Laser therapy in wound healing associated with diabetes mellitus - Review

Insights into the mechanisms of diabetic wounds: pathophysiology, molecular targets, and treatment strategies through conventional and alternative therapies

Diabetes mellitus is a prevalent cause of mortality worldwide and can lead to several secondary issues, including DWs, which are caused by hyperglycemia, diabetic neuropathy, anemia, and ischemia. Roughly 15% of diabetic patient's experience complications related to DWs, with 25% at risk of lower limb amputations. A conventional management protocol is currently used for treating diabetic foot syndrome, which involves therapy using various substances, such as bFGF, pDGF, VEGF, EGF, IGF-I, TGF-β, skin substitutes, cytokine stimulators, cytokine inhibitors, MMPs inhibitors, gene and stem cell therapies, ECM, and angiogenesis stimulators. The protocol also includes wound cleaning, laser therapy, antibiotics, skin substitutes, HOTC therapy, and removing dead tissue. It has been observed that treatment with numerous plants and their active constituents, including Globularia Arabica, Rhus coriaria L., Neolamarckia cadamba, Olea europaea, Salvia kronenburgii, Moringa oleifera, Syzygium aromaticum, Combretum molle, and Myrtus communis, has been found to promote wound healing, reduce inflammation, stimulate angiogenesis, and cytokines production, increase growth factors production, promote keratinocyte production, and encourage fibroblast proliferation. These therapies may also reduce the need for amputations. However, there is still limited information on how to prevent and manage DWs, and further research is needed to fully understand the role of alternative treatments in managing complications of DWs. The conventional management protocol for treating diabetic foot syndrome can be expensive and may cause adverse side effects. Alternative therapies, such as medicinal plants and green synthesis of nano-formulations, may provide efficient and affordable treatments for DWs.

Diabetic Foot Ulcer Management and Treatment: An Overview of Published Patents

BACKGROUND

One of the most challenging effects of diabetes is diabetic foot ulceration (DFU). DFU may occur in up to one-third of individuals with diabetes mellitus (D.M.) at some point in their lives. The major cause of morbidity in D.M. patients is DFU. The length of treatment is difficult, and DFU recurrence is common.

OBJECTIVE

The most crucial element for the treatment and prevention of DFUs require a multidisciplinary approach. Patients who are at risk should be identified, depending on the type of risk, prophylactic actions etc. It is imperative to identify at-risk patients and take preventative measures accordingly.

METHOD

The at-risk diabetes-related foot ulcer was identified based on the risk category classification, while the foot ulcers were evaluated using Wagner's classification system.

RESULTS

Literature reported that patients with lower limb vascular insufficiency, loss of vibratory sensation, or protective sensation loss have an increased risk of developing foot ulcers. Proper categorization and therapeutic measures will be implemented after the DFU has been formed. The appropriate assessment and management of general health status should include glycemic control, the diagnosis and treatment of vascular disease, standard care for wounds, diagnosis, and infection treatments.

CONCLUSION

The review reflects the updated awareness of the treatment and management of DFU based on the current and past literature and patent analysis.

Interaction of the AKT and β-catenin signalling pathways and the influence of photobiomodulation on cellular signalling proteins in diabetic wound healing

The induction of a cells destiny is a tightly controlled process that is regulated through communication between the matrix and cell signalling proteins. Cell signalling activates distinctive subsections of target genes, and different signalling pathways may be used repeatedly in different settings. A range of different signalling pathways are activated during the wound healing process, and dysregulated cellular signalling may lead to reduced cell function and the development of chronic wounds. Diabetic wounds are chronic and are characterised by the inability of skin cells to act in response to reparative inducements. Serine/threonine kinase, protein kinase B or AKT (PKB/AKT), is a central connection in cell signalling induced by growth factors, cytokines and other cellular inducements, and is one of the critical pathways that regulate cellular proliferation, survival, and quiescence. AKT interacts with a variety of other pathway proteins including glycogen synthase kinase 3 beta (GSK3β) and β-catenin. Novel methodologies based on comprehensive knowledge of activated signalling pathways and their interaction during normal or chronic wound healing can facilitate quicker and efficient diabetic wound healing. In this review, we focus on interaction of the AKT and β-catenin signalling pathways and the influence of photobiomodulation on cellular signalling proteins in diabetic wound healing.

Invitro impact of a combination of red and infrared LEDs, infrared laser and magnetic field on biomarkers of oxidative stress and hemolysis of erythrocytes sampled from healthy individuals and diabetes patients

AIMS

Low-intensity infrared laser irradiation with output emissions of the laser and LED for in vitro irradiation of plasma and erythrocyte samples collected from healthy individuals and diabetes mellitus (DM) patients was used in the current study.

METHODS

The generated emission was in the range 0.85-0.89 nm with pulse duration near 130 ns and repetition rates of pulses 50, 150, 600, and 1500 Hz, average power 0, 50, or 100 mW, in the range of 1-9 min for different 30 variants of irradiation. The levels of 2-thiobarbituric-acid reactive substances (TBARS), aldehydic and ketonic derivatives of oxidatively modified proteins (OMP), total antioxidant capacity (TAC), acid-induced resistance of erythrocytes, and activities of the main antioxidant enzymes were assessed in erythrocyte and plasma samples after irradiation.

RESULTS

The low-intensity infrared laser irradiation and low-intensity light emitted by a red LED decreased the lipid peroxidation levels in the erythrocytes of both healthy individuals and DM patients. A statistically significant decrease in TBARS and OMP levels and an increase in the TAC level were observed at the irradiation energy of 34.39 and 68.79 J/cm² for samples collected from both healthy individuals and DM patients. The effects of the irradiation were accompanied by a statistically significant decrease in catalase activity of both healthy individuals and DM patients.

CONCLUSIONS

In many variants of the laser irradiation and low-intensity light emitted by a red LED used in our study, a decrease in the percent of hemolyzed erythrocytes was observed, suggesting that laser therapy protocols should take into account fluencies, frequencies, and wavelengths of the laser before the beginning of treatment, especially in DM patients.

CircARHGAP12 Triggers Mesenchymal Stromal Cell Autophagy to Facilitate its Effect on Repairing Diabetic Wounds by Sponging miR-301b-3p/ATG16L1 and miR-301b-3p/ULK2

Circular RNAs have been confirmed to play vital roles in the development of human diseases. Nevertheless, their effects on modulating mesenchymal stromal cells (MSCs) to heal diabetic wounds are still elusive. In this study, our data revealed that MSCs treated with high glucose displayed an evident reduction in circARHGAP12 expression, whereas autophagy mediated by circARHGAP12 suppressed high glucose-triggered apoptosis of MSCs. Mechanistically, circARHGAP12 was capable of directly interacting with miR-301b-3p and subsequently sponged microRNA to modulate the expression of the miR-301b-3p target genes ATG16L1 and ULK2 and the downstream signaling pathway. Moreover, circARHGAP12 promoted the survival of MSCs in diabetic wounds in vivo and accelerated wound healing. Collectively, these results suggest that circARHGAP12/miR-301b-3p/ATG16L1 and circARHGAP12/miR-301b-3p/ULK2 regulatory networks might be an underlying therapeutic target for MSCs in diabetic wound healing.

Photobiomodulation to Treat Necrotizing Fasciitis

ABSTRACT

The spread of odontogenic infections associated with comorbidities, such as diabetes mellitus, can result in a potentially lethal complication, with rapid necrosis of the superficial fascia, necrotizing fasciitis. In this case report, a female patient, 52 years old, fasting blood glucose of 303 mg/dL with necrotizing fasciitis associated with type 2 diabetes mellitus in the left cervical-thoracic region. She was treated with antibiotics, cervicotomy, abscess drainage, and underwent 10 photobiomodulation sessions with 2 weekly applications of the red wavelength laser to correct tissue loss in the left cervical region. With the development of tissue healing, the formation of granulation tissue increased, absence of necrotic areas, contraction of the edges, and total wound repair. This case emphasizes the effectiveness of photobiomodulation to optimize healing and modulate the inflammatory pattern in the treatment of necrotizing fasciitis sequelae.

Photobiomodulation in diabetic wound healing: A review of red and near-infrared wavelength applications

The development of a painless, non-invasive, and faster way to diabetic wound healing is at the forefront of research. The complexity associated with diabetic wounds makes it a cause for concern amongst diabetic patients and the world at large. Irradiation of cells generates a photobiomodulatory response on cells and tissues, directly causing alteration of cellular processes and inducing diabetic wound repair. Photobiomodulation therapy (PBMT) using red and near-infrared (NIR) wavelengths is being considered as a promising technique for speeding up the rate of diabetic wound healing, eradication of pain and reduction of inflammation through the alteration of diverse cellular and molecular processes. This review presents the extent to which the potential of red and NIR wavelengths have been harnessed in PBMT for diabetic wound healing. Important research challenges and gaps are identified and discussed, and future directions mapped out. This review thus provides useful insights and strategies into improvement of PBMT, including its acceptance within the global medical research community.

Effects of Buprenorphine, Chlorhexidine, and Low-level Laser Therapy on Wound Healing in Mice

Systemic buprenorphine and topical antiseptics such as chlorhexidine are frequently used in research animals to aid in pain control and to reduce infection, respectively. These therapeutics are controversial, especially when used in wound healing studies, due to conflicting data suggesting that they delay wound healing. Low-level laser therapy (LLLT) has been used to aid in wound healing without exerting the systemic effects of therapies such as buprenorphine. We conducted 2 studies to investigate the effects of these common treatment modalities on the rate of wound healing in mice. The first study used models of punch biopsy and dermal abrasion to assess whether buprenorphine HCl or 0.12% chlorhexidine delayed wound healing. The second study investigated the effects of sustained-released buprenorphine, 0.05% chlorhexidine, and LLLT on excisional wound healing. The rate of wound healing was assessed by obtaining photographs on days 0, 2, 4, 7, and 9 for the punch biopsy model in study 1, days 0, 1, 2, 4, 6, 8, 11, and 13 for the dermal abrasion model in study 1, and days 0, 3, 6, and 10 for the mice in study 2. Image J software was used to analyze the photographed wounds to determine the wound area. When comparing the wound area on the above days to the original wound area, no significant differences in healing were observed for any of the treatment groups at any time period for either study. Given the results of these studies, we believe that systemic buprenorphine, topical chlorhexidine, and LLLT can be used without impairing or delaying wound healing in mice.

Parameter-Dependency of Low-Intensity Vibration for Wound Healing in Diabetic Mice

Chronic wounds in diabetic patients represent an escalating health problem, leading to significant morbidity and mortality. Our group previously reported that whole body low-intensity vibration (LIV) can improve angiogenesis and wound healing in diabetic mice. The purpose of the current study was to determine whether effects of LIV on wound healing are frequency and/or amplitude dependent. Wound healing was assessed in diabetic (db/db) mice exposed to one of four LIV protocols with different combinations of two acceleration magnitudes (0.3 and 0.6 g) and two frequencies (45 and 90 Hz) or in non-vibration sham controls. The low acceleration, low frequency protocol (0.3 g and 45 Hz) was the only one that improved wound healing, increasing angiogenesis and granulation tissue formation, leading to accelerated re-epithelialization and wound closure. Other protocols had little to no impact on healing with some evidence that 0.6 g accelerations negatively affected wound closure. The 0.3 g, 45 Hz protocol also increased levels of insulin-like growth factor-1 and tended to increase levels of vascular endothelial growth factor in wounds, but had no effect on levels of basic fibroblast growth factor or platelet derived growth factor-bb, indicating that this LIV protocol induces specific growth factors during wound healing. Our findings demonstrate parameter-dependent effects of LIV for improving wound healing that can be exploited for future mechanistic and therapeutic studies.

Effects of diode low-level laser therapy on healing of tooth extraction sockets: a histopathological study in diabetic rats

Diabetes mellitus is mostly interrelated to deficiency in wound healing. Low-level laser therapy has been shown to exert reliable effects on the acceleration of wound healing process. This study aimed to determine the potential influence of low-level laser therapy (LLLT) on the healing of extraction sockets in diabetic rats. A total of 24 healthy male Wistar rats were selected for this study. After diabetes induction, the maxillary first molars of all rats were extracted bilaterally. Then, the animals were subjected either to Ga-Al-As laser at 808 nm or to Al-Ga-In-P laser at 660 nm at the right extracted socket every day for the next 14 days. The left sockets served as controls. Rats were sacrificed on the 3rd, 5th, 7th, and 14th days after tooth extraction. The samples were examined by a pathologist. LLLT at 808 nm was able to significantly repress inflammation, improve osteoid formation, and promote vascularization in comparison to the non-treated sockets. LLLT at 660 nm significantly suppressed inflammation and developed vascularization in comparison to the non-treated sockets, but failed to improve osteoid formation in the treated sockets. This study suggests that LLLT could be considered as a reliable treatment for wound healing in diabetic experimental rats.

Efficacy of low-level light therapy for improving healing of diabetic foot ulcers: A systematic review and meta-analysis of randomized controlled trials

Diabetic foot ulcers are prevalent among patients with diabetes and negatively affect mortality and life expectancy. This study aimed to synthesize and systematically review the best evidence to assess the efficacy of low-level light therapy in improving healing of diabetic foot ulcers. We search CINAHL, Cochrane Library, EMBASE, ProQuest, PubMed, Scopus, and Web of Science from inception until September 30, 2019. Meta-analysis was performed using the Comprehensive Meta-analysis 3.0 software. Overall effect was measured using Hedges' g and determined using the Z-statistic at a significance level of P < .05. Heterogeneity was assessed using χ² and I² statistics. Twelve randomized controlled trials were included. Meta-analysis revealed that 30.90% of the ulcer area was significantly reduced in the therapy group compared with the control group (Z = 3.95, P < .001) with a very large effect (g = 2.81). A 4.2 cm² reduction of the ulcer area was observed in the therapy group compared with the control group (Z = 2.17, P = .03) with a very large effect (g = 1.37). In addition, diabetic foot ulcers in the therapy group was 4.65 times more likely to heal completely than those in the control group (Z = 3.02, P = .003). Low-level light therapy accelerates wound healing and reduces the size of diabetic foot ulcers. However, our review does not allow any recommendation for the best treatment parameters required to achieve improved healing. Future trials need to include a good design and large sample size in defining the optimal treatment parameters for ulcers of different sizes.

Involvement of Aquaporins in the Intense Pulsed Light-Enhanced Wound Healing in Diabetic Rats

BACKGROUND AND OBJECTIVES

We previously demonstrated that intense pulsed light (IPL) irradiation prior to wounding improved the wound healing in rats with diabetes mellitus (DM). Also, we found that IPL upregulated the expression of aquaporin 3 (AQP3), a protein that is crucial for wound healing, in normal rats. This present study aimed to examine the involvement of AQPs in the IPL-enhanced wound healing in diabetic rats.

STUDY DESIGN/MATERIALS AND METHODS

Streptozotocin was used to induce diabetes in Sprague-Dawley rats. Animals were divided into four groups: normal group, DM only group, DM rats with IPL treatment 2 weeks before wounding (DM + IPL-Pre group), and DM rats with concurrent IPL irradiation and wounding (DM + IPL-Con group). Wounds were created on the dorsal skin of rats. The expressions of AQP1, 3, 4, 7, and 9 in the pre-injured skin, periwound, and wound were determined.

RESULTS

Among all the AQPs analyzed, only the expressions of AQP3 and AQP7 were significantly altered. Unirradiated diabetic rats showed much higher expression level of AQP3 in the regenerating skin compared with normal rats. IPL pretreatment, but not concurrent treatment, attenuated the expression toward the level detected in the normal wounds. In contrast, a lower expression level of AQP7 was noted in the regenerating skin of DM only rats and IPL pretreatment upregulated the expression to a level similar to that in the normal rats.

CONCLUSION

The beneficial effect of IPL pretreatment on the wound healing in diabetic rats might involve a mechanism by which the expression of AQPs is regulated. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Efeitos da laserterapia de baixa intensidade na cicatrização de úlceras nos pés em pessoas com diabetes mellitus

Objetivo: Identificar os efeitos da laserterapia de baixa intensidade na cicatrização do pé diabético. Método: Revisão sistemática nas bases de dados PubMed, LILACS, SciELO, CINAHL, Cochrane, Web of Science e Scopus, em que foram identificados 73 artigos, dos quais seis foram incluídos na amostra final, após verificação dos critérios de elegibilidade. Resultados: Os artigos apontaram como efeitos da laserterapia a efetividade na progressão do processo de reparo tecidual do pé diabético, alívio da dor, ação antiinflamatória, aumento da perfusão tecidual da lesão e melhora da resposta vascular e do sistema nervoso. Conclusão: O laser é uma terapia adjuvante que pode acelerar o processo de cicatrização da lesão, diminuir a dor, melhorar a neovascularização e, assim, minimizar o risco de complicações, como amputação do membro inferior e melhora da qualidade de vida de pessoas com diabetes e integridade da pele prejudicada.

Effects of low-level laser therapy on the healing of foot ulcers in people with diabetes mellitus

Objective: Identify the effects of low-level laser therapy on the healing of diabetic foot. Method: Systematic review of the PubMed, LILACS, SciELO, CINAHL, Cochrane, Web of Science and Scopus databases, in which 92 articles were identified and six were included in the final sample after the eligibility criteria. Results: The articles pointed out as effects of laser therapy the effectiveness in the progression of the tissue repair process of the diabetic foot, pain relief, anti-inflammatory action, increased tissue perfusion of the lesion and improvement of the vascular response and the nervous system. Conclusion: Laser is an adjuvant therapy that can accelerate the wound healing process, relieve pain, improve neovascularization, and thus minimize the risk of complications, such as lower limb amputation and improvement of quality of life for people with diabetes and impaired skin integrity.

Inhibition of autophagy promoted high glucose/ROS-mediated apoptosis in ADSCs

BACKGROUND

Increased apoptosis in adipose tissue-derived stem cells (ADSCs) limits their application in treating diabetes complications. Autophagy is a molecular process that allows cells to degrade and recover damaged macromolecules, and closely interacts with apoptosis. The aim of the present study was to investigate the potential role of autophagy in ADSC apoptosis induced by high glucose.

METHODS

Human ADSCs were cultured in normal or high-glucose medium for 6 h, 12 h, or 24 h. The effects of high glucose on ADSC autophagy, reactive oxygen species (ROS) production, and apoptosis were evaluated. The impact of autophagy on ROS production and apoptosis was explored by treatment with rapamycin or 3-methyladenine (3-MA). The c-jun kinase (JNK) signaling pathway was investigated by pharmacological disruption of SP600125.

RESULTS

ADSCs subjected to high glucose stress showed an obvious induction of autophagy and apoptosis and a significant increase in intracellular ROS levels. The JNK signaling pathway was confirmed to be involved in high glucose-induced autophagy. Pre-treatment with SP600125 or N-acetylcysteine reversed the effects of high glucose on the JNK signaling pathway and autophagy-related proteins. Pretreatment of ADSCs with 3-MA under high glucose stress induced a further increase in ROS levels compared to those of high glucose-treated cells. Furthermore, ADSCs pretreated with 3-MA under high glucose stress showed a marked increase in apoptosis compared with that of the cells treated with high glucose. Conversely, pre-treatment with rapamycin inhibited the apoptosis of ADSCs.

CONCLUSIONS

Taken together, our data suggest that autophagy may play a protective role in high glucose-induced apoptosis in ADSCs. ROS/JNK signaling is essential in upregulating high glucose-induced autophagy. This study provides new insights into the molecular mechanism of autophagy involved in high glucose-induced apoptosis in ADSCs.

Update on management of diabetic foot ulcers

Diabetic foot ulcers (DFUs) are a serious complication of diabetes that results in significant morbidity and mortality. Mortality rates associated with the development of a DFU are estimated to be 5% in the first 12 months, and 5-year morality rates have been estimated at 42%. The standard practices in DFU management include surgical debridement, dressings to facilitate a moist wound environment and exudate control, wound off-loading, vascular assessment, and infection and glycemic control. These practices are best coordinated by a multidisciplinary diabetic foot wound clinic. Even with this comprehensive approach, there is still room for improvement in DFU outcomes. Several adjuvant therapies have been studied to reduce DFU healing times and amputation rates. We reviewed the rationale and guidelines for current standard of care practices and reviewed the evidence for the efficacy of adjuvant agents. The adjuvant therapies reviewed include the following categories: nonsurgical debridement agents, dressings and topical agents, oxygen therapies, negative pressure wound therapy, acellular bioproducts, human growth factors, energy-based therapies, and systemic therapies. Many of these agents have been found to be beneficial in improving wound healing rates, although a large proportion of the data are small, randomized controlled trials with high risks of bias.

Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management

The use of opioid analgesics for postoperative pain management has contributed to the global opioid epidemic. It was recently reported that prescription opioid analgesic use often continued after major joint replacement surgery even though patients were no longer experiencing joint pain. The use of epidural local analgesia for perioperative pain management was not found to be protective against persistent opioid use in a large cohort of opioid-naïve patients undergoing abdominal surgery. In a retrospective study involving over 390,000 outpatients more than 66 years of age who underwent minor ambulatory surgery procedures, patients receiving a prescription opioid analgesic within 7 days of discharge were 44% more likely to continue using opioids 1 year after surgery. In a review of 11 million patients undergoing elective surgery from 2002 to 2011, both opioid overdoses and opioid dependence were found to be increasing over time. Opioid-dependent surgical patients were more likely to experience postoperative pulmonary complications, require longer hospital stays, and increase costs to the health-care system. The Centers for Disease Control and Prevention emphasized the importance of finding alternatives to opioid medication for treating pain. In the new clinical practice guidelines for back pain, the authors endorsed the use of non-pharmacologic therapies. However, one of the more widely used non-pharmacologic treatments for chronic pain (namely radiofrequency ablation therapy) was recently reported to have no clinical benefit. Therefore, this clinical commentary will review evidence in the peer-reviewed literature supporting the use of electroanalgesia and laser therapies for treating acute pain, cervical (neck) pain, low back pain, persistent post-surgical pain after spine surgery (“failed back syndrome”), major joint replacements, and abdominal surgery as well as other common chronic pain syndromes (for example, myofascial pain, peripheral neuropathic pain, fibromyalgia, degenerative joint disease/osteoarthritis, and migraine headaches).