Transdermal CO2 Application in Chronic Wounds

The Tissue Response to Hypoxia: How Therapeutic Carbon Dioxide Moves the Response toward Homeostasis and Away from Instability

Sustained tissue hypoxia is associated with many pathophysiological conditions, including chronic inflammation, chronic wounds, slow-healing fractures, microvascular complications of diabetes, and metastatic spread of tumors. This extended deficiency of oxygen (O₂) in the tissue sets creates a microenvironment that supports inflammation and initiates cell survival paradigms. Elevating tissue carbon dioxide levels (CO₂) pushes the tissue environment toward "thrive mode," bringing increased blood flow, added O₂, reduced inflammation, and enhanced angiogenesis. This review presents the science supporting the clinical benefits observed with the administration of therapeutic CO₂. It also presents the current knowledge regarding the cellular and molecular mechanisms responsible for the biological effects of CO₂ therapy. The most notable findings of the review include (a) CO₂ activates angiogenesis not mediated by hypoxia-inducible factor 1a, (b) CO₂ is strongly anti-inflammatory, (c) CO₂ inhibits tumor growth and metastasis, and (d) CO₂ can stimulate the same pathways as exercise and thereby, acts as a critical mediator in the biological response of skeletal muscle to tissue hypoxia.

Transcutaneous CO2 application accelerates fracture repair in streptozotocin-induced type I diabetic rats

INTRODUCTION

Diabetes mellitus (DM) negatively affects fracture repair by inhibiting endochondral ossification, chondrogenesis, callus formation, and angiogenesis. We previously reported that transcutaneous CO₂ application accelerates fracture repair by promoting endochondral ossification and angiogenesis. The present study aimed to determine whether CO₂ treatment would promote fracture repair in cases with type I DM.

RESEARCH DESIGN AND METHODS

A closed femoral shaft fracture was induced in female rats with streptozotocin-induced type I DM. CO₂ treatment was performed five times a week for the CO₂ group. Sham treatment, where CO₂ was replaced with air, was performed for the control group. Radiographic, histologic, genetic, and biomechanical measurements were taken at several time points.

RESULTS

Radiographic assessment demonstrated that fracture repair was induced in the CO₂ group. Histologically, accelerated endochondral ossification and capillary formation were observed in the CO₂ group. Immunohistochemical assessment indicated that early postfracture proliferation of chondrocytes in callus was enhanced in the CO₂ group. Genetic assessment results suggested that cartilage and bone formation, angiogenesis, and vasodilation were upregulated in the CO₂ group. Biomechanical assessment revealed enhanced mechanical strength in the CO₂ group.

CONCLUSIONS

Our findings suggest that CO₂ treatment accelerates fracture repair in type I DM rats. CO₂ treatment could be an effective strategy for delayed fracture repair due to DM.

Transcutaneous application of the gaseous CO2 for improvement of the microvascular function in patients with diabetic foot ulcers

INTRODUCTION

Microvascular function is impaired in patients with diabetes mellitus (DM) and is involved in numerous DM complications. Several microvascular-supporting interventions have been proposed of which the transcutaneous application of gaseous CO₂ (hereinafter CO₂ therapy) is one of the most promising. The aim of present study was to determine the effect of repeated CO₂ therapies on the cutaneous microvascular function in DM patients with diabetic foot ulcers.

METHODOLOGY

A total of 42 subjects with at least one chronic diabetic foot ulcer were enrolled in the study. They were divided into the experimental group (21 subjects aged 64.6 ± 11.6 years) that underwent 4-week-long treatment with transcutaneous application of gaseous CO₂ (hereinafter CO₂ therapies), and the placebo group (21 subjects aged 65.0 ± 10.7 years) that underwent 4-week-long placebo treatment with transcutaneous application of air. Before the first and after the last treatment in both groups, laser Doppler (LD) flux in foot cutaneous microcirculation, heart rate, and arterial blood pressure measurements were carried out during rest and local thermal hyperaemia (LTH) provocation test.

RESULTS

In the experimental group the following statistically significant changes were observed after the completed treatment 1) increased mean relative powers of LD flux signals during rest in the frequency bands related to NO-independent endothelial (0.07 ± 0.055 vs. 0.048 ± 0.059, p = 0.0058), NO-mediated endothelial (0.154 ± 0.101 vs. 0.113 ± 0.108, p = 0.015), and neurogenic (0.17 ± 0.107 vs. 0.136 ± 0.098, p = 0.018) activity; 2) decreased resting LD flux (35 ± 29 PU vs. 52 ± 56 PU; p = 0.038); and 3) increased peak LD flux as a function of baseline during LTH (482 ± 474%BL vs. 287 ± 262%BL, p = 0.036); there were no statistically significant changes observed in the placebo group. No systemic effects were observed in none of the two groups by means of mean values of heart rate and arterial blood pressure.

CONCLUSIONS

Repeated CO₂ therapies improves the microvasular function in DM patients without any systemic side effects.

The Role of Complex Treatment in Mixed Leg Ulcers - A Case Report of Vascular, Surgical and Physical Therapy

BACKGROUND:

Leg ulcers are a burden to patients, their families and society. The second most common cause of chronic leg ulcers is the mixed arterio-venous type. An 80-year-old female patient presented to our department due to painful enlarging chronic leg ulcer of mixed arteriovenous origin on her left lower leg. She suffered from peripheral arterial occlusive disease stage I and chronic venous insufficiency Widmer grade IIIa, and a number of comorbidities.

AIM:

The aim of our ulcer treatment was a complete and stable wound closure that was hampered by arterial occlusion, exposed tendon, and renal insiffuciency.

CASE REPORT:

To improve the prognosis for ulcer surgery, we performed percutaneous transluminal angioplasty, transcutaneous CO₂ and deep ulcer shaving. The wound was closed by sandwich transplantation using elastin-collagen dermal template and meshed split skin graft. She had a 100% graft take with rapid reduction of severe wound pain.

CONCLUSION:

Complex approaches are necessary, to gain optimum results in leg ulcer therapy in mixed leg ulcers. Therapeutic nihilism should be abandonend.

CO2 Delivery To Accelerate Incisional Wound Healing Following Single Irradiation of Near-Infrared Lamp on the Coordinated Colloids

Traditional wound care methods include wound infection control, adequate nutritional supplements, education of changing position every 2-3 h to avoid tissue hypoxia, vacuum assistant closure, debridement, skin graft, and tissue flap. Electric current stimulation, ultrasound, laser, and hydrotherapy have emerged as adjuvant therapies. However, most, if not all, of these therapies are expensive, and the treatment results are variable. The development of the active methods to improve wound healing is mandatory. CO₂ administration has been known to improve microcirculation and local oxygen supply that are beneficial to wound healing. Here, the metal ion-ligand coordination nanoarchitecture was designed to reveal NIR light-induced CO₂ generation for wound healing. The administration simply topically dropped the colloidal solution on the incisional wound, followed by exposure of near-infrared (NIR) lamp to yield CO₂, resulting in the observation of the accelerated wound healing.

Comorbidities, treatment, and outcome in severe anogenital inverse acne (hidradenitis suppurativa): a 15-year single center report

BACKGROUND

Acne inversa (hidradentitis suppurativa; AI) is a severe chronic relapsing inflammatory skin disease of unknown cause. Anogenital AI has the strongest negative impact on quality of life and causes great disability.

OBJECTIVES

We analyzed patients, comorbities, outcome of extensive surgery, and possible adverse effects.

PATIENTS AND METHODS

We included patients from January 2000 to March 2015 with anogenital AI Hurley grade III. They were further characterized by modified Sartorius scale, gender and age, comorbidities, pretreatments, and type of surgery (open or closed), and complications. Pain was measured by visual analogue scale (VAS). Treatment was performed by wide excision surgery.

RESULTS

A total of 117 patients were identified; mean age was 40.6 ± 12.6 years. The mean modified Sartorius score was 30.4 ± 8.4. Risk factors of obesity and active smoking were seen in 31.6% and 14.5%, respectively. Colostomy was needed in a single patient only. Pain was reduced significantly. Intra- and postoperative complications were seen in 20.5% (24/117).

CONCLUSIONS

Anogenital AI is a severe and potentially life threatening disease. Severe anogenital AI can be effectively treated by aggressive surgery. Outcome depends also on comorbidities.

Disabling Pansclerotic Morphea of Childhood Poses a High Risk of Chronic Ulceration of the Skin and Squamous Cell Carcinoma

Disabling pansclerotic morphea of childhood (DPMC) is a rare and severe variant of scleroderma. This report presents 3 cases that presented to the authors and studies 25 patients from the literature (English language only) for the presence of chronic nonhealing ulcers of skin and skin cancer. The authors identified a total of 30 patients (9 male and 21 female) aged between 1 and 37 years at time of presentation. All cases were less than 14 years old when the disease started. The majority of patients had an aggressive course with deep sclerotic lesions leading to joint contractures and immobility. Five patients suffered from chronic nonhealing leg ulcers (17%), but ulcers were present on other parts of the body (upper limbs, trunk, head) as well (n = 6). Four patients died because of complications of the disease such as sepsis or gangrene. Two patients developed a squamous cell carcinoma at the age of 16 years and 19 years, respectively (6.7%). The available treatment of DMPC-associated ulcers is unsatisfying. Only temporary improvements have been seen in a minority of patients. We report on marked improvement of chronic leg ulcers by a combination of sildenafil 3 × 20 mg/day and repeated application of a porcine small intestinal submucosal acellular matrix.

Extensive Invasive Extramammary Paget's Disease: Surgical Treatment

Extramammary Paget's disease is uncommon. Diagnosis has to be confirmed by histopathology. Treatment is a challenge in cases with extended tumors. We present a 70-year-old male patient with extensive genitoanal Paget's disease. Mohs surgery is the gold standard in such cases. Details of the surgical planning are discussed including wound bed preparation. Radiotherapy may be an alternative.

Topical PDGF-BB results in limited healing in a patient with Werner's syndrome and chronic leg ulcers

Impaired wound healing is a feature of Werner's syndrome. Treatment of one such patient with painful chronic leg ulcers included topical application of PDGF-BB. Granulation increased slightly, enabling full-thickness skin grafting to take place.