Академический Документы
Профессиональный Документы
Культура Документы
Wound healing
Chandan K. Sen and Sashwati Roy
SYNOPSIS
Acute wounds
Introduction
Physical trauma represents one of the most primitive
challenges that threatened survival. In other words,
injury eliminated the unfit. A Sumerian clay tablet (c.
2150 BC) described early wound care that included
washing the wound in beer and hot water, using poultices from substances such as wine dregs and lizard
dung, and bandaging the wound. Ancient scriptures
depicting the science of life or Ayurveda date from the
sixth to seventh century BC, and represent the beginning
of planned physical injury with the intent to cure.1,2
Hippocrates (c. 400 BC) detailed the importance of draining pus from the wound, and Galen (c. 130200 AD)
described the principle of first- and second-intention
healing.3 Wound healing advanced slowly over the centuries, with major advances in the 19th century in the
importance of controlling infection, hemostasis, and
necrotic tissue.4 Today, surgical trauma, taken together
with injury caused during accidents and secondary to
other clinical conditions, e.g., diabetes, represents a substantial cost to society.5 Any solution to wound-healing
problems will require a multifaceted comprehensive
approach. First and foremost, the wound environment
will have to be made receptive to therapies. Second, the
appropriate therapeutic regimen needs to be identified
and provided while managing systemic limitations that
could secondarily limit the healing response. This
chapter aims to present an overall outline of the cutaneous wound-healing process.
Acute wounds
Any violation of live tissue integrity may be regarded
as a wound. Skin is the largest organ of the human body,
covering about 3000 square inches (7620cm2) in an
average adult. The most important role of the skin for
terrestrial animals is to protect the water-rich internal
organs from the dry external environment. As a primary
line of defense against external threats, maintenance of
integrity of the skin is a key prerequisite for healthy
survival. Thus, healthy skin can regenerate and repair
itself under most common conditions. Skin wounds
may be open when manifested as a tear, cut, or puncture. Blunt force trauma may cause closed wounds or
Laceration
241
Puncture wound
three
general
techniques
of
wound
242
14 Wound healing
Scab
Clot
Neutrophils
24 hours
Hemostasis
For bleeding wounds, the highest priority is to stop
bleeding and this is achieved by hemostasis. Hemostasis
is thus a protective physiological response to vascular
injury that results in exposure of blood components to
the subendothelial layers of the vessel wall. Through
successful hemostasis blood loss is prevented by plugging the wound within seconds through vasoconstriction and formation of a hemostatic blood clot consisting
of platelets and fibrin. Hemostasis requires both platelets and the blood coagulation system. The process of
blood coagulation may be subdivided into initiation
and amplification. Initiation is caused by an extrinsic
pathway, whereas amplification is executed by an intrinsic pathway. The intrinsic pathway consists of plasma
factor XI (FXI), IX, and VIII (Fig. 14.3). Tissue factor
(TF) generates a thrombin burst, a process by which
Re-epithelialization
Fibroblast
New
capillary
Granulation
tissue Macrophage
3-7 days
Weeks
Wound contraction
Hemostasis
243
Tissue damage
Vessel injury
Healing
Collagen
FXII
Kallikrein
Prekallikrein
WBC
FXIIa
TF
FXIII Platelet
RBC
HK
Polymerization
and
stabilization
FXIIIa
Intrinsic
pathway
FVII
FXI
FVIIa
FXIa
Ca2+
Phospholipids
Phospholipids
Platelet Extrinsic
pathway
Ca2+
Protein-C
Protein-S
Fibrinogen
TM
TFPI
FIX
FVIII
FIXa
PF3
Antithombin
III
FV
FX
FVIIIa
FVa
Thrombin
Common
pathway
FX
FXa
Prothrombin
244
14 Wound healing
The formation of blood clot is initiated by the proteolytic cleavage of fibrinogen by thrombin. As a result,
fibrin is produced and forms cross-links with each other.
Cross-linked fibrin entraps platelets, and together they
adhere to the subendothelium through adhesion molecules called integrins. Clot fibrin plays a key role in
mounting the inflammatory process as well as in facilitating wound angiogenesis and stromal cell proliferation. Fibrin binds to integrin CD11b/CD18 on infiltrating
monocytes and neutrophils. It also binds to fibroblast
growth factor-2 (FGF-2) and vascular endothelial growth
factor (VEGF) that help the wound tissue vascularize.
Fibrin also binds to insulin-like growth factor-I and promotes stromal cell proliferation.11,12
Blood clot represents the seat of wound chemotaxis.
Thrombin, released by platelets at the wound site, is an
early mediator of clot development.13 Thrombin is a
serine protease that converts soluble plasma fibrinogen
into an insoluble fibrin clot. In addition, it promotes
platelet aggregation. Thrombin function may be viewed
as an interface between the hemostasis phase of wound
healing and the ensuing inflammatory phase as it plays
a potent role in mounting wound inflammation. The
proinflammatory effects of thrombin include stimulation of vasodilation responsible for plasma extravasation, edema, and an increased expression of endothelial
cell adhesion molecules that helps monocytes and others
cells extravasate and infiltrate the wound site. Thrombin
also induces the release of proinflammatory cytokines
like CCL2, interleukin-6 (IL-6), and IL-8 by endothelial
cells. These cytokines induce monocyte chemotaxis.14
Furthermore, thrombin induces the release of inflammatory cytokines by monocytes, including IL-6, interferon-,
IL-1, and tumor necrosis factor- (TNF-). These earlyphase cytokines are typically proinflammatory, which
may govern the differentiation of blood-derived monocytes into M1 wound macrophages.15 Wound chemotaxis is also driven by the degradation of fibrin and
subsequent activation of the complement system. As
part of this process several chemotactic agents and
cytokines are released, which in turn launch the inflammatory phase of wound healing through chemotactic
recruitment of blood-borne immune cells.16 Platelets are
one of the earliest sources of cytokines which execute
immune cell chemotaxis as well as macrophage activation. Once trapped in the fibrin net, platelets release
granules that function as a reservoir for biologically
Inflammation
active proteins, such as RANTES (regulated on activation, normal T cell expressed, and secreted or CCL5),
thrombin, transforming growth factor- (TGF-),
platelet-derived growth factor (PDGF), and VEGF.
CCL5 is one of the most potent monocyte chemoattractants released by platelets after injury. Other cytokines
and chemokines that attract monocytes to the wound
bed include monocyte chemoattractant protein-1
(MCP-1) (CCL2), MIP-1 (CCL3), TGF-, fibronectin,
elastin, C5a, C3a, nerve growth factor, and ECM
components.17,18
Inflammation
Tissue injury triggers an acute-phase inflammation
(Latin, inflammare, to set on fire) response that is meant
to prepare the wound site for subsequent wound closure
(Fig. 14.4). Inflammation encompasses a series of
responses of vascularized tissues of the body to injury.
Local chemical mediators that are biosynthesized during
acute inflammation give rise to the macroscopic events
characterized by Celsus in the first century, namely,
rubor (redness), tumor (swelling), calor (heat), and dolor
(pain). At cellular and molecular levels, inflammation
results from the coordination of manifold systems of
receptors and sensors that affect transcriptional and
posttranslational programs necessary for host defense
and resolution of infection. During normal healing, the
inflammatory response is characterized by spatially and
temporally changing patterns of specific leukocyte
subsets.
Platelets
Formation of the clot or thrombus is dependent on
platelet activation. The platelet-rich blood clot also
entraps polymorphonuclear leukocytes (neutrophils).
This helps amplify blood coagulation and lays the foundation for the subsequent acute-phase inflammatory
response. In a matter of hours after injury, large numbers
of neutrophils extravasate by transmigrating across the
endothelial cell wall of blood capillaries to the wound
site. To enable this, local blood vessels are activated
by proinflammatory cytokines such as IL-1, TNF-,
and interferon-. These cytokines induce the expression
of adhesion molecules necessary for adhesion of
Initiate
tissue
repair
Cytokines
signaling
path to
injury site
245
Neutrophil
6
3
Platelets
Mast cell
Macrophage
1
1 Bacteria and other pathogens enter wound
2 Platelets from blood release blood-clotting proteins at wound site.
3 Mast cells secrete factors that mediate vasodilation and vascular constriction.
Delivery of blood, plasma and cells to injured area
4 Neutrophils and macrophages remove pathogens by phagocytosis
5 Macrophages secrete hormones called cytokines that attract immune system cells
to the site and activate cells involved in tissue repair
6 Inflammatory response continues until the foreign material is eliminated and the
wound is repaired
leukocytes and diapedesis (Fig. 14.5). Adhesion molecules such as integrins as well as P-selectin and E-selectin
play a central role in enabling diapedesis of neutrophils
(Fig. 14.6). These adhesion molecules bind with integrins
expressed on the cell surface of neutrophils, such as
CD11a/CD18 (LFA), CD 11b/CD18 (MAC-1), CD11c/
CD18 (gp150, 95), and CD11d/CD18. Alongside
cytokines, chemokines play a major role in mounting
acute-phase inflammation after injury. Chemokines
include IL-8, MCP-1, and growth-related oncogene-. In
the case of an infected wound, bacterial products such
as lipopolysaccharide and formyl-methionyl peptides
can enhance neutrophil recruitment to the wound site
(Fig. 14.7).
14 Wound healing
246
Rolling
Shedding of
L-selectin
Adhesion
Diapedesis
Neutrophil
Capillary wall
Monocyte
Activating substances
released by
bacteria
and
damaged
tissues
C3a C5a,
chemokines,
histamine,
prostaglandins
and leukotrienes
Lipopolysaccharides,
interleukin-1, and
tumor necrosis factor
L-selectin
Sialyl-Lewis
Interstitial
spaces
Monocyte squeezing
through interstitial space
Integrin
E-selectin
Neutrophils
Neutrophils traverse postcapillary venules at sites of
inflammation, degrade pathogens within phagolysosomes, and undergo apoptosis. Neutrophils serve a
wide range of functions, ranging from phagocytosis of
infectious agents to cleansing of devitalized tissue.
When coated with opsonins (generally complement
and/or antibody), microorganisms bind to specific
receptors on the surface of the phagocyte and invagination of the cell membrane occurs with the incorporation
of the microorganism into an intracellular phagosome.
There follows a burst of oxygen consumption, and
much, if not all, of the extra oxygen consumed is converted to highly reactive oxygen species. This is called
Fibrinplatelet clot
Collagen
Elastin
Red blood
cell
Fibroblast
Cytokines &
growth factors
Inflammation
247
Gram-negative
bacteria
Lipopolysaccharide
Toll-like
receptor
Cell membrane
Nucleus
Cytoplasm
Fig. 14.8 Toll-like receptors: responding to infectious agents and the wound
microenvironment.
Mast cells
Mast cells are best known for their central role in mediating allergic responses. Beyond that function, it is now
248
14 Wound healing
Macrophages
Macrophages represent the predominant cell type in a
healing wound 35 days following injury. The primary
acute function of wound macrophages, which arrive at
an injury site hours later than neutrophils, is to operate
as voracious phagocytes cleansing the wound of all
matrix and cell debris, including fibrin and apoptotic
neutrophils. Macrophages also produce a range of
cytokines, growth and angiogenic factors that drive
fibroblast proliferation and angiogenesis.4,2932 In a
classic study, Leibovich and Ross33 demonstrated that
antimacrophage serum combined with hydrocortisone
Resolution of inflammation
Inflammatory responses elicited by injury are only
helpful to the healing process if they are timely and
transient. Dysregulated inflammation complicates
wound healing.39 Complete resolution of an acute
inflammatory response is the ideal outcome following
an insult. For resolution to ensue, further leukocyte
recruitment must be halted and accompanied by
removal of leukocytes from inflammatory sites. Reso
lution of inflammation is executed by a number of key
factors. At the wound site successful phagocytosis of
dead neutrophils by macrophages is a key factor.
Impairment in macrophage function at the wound site
derails the resolution of inflammation.39 Lipid mediators, such as the lipoxins, resolvins, protectins, and
newly identified maresins, have emerged as a novel
genus of potent and stereoselective players that
counterregulate excessive acute inflammation and
stimulate molecular and cellular events that define
resolution.40 Successful resolution paves the path for
the healing process to progress towards successful
wound closure. Prolonged inflammation may not only
Infection
Infection
Infection is a common problem in chronic wounds, frequently resulting in nonhealing and significant patient
morbidity and mortality.43 Wound infection and the subsequent release of proinflammatory modulators result
in pain and delayed healing. The pain, in turn, compromises the immune response to infection.44 All wounds
become contaminated by bacteria from the surrounding
skin, the local environment, and autologous patient
sources. The local environment is particularly relevant
for hospitalized patients. Colonization is defined as the
presence of proliferating bacteria without a noticeable
host response. Colonization of the wound may enhance
or impede wound healing, depending upon the bacterial load. Bacterial loads in excess of 105 organisms/
gram of tissue are a threat to wound healing, although
this threshold may be altered by the status of the host
immune system and the number and types of bacterial
species present. The concept of critical colonization
is controversial and not universally accepted. Critical
colonization is characterized by increased bacterial
burden or covert infection, and the wound at this stage
may enter a nonhealing, chronic inflammatory state.
Substantial colonization may not cause the obvious
signs of inflammation but will likely affect wound
healing with failure to heal or slowing of progression.
Signs of critical colonization are atrophy or deterioration of granulation tissue, discoloration of granulation
tissue to deep red or gray, increased wound friability,
and increased drainage. The transition to infection
occurs when bacterial proliferation overcomes the hosts
immune response and host injury occurs. Several factors
determine transition from colonization to infection: the
bioburden itself, the virulence of the organisms, the synergistic action of different bacterial species, and the
ability of the host to mount an immune response.43
During the past decade, there has been rapid progress
in the understanding of innate immune recognition
of microbial components and its critical role in host
defense against infection. The early concept of innate
immunity was that it nonspecifically recognized
microbes; however, the discovery of TLRs (Fig. 14.8) in
249
250
14 Wound healing
Biofilm
Vascularization
Vascularization
Angiogenic
factor (VEGF)
production
Release
Angiogenic
factors bind
to endothelial
cell receptors
3
Endothelial cell
activation
Loop
formation
Vascular
stabilization
7
ECM
remodeling
6
5
Endothelial cell
proliferation
Directional
migration
10
Pericyte
Tie-2
y3
251
8
Tube
formation
252
14 Wound healing
Wound closure
Wound contraction and re-epithelialization contribute
to closure of wounds that heal by secondary intention.
Wound contraction represents an early response to
injury that is aimed at juxtaposing the edges of an open
wound.56 This early phase of wound closure appears to
be mediated by a contractile purse-string force produced by a circumferentially arranged band of fusiformshaped epidermal cells situated in the wound margin.57
Fibroblasts at the wound edge tissue are recognized to
play a key role in enabling wound contraction.58 During
the inflammatory phase of wound healing, fibroblasts
acquire smooth-muscle cell characteristics and differentiate into contractile myofibroblasts. The first phenotypic transition of wound edge fibroblasts into so-called
protomyofibroblasts is characterized by neoformation
of contractile -cytoplasmic actin stress fibers and occurs
in response to profibrotic cytokines and to altered properties of the ECM. In the presence of TGF-1 in a
mechanically restrained environment, these cells express
-smooth-muscle actin de novo, which significantly
increases their contractile activity and is a hallmark of
the differentiated myofibroblast.59 Wound contraction
may significantly contribute to wound closure, although
this contribution is much larger in loose-skinned rodents
than in humans.
In an open wound that has undergone contraction,
restoration of an intact epidermal barrier is enabled
through wound epithelialization, also known as
re-epithelialization.60,61 A wound that is not epithelialized is not considered healed, no matter how
perfectly restored the underlying dermal structures
may be. Thus, wound epithelialization, also called
re-epithelialization, is a critical and defining feature of
wound repair. Re-epithelialization of the wound can be
conceptually viewed as the result of three overlapping
keratinocyte functions: migration, proliferation, and differentiation. The sequence of events by which keratinocytes accomplish the task of re-epithelialization is
generally believed to begin with dissolution of cellcell
and cellsubstratum contacts. This is followed by the
polarization and initiation of directional migration in
basal and a subset of suprabasilar keratinocytes over the
provisional wound matrix. A subset of keratinocytes
immediately adjacent to, but not within, the wound bed
then undergoes mitosis. Finally, there is multilayering
of the newly formed epidermis and induction of differentiation specific gene products to restore the functionality of the epidermis. The most limiting factor in
wound re-epithelialization is migration, since defects in
this function, but not in proliferation or differentiation,
are associated with the clinical phenotype of chronic
nonhealing wounds.62 The process of epithelialization
continues until the barrier is re-established and the
wound is covered. The process of re-epithelialization is
accelerated by a moist environment63,64 and is facilitated
by the enzyme matrix metalloproteinase 1, a collagenase
which lessens the affinity of the collagenintegrin
contacts.65
Chronic wounds
Proliferative phase
The proliferative phase starts around 2 days after injury
and normally lasts up to 3 weeks in a healing cutaneous
wound. This phase overlaps with the inflammatory
phase and supports re-epithelialization, the formation
of new blood vessels, and the influx of fibroblasts and
laying down of the ECM. By the time this phase begins,
the degradation of the fibrin clot by the macrophages
has begun and invading endothelial cells and fibroblasts
rapidly fill that space. Migrating fibroblasts produce
the cytokines that induce keratinocytes to migrate and
proliferate.66 Activated macrophages produce several
cytokines, such as PDGF and TNF-, which also induce
fibroblasts to produce keratinocyte growth factor which
in turn induces wound re-epithelialization.60,61
Granulation tissue
The fibrin clot formed during hemostasis participates in
the early inflammatory phase and is replaced by a perfused, fibrous connective tissue that grows from the
base of a wound and is able to fill wounds of almost any
size. During the proliferative phase of wound healing,
this granulation tissue is light red or dark pink in color
because of perfusion by new capillary loops. It is soft to
the touch, moist, and granular in appearance. The granulation tissue serves as a bed for tissue repair. The ECM
of granulation tissue is created and modified by fibroblasts. Initially, it consists of a network of type III collagen, a weaker form of the structural protein that can be
produced rapidly. This is later replaced by the stronger,
long-stranded type I collagen, as evidenced in scar
tissue. Formation and contraction of the granulation
tissue represent integral aspects of the healing wound.
In ischemic wounds, contraction of the granulation
tissue is impaired because of faulty myofibroblast
function, cells responsible for granulation tissue
contraction.67
Chronic wounds
A wound is generally considered chronic if it has not
healed in 4 weeks. Chronic wounds have been also
defined as wounds that have not shown a 2040% reduction in area after 24 weeks of optimal therapy. Standard
253
Venous ulcers
Venous ulcers (stasis ulcer or varicose ulcers) are wounds
that are thought to occur due to improper functioning
of venous valves, usually of the legs. They are the major
cause of chronic wounds, occurring in 5070% of chronic
wound cases.68 Venous ulcers develop mostly along the
medial distal leg, and can be very painful. According to
the revised clinical, etiology, anatomy, and pathophysiology (CEAP) classification of chronic venous disease
published in 2004, a venous ulcer is defined as a fullthickness defect of skin, most frequently in the ankle
region, that fails to heal spontaneously and is sustained
by chronic venous disease.69 Systematically, venous
ulcer may be defined as a defect in the skin with surrounding pigmentation and dermatitis, located in the
lower leg (usually in the gaiter region) that has been
present for greater than 30 days, characterized by
persistent venous hypertension and abnormal venous
function (result of venous reflux and/or obstruction
confirmed by hemodynamic and/or physiologic assessment), without a primary or associated arterial, immunologic, endocrine, or systemic cause. It is recognized
that ulcers can be caused purely by venous pathology
such as venous reflux or obstruction. When these abnormalities are combined with additional pathologic conditions, they contribute to the causation and perpetuation
of the ulcer. The latter situation includes comorbid conditions such as arterial ischemia, swelling and lymphedema, trauma, autoimmune disorders, neurotrophic
conditions, and diabetic vascular disease. These ulcers
are categorized as of mixed origin, in which the venous
component may or may not play a dominant role.
Successful treatment of such ulcers includes not only the
venous component but also concomitant management
of the comorbid condition.
Arterial ulcers
Because both arterial and venous ulcers typically occur
on the lower leg, differentiating between them can be
254
14 Wound healing
Healthy foot
Diabetic foot
Diabetic ulcers
Diabetic ulcers are the most common foot injuries
leading to lower extremity amputation (Figs 14.10 and
14.11). In diabetics, the effects of peripheral neuropathy,
peripheral vascular disease, and infection often combine
to facilitate the development of diabetic ulcers that
can lead to gangrene and amputation. Diabetic persons,
like people who are not diabetic, may develop atherosclerotic disease of large- and medium-sized arteries,
such as aortoiliac and femoropopliteal atherosclerosis.
However, significant atherosclerotic disease of the infrapopliteal segments is particularly common in the
diabetic population. Underlying digital artery disease,
when compounded by an infected ulcer in close proximity, may result in complete loss of digital collaterals and
precipitate gangrene. The reason for the prevalence of
this form of arterial disease in diabetic persons is thought
to result from a number of metabolic abnormalities,
Chronic wounds
255
Saphenous nerve
Deep peroneal nerve
Superficial peroneal
nerve
Medial plantar nerve
Lateral plantar nerve
Calcaneal branch
(tibial nerve)
Sural nerve
Pressure ulcers
Dorsal surface
Plantar surface
including high low-density lipoprotein and verylow-density lipoprotein levels, elevated plasma von
Willebrand factor, inhibition of prostacyclin synthesis,
elevated plasma fibrinogen levels, and increased platelet adhesiveness.71 When peripheral arterial insufficiency complicates neuropathy there is a 10-fold risk of
ulceration progressing to infection, gangrene, and
amputation.72
Peripheral sensory neuropathy affects 50% of diabetic
patients and is attributed to chronic hyperglycemia. It
is a major cause of foot ulceration and lower limb amputation. In addition to poor glucose control, traditional
cardiovascular risk factors for macrovascular disease
are independent-risk factors for incident peripheral
neuropathy. In addition, data from the EURODIAB
cohort suggest that female sex may be an independentrisk factor. This makes it difficult to identify specific
diabetes components of neuropathy.73 Nerve injuries of
the foot can also be caused by penetrating wounds. The
sequelae of such injuries depend on the nerve injured
and the level of the injury. In the foot and ankle, the
main function of the nerves is to provide sensation.
Generally, the tibial nerve and its branches (i.e., the
medial and lateral plantar nerves) innervate the intrinsic musculature, although the deep peroneal nerve
innervates the extensor digitorum brevis and extensor
hallucis brevis muscles (Fig. 14.12). Denervation of these
256
14 Wound healing
ATP
O2
NO
Protein
synthesis
Mature collagen
Superoxide
anion radical
Neutrophil
Macrophage
Endothelial cells
Infectious
pathogens
H2O2
Red blood
cells
Redox
signals
HOCl
Fig. 14.13 Molecular oxygen and its derivatives in wound healing. ATP, adenosine
triphosphate; NO, nitric oxide.
role in the regulation of vascular tone as well as in angiogenesis. In a wound setting, large amounts of molecular oxygen are partially reduced to form reactive oxygen
species (ROS). ROS includes oxygen free radicals such
as superoxide anion as well as its nonradical derivative,
hydrogen peroxide (H2O2). Superoxide anion radical is
the one-electron reduction product of oxygen. NADPH
oxidases represent one major source of superoxide anion
radicals at the wound site. NADPH oxidases in phagocytic cells help fight infection. Superoxide anion also
drives endothelial cell signaling such as required during
angiogenesis. In biological tissues, superoxide anion
radical rapidly dismutates to hydrogen peroxide, either
spontaneously or facilitated by enzymes called superoxide dismutases. Endogenous hydrogen peroxide
drives redox signaling, a molecular network of signal
propagation that supports key aspects of wound healing
such as cell migration, proliferation, and angiogenesis.
Neutrophil-derived hydrogen peroxide may be utilized
by MPO to mediate peroxidation of chloride ions, resulting in the formation of hypochlorous acid (HOCl), a
potent disinfectant (Fig. 14.13).
Three major factors may contribute to wound tissue
hypoxia: (1) peripheral vascular diseases garroting O2
supply; (2) increased O2 demand of the healing tissue;
Stratum corneum
Stratum
granulosum
Keratinocyte in
epidermis
257
Bacteria
Basal layer
Myofibroblast
Endothelial
progenitor cell
Endothelial
cell
Dermis
Pocket of oxygenation
Pocket of hypoxia
Near-anoxic necrotic core
Neutrophil
Macrophage
of VEGF and its receptors leads to insufficient skin angiogenesis.81 Whether cells in the pockets of extreme
hypoxia are O2-responsive is another concern. Even if
such cells may have passed the point of no return in the
survival curve, correction of tissue oxygenation is likely
to help clean up the dead or dying tissue and replace
the void with proliferating neighboring cells. Pockets of
moderate or mild hypoxia are likely to be the point of
origin of successful angiogenic response as long as other
barriers such as infection and epigenetic alterations are
kept to a minimum.
258
14 Wound healing
Redox signaling
Additional high demand for oxygen is placed by a
family of enzymes known as NADPH oxidases, which
are known to be highly active at the wound site.86 Recent
MicroRNAs
Nitric oxide
At the wound site, NO is generated by an oxygendependent biosynthetic process. In the late 1970s,
research was unfolding that implicated NO involvement in the process of vasodilation. By 1986, research
culminated in the identification of NO as the endotheliumderived relaxing factor responsible for the maintenance
of vascular tone, thus implicating NO as a potential
wound-healing agent.100 Maximal NO synthase activity
is noted early in cutaneous wound healing, with sustained production up to 10 days after wounding. Wound
macrophages represent a major source of NO production in the early phase of wound healing.101 Inhibition
of wound NO synthesis lowered wound collagen accumulation and wound-breaking strength, suggesting that
NO synthesis is critical to wound collagen accumulation
and acquisition of mechanical strength. Later it was
demonstrated that wound fibroblasts are phenotypically altered during the healing process to synthesize
NO, which, in turn, regulates their collagen synthetic
and contractile activities.102 The blockade of NO synthesis impairs cutaneous wound healing, acting in early
and late phases of wound repair.103 Interestingly,
impaired diabetic wound healing is associated with
decreased wound NO synthesis.104
MicroRNAs
Wound healing is largely dependent on injury-inducible
protein-coding genes as they serve as drivers of an
259
Inflammation
Disruption of miRNA biogenesis has a major impact on
the overall immune system. Emerging studies indicate
that miRNAs, especially miR-21, miR-146a/b, and miR155, play a key role in regulating several hubs that
orchestrate the inflammatory process.107 miRNAs have
been directly implicated in the pathogenesis of inflammatory diseases such as osteoarthritis and rheumatoid
arthritis. Resolvin-regulated specific miRNAs target
genes involved in resolution of inflammation establish
260
14 Wound healing
a novel resolution circuit involving RvD1 receptordependent regulation of specific miRNAs.108 Fur
thermore, the brain-specific microRNA-124 can tame
inflammation by turning off activated microglial cells
and macrophages.109 Of relevance to tissue repair is also
the regulatory loop where cytokines, including those
elicited following injury, are regulated by miRNAs as
well as regulate miRNA expression.110,111
Angiogenesis
In 20052008, the first series of observations establishing
key significance of miRNAs in the regulation of mammalian vascular biology came from experimental studies
involved in arresting miRNA biogenesis to deplete
the miRNA pools of vascular tissues and cells.112 Dicerdependent biogenesis of miRNA is required for blood
vessel development during embryogenesis. Mice with
endothelial cell-specific deletion of Dicer, a key enzyme
supporting biogenesis of miRNAs, display defective
postnatal angiogenesis. NADPH oxidase-derived ROS
drive wound angiogenesis. Endothelial NADPH oxidase
is subject to control by miRNAs.113 Hypoxia is widely
recognized as a cue that drives angiogenesis as part of
an adaptive response to vascularize the oxygen-deficient
host tissue. Hypoxia-sensitive miR-200b is involved in
such induction of angiogenesis via directly targeting
Ets-1.114 Various aspects of angiogenesis, such as proliferation, migration, and morphogenesis of endothelial
cells, can be regulated by specific miRNAs in an
endothelial-specific manner. miRNAs known to regulate angiogenesis in vivo are referred to as angiomiRs.115
miRNA-126 is specific to endothelial cells and regulates
vascular integrity and developmental angiogenesis.
Manipulating angiomiRs in the setting of tissue repair
represents a new therapeutic approach that could be
effective in promoting wound angiogenesis.
Hypoxia response
Tissue injury is often associated with disruption of vascular supply to the injury site. Thus, the injured tissue
often suffers from insufficient oxygen supply or hypoxia.
Under conditions of additional underlying ischemia,
hypoxia is severe and seriously limits wound healing.79
Hypoxia induces specific miRNAs, collectively referred
to as hypoxamirs.116 miRNA-210 is a classical
Stem cells
Endogenous miRNA-binding sites have been identified
in murine embryonic stem cells (ESCs). miRNAs govern
ESCs function by serving as control hubs managing
regulatory networks. A central importance of such governance is highlighted by the observation that ESCs
lacking miRNAs lose their stemness. ESCs with deficient miRNA biogenesis systems switch to a mode of
ongoing cell division. They do not differentiate on
demand because of failure to turn off the pluripotency
regulatory program.122 miRNAs conduct the orchestra
of critical gene regulatory networks controlled by
pluripotency factors within stem cells. Individual
miRNA-dependent pathways that promote the reprogramming of somatic cells into induced pluripotent
stem (iPS) cells have been now identified. Manipulation
of specific cellular miRNAs helps enhance reprogramming of somatic cells to an ESC-like phenotype, helping
Stem cells
Stem cells
261
Totipotent cells
Blood
stem cells
Other committed
stem cells
Erythrocytes
Platelets
Specialized cells
on
ati
nti
re
tio
n
iffe
-d
tia
en
er
iff
-d
De
on
n
io
iat
nt
Pluripotent
stem cell
re
tro
ati
ffe
Re
nti
re
iffe
-d
Re
Totipotent
cells
Di
The regenerative potential of injured adult tissue suggests the physiological existence of cells capable of participating in the reparative process. The epithelium of
the skin, the epidermis, is in a continuous equilibrium
of growth and differentiation and has the remarkable
capacity to self-renew completely, which relies on reservoirs of stem cells. In mammals, there are two broad
types of stem cells: ESCs that are isolated from the inner
cell mass of blastocysts, and adult stem cells that are
found in various tissues. In adult organisms, stem cells
and progenitor cells act as a repair system for the body,
replenished in adult tissues. Stem cells have the property of self-renewal without differentiation and have the
potential to differentiate into any type of cell. Totipotent
stem cells have the ability to give rise to a whole organism due to their ability to differentiate into embryonic
and extraembryonic cells. Pluripotent stem cells are
derived from totipotent cells and can differentiate into
all cell types but cannot give rise to a new organism (Fig.
14.15). ESCs are derived from the developing embryo,
usually from the inner cell mass of a blastocyst or earlier
morula stages. Lost or damaged cells can be replaced by
differentiation, dedifferentiation, or transdifferentiation
(Fig. 14.16). Recent advances have shown that the addition of a group of genes can not only restore pluripotency in a fully differentiated cell state (differentiation)
but can also induce the cell to proliferate (dedifferentiation) or even switch to another cell type (transdifferentiation). Dedifferentiation is represented by a terminally
differentiated cell reverting back to a less-differentiated
stage from within its own lineage. This process allows
the cell to proliferate again before redifferentiating,
leading to the replacement of those cells that have been
Progenitor cells
Blood
stem
cells
Other
tissues
Red blood
cells
White blood
cells
Muscle
Nerve
Bone
Trans-differentiation
14 Wound healing
262
Hair shaft
Skeletal
muscle
Liver
Sebaceous gland
Outer root sheath
Basement
membrane
Bone marrow
stromal cell
Epithelial
cell
Blood cells
Neuron
TA cell
Glial cell
Blood
vessel
Basement membrane
CNS
stem cells
Fat cell
Paneth cell
Stem cell
Cardiac muscle
B
Mesenchymal cell
Fig. 14.17 Bone marrow stem cells. CNS, central nervous system.
Fig. 14.18 Stem cells in the epidermis. Hair follicles act as reservoirs of stem
cells in the skin. (A) Cross-sectional view of a hair follicle. The matrix stem cells
differentiate into various parts of the hair while the long-term stem cells are present
in the bulge region. The stem cells from the bulge maintain the sebaceous gland
and epidermal stem cells. (B) A mammalian gut crypt. Stem cells are located at the
basal region with the Paneth cells. The transit amplifying (TA) cells are stem cell
progeny which move upwards and differentiate.
Stem cells
263
264
14 Wound healing
Scar
Scars (also called cicatrices) are macroscopic fibrous
tissue that visibly replaces normal skin after injury.
There is a wide spectrum of skin scarring postwounding, including scarless fetal wound healing, fine-line
(normal) scars, stretched (widespread) scars, atrophic
Scar
265
Hypertrophic scar
Keloid
266
14 Wound healing
Acknowledgment
Supported by NIH RO1 grants GM069589, GM077185,
NS42617, DK076566, and HL 073087. The authors thank
Sabyasachi Biswas PhD, Rashmet Reen PhD, and Viren
Patel MD for support in writing this article.
References
References
1. Mehra R. Historical survey of wound healing. Bull
Indian Inst Hist Med Hyderabad. 2002;32:159175.
2. Wangensteen OH. Surgeons and wound management:
historical aspects. Conn Med. 1975;39:568574.
3. Broughton 2nd. G, Janis JE, Attinger CE. A brief
history of wound care. Plast Reconstr Surg. 2006;117:
6S-11S.
4. Eming SA, Krieg T, Davidson JM. Inflammation in
wound repair: molecular and cellular mechanisms.
J Invest Dermatol. 2007;127:514525.
5. Sen CK, Gordillo GM, Roy S, et al. Human skin
wounds: a major and snowballing threat to public
health and the economy. Wound Repair Regen. 2009;17:
763771.
6. Mackman N, Tilley RE, Key NS. Role of the extrinsic
pathway of blood coagulation in hemostasis and
thrombosis. Arterioscler Thromb Vasc Biol. 2007;27:
16871693.
7. Schecter AD, Spirn B, Rossikhina M, et al. Release of
active tissue factor by human arterial smooth muscle
cells. Circ Res. 2000;87:126132.
8. Smyth SS, McEver RP, Weyrich AS, et al. Platelet
functions beyond hemostasis. J Thromb Haemost.
2009;7:17591766.
9. Huntington JA. Molecular recognition mechanisms of
thrombin. J Thromb Haemost. 2005;3:18611872.
10. Midwood KS, Williams LV, Schwarzbauer JE. Tissue
repair and the dynamics of the extracellular matrix.
Int J Biochem Cell Biol. 2004;36:10311037.
11. Sahni A, Odrljin T, Francis CW. Binding of basic
fibroblast growth factor to fibrinogen and fibrin. J Biol
Chem. 1998;273:75547559.
12. Tuan TL, Wu H, Huang EY, et al. Increased
plasminogen activator inhibitor-1 in keloid fibroblasts
may account for their elevated collagen accumulation
in fibrin gel cultures. Am J Pathol. 2003;162:15791589.
13. He S, Blomback M, Bark N, et al. The direct thrombin
inhibitors (argatroban, bivalirudin and lepirudin) and
the indirect Xa-inhibitor (danaparoid) increase fibrin
network porosity and thus facilitate fibrinolysis.
Thromb Haemost. 2010;103:10761084.
14. Marin V, Montero-Julian FA, Gres S, et al. The IL-6soluble IL-6Ralpha autocrine loop of endothelial
activation as an intermediate between acute and
chronic inflammation: an experimental model
involving thrombin. J Immunol. 2001;167:34353442.
15. Delavary BM, van der Veer WM, van Egmond M, et al.
Macrophages in skin injury and repair. Immunobiology.
2011.
16. Baum CL, Arpey CJ. Normal cutaneous wound
healing: clinical correlation with cellular and
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
266.e1
266.e2
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
14 Wound healing
References
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
266.e3
266.e4
14 Wound healing
98. Sen CK. The general case for redox control of wound
repair. Wound Repair Regen. 2003;11:431438.
At very low concentrations, reactive oxygen species may
regulate cellular signaling pathways by redox-dependent
mechanisms. Redox-based strategies may serve as effective
adjuncts to jump-start healing of chronic wounds. The
review focuses on the understanding of wound site
redox biology and novel insights into the fundamental
mechanisms that would help to optimize conditions for
oxygen therapy.
99. Stone JR, Yang S. Hydrogen peroxide: a signaling
messenger. Antioxid Redox Signal. 2006;8:243270.
100. Schaffer MR, Tantry U, Gross SS, et al. Nitric oxide
regulates wound healing. J Surg Res. 1996;63:237240.
101. Lee RH, Efron D, Tantry U, et al. Nitric oxide in the
healing wound: a time-course study. J Surg Res.
2001;101:104108.
102. Schaffer MR, Efron PA, Thornton FJ, et al. Nitric oxide,
an autocrine regulator of wound fibroblast synthetic
function. J Immunol. 1997;158:23752381.
103. Amadeu TP, Costa AM. Nitric oxide synthesis
inhibition alters rat cutaneous wound healing. J Cutan
Pathol. 2006;33:465473.
104. Schaffer MR, Tantry U, Efron PA, et al. Diabetesimpaired healing and reduced wound nitric oxide
synthesis: a possible pathophysiologic correlation.
Surgery. 1997;121:513519.
105. Pasquinelli AE. Molecular biology. Paring miRNAs
through pairing. Science. 2010;328:14941495.
106. Banerjee J, Chan YC, Sen CK. MicroRNAs in skin and
wound healing. Physiol Genomics. 2010.
MicroRNAs (MiRNAs) are small endogenous RNA
molecules about 22 nucleotides in length that are capable of
posttranscriptional gene regulation by binding to their
target messenger RNAs (mRNAs). This review focuses on
the role of miRNAs in cutaneous biology, the various
methods of microRNA modulation and the therapeutic
opportunities in treatment of skin diseases and wound
healing.
107. Roy S, Sen CK. miRNA in innate immune responses:
novel players in wound inflammation. Physiol
Genomics. 2011;43:557565.
108. Recchiuti A, Krishnamoorthy S, Fredman G, et al.
MicroRNAs in resolution of acute inflammation:
identification of novel resolvin D1-miRNA circuits.
FASEB J. 2011;25:544560.
109. Ponomarev ED, Veremeyko T, Barteneva N, et al.
MicroRNA-124 promotes microglia quiescence and
suppresses EAE by deactivating macrophages via the
C/EBP-alpha-PU.1 pathway. Nat Med. 2011;17:6470.
110. Asirvatham AJ, Magner WJ, Tomasi TB. miRNA
regulation of cytokine genes. Cytokine. 2009;45:5869.
111. Hata A, Davis BN. Control of microRNA biogenesis by
TGFbeta signaling pathway-A novel role of Smads in
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
References
127.
128.
129.
130.
131.
132.
133.
134.
135.
136.
137.
138.
266.e5