results obtained from these in vitro studies ambiguous. Future Directions: Deciphering the relationship between growth factors and KC migration is critical for understanding the process of wound healing in normal and disease states. Insights into the basic science of the effects of growth factors on KC migration will hopefully lead to the development of new therapies to treat acute and chronic wounds.

Evidence-based medicine: pressure sores

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Cite risk factors for pressure sore development. 2. Detail the pathophysiology of pressure sores. 3. List the types and classification of pressure sores. 4. Consider the various nonsurgical conservative wound management strategies. 5. Describe the appropriate surgical interventions for each pressure sore type. 6. Understand the causes of recurrent pressure sores and methods of avoiding recurrence.

SUMMARY

Pressure sores are the result of unrelieved pressure, usually over a bony prominence. With an estimated 2.5 million pressure ulcers treated annually in the United States at a cost of $11 billion, pressure sores represent a costly and labor-intensive challenge to the health care system. A comprehensive team approach can address both prevention and treatment of these recalcitrant wounds. Consideration must be given to the patient's medical and socioeconomic condition, as these factors are significantly related to outcomes. Mechanical prophylaxis, nutritional optimization, treatment of underlying infection, and spasm control are essential in management. A variety of pressure sore patterns exist, with surgical approaches directed to maximize future coverage options. A comprehensive approach is detailed in this article to provide the reader with the range of treatment options available.

Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends

Pressure ulcers in spinal cord injury represent a challenging problem for patients, their caregivers, and their physicians. They often lead to recurrent hospitalizations, multiple surgeries, and potentially devastating complications. They present a significant cost to the healthcare system, they require a multidisciplinary team approach to manage well, and outcomes directly depend on patients' education, prevention, and compliance with conservative and surgical protocols. With so many factors involved in the successful treatment of pressure ulcers, an update on their comprehensive management in spinal cord injury is warranted. Current concepts of local wound care, surgical options, as well as future trends from the latest wound healing research are reviewed to aid medical professionals in treating patients with this difficult problem.

Epidermal Growth Factor and Epidermal Growth Factor Receptor: The Yin and Yang in the Treatment of Cutaneous Wounds and Cancer

SIGNIFICANCE

Epidermal growth factor (EGF) and EGF receptor (EGFR) play an essential role in wound healing through stimulating epidermal and dermal regeneration. The development of new therapies for enhancing wound healing has included the use of EGF. In addition, EGFR inhibitors (EGFRis) have become a therapeutic option for the treatment of cancer. Thus, therapies targeting EGF/EGFR are useful for the treatment of both cutaneous wounds and cancer.

RECENT ADVANCES

Identification of EGFR as a regulator of normal and pathological cell function has allowed for the development of EGFRis for the treatment of cancer and topical administration of EGF to enhance wound healing.

CRITICAL ISSUES

The use of EGFRi has emerged as an option for metastatic cancers. These drugs induce dermatological toxicity, a papulopustular rash that is pruritic and painful; chronic use may negatively impact wound healing. Currently, there is no standard therapy to alleviate the side effects caused by EGFRi administration except to reduce or eliminate EGFRi usage. Therefore, side effects from these drugs should be taken into consideration on patients prone to develop chronic wounds and with cutaneous injuries.

FUTURE DIRECTIONS

There is a need for adjunctive treatment to eliminate dermatological toxicity from EGFRi use. The development of new downstream targets of EGFR may be a rational strategy to reduce potential cutaneous side effects and provide a better strategy for the treatment of cancer. Until then, the topical use of EGF could be used to ameliorate dermatological lesions caused by EGFRi.

Proliferation of fibroblasts and endothelial cells is enhanced by treatment with Phyllocaulis boraceiensis mucus

Previously, mucus of some molluscs has been studied as a potential source of new natural compounds capable of inducing cell proliferation and of remodelling tissue. Here, the focus of the study is possible use of mucus released by Phyllocaulis boraceiensis - a compound inducing cell proliferation and enhancing collagen synthesis in dermal fibroblasts and inducing proliferation human endothelial cell cultures. Fibroblasts treated with P. boraceiensis mucus at concentrations below 0.012 μg/μl developed high rates of proliferation, as evaluated using MTT assay; the proliferative effect was dose-dependent. Production and secretion of extracellular matrix components and collagen type I fibres were enhanced after 24 h of treatment, revealing a hormesis effect, biphasic dose response - low dose for proliferation yet toxic at high dose. No significant change in proliferation was observed in treated endothelial cells and production of lipid polyunsaturated free radicals was low in both cell types. Treatment with P. boraceiensis mucus produced pronounced changes in fibroblast cell number and morphology, and in quantities of well-ordered collagen deposition. These results support the premise that Phyllocaulis boraceiensis mucus demonstrates proliferative properties in cells involved in the healing process.

A RHAMM mimetic peptide blocks hyaluronan signaling and reduces inflammation and fibrogenesis in excisional skin wounds

Hyaluronan is activated by fragmentation and controls inflammation and fibroplasia during wound repair and diseases (eg, cancer). Hyaluronan-binding peptides were identified that modify fibrogenesis during skin wound repair. Peptides were selected from 7- to 15mer phage display libraries by panning with hyaluronan-Sepharose beads and assayed for their ability to block fibroblast migration in response to hyaluronan oligosaccharides (10 kDa). A 15mer peptide (P15-1), with homology to receptor for hyaluronan mediated motility (RHAMM) hyaluronan binding sequences, was the most effective inhibitor. P15-1 bound to 10-kDa hyaluronan with an affinity of K(d) = 10(-7) and appeared to specifically mimic RHAMM since it significantly reduced binding of hyaluronan oligosaccharides to recombinant RHAMM but not to recombinant CD44 or TLR2,4, and altered wound repair in wild-type but not RHAMM(-/-) mice. One topical application of P15-1 to full-thickness excisional rat wounds significantly reduced wound macrophage number, fibroblast number, and blood vessel density compared to scrambled, negative control peptides. Wound collagen 1, transforming growth factor β-1, and α-smooth muscle actin were reduced, whereas tenascin C was increased, suggesting that P15-1 promoted a form of scarless healing. Signaling/microarray analyses showed that P15-1 blocks RHAMM-regulated focal adhesion kinase pathways in fibroblasts. These results identify a new class of reagents that attenuate proinflammatory, fibrotic repair by blocking hyaluronan oligosaccharide signaling.

Medical management of diabetic foot infections

Diabetic foot infections (DFIs) are a commonly encountered medical problem. They are associated with an increased frequency and length of hospitalization and risk for lower-extremity amputation. Furthermore, they have substantial economic consequences. Patients with diabetes mellitus are particularly susceptible to foot infections because of neuropathy, vascular insufficiency, and diminished neutrophil function. The approach to managing DFIs starts with determining if an infection exists. If an infection exists, then the type, severity, extent of infection, and risk factors for resistant organisms should be determined through history, physical examination, and additional laboratory and radiological testing. Optimal management requires surgical debridement, pressure offloading, effective antibiotic therapy, wound care and moisture, maintaining good vascular supply, and correction of metabolic abnormalities, such as hyperglycemia, through a multidisciplinary team. Empiric antibiotics for DFIs vary based on the severity of the infection, but must include anti-staphylococcal coverage.