Hard-to-heal wounds, biofilm and wound healing: an intricate interrelationship

Functional and molecular insights in topical wound healing by ascorbic acid

The skin acts as a vital barrier against external threats and regulates moisture levels. The skin's repair and rejuvenation encompass complex molecular and cellular mechanisms, constituting an essential yet intricate process to preserve skin integrity following trauma or surgical intervention. Acute wound repair unfolds through different interrelated stages, whereas chronic wounds pose significant healthcare challenges, often linked to conditions like diabetes and vascular diseases. Understanding of wound physiology is crucial for developing effective treatments. Chronic wounds require more comprehensive treatments, including surgical debridement, glycemic control, and antibiotic therapy. Ascorbic acid (AA) emerges as a promising wound-healing agent because it facilitates collagen synthesis, enhances antioxidant defense, promotes re-epithelialization and angiogenesis, regulates pH, and exhibits antimicrobial properties. Research outcomes on applying AA-based formulations on wound environment demonstrated its potential to accelerate wound closure and tissue regeneration, offering hope for improved wound management and reduced healthcare burdens associated with chronic wounds. The application of AA, which often utilizes innovative delivery methods and synergistic combinations with other actives, shows promise in preclinical studies for superior efficacy, biocompatibility, and controlled release profiles. Overall, AA-based therapies represent a significant avenue for advancing wound care and addressing the challenges of chronic wounds in healthcare systems.

Current State of Knowledge Regarding the Treatment of Cranial Bone Defects: An Overview

In this article, an analysis of the problem of treating bone defects using cranial bone disorders as an example is presented. The study was performed in the context of the development of various implant biomaterials used to fill bone defects. An analysis of the requirements for modern materials is undertaken, indicating the need for their further development. The article focuses particular attention on these biomaterial properties, which have an influence on bioresorbability and promote osteointegration and bone growth. The analysis showed the need for further development of biomaterials, the characteristics of which may be multifunctionality. Multifunctional scaffolds are those that simultaneously fill and stabilize the defect and contribute to the proper process of regeneration and reconstruction of cranial bones. Due to the complex structure of the skull and special protective functions, there is a need to develop innovative implants. Implants with complex geometries can be successfully manufactured using additive technologies.

Sub-Micrometer Polycaprolactone and Polyethylene Glycol-Based Fiber Mats With Iodine and Its Potential for Wound Healing

This study introduces an innovative approach to developing advanced antimicrobial wound dressings by engineering fiber mats of polycaprolactone (PCL) and polycaprolactone/polyethylene glycol (PCL/PEG) loaded with iodine using solution blow spinning (SBS). The mats exhibited a unique morphology, combining fibers and beads, with average fiber diameters of 570 nm for 12% (w/v) PCL and 470 nm for 1% (w/v) PEG in 12% (w/v) PCL, and bead diameters of 11.34 μm and 10.43 μm, respectively. PEG incorporation rendered the mats hydrophilic and significantly enhanced their swelling capacity, which is essential for wound exudate management. Remarkably, iodine was incorporated at a concentration specifically optimized to achieve its minimum inhibitory concentration (MIC) against a range of microorganisms while preserving the structural integrity and release profile of the mats. While PEG facilitated a higher initial iodine release rate, equilibrium was achieved after 5 days. UV-Vis spectroscopy unveiled the formation of transient iodine complexes with both PCL and PEG, underscoring their functional synergy. Biological assays revealed that PCL/PEG mats loaded with 4.26 mg/mL of iodine (PCL/PEG 3MIC) exhibited potent antimicrobial efficacy against gram-positive and gram-negative bacteria, as well as fungi, alongside significant in vitro wound healing potential. These findings underscore the promise of PCL/PEG iodine-loaded mats as an innovative platform for next-generation antimicrobial wound care, combining effective infection control with enhanced wound healing capabilities.

Gentamicin ointment effect on hard-to-heal wounds: a case series

OBJECTIVE

The presence of microorganisms in a wound may lead to the development of pathologically extensive inflammation, and either delay or prevent the healing of hard-to-heal (chronic) wounds. The aim of this case series is to explore the use of topical gentamicin ointment, an aminoglycoside with activity against aerobic Gram-negative bacteria, as an option to address hard-to-heal wounds.

METHOD

We present a retrospective case series of patients with hard-to-heal wounds of varying pathophysiologies treated with topical gentamicin.

RESULTS

Regardless of the inciting aetiology, all 10 of the presented patients responded to topical gentamicin as evidenced by resolution of much of the inflammation and reduction in wound size or complete wound closure.

CONCLUSION

By helping to clear the bacteria-induced biofilm that may be present on a hard-to-heal wound, gentamicin may allow the wound healing process to continue past the inflammatory phase, and onto proliferation, remodelling and eventual closure.

Local Treatment of Wound Infections: A Review of Clinical Trials from 2013 to 2024

Significance: Management of infection is a critical aspect of wound care. It involves the application of various interventions to treat the wound and prevent the infection from spreading to other parts of the body, which may lead to serious complications, including sepsis. Local treatment of skin wound infections is the favored route of administration, reducing the risk of adverse systemic effects while providing very high therapeutic concentrations at the target site. The purpose of this article was to review clinical trials from 2013 and onward, focusing on local treatment of acute wounds and burns as well as chronic wounds as their primary outcome measurement. Recent Advances: Based on our literature search, 49 clinical trials were focusing on treating infected chronic wounds, and 6 trials studied infection as their primary outcome in acute wounds during the last 10 years. Critical Issues: Currently commercially available local treatments do not prevent the onset of invasive infection. Therefore, there is a need for more effective local therapies. Future Directions: Despite multiple preclinical studies introducing novel and promising strategies in terms of novel antimicrobial agents and delivery methods to prevent and treat skin wound infections locally, many have yet to be tested in a clinical setting. These preclinically tested approaches could still be valuable additions to today's care of infected skin wounds.

Reversible Schiff Base Chemistry in Arginine-Grafted Regenerated Cellulose Hydrogel: Integration of Chitosan and Zinc Ions for Enhanced Hemostasis, Antibacterial Action, and Accelerated Wound Healing

Wound healing presents a formidable challenge for global healthcare systems. We aimed to address this challenge by designing a multifunctional wound dressing tailored to meet diverse therapeutic needs. Arginine (Arg), selected for its ability to promote wound healing, is grafted onto aldehyde-modified regenerated cellulose (DAC) via Schiff base bonds for a reversible controlled release. At the same time, DAC provides hemostatic function, while Zn2+ plays an antibacterial role and strengthens cross-linking within the dressing matrix. The hydrogels were characterized by FTIR, XRD, SEM, and EDS. Mechanical strength, adhesion, swelling, water retention, oxygen permeability, hemostasis, antioxidant capacity, and antibacterial activity were all rigorously evaluated to demonstrate the superior properties of the dressing, which promotes accelerated wound healing. The skin of injured mice has been shown to recover almost completely within 13 days of dressing treatment. These findings highlight the potential of this innovative multifunctional wound dressing to address complex wound management challenges.

Advances in Smart-Response Hydrogels for Skin Wound Repair

Hydrogels have emerged as promising candidates for biomedical applications, especially in the treatment of skin wounds, as a result of their unique structural properties, highly tunable physicochemical properties, and excellent biocompatibility. The integration of smart-response features into hydrogels allows for dynamic responses to different external or internal stimuli. Therefore, this paper reviews the design of different smart-responsive hydrogels for different microenvironments in the field of skin wound therapy. First, the unique microenvironments of three typical chronic difficult-to-heal wounds and the key mechanisms affecting wound healing therapeutic measures are outlined. Strategies for the construction of internal stimulus-responsive hydrogels (e.g., pH, ROS, enzymes, and glucose) and external stimulus-responsive hydrogels (e.g., temperature, light, electricity, and magnetic fields) are highlighted from the perspective of the wound microenvironment and the in vitro environment, and the constitutive relationships between material design, intelligent response, and wound healing are revealed. Finally, this paper discusses the severe challenges faced by smart-responsive hydrogels during skin wound repair and provides an outlook on the combination of smart-responsive hydrogels and artificial intelligence to give scientific direction for creating and using hydrogel dressings that respond to stimuli in the clinic.

Combinatorial Effects of Ursodeoxycholic Acid and Antibiotic in Combating Staphylococcus aureus Biofilm: The Roles of ROS and Virulence Factors

Staphylococcus aureus is a biofilm-forming bacterium responsible for various human infections, one particularly challenging to treat due to its antibiotic resistance. Biofilms can form on both soft tissues and medical devices, leading to persistent and hard-to-treat infections. Combining multiple antimicrobials is a potential approach to overcoming this resistance. This study explored the effects of ursodeoxycholic acid (UDCA) combined with the antibiotic ciprofloxacin against S. aureus biofilms, aiming to evaluate any synergistic effects. Results showed that UDCA and ciprofloxacin co-treatment significantly reduced biofilm formation and disrupted pre-formed biofilms more effectively than either agent alone (p < 0.01). The combination also displayed a slight synergistic effect, with a fractional inhibitory concentration of 0.65. Additionally, the treatment reduced the production of extracellular polymeric substances, increased reactive oxygen species production, decreased metabolic activity, altered cell membrane permeability, and lowered cell surface hydrophobicity in S. aureus. Furthermore, it diminished biofilm-associated pathogenic factors, including proteolytic activity and staphyloxanthin production. Overall, the UDCA-ciprofloxacin combination shows considerable promise as a strategy to combat infections related to staphylococcal biofilms, offering a potential solution to the healthcare challenges posed by antibiotic-resistant S. aureus.

Analysis of risk factors related to chronic non-healing wound infection and the construction of a clinical prediction model

This study is aimed to analyse the risk factors associated with chronic non-healing wound infections, establish a clinical prediction model, and validate its performance. Clinical data were retrospectively collected from 260 patients with chronic non-healing wounds treated in the plastic surgery ward of Shanxi Provincial People's Hospital between January 2022 and December 2023 who met the inclusion criteria. Risk factors were analysed, and a clinical prediction model was constructed using both single and multifactor logistic regression analyses to determine the factors associated with chronic non-healing wound infections. The model's discrimination and calibration were assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve and calibration curve. Multivariate logistic regression analysis identified several independent risk factors for chronic non-healing wound infection: long-term smoking (odds ratio [OR]: 4.122, 95% CI: 3.412-5.312, p < 0.05), history of diabetes (OR: 3.213, 95% CI: 2.867-4.521, p < 0.05), elevated C-reactive protein (OR: 2.981, 95% CI: 2.312-3.579, p < 0.05), elevated procalcitonin (OR: 2.253, 95% CI: 1.893-3.412, p < 0.05) and reduced albumin (OR: 1.892, 95% CI: 1.322-3.112, p < 0.05). The clinical prediction model's C-index was 0.762, with the corrected C-index from internal validation using the bootstrap method being 0.747. The ROC curve indicated an area under the curve (AUC) of 0.762 (95% CI: 0.702-0.822). Both the AUC and C-indexes ranged between 0.7 and 0.9, suggesting moderate-to-good predictive accuracy. The calibration chart demonstrated a good fit between the model's calibration curve and the ideal curve. Long-term smoking, diabetes, elevated C-reactive protein, elevated procalcitonin and reduced albumin are confirmed as independent risk factors for bacterial infection in patients with chronic non-healing wounds. The clinical prediction model based on these factors shows robust performance and substantial predictive value.

Host-Microbiome Crosstalk in Chronic Wound Healing

The pathogenesis of chronic wounds (CW) involves a multifaceted interplay of biochemical, immunological, hematological, and microbiological interactions. Biofilm development is a significant virulence trait which enhances microbial survival and pathogenicity and has various implications on the development and management of CW. Biofilms induce a prolonged suboptimal inflammation in the wound microenvironment, associated with delayed healing. The composition of wound fluid (WF) adds more complexity to the subject, with proven pro-inflammatory properties and an intricate crosstalk among cytokines, chemokines, microRNAs, proteases, growth factors, and ECM components. One approach to achieve information on the mechanisms of disease progression and therapeutic response is the use of multiple high-throughput 'OMIC' modalities (genomic, proteomic, lipidomic, metabolomic assays), facilitating the discovery of potential biomarkers for wound healing, which may represent a breakthrough in this field and a major help in addressing delayed wound healing. In this review article, we aim to summarize the current progress achieved in host-microbiome crosstalk in the spectrum of CW healing and highlight future innovative strategies to boost the host immune response against infections, focusing on the interaction between pathogens and their hosts (for instance, by harnessing microorganisms like probiotics), which may serve as the prospective advancement of vaccines and treatments against infections.

Metal-based nanoparticles: an alternative treatment for biofilm infection in hard-to-heal wounds

Metal-based nanoparticles (MNPs) are promoted as effective compounds in the treatment of bacterial infections and as possible alternatives to antibiotics. These MNPs are known to affect a broad spectrum of microorganisms using a multitude of strategies, including the induction of reactive oxygen species and interaction with the inner structures of the bacterial cells. The aim of this review was to summarise the latest studies about the effect of metal-based nanoparticles on pathogenic bacterial biofilm formed in wounds, using the examples of Gram-positive bacterium Staphylococcus aureus and Gram-negative bacterium Pseudomonas aeruginosa, as well as provide an overview of possible clinical applications.

Injectable Hydrogels with Integrated Ph Probes and Ultrasound-Responsive Microcapsules as Smart Wound Dressings for Visual Monitoring and On-Demand Treatment of Chronic Wounds

Hydrogel dressings capable of infection monitoring and precise treatment administration show promise for advanced wound care. Existing methods involve embedd ingorganic dyes or flexible electronics into preformed hydrogels, which raise safety issues and adaptability challenges. In this study, an injectable hydrogel based smart wound dressing is developed by integrating food-derived anthocyanidin as a visual pH probe for infection monitoring and poly(L-lactic acid) microcapsules as ultrasound-responsive delivery systems for antibiotics into a poly(ethylene glycol) hydrogel. This straightforwardly prepared hydrogel dressing maintains its favorable properties for wound repair, including porous morphology and excellent biocompatibility. In vitro experiments demonstrated that the hydrogel enabled visual assessment of pH within the range of 5 ∼ 9.Meanwhile, the release of antibiotics could be triggered and controlled by ultrasound. In vivo evaluations using infected wounds and diabetic wounds revealed that the wound dressing effectively detected wound infection by monitoring pH levels and achieved antibacterial effects through ultrasound-triggered drug release. This led to significantly enhanced wound healing, as validated by histological analysis and the measurement of inflammatory cytokine levels. This injectable hydrogel-based smart wound dressing holds great potential for use in clinical settings to inform timely and precise clinical intervention and in community to improve wound care management.

pH-responsive double-enzyme active metal-organic framework for promoting the healing of infected wounds

The abuse of antibiotics accelerates the spread and evolution of drug-resistant bacteria, which seriously threatens human health. Hydroxyl radicals (•OH) are generated by peroxidase in the presence of H2O2, which is strongly oxidizing and can effectively kill bacteria. However, high production costs and poor stability limit the clinical use of natural enzymes. "Nanozyme" is a general term for nanomaterials with catalytic activity similar to that of biological enzymes. Compared to biological enzymes, nanozymes have the advantages of low cost, facile preparation, and easy storage, making them a good choice for the development of antibacterial agents. Here, a nickel-based metal-organic framework (Ni-MOF) with dual enzymatic activity that switches depending on the pH environment was studied. In a slightly acidic environment, Ni-MOF can react with hydrogen peroxide to produce hydroxyl radicals that kill bacteria; in a neutral environment, Ni-MOF instead removes excessive reactive oxygen species (ROS) and promotes the transformation of macrophages into M2 macrophages. Compared to most nanozymes, Ni-MOF has unique electrical conductivity and better biosafety. The results of animal experiments show that Ni-MOF can not only treat infected wounds but also promote the healing of acute wounds and exhibits great clinical application potential.

Molecular Aspects of the Functioning of Pathogenic Bacteria Biofilm Based on Quorum Sensing (QS) Signal-Response System and Innovative Non-Antibiotic Strategies for Their Elimination

One of the key mechanisms enabling bacterial cells to create biofilms and regulate crucial life functions in a global and highly synchronized way is a bacterial communication system called quorum sensing (QS). QS is a bacterial cell-to-cell communication process that depends on the bacterial population density and is mediated by small signalling molecules called autoinducers (AIs). In bacteria, QS controls the biofilm formation through the global regulation of gene expression involved in the extracellular polymeric matrix (EPS) synthesis, virulence factor production, stress tolerance and metabolic adaptation. Forming biofilm is one of the crucial mechanisms of bacterial antimicrobial resistance (AMR). A common feature of human pathogens is the ability to form biofilm, which poses a serious medical issue due to their high susceptibility to traditional antibiotics. Because QS is associated with virulence and biofilm formation, there is a belief that inhibition of QS activity called quorum quenching (QQ) may provide alternative therapeutic methods for treating microbial infections. This review summarises recent progress in biofilm research, focusing on the mechanisms by which biofilms, especially those formed by pathogenic bacteria, become resistant to antibiotic treatment. Subsequently, a potential alternative approach to QS inhibition highlighting innovative non-antibiotic strategies to control AMR and biofilm formation of pathogenic bacteria has been discussed.

The healing effect of Pseudomonas Quinolone Signal (PQS) with co-infection of Staphylococcus aureus and Pseudomonas aeruginosa: A preclinical animal co-infection model

BACKGROUND

Because of the rise in antibiotic resistance and the control of pathogenicity, polymicrobial bacterial biofilms exacerbate wound infections. Since bacterial quorum sensing (QS) signals can dysregulate biofilm development, they are interesting therapeutic treatments. In this study, Pseudomonas Quinolone Signal (PQS) was used to treat an animal model of a wound that had both Staphylococcus aureus and Pseudomonas aeruginosa co-infection.

METHODS

S. aureus and P. aeruginosa mono- and co-infection models were developed in vitro on the L-929 cell line and in an animal model of wound infection. Moreover, PQS was extracted and purified using liquid chromatography. Then, the mono- and co-infection models were treated by PQS in vitro and in vivo. RT-PCR analysis was used to look into changes in biofilm, QS, tissue regeneration, and apoptosis genes after the treatment.

RESULTS

PQS significantly disrupted established biofilm up to 90% in both in vitro and in vivo models. Moreover, a 93% reduction in the viability of S. aureus and P. aeruginosa was detected during the 10 days of treatment in comparison to control groups. In addition, the biofilm-encoding and QS-regulating genes were down-regulated to 75% in both microorganisms. Also, fewer epithelial cells died when treated with PQS compared to control groups in both mono- and co-infection groups.

CONCLUSION

According to this study, PQS may facilitate wound healing by stimulating the immune system and reducing apoptosis. It seems to be a potential medication to use in conjunction with antibiotics to treat infections that are difficult to treat.

Local low-frequency vibration accelerates healing of full-thickness wounds in a hyperglycemic rat model

AIMS/INTRODUCTION

Local low-frequency vibration (LLFV) promotes vasodilation and blood flow, enhancing wound healing in diabetic foot ulcers with angiopathy. However, vibration-induced vasodilation does not occur, owing to chronic hyperglycemia and inflammation. We hypothesized that LLFV improves glycometabolism and inflammation, leading to vasodilation and angiogenesis in diabetic wounds. Therefore, this study investigated the effect of LLFV on wound healing in hyperglycemic rats, primarily focusing on glycometabolism, inflammation, vasodilation, and angiogenesis.

MATERIALS AND METHODS

Streptozotocin-induced hyperglycemic Sprague-Dawley rats were used in this study. We applied LLFV to experimentally-induced wounds at 50 Hz and 0, 600, 1,000 or 1,500 mVpp for 40 min/day from post-wounding days (PWD) 1-14.

RESULTS

The relative wound areas in the 600 and 1,000 mVpp groups on PWD 5-7 were significantly smaller than those at 0 mVpp. The expression of Glo-1 (1,500 mVpp) and Slc2A4 (1,000 and 1,500 mVpp) was upregulated on PWD 4 and 14, respectively. However, there was no difference in methylglyoxal expression levels in any group until PWD 14. At 1,000 mVpp, the expression of Tnfa on PWD 4, and that of Ptx3 and Ccl2 on PWD 14 was downregulated. Furthermore, the M1/M2 macrophage ratio was considerably decreased on both days. The expression of Nos3, Vegfa and vascular endothelial growth factor A was upregulated on PWD 4. In addition, vasodilation and angiogenesis were more obvious on PWD 14 with 1,000 mVpp.

CONCLUSIONS

The results suggest that LLFV promotes wound healing, improves glycometabolism and inflammation, and enhances vasodilation and angiogenesis in hyperglycemic wounds.

Efficacy of wearable vibration dressings on full-thickness wound healing in a hyperglycemic rat model

Local low-frequency vibration promotes blood flow and wound healing in hard-to-heal diabetic foot ulcers (DFUs). However, vibration treatment is challenging in patients with DFUs due to wound management difficulties and low adherence. Consequently, developing wearable self-care devices becomes imperative for effective wound healing. This study introduces a wearable vibration dressing and assesses its impact on wound healing in hyperglycemic rats. Low-frequency vibration at 52 Hz was applied to the wound for 40 min/day in awake rats. Relative wound areas on post-wounding days (PWDs) 4-7 were significantly smaller and the wound closure rate was significantly higher in the vibration group than in the control group (p < 0.05, respectively). The total haemoglobin at baseline and after vibration on post-wounding day 7 was significantly larger in the vibration group than in the control group (p < 0.05). On PWD 7, the thickness of the granulation tissue was significantly higher in the vibration group than in the control group (p < 0.05). Moreover, the number of blood vessels at the wound site and vascular endothelial growth factor A protein expression were significantly higher in the vibration group than in the control group (p < 0.05, respectively). The ratio of (CD68+ /iNOS+ )/(CD163+ ) macrophages in the vibration group was significantly lower than that in the control group (p < 0.05). These results indicate the potential of wearable vibration dressings as new self-care devices that can promote angiogenesis and blood flow, improve inflammation, and enhance wound healing in DFUs.

Polymers and Bioactive Compounds with a Macrophage Modulation Effect for the Rational Design of Hydrogels for Skin Regeneration

The development of biomaterial platforms for dispensing reagents of interest such as antioxidants, growth factors or antibiotics based on functional hydrogels represents a biotechnological solution for many challenges that the biomedicine field is facing. In this context, in situ dosing of therapeutic components for dermatological injuries such as diabetic foot ulcers is a relatively novel strategy to improve the wound healing process. Hydrogels have shown more comfort for the treatment of wounds due to their smooth surface and moisture, as well as their structural affinity with tissues in comparison to hyperbaric oxygen therapy, ultrasound, and electromagnetic therapies, negative pressure wound therapy or skin grafts. Macrophages, one of the most important cells of the innate immune system, have been described as the key not only in relation to the host immune defense, but also in the progress of wound healing. Macrophage dysfunction in chronic wounds of diabetic patients leads to a perpetuating inflammatory environment and impairs tissue repair. Modulating the macrophage phenotype from pro-inflammatory (M1) to anti-inflammatory (M2) could be a strategy for helping to improve chronic wound healing. In this regard, a new paradigm is found in the development of advanced biomaterials capable of inducing in situ macrophage polarization to offer an approach to wound care. Such an approach opens a new direction for the development of multifunctional materials in regenerative medicine. This paper surveys emerging hydrogel materials and bioactive compounds being investigated to induce the immunomodulation of macrophages. We propose four potential functional biomaterials for wound healing applications based on novel biomaterial/bioactive compound combination that are expected to show synergistic beneficial outcomes for the local differentiation of macrophages (M1-M2) as a therapeutic strategy for chronic wound healing improvement.

Effectiveness of a polyhexamethylene biguanide-containing wound cleansing solution using experimental biofilm models

OBJECTIVE

Antiseptics are widely used in wound management to prevent or treat wound infections, and have been shown to have antibiofilm efficacy. The objective of this study was to assess the effectiveness of a polyhexamethylene biguanide (PHMB)-containing wound cleansing and irrigation solution on model biofilm of pathogens known to cause wound infections compared with a number of other antimicrobial wound cleansing and irrigation solutions.

METHOD

Staphylococcus aureus and Pseudomonas aeruginosa single-species biofilms were cultured using microtitre plate and Centers for Disease Control and Prevention (CDC) biofilm reactor methods. Following a 24-hour incubation period, the biofilms were rinsed to remove planktonic microorganisms and then challenged with wound cleansing and irrigation solutions. Following incubation of the biofilms with a variety of concentrations of the test solutions (50%, 75% or 100%) for 20, 30, 40, 50 or 60 minutes, remaining viable organisms from the treated biofilms were quantified.

RESULTS

The six antimicrobial wound cleansing and irrigation solutions used were all effective in eradicating Staphylococcus aureus biofilm bacteria in both test models. However, the results were more variable for the more tolerant Pseudomonas aeruginosa biofilm. Only one of the six solutions (sea salt and oxychlorite/NaOCl-containing solution) was able to eradicate Pseudomonas aeruginosa biofilm using the microtitre plate assay. Of the six solutions, three (a solution containing PHMB and poloxamer 188 surfactant, a solution containing hypochlorous acid (HOCl) and a solution containing NaOCl/HOCl) showed increasing levels of eradication of Pseudomonas aeruginosa biofilm microorganisms with increasing concentration and exposure time. Using the CDC biofilm reactor model, all six cleansing and irrigation solutions, except for the solution containing HOCl, were able to eradicate Pseudomonas aeruginosa biofilms such that no viable microorganisms were recovered.

CONCLUSION

This study demonstrated that a PHMB-containing wound cleansing and irrigation solution was as effective as other antimicrobial wound irrigation solutions for antibiofilm efficacy. Together with the low toxicity, good safety profile and absence of any reported acquisition of bacterial resistance to PHMB, the antibiofilm effectiveness data support the alignment of this cleansing and irrigation solution with antimicrobial stewardship (AMS) strategies.

The Role of Physical Therapies in Wound Healing and Assisted Scarring

Wound healing (WH) is a complex multistep process in which a failure could lead to a chronic wound (CW). CW is a major health problem and includes leg venous ulcers, diabetic foot ulcers, and pressure ulcers. CW is difficult to treat and affects vulnerable and pluripathological patients. On the other hand, excessive scarring leads to keloids and hypertrophic scars causing disfiguration and sometimes itchiness and pain. Treatment of WH includes the cleaning and careful handling of injured tissue, early treatment and prevention of infection, and promotion of healing. Treatment of underlying conditions and the use of special dressings promote healing. The patient at risk and risk areas should avoid injury as much as possible. This review aims to summarize the role of physical therapies as complementary treatments in WH and scarring. The article proposes a translational view, opening the opportunity to develop these therapies in an optimal way in clinical management, as many of them are emerging. The role of laser, photobiomodulation, photodynamic therapy, electrical stimulation, ultrasound therapy, and others are highlighted in a practical and comprehensive approach.

Effect of matrix metalloproteinases on the healing of diabetic foot ulcer: A systematic review

BACKGROUND

This study aims to discuss the expression of matrix metalloproteinase in wound healing of diabetic foot ulcers and further summarize the strategies of targeted matrix metalloproteinase and its inhibitors in the treatment of diabetic foot ulcers.

METHODS

Following PRISMA-SCR guidelines, databases (PubMed, Home-PMC-NCBI, CINAHL, Web of Science) were systematically searched from inception to 19 June 2022. Newcastle-Ottawa Scale (NOS) was used to evaluate the bias risk of the included studies.

RESULTS

Eight studies are finally eligible for our systematic review. The combined data analysis of 8 studies showed that there were no significant difference in age(p = 0.110), duration of diabetes(p = 0.197), glycosylated hemoglobin content(p = 0.489), size(p = 0.133) and depth(p＞0.05) of initial ulcer between the ulcer wound healing group and the non-healing group. MMP-1, 2, 8, 9, and TIMP-1, 2 affected the healing of DFUs. In the DFUs healing group, the concentrations of MMP (MMP-1, 2, 8, 9) decreased, and the concentration of TIMP-1 increased.

CONCLUSION

Our study showed that high levels of MMP-1, 2, 9 delayed the healing of diabetic foot ulcers, and high expression of MMP-8 in tissues improved wound healing. This study also summarized the effective intervention strategies for the treatment of diabetic foot ulcers.

'Granulitis': defining a common, biofilm-induced, hyperinflammatory wound pathology

The hard-to-heal (chronic) wound condition, now believed to be inextricably linked to the presence of microbial biofilm, has posed challenges in translating scientific understanding to clinical practice in recent decades. During this time, multiple descriptive terms of the wound pathology have been described, including critical colonisation, biofilm infection and inflammatory stasis. However, the absence of naming this disease state as a specifically identified condition that is tangible to treat has led to some confusion and delay in possible therapeutic approaches. When there is clinical uncertainty of wound status, antibiotics are too often inappropriately administered as a precaution. We therefore propose that introducing the term 'granulitis' (inflamed, unhealthy granulation tissue) could be used to identify the biofilm-induced, persistent inflammatory wound condition. This will help to raise clinician and public awareness of the condition, guide appropriate and prompt local wound hygiene, and encourage allocation of adequate resources to improve wound healing outcomes globally.

Novel Curcumin-Encapsulated α-Tocopherol Nanoemulsion System and Its Potential Application for Wound Healing in Diabetic Animals

Objective

This project was aimed at formulating a novel nanoemulsion system and evaluating it for open incision wound healing in diabetic animals.

Methods

The nanoemulsions were characterized for droplet size and surface charge, drug content, antioxidant and antimicrobial profiling, and wound healing potential in diabetic animals. The skin samples excised were also analyzed for histology, mechanical strength, and vibrational and thermal analysis.

Results

The optimized nanoemulsion (CR-NE-II) exhibited droplet size of26.76 ± 0.9 nm with negative surface charge (−10.86 ± 1.06 mV), was homogenously dispersed with drug content of68.05 ± 1.2%, released almost82.95 ± 2.2%of the drug within first 2 h of experiment with synergistic antioxidant (95 ± 2.1%) and synergistic antimicrobial activity against selected bacterial strains in comparison to blank nanoemulsion, and promoted significantly fast percent reepithelization (96.47%). The histological, vibrational, thermal, and strength analysis of selected skin samples depicted a uniform and even distribution of collagen fibers which translated into significant increase in strength of skin samples in comparison to the control group.

Conclusions

The optimized nanoemulsion system significantly downregulated the oxidative stress, enhanced collagen deposition, and precluded bacterial contamination of wound, thus accelerating the skin tissue regeneration process.

Robbing Peter to Pay Paul: Chlorhexidine gluconate demonstrates short-term efficacy and long-term cytotoxicity

Wound cleansing agents are routine in wound care and preoperative preparation. Antiseptic activity intends to prevent contaminating microbes from establishing an infection while also raising concerns of cytotoxicity and delayed wound healing. We evaluated the cytotoxicity of five clinically used wound cleaning agents (saline, povidone iodine, Dove® and Dial® soaps, and chlorhexidine gluconate [CHG]) using both an ex vivo and in vivo human skin xenograft mouse model, in contrast to classical in vitro models that lack the structural and compositional heterogeneity of human skin. We further established an ex vivo wound contamination model inoculated with ~100 cells of Pseudomonas aeruginosa or Staphylococcus aureus to evaluate antimicrobial efficacy. Scanning electron microscopy and confocal microscopy were used to evaluate phenotypic and spatial characteristics of bacterial cells in wound tissue. CHG significantly reduced metabolic activity of the skin explants, while all treatments except saline affected local cellular viability. CHG cytotoxicity persisted and progressed over 14 days, impairing wound healing in vivo. Within the contamination model, CHG treatment resulted in a significant reduction of P. aeruginosa wound surface counts at 24 h post-treatment. However, this effect was transient and serial application of CHG had no effect on both P. aeruginosa or S. aureus microbial growth. Microscopy revealed that viable cells of P. aeruginosa reside deep within wound tissue post-CHG application, likely serving as a reservoir to re-populate the tissue to a high bioburden. We reveal concerning cytotoxicity and limited antimicrobial activity of CHG in human skin using clinically relevant models, with the ability to resolve spatial localization and temporal dynamics of tissue viability and microbial growth.

Wound-Healing Promotion and Anti-Inflammatory Properties of Carvacrol Prodrugs/Hyaluronic Acid Formulations

Background. Wound healing (WH) is a complex process involving several stages, such as hemostasis, inflammation, re-epithelialization, and remodeling. Many factors can impair WH, and different pharmacological approaches were studied to date, but the increase in antibiotic resistance, invasiveness, treatment duration, and high cost, have often hampered the resolution of the wound. In this study, we investigated the possible application of water-soluble carvacrol prodrugs (WSCPs) and hyaluronic acid (HA) and their formulations (WSCPs/HA) to improve WH and regulate the inflammatory response. Materials and methods. Firstly, the cytotoxicity of 0.1, 1 and 10 µg/mL of HA, WSCPs and WSCPs/HA formulations were evaluated on HaCaT cells and THP-1 cell lines. The ability of WSCPs/HA formulations to modulate wound repair was evaluated in an in vitro model of WH, using HaCaT cells at 6, 18, and 24 h. The expression of WH mediators, after wound closure was determined by qRT-PCR. Following, we polarized THP-1 cells in M1/M2-like macrophages and tested the anti-inflammatory properties of WSCPs/HA formulations. After, we tested the in vitro WH model for the effects of conditioned medium (CM) from M1/M2-like cells cultured in the presence of WSCPs/HA. Results. Results showed that WSCPs/HA formulations were able to significantly raise the wound closure rate, compared to the single constituents, promoting a complete wound closure after 18 h for WSCP1/HA (10 µg/mL) and after 24 h for WSCP2/HA (10 µg/mL), modulating the MMPs, TGFβ, and COX-2 gene expression. The effects of CM derived from M1/M2 polarized cells cultured in the presence of WSCPs/HA determined WH regulation, with a better ability of the WSCP2/HA formulation to modulate the time-dependent expression of reparative and inflammatory mediators. Conclusion. Our data underline the possible application of WSCPs/HA formulations as bioactive agents for the regulation of the wound repair process by the modulation of inflammatory and remodeling phases, affecting the activity of immune cells.

Biofabrication of ZnO/Malachite nanocomposite and its coating with chitosan to heal infectious wounds

Recently, nanocomposites produced from clays and metals coated with chitosan have shown wound healing activity. This study aimed to synthesize the zinc oxide/malachite nanocomposite (ZnO/Mlt-NC) and its coating form with chitosan (ZnO/Mlt/Chsn-NC). Physicochemical characterization of the produced nanocomposites was investigated. Biomedical effects of nanocomposites, such as in vivo and in vitro antibacterial activity, antioxidant properties, cytotoxicity, and modulation in the gene expressions of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-10 (IL-10), and transforming growth factor-β (TGF-β) and histopathological parameters, were also investigated. Expression intensities of basic fibroblast growth factor (bFGF) and tumor necrosis factor alpha (TNF-α) were also investigated by immunofluorescence staining. To investigate biomedical effects under in vivo conditions, infected wounds were induced and inoculated with Staphylococcus aureus (ATCC 25923), and Pseudomonas aeruginosa (ATCC 27853). The results indicated spherical ZnO nanoparticles on the surface of malachite and strong antibacterial activity and antioxidant properties. The ointments produced from the nanocomposites also exhibited wound healing activity. The administration of the ointments prepared from ZnO/Mlt, and ZnO/Mlt/Chsn NCs decreased the expressions of IL-1β, IL-6, and TNF-α, while it increased the expressions of IL-10, TGF-β and bFGF. In sum, the nanocomposites produced from ZnO, malachite, and chitosan had better biological activity than ZnO/Malachite nanocomposites. We suggest applying ZnO/Mlt/Chsn nanocomposites in the structure of ointments to treat infected wounds after future clinical studies.

A Combination of the Natural Molecules Gallic Acid and Carvacrol Eradicates P. aeruginosa and S. aureus Mature Biofilms

Wound infection, especially the development of bacterial biofilms, delays wound healing and is a major public health concern. Bacteria in biofilms are more tolerant to antimicrobial agents, and new treatments to eradicate mature biofilms are needed. Combining antimicrobial molecules with different mechanisms of action is an attractive strategy to tackle the heterogeneous nature of microbial communities in biofilms. This study focused on three molecules of natural origin: gallic acid (G), carvacrol (K) and curcumin (Q). Their abilities, individually or in combination, to eradicate biofilms were quantified on mono- and dual-species mature biofilms of Pseudomonas aeruginosa and Staphylococcus aureus, the strains most commonly found in infected wounds. G presented biofilm eradicating activity on P. aeruginosa, whereas K had biofilm eradicating activity on S. aureus and P. aeruginosa. Q had no potent biofilm eradicating activity. The combination of G and K increased the effects previously observed on P. aeruginosa biofilm and led to complete eradication of S. aureus biofilm. This combination was also efficient in eradicating a dual-species biofilm of S. aureus and P. aeruginosa. This work demonstrates that K and G used in combination have a strong and synergistic eradicating activity on both mono- and dual-species mature biofilms of S. aureus and P. aeruginosa and may therefore represent an efficient alternative for the treatment of biofilms in wounds.

An Overview on the Recent Advances in the Treatment of Infected Wounds: Antibacterial Wound Dressings

A wound can be surgical, cuts from an operation or due to accident and trauma. The infected wound, as a result of bacteria growth within the damaged skin, interrupts the natural wound healing process and significantly impacts the quality of life. Wound dressing is an important segment of the skincare industry with its economic burden estimated at $ 20.4 billion (in 2021) in the global market. The results of recent clinical trials suggest that the use of modern dressings can be the easiest, most accessible, and most cost-effective way to treat chronic wounds and, hence, holds significant promise. With the sheer number of dressings in the market, the selection of correct dressing is confusing for clinicians and healthcare workers. The aim of this research was to review widely used types of antibacterial wound dressings, as well as emerging products, for their efficiency and mode of action. In this review, we focus on introducing antibiotics and antibacterial nanoparticles as two important and clinically widely used categories of antibacterial agents. The perspectives and challenges for paving the way for future research in this field are also discussed. This article is protected by copyright. All rights reserved.

Combination Therapies for Biofilm Inhibition and Eradication: A Comparative Review of Laboratory and Preclinical Studies

Microbial biofilms are becoming increasingly difficult to treat in the medical setting due to their intrinsic resistance to antibiotics. To combat this, several biofilm dispersal agents are currently being developed as treatments for biofilm infections. Combining biofilm dispersal agents with antibiotics is emerging as a promising strategy to simultaneously disperse and eradicate biofilms or, in some cases, even inhibit biofilm formation. Here we review studies that have investigated the anti-biofilm activity of some well-studied biofilm dispersal agents (e.g., quorum sensing inhibitors, nitric oxide/nitroxides, antimicrobial peptides/amino acids) in combination with antibiotics from various classes. This review aims to directly compare the efficacy of different combination strategies against microbial biofilms and highlight synergistic treatments that warrant further investigation. By comparing across studies that use different measures of efficacy, we can conclude that treating biofilms in vitro and, in some limited cases in vivo, with a combination of an anti-biofilm agent and an antibiotic, appears overall more effective than treating with either compound alone. The review identifies the most promising combination therapies currently under development as biofilm inhibition and eradication therapies.

Immunology of Acute and Chronic Wound Healing

Skin wounds greatly affect the global healthcare system, creating a substantial burden on the economy and society. Moreover, the situation is exacerbated by low healing rates, which in fact are overestimated in reports. Cutaneous wounds are generally classified into acute and chronic. The immune response plays an important role during acute wound healing. The activation of immune cells and factors initiate the inflammatory process, facilitate wound cleansing and promote subsequent tissue healing. However, dysregulation of the immune system during the wound healing process leads to persistent inflammation and delayed healing, which ultimately result in chronic wounds. The microenvironment of a chronic wound is characterized by high quantities of pro-inflammatory macrophages, overexpression of inflammatory mediators such as TNF-α and IL-1β, increased activity of matrix metalloproteinases and abundance of reactive oxygen species. Moreover, chronic wounds are frequently complicated by bacterial biofilms, which perpetuate the inflammatory phase. Continuous inflammation and microbial biofilms make it very difficult for the chronic wounds to heal. In this review, we discuss the role of innate and adaptive immunity in the pathogenesis of acute and chronic wounds. Furthermore, we review the latest immunomodulatory therapeutic strategies, including modifying macrophage phenotype, regulating miRNA expression and targeting pro- and anti-inflammatory factors to improve wound healing.