Skin Wound Healing Process and New Emerging Technologies for Skin Wound Care and Regeneration

Attachment and Growth of Fibroblast Cells on Poly (2-Methoxyethyl Acrylate) Analog Polymers as Coating Materials

The regulation of adhesion and the subsequent behavior of fibroblast cells on the surface of biomaterials is important for successful tissue regeneration and wound healing by implanted biomaterials. We have synthesized poly(ω-methoxyalkyl acrylate)s (PMCxAs; x indicates the number of methylene carbons between the ester and ethyl oxygen), with a carbon chain length of x = 2–6, to investigate the regulation of fibroblast cell behavior including adhesion, proliferation, migration, differentiation and collagen production. We found that PMC2A suppressed the cell spreading, protein adsorption, formation of focal adhesion, and differentiation of normal human dermal fibroblasts, while PMC4A surfaces enhanced them compared to other PMCxAs. Our findings suggest that fibroblast activities attached to the PMCxA substrates can be modified by changing the number of methylene carbons in the side chains of the polymers. These results indicate that PMCxAs could be useful coating materials for use in skin regeneration and wound dressing applications.

A cut above the rest: oxidative stress in chronic wounds and the potential role of polyphenols as therapeutics

OBJECTIVES

The pathophysiology of chronic wounds typically involves redox imbalance and inflammation pathway dysregulation, often with concomitant microbial infection. Endogenous antioxidants such as glutathione and tocopherols are notably reduced or absent, indicative of significant oxidative imbalance. However, emerging evidence suggests that polyphenols could be effective agents for the amelioration of this condition. This review aims to summarise the current state of knowledge surrounding redox imbalance in the chronic wound environment and the potential use of polyphenols for the treatment of chronic wounds.

KEY FINDINGS

Polyphenols provide a multi-faceted approach towards the treatment of chronic wounds. Firstly, their antioxidant activity allows direct neutralisation of harmful free radicals and reactive oxygen species, assisting in restoring redox balance. Upregulation of pro-healing and anti-inflammatory gene pathways and enzymes by specific polyphenols further acts to reduce redox imbalance and promote wound healing actions, such as proliferation, extracellular matrix deposition and tissue remodelling. Finally, many polyphenols possess antimicrobial activity, which can be beneficial for preventing or resolving infection of the wound site.

SUMMARY

Exploration of this diverse group of natural compounds may yield effective and economical options for the prevention or treatment of chronic wounds.

The biological processes during wound healing

Numerous individuals suffer from impaired wound healing, such as chronic ulcers, severe burns and immune disorders, resulting in both public health and economic burdens. Skin is the first line of defense and the largest organ of the human body, however, an incomplete understanding of underlying cellular and molecular mechanisms of dermal repair leads to a lack of effective therapy for healing impaired wounds. There are strong clinical and social needs for improved therapeutic approaches to enhance endogenous tissue repair and regenerative capacity. The purpose of this review is to illuminate the cellular and molecular aspects of the healing process and highlight potential therapeutic strategies to accelerate translational research and the development of clinical therapies in dermal wounds.

Development of nanostructured bioplastic material for wound healing

The development of new biomaterials whose characteristics are as close as possible to the properties of living human tissues is one of the most promising areas of regenerative medicine. This work aimed at creating a bioplastic material based on collagen, elastin and hyaluronic acid and studying its structure and properties to assess the prospects for further use in clinical practice. Bioplastic material was obtained by mixing collagen, hyaluronic acid and elastin in predetermined proportions with distilled water. We treated the material with photochemical crosslinking to stabilize biofilm in a liquid medium and form a nanostructured scaffold. A commercial human skin fibroblast cell culture was used to assess the biomaterial cytotoxicity and biocompatibility. The visualization and studies of the biomaterial structure were performed using light and scanning electron microscopy. It has been shown that the obtained biomaterial is characterized by high resilience; it has also a high porosity. The co-culturing of the bioplastic material and human fibroblasts did not reveal any of its cytotoxic effects on cells in culture. It was shown that the biomaterial samples could maintain physical properties in the culture medium for more than 10 days, while the destruction of the matrix was observed 3–4 weeks after the beginning of incubation. Thus, the created biomaterial can be used on damaged skin areas due to its physical properties and structure. The use of the developed biomaterial provides effective conditions for good cell proliferation, which allows us to consider it as a promising wound cover for use in clinical practice.

Current Insight of Printability Quality Improvement Strategies in Natural-Based Bioinks for Skin Regeneration and Wound Healing

Skin tissue engineering aimed to replace chronic tissue injury commonly occurred due to severe burn and chronic wound in diabetic ulcer patients. The normal skin is unable to be regenerated until the seriously injured tissue is disrupted and losing its function. 3D-bioprinting has been one of the effective methods for scaffold fabrication and is proven to replace the conventional method, which reported several drawbacks. In light of this, researchers have developed a new fabrication approach via 3D-bioprinting by combining biomaterials (bioinks) with cells and biomolecules followed by a suitable crosslinking approach. This advanced technology has been subcategorised into three different printing techniques including inject-based, laser-based, and extrusion-based printing. However, the printable quality of the currently available bioinks demonstrated shortcomings in the physicochemical and mechanical properties. This review aims to identify the limitations raised by using natural-based bioinks and the optimum temperature for various applied printing techniques. It is essential to ensure maintaining the acceptable printed scaffold property such as the optimum pore sizes and porosity that allow cell migration activity. In addition, the properties required for an ideal bioinks design for better scaffold printability were also summarised.

Liposomes-in-chitosan hydrogel boosts potential of chlorhexidine in biofilm eradication in vitro

Successful treatment of skin infections requires eradication of biofilms found in up to 90 % of all chronic wounds, causing delayed healing and increased morbidity. We hypothesized that chitosan hydrogel boosts the activity of liposomally-associated membrane active antimicrobials (MAA) and could potentially improve bacterial and biofilm eradication. Therefore, liposomes (∼300 nm) bearing chlorhexidine (CHX; ∼50 μg/mg lipid) as a model MAA were incorporated into chitosan hydrogel. The novel CHX-liposomes-in-hydrogel formulation was optimized for skin therapy. It significantly inhibited the production of nitric oxide (NO) in lipopolysaccharide (LPS)-induced macrophage and almost completely reduced biofilm formation. Moreover, it reduced Staphylococcus aureus and Pseudomonas aeruginosa adherent bacterial cells in biofilm by 64.2-98.1 %. Chitosan hydrogel boosted the anti-inflammatory and antimicrobial properties of CHX.

Injectable and Degradable PEG Hydrogel with Antibacterial Performance for Promoting Wound Healing

Injectable and degradable PEG hydrogel was prepared via Michael-type addition between cross-linking monomer 4-arm-PEG-MAL and two cross-linkers of hydrolysis degradable PEG-diester-dithiol and non-degradable PEG-dithiol, and it had a porous structure with the uniform pore size. The biocompatibility assays in vitro indicated that PEG hydrogel had excellent biocompatibility and can be degraded naturally without leading to any negative impact on cells. The results of antibacterial experiments showed that PEG hydrogel can inhibit the growth of bacteria. Furthermore, the Cell Counting Kit-8 (CCK-8) assay, LIVE/DEAD cell staining, and scratch healing experiments proved that PEG hydrogel can promote cell proliferation and migration, which had been further confirmed in in vivo experiments on the rat wound models. All experimental results demonstrated that PEG hydrogel is an injectable antibacterial dressing, which can promote the process of wound healing and has great potential in the field of wound healing.

Development of Cephradine-Loaded Gelatin/Polyvinyl Alcohol Electrospun Nanofibers for Effective Diabetic Wound Healing: In-Vitro and In-Vivo Assessments

Diabetic wound infections caused by conventional antibiotic-resistant Staphylococcus aureus strains are fast emerging, leading to life-threatening situations (e.g., high costs, morbidity, and mortality) associated with delayed healing and chronic inflammation. Electrospinning is one of the most widely used techniques for the fabrication of nanofibers (NFs), induced by a high voltage applied to a drug-loaded polymer solution. Particular attention is given to electrospun NFs for pharmaceutical applications (e.g., original drug delivery systems) and tissue regeneration (e.g., as tissue scaffolds). However, there is a paucity of reports related to their application in diabetic wound infections. Therefore, we prepared eco-friendly, biodegradable, low-immunogenic, and biocompatible gelatin (GEL)/polyvinyl alcohol (PVA) electrospun NFs (BNFs), in which we loaded the broad-spectrum antibiotic cephradine (Ceph). The resulting drug-loaded NFs (LNFs) were characterized physically using ultraviolet-visible (UV-Vis) spectrophotometry (for drug loading capacity (LC), drug encapsulation efficiency (EE), and drug release kinetics determination), thermogravimetric analysis (TGA) (for thermostability evaluation), scanning electron microscopy (SEM) (for surface morphology analysis), and Fourier-transform infrared spectroscopy (FTIR) (for functional group identification). LNFs were further characterized biologically by in-vitro assessment of their potency against S. aureus clinical strains (N = 16) using the Kirby-Bauer test and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, by ex-vivo assessment to evaluate their cytotoxicity against primary human epidermal keratinocytes using MTT assay, and by in-vivo assessment to estimate their diabetic chronic wound-healing efficiency using NcZ10 diabetic/obese mice (N = 18). Thin and uniform NFs with a smooth surface and standard size (<400 nm) were observed by SEM at the optimized 5:5 (GEL:PVA) volumetric ratio. FTIR analyses confirmed the drug loading into BNFs. Compared to free Ceph, LNFs were significantly more thermostable and exhibited sustained/controlled Ceph release. LNFs also exerted a significantly stronger antibacterial activity both in-vitro and in-vivo. LNFs were significantly safer and more efficient for bacterial clearance-induced faster chronic wound healing. LNF-based therapy could be employed as a valuable dressing material to heal S. aureus-induced chronic wounds in diabetic subjects.

Isoegomaketone from Perilla frutescens (L.) Britt Stimulates MAPK/ERK Pathway in Human Keratinocyte to Promote Skin Wound Healing

Skin wound healing is essential for recovery from injury, and delayed or impaired wound healing is a severe therapeutic challenge. Keratinocytes, a major component of the epidermis, play crucial roles in reepithelialization during wound healing including cell proliferation. Recent studies have shown that compounds from natural products have candidates for healing skin injury. Isoegomaketone (IK), isolated from leaves of Perilla frutescens var. crispa (Lamiaceae), has various bioactivities. However, the effect of IK on cutaneous wound healing processes has not been studied yet. In this study, we demonstrated that IK exhibits therapeutic wound healing effects using the human keratinocyte cell line HaCaT. Notably, IK promoted cell proliferation and migration in a dose-dependent manner in vitro, and treatment with 10 μM IK upregulated these processes by approximately 1.5-fold after 24 h compared with the control. IK induced the activation of the MAPK/ERK pathway and cell cycle progression to the S and G2/M phases. Thus, this study demonstrates IK as a potential candidate to upregulate wound healing that may provide therapeutic benefits to patients with delayed wound healing.

Development of nanostructured bioplastic material for wound healing

The development of new biomaterials whose characteristics are as close as possible to the properties of living human tissues is one of the most promising areas of regenerative medicine. This work aimed at creating a bioplastic material based on collagen, elastin and hyaluronic acid and studying its structure and properties to assess the prospects for further use in clinical practice. Bioplastic material was obtained by mixing collagen, hyaluronic acid and elastin in predetermined proportions with distilled water. We treated the material with photochemical crosslinking to stabilize biofilm in a liquid medium and form a nanostructured scaffold. A commercial human skin fibroblast cell culture was used to assess the biomaterial cytotoxicity and biocompatibility. The visualization and studies of the biomaterial structure were performed using light and scanning electron microscopy. It has been shown that the obtained biomaterial is characterized by high resilience; it has also a high porosity. The co-culturing of the bioplastic material and human fibroblasts did not reveal any of its cytotoxic effects on cells in culture. It was shown that the biomaterial samples could maintain physical properties in the culture medium for more than 10 days, while the destruction of the matrix was observed 3–4 weeks after the beginning of incubation. Thus, the created biomaterial can be used on damaged skin areas due to its physical properties and structure. The use of the developed biomaterial provides effective conditions for good cell proliferation, which allows us to consider it as a promising wound cover for use in clinical practice.

Copper-containing bioactive glasses and glass-ceramics: From tissue regeneration to cancer therapeutic strategies

Copper is one of the most used therapeutic metallic elements in biomedicine, ranging from antibacterial approaches to cancer theranostics. This element could be easily incorporated into different types of biomaterials; specifically, copper-doped bioactive glasses (BGs) provide great opportunities for biomedical engineers and clinicians as regards their excellent biocompatibility and regenerative potential. Although copper-incorporated BGs are mostly used in bone tissue engineering, accelerated soft tissue healing is achievable, too, with interesting potentials in wound treatment and skin repair. Copper can modulate the physico-chemical properties of BGs (e.g., reactivity with bio-fluids) and improve their therapeutic potential. Improving cell proliferation, promoting angiogenesis, reducing or even prohibiting bacterial growth are counted as prominent biological features of copper-doped BGs. Recent studies have also suggested the suitability of copper-doped BGs in cancer photothermal therapy (PTT). However, more research is needed to determine the extent to which copper-doped BGs are actually applicable for tissue engineering and regenerative medicine strategies in the clinic. Moreover, copper-doped BGs in combination with polymers may be considered in the future to produce relatively soft, pliable composites and printable inks for use in biofabrication.

Polyphenols: A Promising Avenue in Therapeutic Solutions for Wound Care

In chronic wounds, the regeneration process is compromised, which brings complexity to the therapeutic approaches that need to be adopted, while representing an enormous loss in the patients’ quality of life with consequent economical costs. Chronic wounds are highly prone to infection, which can ultimately lead to septicemia and morbidity. Classic therapies are increasing antibiotic resistance, which is becoming a critical problem beyond complex wounds. Therefore, it is essential to study new antimicrobial polymeric systems and compounds that can be effective alternatives to reduce infection, even at lower concentrations. The biological potential of polyphenols allows them to be an efficient alternative to commercial antibiotics, responding to the need to find new options for chronic wound care. Nonetheless, phenolic compounds may have some drawbacks when targeting wound applications, such as low stability and consequent decreased biological performance at the wound site. To overcome these limitations, polymeric-based systems have been developed as carriers of polyphenols for wound healing, improving its stability, controlling the release kinetics, and therefore increasing the performance and effectiveness. This review aims to highlight possible smart and bio-based wound dressings, providing an overview of the biological potential of polyphenolic agents as natural antimicrobial agents and strategies to stabilize and deliver them in the treatment of complex wounds. Polymer-based particulate systems are highlighted here due to their impact as carriers to increase polyphenols bioavailability at the wound site in different types of formulations.

Unilateral Tessier 7 cleft: Case report of Z-plasty with geometric broken line repair and literature review

Tessier 7 clefts are a rare congenital anomaly, usually surgically repaired with Z-plasty or other reconstructive methods, although undesirable scars may result. We present a review of the literature and a case of unilateral Tessier 7 cleft repaired with a novel reconstruction technique using a combined Z-plasty and geometric broken line closure (GBLC) to camouflage and irregularize the otherwise linear scar. We present this case to expand the armamentarium of surgical options to address Tessier 7 clefts and to review techniques for repair.

Rifampicin-Loaded Alginate-Gelatin Fibers Incorporated within Transdermal Films as a Fiber-in-Film System for Wound Healing Applications

The various biological and molecular cascades including different stages or phases such as inflammation, tissue proliferation, and remodeling phases, which significantly define the wound healing process. The natural matrix system is suggested to increase and sustain these cascades. Biocompatible biopolymers, sodium alginate and gelatin, and a drug (Rifampicin) were used for the preparation of fibers into a physical crosslinking solution using extrusion-gelation. The formed fibers were then loaded in transdermal films for wound healing applications. Rifampicin, an antibiotic, antibacterial agent was incorporated into fibers and afterwards the fibers were loaded into transdermal films. Initially, rifampicin fibers were developed using biopolymers including alginate and gelatin, and were further loaded into polymeric matrix which led to the formation of transdermal films. The transdermal films were coded as TF1, TF2, TF3 and TF4.The characterization technique, FTIR, was used to describe molecular transitions within fibers, transdermal films, and was further corroborated using SEM and XRD. In mechanical properties, the parameters, such as tensile strength and elongation-at-break (extensibility), were found to be ranged between 2.32 ± 0.45 N/mm² to 14.32 ± 0.98 N/mm² and 15.2% ± 0.98% to 30.54% ± 1.08%. The morphological analysis firmed the development of fibers and fiber-loaded transdermal films. Additionally, physical evaluation such as water uptake study, water transmission rate, swelling index, moisture content, and moisture uptake study were executed to describe comparative interpretation of the formulations developed. In vivo studies were executed using a full thickness cutaneous wound healing model, the transdermal films developed showed higher degree of contraction, i.e., 98.85% ± 4.04% as compared to marketed formulation (Povidone). The fiber-in-film is a promising delivery system for loading therapeutic agents for effective wound care management.

Topographical and Biomechanical Guidance of Electrospun Fibers for Biomedical Applications

Electrospinning is gaining increasing interest in the biomedical field as an eco-friendly and economic technique for production of random and oriented polymeric fibers. The aim of this review was to give an overview of electrospinning potentialities in the production of fibers for biomedical applications with a focus on the possibility to combine biomechanical and topographical stimuli. In fact, selection of the polymer and the eventual surface modification of the fibers allow selection of the proper chemical/biological signal to be administered to the cells. Moreover, a proper design of fiber orientation, dimension, and topography can give the opportunity to drive cell growth also from a spatial standpoint. At this purpose, the review contains a first introduction on potentialities of electrospinning for the obtainment of random and oriented fibers both with synthetic and natural polymers. The biological phenomena which can be guided and promoted by fibers composition and topography are in depth investigated and discussed in the second section of the paper. Finally, the recent strategies developed in the scientific community for the realization of electrospun fibers and for their surface modification for biomedical application are presented and discussed in the last section.

Pharmaceutical evaluation of atorvastatin-loaded nanostructured lipid carriers incorporated into the gelatin/hyaluronic acid/polycaprolactone scaffold for the skin tissue engineering

In this study, gelatin/hyaluronic acid (HA) scaffolds containing different amounts of atorvastatin-loaded nanostructured lipid carriers (NLCs) coated entirely with polycaprolactone (PCL) film were fabricated for skin regeneration. 12 atorvastatin-loaded NLCs formulations were synthesized, and particle size, zeta potential, drug entrapment efficiency (EE), and drug release of the formulations were determined. The optimum freeze-dried atorvastatin-loaded NLCs were added in 3 different weight percentages to the gelatin and HA membranous scaffolds. Thereafter, the membranes were coated entirely by a thin layer of the PCL. They were characterized, and then mechanical properties, in vitro degradation and in vitro drug release were assessed. Moreover, human dermal fibroblasts (HDF) were cultured on the prepared nanocomposite scaffolds in order to investigate the cytotoxicity by the MTT assay after the first day, third day, and fifth day. Results revealed that the most favorable atorvastatin-loaded NLCs had 99.54 nm average particle size, -24.30 mV zeta potential, 97.98% EE, and 75.24% drug release within 237 hrs. Mechanical tests indicated that all the three scaffolds had approximately a 90 MPa elastic modulus which was more than two-fold of tensile modulus of normal human skin. The in vitro degradation test demonstrated that the membranes were degraded up to 98% after 5 days, and the scaffolds drug release efficiency (DRE) was in a range of 75-79% during those 5 days. The MTT assay results confirmed the cytocompatibility of the scaffolds. The scaffold containing 54.1 wt% NCLs was the optimum sample (S₃). Scanning Electron Microscopy (SEM) images of the latter one showed the uniform distribution of the NLCs with an average size of 150 nm, and the images of cultured HDF illustrated the good cell attachment. In conclusion, suitable physicochemical and biological properties of the novel gelatin/HA/PCL nanocomposite scaffold containing 54.1 wt% atorvastatin-loaded NLCs (S₃) can be a good candidate for skin regeneration.

Scar-Free Healing: Current Concepts and Future Perspectives

Every year, millions of people develop scars due to skin injuries after trauma, surgery, or skin burns. From the beginning of wound healing development, scar hyperplasia, and prolonged healing time in wound healing have been severe problems. Based on the difference between adult and fetal wound healing processes, many promising therapies have been developed to decrease scar formation in skin wounds. Currently, there is no good or reliable therapy to cure or prevent scar formation. This work briefly reviews the engineering methods of scarless wound healing, focusing on regenerative biomaterials and different cytokines, growth factors, and extracellular components in regenerative wound healing to minimize skin damage cell types, and scar formation.

Development and Optimization of Naringenin-Loaded Chitosan-Coated Nanoemulsion for Topical Therapy in Wound Healing

The potential role of naringenin (NAR), a natural flavonoid, in the treatment of chronic wound has prompted the present research to deliver the drug in nanoemulsion (NE) form, where synergistic role of chitosan was achieved through development of chitosan-coated NAR NE (CNNE). The NE consisted of Capryol 90, Tween 20 and Transcutol P, which was fabricated by low-energy emulsification method to encapsulate NAR within the oil core. The optimization of the formulated NEs was performed using Box-Behnken statistical design to obtain crucial variable parameters that influence globule size, size distribution and surface charge. Finally, the optimized formulation was coated with different concentrations of chitosan and subsequently characterized in vitro. The size of the CNNE was found to be increased when the drug-loaded formulation was coated with chitosan. Controlled release characteristics depicted 67-81% release of NAR from the CNNE, compared to 89% from the NE formulation. Cytotoxicity study of the formulation was performed in vitro using fibroblast cell line (NIH-3T3), where no inhibition in proliferation of the cells was observed with CNNE. Finally, the wound healing potential of the CNNE was evaluated in an abrasion-created wound model in experimental animals where the animals were treated and compared histologically at 0 and 14 days. Significant improvement in construction of the abrasion wound was observed when the animals were treated with formulated CNNE, whereas stimulation of skin regeneration was depicted in the histological examination. Therefore, it could be summarized that the chitosan coating of the developed NAR NE is a potential platform to accelerate healing of wounds.