The electric field near human skin wounds declines with age and provides a noninvasive indicator of wound healing

A bioelectronic device for electric field treatment of wounds reduces inflammation in an in vivo mouse model

Electrical signaling plays a crucial role in the cellular response to tissue injury in wound healing and an external electric field (EF) may expedite the healing process. Here, we have developed a standalone, wearable, and programmable electronic device to administer a well-controlled exogenous EF, aiming to accelerate wound healing in an in vivo mouse model to provide pre-clinical evidence. We monitored the healing process by assessing the re-epithelization rate and the ratio of M1/M2 macrophage phenotypes through histology staining. Following three days of treatment, the M1/M2 macrophage ratio decreased by 30.6% and the re-epithelization in the EF-treated wounds trended towards a non-statically significant 24.2% increase compared to the control. These findings provide point towards the effectiveness of the device in shortening the inflammatory phase by promoting reparative macrophages over inflammatory macrophages, and in speeding up re-epithelialization. Our wearable device supports the rationale for the application of programmed EFs for wound management in vivo and provides an exciting basis for further development of our technology based on the modulation of macrophages and inflammation to better wound healing.

Migration of human T cells can be differentially directed by electric fields depending on the extracellular microenvironment

T cell migration plays an essential role in the immune response and T cell-based therapies. It can be modulated by chemical and physical cues such as electric fields (EFs). The mechanisms underlying electrotaxis (cell migration manipulated by EFs) are not fully understood and systematic studies with immune cells are rare. In this in vitro study, we show that direct current EFs with strengths of physiologically occurring EFs (25-200 mV/mm) can guide the migration of primary human CD4+ and CD8+ T cells on 2D substrates toward the anode and in a 3D environment differentially (CD4+ T cells show cathodal and CD8+ T cells show anodal electrotaxis). Overall, we find that EFs present a potent stimulus to direct T cell migration in different microenvironments in a cell-type-, substrate-, and voltage-dependent manner, while not significantly influencing T cell differentiation or viability.

Effects of pulsed electrical stimulation on α-smooth muscle actin and type I collagen expression in human dermal fibroblasts

Pulsed electrical stimulation (PES) is known to affect cellular activities. We previously found PES to human dermal fibroblasts (HFs) promoted platelet-derived growth factor subunit A (PDGFA) gene expression, which enhanced proliferation. In this study, we investigated PES effects on fibroblast collagen production and differentiation into myofibroblasts. HFs were electrically stimulated at 4800 Hz and 5 V for 60 min. Imatinib, a specific inhibitor of PDGF receptors, was treated before PES. After 6 h of PES, PDGFA, α-smooth muscle actin (α-SMA), and collagen type I α1 chain gene expressions were upregulated in PES group. Imatinib suppressed the promoted expression except for PDGFA. Immunofluorescence staining and enzyme-linked immunosorbent assay showed the production of α-SMA and collagen I was enhanced in PES group but suppressed in PES + imatinib group at 48 h after PES. Therefore, PES promotes the production of α-SMA and collagen I in fibroblasts, which is triggered by PDGFA that is upregulated early after PES.

Flexible Organic Photovoltaic-Powered Hydrogel Bioelectronic Dressing With Biomimetic Electrical Stimulation for Healing Infected Diabetic Wounds

Electrical stimulation (ES) is proposed as a therapeutic solution for managing chronic wounds. However, its widespread clinical adoption is limited by the requirement of additional extracorporeal devices to power ES-based wound dressings. In this study, a novel sandwich-structured photovoltaic microcurrent hydrogel dressing (PMH dressing) is designed for treating diabetic wounds. This innovative dressing comprises flexible organic photovoltaic (OPV) cells, a flexible micro-electro-mechanical systems (MEMS) electrode, and a multifunctional hydrogel serving as an electrode-tissue interface. The PMH dressing is engineered to administer ES, mimicking the physiological injury current occurring naturally in wounds when exposed to light; thus, facilitating wound healing. In vitro experiments are performed to validate the PMH dressing's exceptional biocompatibility and robust antibacterial properties. In vivo experiments and proteomic analysis reveal that the proposed PMH dressing significantly accelerates the healing of infected diabetic wounds by enhancing extracellular matrix regeneration, eliminating bacteria, regulating inflammatory responses, and modulating vascular functions. Therefore, the PMH dressing is a potent, versatile, and effective solution for diabetic wound care, paving the way for advancements in wireless ES wound dressings.

Piezoelectric and Triboelectric Nanogenerators for Enhanced Wound Healing

Wound healing is a highly orchestrated biological process characterized by sequential phases involving inflammation, proliferation, and tissue remodeling, and the role of endogenous electrical signals in regulating these phases has been highlighted. Recently, external electrostimulation has been shown to enhance these processes by promoting cell migration, extracellular matrix formation, and growth factor release while suppressing pro-inflammatory signals and reducing the risk of infection. Among the innovative approaches, piezoelectric and triboelectric nanogenerators have emerged as the next generation of flexible and wireless electronics designed for energy harvesting and efficiently converting mechanical energy into electrical power. In this review, we discuss recent advances in the emerging field of nanogenerators for harnessing electrical stimulation to accelerate wound healing. We elucidate the fundamental mechanisms of wound healing and relevant bioelectric physiology, as well as the principles underlying each nanogenerator technology, and review their preclinical applications. In addition, we address the prominent challenges and outline the future prospects for this emerging era of electrical wound-healing devices.

Development of Novel Multifunctional Electroactive, Self-Healing, and Tissue Adhesive Scaffold To Accelerate Cutaneous Wound Healing and Hemostatic Materials

Designing a multifunctional conducting hydrogel wound dressing of suitable mechanical properties, adhesiveness, self-healing, autolytic debridement, antibacterial properties, and radical scavenging ability, as well as retaining an appropriate level of moisture around the wound is highly desirable in clinical application for treating cutaneous wounds healing. Here, we designed a novel class of electroactive hydrogel based on thiol-functionalized silver-graphene oxide nanoparticles (GO/Ag/TGA) core polyaniline (PANI) shell GO/Ag/TGA/PANI nanocomposites. Thus, a series of physically cross-linked hydrogel based on GO/Ag/TGA/PANI and poly(vinyl alcohol) (PVA) was prepared by freeze-thawing method. The hydrogel was characterized by XRD, UV, FTIR, TGA, TEM, SEM, Raman spectroscopy, cyclic voltammetry (CV), and four probes test. The hydrogel showed favorable properties such as excellent tensile strength, suitable gelation time (30-56 s), tunable rheological properties (G' ∼ 1 kPa), adhesiveness, and interconnected porous structure (freeze-dried). Besides this, the hydrogel also exhibits excellent exudate uptake capacity (10.4-0.2 g/g), high swelling ratio (72.4 to 93.5%), long-term antibacterial activity against multidrug-resistant (MDR) bacterial isolates, promising antioxidant (radical scavenging) efficiency, keeping the wound moisturized, prominent hemostatic efficiency, and fast self-healing ability to bear deformation. Interestingly, in vivo experiments indicated that electroactive hydrogels can significantly promote the healing rate of artificial wounds in rats, and histological analysis by H&E reveals higher granulation tissue thickness, collagen deposition, hair follicles, dermal papillary, keratinocytes, and marked increase (P < 0.05) in hydroxyproline at the wound site during 15 days of healing of impaired wounds. On the basis of vivo and vitro assay results, it is concluded that electroactive-hydrogel-attributed multifunctional properties may serve as suitable scaffold for treating chronic wound healing and skin regeneration.

Electrochemical Devices in Cutaneous Wound Healing

In healthy skin, vectorial ion transport gives rise to a transepithelial potential which directly impacts many physiological aspects of skin function. A wound is a physical defect that breaches the epithelial barrier and changes the electrochemical environment of skin. Electroceutical dressings are devices that manipulate the electrochemical environment, host as well as microbial, of a wound. In this review, electroceuticals are organized into three mechanistic classes: ionic, wireless, and battery powered. All three classes of electroceutical dressing show encouraging effects on infection management and wound healing with evidence of favorable impact on keratinocyte migration and disruption of wound biofilm infection. This foundation sets the stage for further mechanistic as well as interventional studies. Successful conduct of such studies will determine the best dosage, timing, and class of stimulus necessary to maximize therapeutic efficacy.

Bioelectronic microfluidic wound healing: a platform for investigating direct current stimulation of injured cell collectives

Upon cutaneous injury, the human body naturally forms an electric field (EF) that acts as a guidance cue for relevant cellular and tissue repair and reorganization. However, the direct current (DC) flow imparted by this EF can be impacted by a variety of diseases. This work delves into the impact of DC stimulation on both healthy and diabetic in vitro wound healing models of human keratinocytes, the most prevalent cell type of the skin. The culmination of non-metal electrode materials and prudent microfluidic design allowed us to create a compact bioelectronic platform to study the effects of different sustained (12 hours galvanostatic DC) EF configurations on wound closure dynamics. Specifically, we compared if electrotactically closing a wound's gap from one wound edge (i.e., uni-directional EF) is as effective as compared to alternatingly polarizing both the wound's edges (i.e., pseudo-converging EF) as both of these spatial stimulation strategies are fundamental to the eventual translational electrode design and strategy. We found that uni-directional electric guidance cues were superior in group keratinocyte healing dynamics by enhancing the wound closure rate nearly three-fold for both healthy and diabetic-like keratinocyte collectives, compared to their non-stimulated respective controls. The motility-inhibited and diabetic-like keratinocytes regained wound closure rates with uni-directional electrical stimulation (increase from 1.0 to 2.8% h^-1) comparable to their healthy non-stimulated keratinocyte counterparts (3.5% h^-1). Our results bring hope that electrical stimulation delivered in a controlled manner can be a viable pathway to accelerate wound repair, and also by providing a baseline for other researchers trying to find an optimal electrode blueprint for in vivo DC stimulation.

Possible Synergies of Nanomaterial-Assisted Tissue Regeneration in Plasma Medicine: Mechanisms and Safety Concerns

Cold atmospheric plasma and nanomedicine originally emerged as individual domains, but are increasingly applied in combination with each other. Most research is performed in the context of cancer treatment, with only little focus yet on the possible synergies. Many questions remain on the potential of this promising hybrid technology, particularly regarding regenerative medicine and tissue engineering. In this perspective article, we therefore start from the fundamental mechanisms in the individual technologies, in order to envision possible synergies for wound healing and tissue recovery, as well as research strategies to discover and optimize them. Among these strategies, we demonstrate how cold plasmas and nanomaterials can enhance each other's strengths and overcome each other's limitations. The parallels with cancer research, biotechnology and plasma surface modification further serve as inspiration for the envisioned synergies in tissue regeneration. The discovery and optimization of synergies may also be realized based on a profound understanding of the underlying redox- and field-related biological processes. Finally, we emphasize the toxicity concerns in plasma and nanomedicine, which may be partly remediated by their combination, but also partly amplified. A widespread use of standardized protocols and materials is therefore strongly recommended, to ensure both a fast and safe clinical implementation.

Metal-Free Perovskite Piezoelectric Nanogenerators for Human-Machine Interfaces and Self-Powered Electrical Stimulation Applications

Single crystal metal-free halide perovskites have received great attention in recent years owing to their excellent piezoelectric and ferroelectric properties. However, the nanotoxicity and piezoelectricity within the nanoscale of such materials have yet been reported for the demonstration of practical applications. In this work, the observation of intrinsic piezoelectricity in metal-free perovskite (MDABCO-NH₄ I₃ ) films using piezoresponse force microscopy (PFM) is reported. A cytotoxicity test is also performed on MDABCO-NH₄ I₃ to evaluate its low-toxic nature. The as-synthesized MDABCO-NH₄ I₃ is further integrated into a piezoelectric nanogenerator (PENG). The MDABCO-NH₄ I₃ -based PENG (MN-PENG) exhibits optimal output voltage and current of 15.9 V and 54.5 nA, respectively. In addition, the MN-PENG can serve as a self-powered strain sensor for human-machine interface applications or be adopted in in vitro electrical stimulation devices. This work demonstrates a path of perovskite-based PENG with high performance, low toxicity, and multifunctionality for future advanced wearable sensors and portable therapeutic systems.

Electrical aspects of skin as a pathway to engineering skin devices

Skin is one of the indispensable organs for life. The epidermis at the outermost surface provides a permeability barrier to infectious agents, chemicals, and excessive loss of water, while the dermis and subcutaneous tissue mechanically support the structure of the skin and appendages, including hairs and secretory glands. The integrity of the integumentary system is a key for general health, and many techniques have been developed to measure and control this protective function. In contrast, the effective skin barrier is the major obstacle for transdermal delivery and detection. Changes in the electrical properties of skin, such as impedance and ionic activity, is a practical indicator that reflects the structures and functions of the skin. For example, the impedance that reflects the hydration of the skin is measured for quantitative assessment in skincare, and the current generated across a wound is used for the evaluation and control of wound healing. Furthermore, the electrically charged structure of the skin enables transdermal drug delivery and chemical extraction. This paper provides an overview of the electrical aspects of the skin and summarizes current advances in the development of devices based on these features.

Electrical stimulation for pain reduction in hard-to-heal wound healing

OBJECTIVE

Despite treatment advances over the past 30 years, the societal impact of hard-to-heal wounds is increasingly burdensome. An unresolved issue is wound pain, which can make many treatments, such as compression in venous leg ulcers, intolerable. The aim of this review is to present the evidence and stimulate thinking on the use of electrical stimulation devices as a treatment technology with the potential to reduce pain, improve adherence and thus hard-to-heal wound outcomes.

METHOD

A literature search was conducted for clinical studies up to August 2020 reporting the effects of electrical stimulation devices on wound pain. Devices evoking neuromuscular contraction or direct spinal cord stimulation were excluded.

RESULTS

A total of seven publications (three non-comparative and four randomised trials) were identified with four studies reporting a rapid (within 14 days) reduction in hard-to-heal wound pain. Electrical stimulation is more widely known for accelerated healing and is one of the most evidence-based technologies in wound management, supported by numerous in vitro molecular studies, five meta-analyses, six systematic reviews and 30 randomised controlled trials (RCTs). Despite this wealth of supportive evidence, electrical stimulation has not yet been adopted into everyday practice. Some features of electrical stimulation devices may have hampered adoption in the past.

CONCLUSION

As new, pocket-sized, portable devices allowing convenient patient treatment and better patient adherence become more widely available and studied in larger RCTs, the evidence to date suggests that electrical stimulation should be considered part of the treatment options to address the challenges of managing and treating painful hard-to-heal wounds.

Piezoelectric core-shell PHBV/PDX blend scaffolds for reduced superficial wound contraction and scarless tissue regeneration

The use of non-invasive scaffold materials which can mimic the innate piezoelectric properties of biological tissues is a promising strategy to promote native tissue regeneration. Piezoelectric and cell instructive electrospun core-shell PDX/PHBV mats have been engineered to promote native tissue and skin regeneration. In depth physicochemical characterisation, in vitro and in vivo studies of a rat model showed that the 20/80 PDX/PHBV composition possessed the right balance of physicochemical and piezoelectric properties leading to enhanced fibroblast stimulation, proliferation and migration, reduced fibroblast-mediated contraction and macrophage-induced inflammation, improved keratinocyte proliferation, proper balance between endothelial cell phenotypes, decreased in vivo fibrosis and accelerated in vivo scarless wound regeneration. Overall, this study highlights the importance of exploiting cell-material interactions to match tissue biological needs to sustain the wound healing cascade.

Electrical Stimulation to Enhance Wound Healing

Electrical stimulation (ES) can serve as a therapeutic modality accelerating the healing of wounds, particularly chronic wounds which have impaired healing due to complications from underlying pathology. This review explores how ES affects the cellular mechanisms of wound healing, and its effectiveness in treating acute and chronic wounds. Literature searches with no publication date restrictions were conducted using the Cochrane Library, Medline, Web of Science, Google Scholar and PubMed databases, and 30 full-text articles met the inclusion criteria. In vitro and in vivo experiments investigating the effect of ES on the general mechanisms of healing demonstrated increased epithelialization, fibroblast migration, and vascularity around wounds. Six in vitro studies demonstrated bactericidal effects upon exposure to alternating and pulsed current. Twelve randomized controlled trials (RCTs) investigated the effect of pulsed current on chronic wound healing. All reviewed RCTs demonstrated a larger reduction in wound size and increased healing rate when compared to control groups. In conclusion, ES therapy can contribute to improved chronic wound healing and potentially reduce the financial burden associated with wound management. However, the variations in the wound characteristics, patient demographics, and ES parameters used across studies present opportunities for systematic RCT studies in the future.

Optimizing microenvironment by integrating negative pressure and exogenous electric fields via a flexible porous conductive dressing to accelerate wound healing

Wound healing is a complex and sequential biological process that involves multiple stages. Current treatments for nonhealing or chronic wounds are unsatisfactory as they exert a single effect on one specific activity. Herein, we constructed a silver nanowire (AgNW)-based, three-dimensional (3D), porous foam dressing that is flexible and conductive. This conductive foam dressing was composed of AgNWs modified with a stable hydrophobic coating and porous polyurethane (PU), providing a skeleton to support the 3D conductive networks. The AgNWs-PU foam dressing exhibited favorable biocompatibility, outstanding electrical properties, excellent bending-compression durability, and long-term stability under wet conditions, making it suitable for wound treatment. Via the conductive foam dressing, negative pressure and exogenous wound directional electric fields (EFs) could be integrated for simultaneous implementation, and the artificial jointly constructed microenvironment promoted wound healing in a system. This novel "all-in-one" device presented intrinsic multifunctionality, including the drainage of pus and necrotic tissue, mitigation of inflammation, promotion of cell proliferation, direction of keratinocyte migration, and induction of angiogenesis. An immunohistochemical assay and western blot analysis illustrated that the angiogenesis and cell proliferation pathways in the tissue were significantly activated when this novel therapy was adopted. More importantly, the practical performance of this "all-in-one" device was demonstrated by assessment of full-thickness defect wounds in model pigs. Comparing the percentage of residual wound area after administration of traditional treatment (25.82 ± 3.52%) and the novel treatment (3.07 ± 1.23%) demonstrated the promising applications of this novel treatment in clinical wound healing.

Recent innovations in artificial skin

The skin is a "smart", multifunctional organ that is protective, self-healing and capable of sensing and many forms of artificial skins have been developed with properties and functionalities approximating those of natural skin. Starting from specific commercial products for the treatment of burns, progress in two fields of research has since allowed these remarkable materials to be viable skin replacements for a wide range of dermatological conditions. This review maps out the development of bioengineered skin replacements and synthetic skin substitutes, including electronic skins. The specific behaviors of these skins are highlighted, and the performances of both types of artificial skins are evaluated against this. Moving beyond mere replication, highly advanced artificial skin materials are also identified as potential augmented skins that can be used as flexible electronics for health-care monitoring and other applications.

Effects of pulsed electrical stimulation on growth factor gene expression and proliferation in human dermal fibroblasts

Human dermal fibroblast proliferation plays an important role in skin wound healing, and electrical stimulation (ES) promotes skin wound healing. Although the use of ES for skin wound healing has been investigated, the mechanism underlying the effects of ES on cells is still unclear. This study examined the effects of pulsed electrical stimulation (PES) on human dermal fibroblasts. Normal adult human dermal fibroblasts were exposed to a frequency of 4800 Hz, voltage of 1-5 V, and PES exposure time of 15, 30, and 60 min. Dermal fibroblast proliferation and growth factor gene expression were investigated for 6-48 h post PES. Dermal fibroblast proliferation significantly increased from 24 to 48 h post PES at a voltage of 5 V and PES exposure time of 60 min. Under the same conditions, post PES, platelet-derived growth factor subunit A (PDGFA), fibroblast growth factor 2 (FGF2), and transforming growth factor beta 1 (TGF-β1) expression significantly increased from 6 to 24 h, 12 to 48 h, and 24 to 48 h, respectively. Imatinib, a specific inhibitor of platelet-derived growth factor receptor, significantly inhibited the proliferation of dermal fibroblasts promoted by PES, suggesting that PDGFA expression, an early response of PES, was involved in promoting the cell proliferation. Therefore, PES at 4800 Hz may initially promote PDGFA expression and subsequently stimulate the expression of two other growth factors, resulting in dermal fibroblast proliferation after 24 h or later. In conclusion, PES may activate the cell growth phase of wound healing.

A pulsed current electric field alters protein expression creating a wound healing phenotype in human skin cells

Aim: Pulsed current (PC) electric field (EF) devices promote healing in chronic wounds but the underpinning mechanisms are largely unknown. The gap between clinical evidence and mechanistic understanding limits device uptake in clinics. Materials & methods: Migration, proliferation and gene/protein expression profiles were investigated in the presence/absence of PCEF, in skin: keratinocytes (NHK); dermal fibroblasts (HDF); dermal microvascular endothelial cells (HDMEC) and macrophages (THP-1). Results: While PCEF had little effect on migration or proliferation, it significantly altered the expression of 31 genes and the secretion of 7 pro-angiogenic and pro-regenerative growth factors using ELISAs. Conclusion: PCEF significantly altered skin cell genomes/proteomes which provides some evidence of how PCEF devices promote healing of chronic wounds.

A Model and Simulation With Therapeutic Device-Protocol Design Implications for Acute and Chronic Wounds

An understanding of healing processes for different tissues and organs, along with the development of appropriate therapeutic devices and treatment protocols, requires an appreciation for the mechanisms-of-action and sequencing of many interconnected chemical, electrical, mechanical, and optical activities. Unfortunately, the substantial contributions that endogenous electrical mechanisms-of-action provide in healing and regulation are often overlooked, resulting in a poor transfer of knowledge from science, to engineering, and finally, to therapy. The wide variety of healing processes, their therapeutic implications, and the devices and protocol designs that are most effective cannot be understood or addressed adequately without an understanding of the endogenous electrical mechanisms-of-action associated with wound healing. Achieving this level of understanding can be enhanced by the use of appropriate models and simulations that are based on physiological/biochemical system response characteristics.

Enhancing Effect of 100.414-kHz Electromagnetic Field Produced by Defender's Pulse Generator on the ChIFN γ-Like Molecule Inducing Capacity of Lens culinaris Agglutinin and 10% PBS Washouts of Different Holocene Minerals

Macrophages play key role in host defense and tissue repair, and thus understanding regulation of their function is important. For instance, our previous results have shown that in chicken macrophage system (CoMA cell line), application of a pulse of electromagnetic fields of frequencies 0.618, 1.054, 5.229, and 100.414 kHz induces production of interferon γ-like molecules. In this study, we have shown that the electromagnetic field of 100.414 kHz is the most effective in inducing synthesis of chicken interferon γ and chicken interferon γ-like molecules in CoMA cells, especially when combined with Lens culinaris agglutinin and 10% phosphate-buffered saline washouts of different Holocene minerals. A 2-minute pulse of electromagnetic field was produced by Defender's pulse generator. Both chicken interferon γ and chicken interferon γ-like molecules from the cell supernatant were evaluated by an antiviral assay and were also analyzed with reverse-phase high-performance liquid chromatography on Phenomenex, Aeris peptide columns. Our results show that application of a single inducing factor ( Lens culinaris agglutinin, 100.414 kHz electromagnetic field, 10% phosphate buffer saline washout) or combined usage of 2 of them moderately stimulated production of chicken interferon γ-like molecules (from 1.550 to 48.028 IU/mL), whereas the combination of 10% phosphate-buffered saline washout of Koprivnica rock + Lens culinaris agglutinin + 100.414 kHz/9 V resulted in an output of 162.122 IU/mL. Hence, we may conclude that a combined use of electromagnetic field, Holocene minerals, and Lens culinaris agglutinin greatly stimulates synthesis of chicken interferon γ-like molecules in CoMA cells.

Electrotaxis: Cell Directional Movement in Electric Fields

Electrotaxis plays an important role during embryogenesis, inflammation, wound healing, and tumour metastasis. However, the mechanisms at play during electrotaxis are still poorly understood. Therefore intensive studies on signaling pathways involved in this phenomenon should be carried out. In this chapter, we described an experimental system for studying electrotaxis of Amoeba proteus, mouse embryonic fibroblasts (MEF), Walker carcinosarcoma cells WC256, and bone marrow adherent cells (BMAC).

Studying Electrotaxis in Microfluidic Devices

Collective cell migration is important in various physiological processes such as morphogenesis, cancer metastasis and cell regeneration. Such migration can be induced and guided by different chemical and physical cues. Electrotaxis, referring to the directional migration of adherent cells under stimulus of electric fields, is believed to be highly involved in the wound-healing process. Electrotactic experiments are conventionally conducted in Petri dishes or cover glasses wherein cells are cultured and electric fields are applied. However, these devices suffer from evaporation of the culture medium, non-uniformity of electric fields and low throughput. To overcome these drawbacks, micro-fabricated devices composed of micro-channels and fluidic components have lately been applied to electrotactic studies. Microfluidic devices are capable of providing cells with a precise micro-environment including pH, nutrition, temperature and various stimuli. Therefore, with the advantages of reduced cell/reagent consumption, reduced Joule heating and uniform and precise electric fields, microfluidic chips are perfect platforms for observing cell migration under applied electric fields. In this paper, I review recent developments in designing and fabricating microfluidic devices for studying electrotaxis, aiming to provide critical updates in this rapidly-growing, interdisciplinary field.

Nature's Electric Potential: A Systematic Review of the Role of Bioelectricity in Wound Healing and Regenerative Processes in Animals, Humans, and Plants

Natural endogenous voltage gradients not only predict and correlate with growth and development but also drive wound healing and regeneration processes. This review summarizes the existing literature for the nature, sources, and transmission of information-bearing bioelectric signals involved in controlling wound healing and regeneration in animals, humans, and plants. It emerges that some bioelectric characteristics occur ubiquitously in a range of animal and plant species. However, the limits of similarities are probed to give a realistic assessment of future areas to be explored. Major gaps remain in our knowledge of the mechanistic basis for these processes, on which regenerative therapies ultimately depend. In relation to this, it is concluded that the mapping of voltage patterns and the processes generating them is a promising future research focus, to probe three aspects: the role of wound/regeneration currents in relation to morphology; the role of endogenous flux changes in driving wound healing and regeneration; and the mapping of patterns in organisms of extreme longevity, in contrast with the aberrant voltage patterns underlying impaired healing, to inform interventions aimed at restoring them.

Electrical Stimulation for Wound-Healing: Simulation on the Effect of Electrode Configurations

Endogenous electric field is known to play important roles in the wound-healing process, mainly through its effects on protein synthesis and cell migration. Many clinical studies have demonstrated that electrical stimulation (ES) with steady direct currents is beneficial to accelerating wound-healing, even though the underlying mechanisms remain unclear. In the present study, a three-dimensional finite element wound model was built to optimize the electrode configuration in ES. Four layers of the skin, stratum corneum, epidermis, dermis, and subcutis, with defined thickness and electrical properties were modeled. The main goal was to evaluate the distributions of exogenous electric fields delivered with direct current (DC) stimulation using different electrode configurations such as sizes and positions. Based on the results, some guidelines were obtained in designing the electrode configuration for applications of clinical ES.

Electric field as a potential directional cue in homing of bone marrow-derived mesenchymal stem cells to cutaneous wounds

Bone marrow-derived cells are thought to participate and enhance the healing process contributing to skin cells or releasing regulatory cytokines. Directional cell migration in a weak direct current electric field (DC-EF), known as electrotaxis, may be a way of cell recruitment to the wound site. Here we examined the influence of electric field on bone marrow adherent cells (BMACs) and its potential role as a factor attracting mesenchymal stem cells to cutaneous wounds. We observed that in an external EF, BMAC movement was accelerated and highly directed with distinction of two cell populations migrating toward opposite poles: mesenchymal stem cells migrated toward the cathode, whereas macrophages toward the anode. Analysis of intracellular pathways revealed that macrophage electrotaxis mostly depended on Rho family small GTPases and calcium ions, but interruption of PI3K and Arp2/3 had the most pronounced effect on electrotaxis of MSCs. However, in all cases we observed only a partial decrease in directionality of cell movement after inhibition of certain proteins. Additionally, although we noticed the accumulation of EGFR at the cathodal side of MSCs, it was not involved in electrotaxis. Moreover, the cell reaction to EF was very dynamic with first symptoms occurring within <1min. In conclusion, the physiological DC-EF may act as a factor positioning bone marrow cells within a wound bed and the opposite direction of MSC and macrophage movement did not result either from utilizing different signalling or redistribution of investigated cell surface receptors.

Enhanced Neurogenic Biomarker Expression and Reinnervation in Human Acute Skin Wounds Treated by Electrical Stimulation

Electrical stimulation (ES) is known to promote cutaneous healing; however, its ability to regulate reinnervation remains unclear. First, we show that ES treatment of human acute cutaneous wounds (n = 40) increased reinnervation. Next, to define neurophysiologic mechanisms through which ES affects repair, microarray analysis of wound biopsy samples was performed on days 3, 7, 10, and 14 after wounding. This identified neural differentiation biomarkers TUBB3 (melanocyte development and neuronal marker) and its upstream molecule FIG4 (phosphatidylinositol (3,5)-bisphosphate 5-phosphatase) as significantly up-regulated after ES treatment. To demonstrate a functional ES-TUBB3 axis in cutaneous healing, we showed increased TUBB3⁺ melanocytes and melanogenesis plus FIG4 and nerve growth factor expression, suggesting higher cellular differentiation. In support of this role of ES to regulate neural crest-derived cell fate and differentiation in vivo, knockdown of FIG4 in neuroblastoma cells resulted in vacuologenesis and cell degeneration, whereas ES treatment after FIG4-small interfering RNA transfection enhanced neural differentiation, survival, and integrity. Further characterization showed increased TUBB3⁺ and protein gene product 9.5⁺ Merkel cells during in vivo repair, after ES. We demonstrate that ES contributes to increased expression of neural differentiation biomarkers, reinnervation, and expansion of melanocyte and Merkel cell pool during repair. Targeted ES-assisted acceleration of healing has significant clinical implications.

Kindlin-1 Regulates Keratinocyte Electrotaxis

Kindler syndrome (KS) is an autosomal recessive blistering skin disease resulting from pathogenic mutations in FERMT1. This gene encodes kindlin-1, a focal adhesion protein involved in activation of the integrin family of extracellular matrix receptors. Most cases of KS show a marked reduction or complete absence of the kindlin-1 protein in keratinocytes, resulting in defective cell adhesion and migration. Electric fields also act as intrinsic regulators of adhesion and migration in the skin, but the molecular mechanisms by which this occurs are poorly understood. Here we show that keratinocytes derived from KS patients are unable to undergo electrotaxis, and this defect is restored by overexpression of wild-type kindlin-1 but not a W612A mutation that prevents kindlin-integrin binding. Moreover, deletion of the pleckstrin homology domain of kindlin-1 also failed to rescue electrotaxis in KS cells, indicating that both integrin and lipid binding are required for this function. Kindlin-1 was also required for the maintenance of lamellipodial protrusions during electrotaxis via electric field-activated β1 integrin. Indeed, inhibition of β1 integrins also leads to loss of electrotaxis in keratinocytes. Our data suggest that loss of kindlin-1 function may therefore result in epithelial insensitivity to electric fields and contribute to KS disease pathology.

Diabetic cornea wounds produce significantly weaker electric signals that may contribute to impaired healing

Wounds naturally produce electric signals which serve as powerful cues that stimulate and guide cell migration during wound healing. In diabetic patients, impaired wound healing is one of the most challenging complications in diabetes management. A fundamental gap in knowledge is whether diabetic wounds have abnormal electric signaling. Here we used a vibrating probe to demonstrate that diabetic corneas produced significantly weaker wound electric signals than the normal cornea. This was confirmed in three independent animal models of diabetes: db/db, streptozotocin-induced and mice fed a high-fat diet. Spatial measurements illustrated that diabetic cornea wound currents at the wound edge but not wound center were significantly weaker than normal. Time lapse measurements revealed that the electric currents at diabetic corneas lost the normal rising and plateau phases. The abnormal electric signals correlated significantly with impaired wound healing. Immunostaining suggested lower expression of chloride channel 2 and cystic fibrosis transmembrane regulator in diabetic corneal epithelium. Acute high glucose exposure significantly (albeit moderately) reduced electrotaxis of human corneal epithelial cells in vitro, but did not affect the electric currents at cornea wounds. These data suggest that weaker wound electric signals and impaired electrotaxis may contribute to the impaired wound healing in diabetes.

ATP Release and P2 Y Receptor Signaling are Essential for Keratinocyte Galvanotaxis

Repair to damaged tissue requires directional cell migration to heal the wound. Immediately upon wounding an electrical guidance cue is created with the cathode of the electric field (EF) located at the center of the wound. Previous research has demonstrated directional migration of keratinocytes toward the cathode when an EF of physiological strength (100-150 mV/mm) is applied in vitro, but the "sensor" by which keratinocytes sense the EF remains elusive. Here we use a customized chamber design to facilitate the application of a direct current (DC) EF of physiological strength (100 mV/mm) to keratinocytes whilst pharmacologically modulating the activation of both connexin hemichannels and purinergic receptors to determine their role in EF-mediated directional keratinocyte migration, galvanotaxis. In addition, keratinocytes were exposed to DiSCAC2 (3) dye to visualize membrane potential changes within the cell upon exposure to the applied DC EF. Here we unveil ATP-medicated mechanisms that underpin the initiation of keratinocyte galvanotaxis. The application of a DC EF of 100 mV/mm releases ATP via hemichannels activating a subset of purinergic P2 Y receptors, locally, to initiate the directional migration of keratinocytes toward the cathode in vitro, the center of the wound in vivo. The delineation of the mechanisms underpinning galvanotaxis extends our understanding of this endogenous cue and will facilitate the optimization and wider use of EF devices for chronic wound treatment. J. Cell. Physiol. 230: 181-191, 2016. © 2015 Wiley Periodicals, Inc.

Electrically Activated Primary Human Fibroblasts Improve In Vitro and In Vivo Skin Regeneration

Electrical stimulation (ES) changes cellular behaviors and thus constitutes a potential strategy to promote wound healing. However, well-controlled in vitro findings have yet to be translated to in vivo trials. This study was to demonstrate the feasibility and advantages of transplanting electrically activated cells (E-Cells) to help wound healing. Primary human skin fibroblasts were activated through well defined ES and cultured with keratinocytes to generate engineered human skin (EHS), which were transplanted to nu/nu mice. The electrically activated EHS grafts were analyzed at 20 and 30 days post-grafting, showing faster wound closure, thick epidermis, vasculature, and functional basement membrane containing laminin and type IV collagen that were totally produced by the implanted human cells. Because a variety of cells can be electrically activated, E-Cells may become a new cell source and the transplantation of E-Cells may represent a new strategy in wound healing and tissue engineering. J. Cell. Physiol. 231: 1814-1821, 2016. © 2015 Wiley Periodicals, Inc.

Electric fields are novel determinants of human macrophage functions

Macrophages are key cells in inflammation and repair, and their activity requires close regulation. The characterization of cues coordinating macrophage function has focused on biologic and soluble mediators, with little known about their responses to physical stimuli, such as the electrical fields that are generated naturally in injured tissue and which accelerate wound healing. To address this gap in understanding, we tested how properties of human monocyte-derived macrophages are regulated by applied electrical fields, similar in strengths to those established naturally. With the use of live-cell video microscopy, we show that macrophage migration is directed anodally by electrical fields as low as 5 mV/mm and is electrical field strength dependent, with effects peaking ∼300 mV/mm. Monocytes, as macrophage precursors, migrate in the opposite, cathodal direction. Strikingly, we show for the first time that electrical fields significantly enhance macrophage phagocytic uptake of a variety of targets, including carboxylate beads, apoptotic neutrophils, and the nominal opportunist pathogen Candida albicans, which engage different classes of surface receptors. These electrical field-induced functional changes are accompanied by clustering of phagocytic receptors, enhanced PI3K and ERK activation, mobilization of intracellular calcium, and actin polarization. Electrical fields also modulate cytokine production selectively and can augment some effects of conventional polarizing stimuli on cytokine secretion. Taken together, electrical signals have been identified as major contributors to the coordination and regulation of important human macrophage functions, including those essential for microbial clearance and healing. Our results open up a new area of research into effects of naturally occurring and clinically applied electrical fields in conditions where macrophage activity is critical.

Elucidating the Role of Injury-Induced Electric Fields (EFs) in Regulating the Astrocytic Response to Injury in the Mammalian Central Nervous System

Injury to the vertebrate central nervous system (CNS) induces astrocytes to change their morphology, to increase their rate of proliferation, and to display directional migration to the injury site, all to facilitate repair. These astrocytic responses to injury occur in a clear temporal sequence and, by their intensity and duration, can have both beneficial and detrimental effects on the repair of damaged CNS tissue. Studies on highly regenerative tissues in non-mammalian vertebrates have demonstrated that the intensity of direct-current extracellular electric fields (EFs) at the injury site, which are 50-100 fold greater than in uninjured tissue, represent a potent signal to drive tissue repair. In contrast, a 10-fold EF increase has been measured in many injured mammalian tissues where limited regeneration occurs. As the astrocytic response to CNS injury is crucial to the reparative outcome, we exposed purified rat cortical astrocytes to EF intensities associated with intact and injured mammalian tissues, as well as to those EF intensities measured in regenerating non-mammalian vertebrate tissues, to determine whether EFs may contribute to the astrocytic injury response. Astrocytes exposed to EF intensities associated with uninjured tissue showed little change in their cellular behavior. However, astrocytes exposed to EF intensities associated with injured tissue showed a dramatic increase in migration and proliferation. At EF intensities associated with regenerating non-mammalian vertebrate tissues, these cellular responses were even more robust and included morphological changes consistent with a regenerative phenotype. These findings suggest that endogenous EFs may be a crucial signal for regulating the astrocytic response to injury and that their manipulation may be a novel target for facilitating CNS repair.

H(+)/K(+) ATPase activity is required for biomineralization in sea urchin embryos

The bioelectrical signatures associated with regeneration, wound healing, development, and cancer are changes in the polarization state of the cell that persist over long durations, and are mediated by ion channel activity. To identify physiologically relevant bioelectrical changes that occur during normal development of the sea urchin Lytechinus variegatus, we tested a range of ion channel inhibitors, and thereby identified SCH28080, a chemical inhibitor of the H(+)/K(+) ATPase (HKA), as an inhibitor of skeletogenesis. In sea urchin embryos, the primary mesodermal lineage, the PMCs, produce biomineral in response to signals from the ectoderm. However, in SCH28080-treated embryos, aside from randomization of the left-right axis, the ectoderm is normally specified and differentiated, indicating that the block to skeletogenesis observed in SCH28080-treated embryos is PMC-specific. HKA inhibition did not interfere with PMC specification, and was sufficient to block continuing biomineralization when embryos were treated with SCH28080 after the initiation of skeletogenesis, indicating that HKA activity is continuously required during biomineralization. Ion concentrations and voltage potential were abnormal in the PMCs in SCH28080-treated embryos, suggesting that these bioelectrical abnormalities prevent biomineralization. Our results indicate that this effect is due to the inhibition of amorphous calcium carbonate precipitation within PMC vesicles.

A large-scale screen reveals genes that mediate electrotaxis in Dictyostelium discoideum

Directional cell migration in an electric field, a phenomenon called galvanotaxis or electrotaxis, occurs in many types of cells, and may play an important role in wound healing and development. Small extracellular electric fields can guide the migration of amoeboid cells, and we established a large-scale screening approach to search for mutants with electrotaxis phenotypes from a collection of 563 Dictyostelium discoideum strains with morphological defects. We identified 28 strains that were defective in electrotaxis and 10 strains with a slightly higher directional response. Using plasmid rescue followed by gene disruption, we identified some of the mutated genes, including some previously implicated in chemotaxis. Among these, we studied PiaA, which encodes a critical component of TORC2, a kinase protein complex that transduces changes in motility by activating the kinase PKB (also known as Akt). Furthermore, we found that electrotaxis was decreased in mutants lacking gefA, rasC, rip3, lst8, or pkbR1, genes that encode other components of the TORC2-PKB pathway. Thus, we have developed a high-throughput screening technique that will be a useful tool to elucidate the molecular mechanisms of electrotaxis.

Angiogenesis is induced and wound size is reduced by electrical stimulation in an acute wound healing model in human skin

Angiogenesis is critical for wound healing. Insufficient angiogenesis can result in impaired wound healing and chronic wound formation. Electrical stimulation (ES) has been shown to enhance angiogenesis. We previously showed that ES enhanced angiogenesis in acute wounds at one time point (day 14). The aim of this study was to further evaluate the role of ES in affecting angiogenesis during the acute phase of cutaneous wound healing over multiple time points. We compared the angiogenic response to wounding in 40 healthy volunteers (divided into two groups and randomised), treated with ES (post-ES) and compared them to secondary intention wound healing (control). Biopsy time points monitored were days 0, 3, 7, 10, 14. Objective non-invasive measures and H&E analysis were performed in addition to immunohistochemistry (IHC) and Western blotting (WB). Wound volume was significantly reduced on D7, 10 and 14 post-ES (p = 0.003, p = 0.002, p<0.001 respectively), surface area was reduced on days 10 (p = 0.001) and 14 (p<0.001) and wound diameter reduced on days 10 (p = 0.009) and 14 (p = 0.002). Blood flow increased significantly post-ES on D10 (p = 0.002) and 14 (p = 0.001). Angiogenic markers were up-regulated following ES application; protein analysis by IHC showed an increase (p<0.05) in VEGF-A expression by ES treatment on days 7, 10 and 14 (39%, 27% and 35% respectively) and PLGF expression on days 3 and 7 (40% on both days), compared to normal healing. Similarly, WB demonstrated an increase (p<0.05) in PLGF on days 7 and 14 (51% and 35% respectively). WB studies showed a significant increase of 30% (p>0.05) on day 14 in VEGF-A expression post-ES compared to controls. Furthermore, organisation of granulation tissue was improved on day 14 post-ES. This randomised controlled trial has shown that ES enhanced wound healing by reduced wound dimensions and increased VEGF-A and PLGF expression in acute cutaneous wounds, which further substantiates the role of ES in up-regulating angiogenesis as observed over multiple time points. This therapeutic approach may have potential application for clinical management of delayed and chronic wounds.

A multi-scale feedback control system model for wound healing electrical activity: therapeutic device/protocol implications

Regulation, growth and healing in biological systems involve many interconnected and interdependent processes that include chemical and electrical mechanisms of action. Unfortunately, the significant contributions that electrical events provide are often overlooked; resulting in a poor transfer of knowledge from science, to engineering and finally to therapy. Wound site electrical processes can influence cell migration, fluid transport, cellular signaling events, gene expression, cell differentiation and cell proliferation; affecting both form and function at the cell, tissue and organ levels. Wound healing, and its interrelationships with transport, regeneration, and growth, cannot be understood or therapeutically assisted unless both chemical and electrical activities associated with the healing process are addressed.

Utilizing custom-designed galvanotaxis chambers to study directional migration of prostate cells

The physiological electric field serves specific biological functions, such as directing cell migration in embryo development, neuronal outgrowth and epithelial wound healing. Applying a direct current electric field to cultured cells in vitro induces directional cell migration, or galvanotaxis. The 2-dimensional galvanotaxis method we demonstrate here is modified with custom-made poly(vinyl chloride) (PVC) chambers, glass surface, platinum electrodes and the use of a motorized stage on which the cells are imaged. The PVC chambers and platinum electrodes exhibit low cytotoxicity and are affordable and re-useable. The glass surface and the motorized microscope stage improve quality of images and allow possible modifications to the glass surface and treatments to the cells. We filmed the galvanotaxis of two non-tumorigenic, SV40-immortalized prostate cell lines, pRNS-1-1 and PNT2. These two cell lines show similar migration speeds and both migrate toward the cathode, but they do show a different degree of directionality in galvanotaxis. The results obtained via this protocol suggest that the pRNS-1-1 and the PNT2 cell lines may have different intrinsic features that govern their directional migratory responses.

Electrical stimulation enhances epidermal proliferation in human cutaneous wounds by modulating p53-SIVA1 interaction

Cutaneous wounds establish endogenous "wound current" upon injury until re-epithelialization is complete. Keratinocyte proliferation, regulated partly by p53, is required for epidermal closure. SIVA1 promotes human double minute 2 homolog (HDM2)-mediated p53 regulation. However, the role of SIVA1 in wound healing is obscure. Here, we report that electrical stimulation (ES) accelerates wound healing by upregulating SIVA1 and its subsequent ability to modulate p53 activities. Cultured donut-shaped human skin explants, subjected to ES, exhibited better epidermal stratification, increased proliferation, and upregulation of gene and protein expression of HDM2/SIVA1, compared with non-ES-treated explants. ES significantly increased in vitro keratinocyte proliferation and phospho-p53-SIVA1 interaction; however, this showed stable expression of phospho-p53, which increased significantly in the absence of SIVA1. Here, HDM2 alone was unable to downregulate nuclear-accumulated phospho-p53, which was evident from decreased proliferation and increased sub-G1 population seen by flow cytometry. Further examination of the epidermis of human cutaneous wounds showed higher p53-SIVA1 coexpression and proliferation 7 days after injury in ES-treated wounds compared with control wounds. In summary, ES-inducible SIVA1 modulates p53 activities in proliferating keratinocytes, and exogenous ES affects p53/HDM2/SIVA1 axis leading to increased proliferation during re-epithelialization. This highlights ES as a potential strategy for enhancing cutaneous repair.

Matrix hyaluronan-activated CD44 signaling promotes keratinocyte activities and improves abnormal epidermal functions

Hyaluronan (HA), a major component of the extracellular matrix, is enriched in skin tissues, particularly the epidermis. HA binds to a ubiquitous, abundant, and functionally important family of cell surface receptors, CD44. This article reviews the current evidence for HA/CD44-mediated activation of RhoGTPase signaling and calcium mobilization, leading to the regulation of keratinocyte activities and various epidermal functions. It further discusses the role of HA-mediated CD44 interactions with unique downstream effectors, such as RhoGTPases (RhoA and Rac1), Rho-kinase, protein kinase-Nγ, and phosphoinositide-specific phospholipases (phospholipases Cε and Cγ1) in coordinating certain intracellular signaling pathways, such as calcium mobilization, phosphatidylinositol 3-kinase-AKT activation, cortactin-actin binding, and actin-associated cytoskeleton reorganization; generating the onset of important keratinocyte activities, such as cell adhesion, proliferation, migration, and differentiation; and performing epidermal functions. Topical application of selective HA fragments (large versus small HA) to the skin of wild-type mice (but not CD44 knockout mice) improves keratinocyte-associated epidermal functions and accelerates permeability barrier recovery and skin wound healing. Consequently, specific HA fragment (large versus small HA)-mediated signaling events (through the CD44 receptor) are required for keratinocyte activities, which offer new HA-based therapeutic options for patients experiencing epidermal dysfunction and skin damage as well as aging-related skin diseases, such as epidermal thinning (atrophy), permeability barrier dysfunction, and chronic nonhealing wounds.

The Electrical Response to Injury: Molecular Mechanisms and Wound Healing

Significance: Natural, endogenous electric fields (EFs) and currents arise spontaneously after wounding of many tissues, especially epithelia, and are necessary for normal healing. This wound electrical activity is a long-lasting and regulated response. Enhancing or inhibiting this electrical activity increases or decreases wound healing, respectively. Cells that are responsible for wound closure such as corneal epithelial cells or skin keratinocytes migrate directionally in EFs of physiological magnitude. However, the mechanisms of how the wound electrical response is initiated and regulated remain unclear. Recent Advances: Wound EFs and currents appear to arise by ion channel up-regulation and redistribution, which are perhaps triggered by an intracellular calcium wave or cell depolarization. We discuss the possibility of stimulation of wound healing via pharmacological enhancement of the wound electric signal by stimulation of ion pumping. Critical Issues: Chronic wounds are a major problem in the elderly and diabetic patient. Any strategy to stimulate wound healing in these patients is desirable. Applying electrical stimulation directly is problematic, but pharmacological enhancement of the wound signal may be a promising strategy. Future Directions: Understanding the molecular regulation of wound electric signals may reveal some fundamental mechanisms in wound healing. Manipulating fluxes of ions and electric currents at wounds might offer new approaches to achieve better wound healing and to heal chronic wounds.

E-cadherin plays an essential role in collective directional migration of large epithelial sheets

In wound healing and development, large epithelial sheets migrate collectively, in defined directions, and maintain tight cell-cell adhesion. This type of movement ensures an essential function of epithelia, a barrier, which is lost when cells lose connection and move in isolation. Unless wounded, epithelial sheets in cultures normally do not have overall directional migration. Cell migration is mostly studied when cells are in isolation and in the absence of mature cell-cell adhesion; the mechanisms of the migration of epithelial sheets are less well understood. We used small electric fields (EFs) as a directional cue to instigate and guide migration of epithelial sheets. Significantly, cells in monolayer migrated far more efficiently and directionally than cells in isolation or smaller cell clusters. We demonstrated for the first time the group size-dependent directional migratory response in several types of epithelial cells. Gap junctions made a minimal contribution to the directional collective migration. Breaking down calcium-dependent cell-cell adhesion significantly reduced directional sheet migration. Furthermore, E-cadherin blocking antibodies abolished migration of cell sheets. Traction force analysis revealed an important role of forces that cells in the leading rows exert on the substratum. With EF, the traction forces of the leading edge cells coordinated in directional re-orientation. Our study thus identifies a novel mechanism--E-cadherin dependence and coordinated traction forces of leading cells in collective directional migration of large epithelial sheets.