JOURNAL OF PATHOLOGY, VOL.
178 5-10 (1996)
REVIEW ARTICLE
THE ROLE OF CYTOKINES IN WOUND HEALING
J . SLAVIN
Department of Surgery, Royal Liverpool University Hospital, Liverpool, U.K.
INTRODUCTION
Wound healing consists of a series of coordinated
events involving division, migration, and differentiation
of a variety of cells, driven by locally released media-
tors;' an inflammatory response is an integral part of
this process, at least in the adult. It is the purpose of this
paper to review the role of cytokines in wound repair
and its associated inflammation. Given the constraints
of space, in-depth discussion is restricted to a group of
six cytokines (TGF-P, bFGF, VEGF, PDGF, KGF, and
MCP- 1/JE*) which are all directly implicated in the
control of repair. Each cytokine has as its major role
the stimulation of a particular facet of the healing
process, such as angiogenesis or matrix protein deposi-
tion. This review draws together disparate information
to illustrate such a role for each cytokine. Although
much of the work presented is experimental, direct
clinical therapeutic applications are now feasible.
CYTOKINES AS FACTORS IN REPAIR
Platelet-derived growth factor (PDGF)
PDGF was originally isolated from the alpha granules
of platelets as an extract with mitogenic activity for
smooth muscle cells. It is a dimeric protein consisting of
A and B chains bound by disulphide bridges; all three
forms (AA, AB, BB) are found naturally.* PDGF stimu-
lates the production by monocyte/macrophages of other
growth factors such as TGF-P.3Thus, PDGF released by
platelets is pro-inflammatory, attracting leucocytes and
fibroblasts to a healing wound, stimulating their division,
and maintaining the further activities of these cells by
both paracrine and autocrine mechanism^.^
Monocyte chemotactic potein 1 (MCP-IIJE)
Exposure of 3T3 fibroblasts to PDGF leads to cellular
division and upregulation of about eight 'early response'
genes that are thought to initiate and direct replication.
One of these is JE, which in the mouse encodes a small,
secreted glycoprotein whose function was initially
~ n k n o w n .However,
~ specific monocyte chemotactic
Addressee for correspondence: J. Slavin, Department of Surgery,
University of Liverpool, PO Box 147, Liverpool L69 3BX, U.K.
*Abbreviations used in this article: PDGF: platelet-derived growth
factor; VEGF: vascular endothelial growth factor; bFGF: basic
fibroblast growth factor; KGF: keratinocyte growth factor; TGF-P:
transforming growth factor beta; MCP-UJE: monocyte chemotactic
protein 1.
CCC 0022-3417/96/010005-06
01996 by John Wiley & Sons, Ltd.
activity in culture and tissue extracts was identified
by several groups. In 1989, the human homologue of
JE was finally cloned and is now termed monocyte
chemotactic protein-1.'
Human MCP-1 is a basic peptide with a predicted
mass of about 87 kD. It is a monocyte chemoattractant
and activator but has no neutrophil chemotactic activ-
ity.6 MCP-1/JE is produced by many cell types, includ-
ing fibroblasts and endothelial cells. Following platelet
degradation and release of PDGF, tissue cells are
stimulated to synthesize MCP- 1/JE, providing a persist-
ing stimulus for infiltration of monocytes into a wound.4
Transforming growth factor beta (TGF-P)
TGF-P is a 25 kD homodimeric peptide. Three types
of human TGF-j3 have been identified showing signifi-
cant sequence homology and similar biological activity.
Most of the published literature relates to TGF-j?,.
TGF-P receptors are widely distributed and found on
essentially all cell types. TGF-P is produced by a variety
of cell types, including activated macrophages, fibro-
blasts, and lymphocytes; platelets are also a rich ~ o u r c e . ~
TGF-P is released as an inactive peptide bound to its
propeptide and requires activation either by proteolysis
or as a result of the acid environment within a wound.*
It is chemotactic for both macrophages and fibroblasts,
although at femtomolar concentration^.^
TGF-P stimulates cell division in some circumstances
and in others it is inhibitory. The precise effect is
dependent on the presence of other growth factors or the
particular cell line being ~ t u d i e d .TGF-P
~ stimulates
fibroblast division at low concentrations but stimulates
differentiation at high concentrations. The differentiated
phenotype is associated with increased collagen and
matrix produ~tion.~ TGF-P treatment decreases syn-
thesis of collagenase by cultured fibroblasts and
increases production of the interstitial collagenase
inhibitor, tissue inhibitor of metalloproteinases-1
(TIMP- l)." TGF-P is pro-inflammatory, stimulating
non-specific immunity and the initial immune response
to a new antigen, but is immunosuppressiveif an antigen
has been encountered previously. Injected subcutane-
ously, TGF-P stimulates an inflammatory infiltrate and
causes angiogenesis and fibrosis." TGF-/3 is a critical
peptide controlling repair, attracting cells to a wound,
but most importantly, promoting subsequent deposition
of collagen and matrix. If any particular cytokine
deserves to be described as a 'wound hormone', it is
TGF-P.
Received 12 April 1995
Accepted 4 July 1995
6 J. SLAVlN
Basic fibroblast growth factor (bFGF)
bFGF was identified as a partially purified prep-
aration derived from neuroendocrine tissue, which
stimulated the division of 3T3 fibroblasts. It is now clear
that bFGF is found throughout the body.I2 bFGF is
synthesized without a leader sequence and thus conven-
tional secretion via the endoplasmic reticulum does not
occur. Alternative methods of release have been pro-
posed, such as following cell death or damage. Other
proteins which lack a secretion signal, such as
interleukin- lp, are released by exocytosis and this
method has also been proposed for FGF.13
Heparin is structurally related to the carbohydrate
extracellular matrix that surrounds cells. bFGF
binds avidly to both. Endothelial cells grown in culture
synthesize bFGF and the cytokine can be extracted
from the extracellular matrix secreted by these cells.
Immunostaining of tissue sections demonstrates bFGF
reactivity in subendothelial basement membrane. As-
sociation with subendothelial matrix heparin and
heparan has thus been suggested as a reservoir of
inactive bFGF. l4
bFGF is chemotactic and mitogenic for cells of
mesenchymal and neuroectodermal origin, including
fibroblasts. It is also a potent endothelial cell mitogen.12
New blood vessel formation involves the initial destruc-
tion of capillary basement membrane, the migration and
division of endothelial cells, and then reformation of
capillary structures. bFGF stimulates all these activities
in cultured endothelial ~ e 1 l s . Tissue
l~ plasminogen acti-
vator activates the fibrinolytic system and also indirectly
activates many other enzymes, including collagenases
and cytokines such as TGF-P. l 6 Plasminogen activator
secretion by bovine aortic endothelial cells is increased
following treatment with bFGF, as is the production of
interstitial collagenase.'7 In vivo FGF is a potent direct-
acting angiogenic factor and stimulates neovasculariz-
ation when applied to the rabbit cornea. l 8 Antibodies
to bFGF impair deposition of granulation tissue in a
wound chamber." These observations suggest that
bFGF has a central role in neovascularization and thus
in the formation of granulation tissue.
Vascular endothelial growth factor (VEGF)
VEGF is a heparin-binding endothelial growth factor
first identified in conditioned media of bovine pituitary
follicular cells. It is a dimeric protein with a molecular
mass of about 45 kDZ0 and is a direct-acting mitogen
whose activity appears specific for vascular endothelial
cells. Its effects in vivo and on cultured endothelial cells
are similar to those of bFGF. In situ hybridization
shows that VEGF mRNA is widely distributed and
expressed at particularly high levels in areas of active
vascular proliferation. Ligand autoradiography demon-
strates VEGF binding sites on vascular endothelium.21
VEGF acts synergistically with bFGF to stimulate
endothelial cell function;22 both cytokines are thus
implicated in the control of the angiogenesis seen during
repair.
Keratinocyte growth factor (KGF)
KGF is a member of the fibroblast growth factor
family. It is alternatively designated FGF-7 and was
identified as a mitogen for a murine keratinocyte cell
line. It is a specific potent chemoattractant and mitogen
for keratinocytes, with minimal effects upon cells of
mesodermal origin, unlike other members of the FGF
family.23 KGF may constitute the dermal/epidermal
signal stimulating re-epithelialization.
WOUND REPAIR AS A CELLULAR CASCADE
Following injury, platelet degranulation releases a
number of chemotactic factors including TGF-fi and
PDGF. Circulating peripheral blood leucocytes migrate
into the wound space. Migration is complex, involving
leucocyte recognition of endothelial cells and matrix
components via specific adhesion molecules. Cytokines
upregulate the expression of adhesion molecules on both
endothelial and leucocyte populations. For example,
TGF-jl treatment of monocytes upregulates P1 integrin
receptors that modulate cellular interaction with matrix
components."
Neutrophil numbers peak at 24 h and then gradually
fall. In the absence of infection, neutrophils are not
required for normal tissue repair. I Twenty-four hours
after injury, monocytes begin to be seen within a wound,
total numbers peaking at 48 h post-injury. Monocytes
mature into macrophages' and are now considered an
essential source of cytokines driving repair. Both
PDGF2 and TGF-p' have monocyte chemotactic activ-
ity at appropriate concentrations. PDGF also induces
the synthesis of MCP-1/JE by surrounding tissue cells
and this constitutes a persisting stimulus for monocyte
infi~tration.~
During adult life, rapid cellular division is rare and
usually occurs as part of a response to injury, for
example during wound repair. In contrast to the up-
regulation seen with many cytokines, downregulation of
repressors of cellular replication, such as p53, occurs
within a wound. As healing progresses, the expression of
cytokines is suppressed and that of p53 increases
again.24Rapid uncontrolled cellular division also occurs
in malignant tumours. There are many functional simi-
larities between the growth of a malignant neoplasm and
wound repair. Both are associated with angiogenesis,
collagen and matrix deposition, and inflammation. In
some respects, malignancy can be thought of as a type of
'abnormal wound', in which there are no homeostatic
mechanisms to terminate repair.2s
Macrophages synthesize cytokineslgrowth factors
including TGF-P,7 FGF,I2 VEGF,26 and MCP-1/JE.5
Fluid removed from wound chambers or collected from
acute or chronic wounds contains FGF and TGF-p.27,28
Depletion of wound macrophages severely impairs
repair.29 It is proposed that macrophages release
cytokines/growth factors and these stimulate and con-
trol matrix protein deposition, angiogenesis, and
re-epithelialization.
From day 3, fibroblasts which are derived from sur-
rounding dermal elements are encountered in increasing
 CYTOKINES AND WOUND HEALING
numbers within a wound.' Fibroblasts migrate, divide,
differentiate, and begin to deposit the collagen that
forms part of the substance of granulation tissue. Col-
lagen metabolism within a wound is a balance between
synthesis and degradation. Digestion of mature collagen
follows cleavage at a specific site within the triple
alpha helix, by interstitial collagenase (matrix
metallopr~teinase-l).~~ Interstitial collagenase is present
in healing wounds and is produced by a number of cell
types, including endothelial cells, monocytes, and
fibroblasts. It is released in an inactive form and proteo-
lytic cleavage by plasmin or stromelysin generates active
enzyme. l6 Tissue inhibitors of metalloproteinases
(TIMPs) are important in regulating collagenase activ-
ity. These small inducible proteins bind to and inactivate
5 ~'
P
colla e n a ~ e . TGF- is a potent stimulator of procol-
lagen and TIMP-1 production and blocks induction
of collagenase by other cytokines." Thus, TGF-P has a
pivotal role inhibiting collagenolysis and directing the
deposition of collagen and other matrix proteins.
The centre of a wound is hypoxic. New blood vessel
growth is essential for normal fibroblast and leucocyte
function. Activated macrophages are integral to the
neovascular response and release both bFGFI2 and
VEGF.26 bFGF is also released following enzymatic
degradation of subendothelial basement membrane.I4
Endothelial cell migration and division occur, stimu-
lated in part by bFGF and VEGF. Small capillary loops
form and canalize, permitting blood flow. Oxygen
and nutrients allow fibroblasts to follow, divide, and
synthesize collagen and other matrix proteins.32
Extracellular matrix is formed in part by carbohy-
drate glycosaminoglycans. Many of these are combined
with protein core molecules to form proteoglycan
molecules. Interaction between cells, these core mol-
ecules and their carbohydrate elements is critical in
determining henotype. Many growth factors, including
basic FGF,1gVEGF,21 and PDGF: also bind matrix
molecules. Thus, interactions of matrix growth factor
and cell together are important in determining both
cellular behaviour and the action of a number of
~ytokines.~'
Open wounds heal by a mixture of granulation tissue
formation and re-epithelialization. Re-epithelialization
occurs from residual epidermal appendages and
ingrowth from the lateral margins of the wound. In situ
hybridization demonstrates massive induction of KGF
mRNA 1 day after skin injury.34 The highest levels of
expression are in the dermis, at the wound edge, and in
the hypodermis below the wound. Messenger RNA
encoding the receptor for this growth factor is predomi-
nantly expressed in the epidermis. This suggests that
keratinocytes are stimulated by dermally-derived KGF
during wound healing and that KGF may be the
cytokine driving re-epithelialization.
Wound contracture reduces wound size considerably,
although in man its contribution is somewhat limited
by the fixed nature of skin. In vitro, fibroblasts align
themselves along the fibrils of a collagen gel and pro-
mote a similar process by an energy-dependent mech-
anism. TGF-P can be shown to stimulate the contraction
of collagen gels in ~ i t r oInitially,
. ~ ~ fibroblasts produce a
7
loose mix of type I and IT1 collagens and other matrix
proteins. Over the next few weeks to months, remodel-
ling of a scar occurs and type I collagen replaces type 111.
The vascularity of the wound decreases until eventually
an acellular fibrous scar is produced. The factors
involved in this transformation are less clearly defined;
although we have identified a number of start signals, we
have yet to elucidate the signals that limit subsequent
events.36
PHARMACOLOGICAL MANIPULATION OF
REPAIR
Great interest has been shown in the possible use of
recombinant cytokines to manipulate repair. A wound
chamber provides an effective method of studying the
production of granulation tissue and this can be used
in assessing the efficacy of such potential therapeutic
agents. Cells infiltrate in a predictable sequence, divide,
and synthesize collagen and matrix. A number of
parameters may be used to assess healing, such as
histology, dry weight, or DNAlhydroxyprolinelprotein
content of deposited tissue. Numerous experiments have
demonstrated that bFGF, TGF-p, and PDGF increase
one or more of these parameters. Topical application
of a cytokine might be used to promote cellular chemo-
taxis, division, production of further growth
factors, angiogenesis, and matrix protein synthesis.36
Pharmacology of experimental wounds
An incisional skin wound, with healing assessed by
the measurement of breaking strength, is similar to a
surgical wound. The strength of a wound is dependent
on both the amount and the organization of the collagen
that it contains. A wound initially has little strength, but
with the passage of time this increases in a predictable
manner. Wound strength is an indirect but useful
measure of collagen deposition. Topical application of
PDGF and of TGF-P both accelerate the rate of gain in
strength of healing incisional wounds in rats.37 PDGF-
treated wounds are characterized by an earlier and
increased accumulation of monocytes/mdcrophages.
Pro-inflammatory agents, such as glucan, stimulate
repair by increasing the inflammation present within a
wound. Increased numbers of macrophages release
cytokines and growth factors including TGF-P, which
stimulate fibroblast collagen synthesis. Topical PDGF
stimulates repair in this way, increasing monocyte in-
filtration and thus indirectly increasing TGF-P tissue
level^.^ TGF-P-treated wounds demonstrate marked
fibroblast procollagen immunostaining and it is likely
that TGF-P also influences fibroblast function throu h
direct stimulation of collagen and TIMP- 1 secretion.&
Incisional wounds treated with bFGF become increas-
ingly cellular as the dose of the applied growth factor
increases and at higher doses gain in wound strength is
impaired.39 In addition to its chemotacticlmitogenic
effects on both endothelial cells and fibroblasts, FGF is
a potent in&ibitor of collagen deposition by cultured
fibroblasts; too much angiogenesis may not be good for
repair.
8 J. SLAVIN
Open wounds heal by second intention. The basic
mechanisms of repair are similar to those in an incisional
wound. In the rabbit ear dermal ulcer model, a disc of
tissue is removed down to the ear cartilage. The wound
edge is fixed; thus, the contribution of wound contrac-
tion to repair is limited. Healing is measured by assess-
ing granulation tissue formation in the wound space
using histomorphometry. Using this model, topical
bFGF, PDGF, or TGF-P increases the tissue de-
p ~ s i t e d . ~Wounds
' treated with basic FGF contain
increased amounts of poor quality, collagen-deficient,
and hypercellular granulation tissue. PDGF-treated
wounds contain increased amounts of leucocyte-rich
granulation tissue. TGF-/?-treated wounds demonstrate
histological evidence of increased deposition of collagen
early in the repair process.
Topically applied KGF in partial-thickness porcine
skin wounds stimulates re-epithelialization. Epidermis
from KGF-treated wound sites is significantly thicker
compared with mirror-image control sites.42
Fetal tissue repair
Cutaneous healing in the fetus within the first trimes-
ter occurs without scarring. Fetal wounds are character-
ized by a lack of inflammation and it has been suggested
that adult repair with scar formation is a consequence of
the associated inflammation. Much interest is currently
focused on exploiting this basic o b ~ e r v a t i o n .TGF-/?
~~
may be partly responsible for the inflammatory infiltrate
seen in adult wounds. Immunohistochemical staining of
fetal wounds failed to demonstrate the presence of
TGF-P. TGF-/? neutralizing antibody applied directly to
a healing wound reduced scar formation in adult rats.44
Chemotherapy
Depletion of circulating monocytes deprives a wound
of macrophages and impairs repair. Grotendorst et al.
measured PDGF and TGF-P levels in wound chambers
in adriamycin-treated rats and found low levels in
comparison with saline-treated control^.'^ Exogenous
replacement of TGF-/? within the chambers of
adriamycin-treated rats returns healing to normal.45
Both TGF-/? and procollagen wound mRNA levels are
decreased in rat wounds following treatment with doxo-
rubicin. Addition of exogenous TGF-/? to wounds
returns procollagen mRNA levels to normal or even
supra-normal levels.46This is therefore further evidence
that TGF-j? released by monocytes/macrophages
appears to be an important signal stimulating collagen
deposition. Exogenous replacement in situations of
impaired inflammation restores tissue repair to apparent
normality.
Radiotherapy
Total-body irradiation with a cobalt-60 photon beam
decreases circulating monocyte counts, whilst having
little direct effect on subcutaneous tissues. Megavoltage
electron beam surface irradiation impairs surface heal-
ing, whilst sparing the bone marrow. Topical TGF-/?
reverses the healing deficit seen with total-body irradi-
ation, but not that seen with surface i r r a d i a t i ~ n . ~ ~
Topical PDGF was ineffective as a stimulant of repair in
monocyte-depleted animals treated with either cytotoxic
agents or total-body irradiation, supporting the hypoth-
esis that the influence of PDGF on repair is mediated by
recruited inflammatory cells.
Glucocorticoid treatment
Glucocorticoid administration impairs healing. Treat-
ment of cultured fibroblasts with dexamethasone
decreases collagen and TIMP-1 synthesis and thus
glucocorticoids may directly decrease collagen depo-
sition in v ~ v o . ~ ' Glucocorticoids are also anti-
inflammatory; wounds in treated animals contain fewer
mononuclear cells and this may also interfere with
repair. Downregulation of MCP- 1/JE seen in fibroblasts
cultured with glucoc~rticoid~~ could underlie the anti-
inflammatory effect of glucocorticoid treatment. Topical
TGF-/?, but not PDGF, reverses glucocorticoid impair-
ment of repair in rat wounds healing by both first and
second i n t e n t i ~ nNo
. ~ increase in inflammatory infiltrate
is seen following treatment with TGF-/i3 TGF-/? topical
reverses the negative influence of glucocorticoids on the
collagen metabolism of cultured fibroblasts; this sug-
gests that TGF-P exerts a direct stimulatory effect on
fibroblast collagen deposition in glucocorticoid-treated
animals.48
Parenteral TGF-P
Tissue repair is also impaired in elderly animals,
which have deficient macrophage and fibroblast function
in comparison with younger animals. A single intra-
venous dose of TGF-/? accelerates healin in young male
steroid-treated rats and in aged rats." TGF-/3 has a
short half-life in the circulation. Given as an intravenous
dose, TGF-/3 can have no directional chemotactic effect.
It may act directly upon fibroblast migration and colla-
gen synthesis. Alternatively, stimulation of repair could
be due to TGF-Fs known pro-inflammatory effects.' '
Beneficial modulation of tissue repair by the parenteral
administration of a single dose of a cytokine has not
previously been shown. There are clear potential clinical
applications.
Clinical implications
Individual cytokines influence wound repair in differ-
ent ways. It has also become clear that no single
definition of a 'better wound' exists. For example, a
plastic surgeon may wish to avoid the disfigurement of a
facial scar, but a general surgeon may depend on that
same fibrotic process for the safe repair of a laparotomy
wound. No amount of cytokine can substitute for basic
surgical principles such as asepsis, adequate debride-
ment, and lack of suture tension. Similarly, a cytokine
cannot negate the requirement for an adequate blood
supply or compensate for an inadequate sensory system.
However, if a defined aspect of repair in a particular
wound can be identified, then its pharmacological
manipulation will be possible.
 CYTOKINES AND WOUND HEALING
CONCLUSION
Adult tissue repair is initiated by platelet degranu-
lation and is characterized by a limited inflammatory
infiltrate. Macrophages are a source of further cytokines
driving repair. Factors such as PDGF, which stimulate
inflammation and increase macrophage infiltration into
wounds, can stimulate healing. TGF-j3 released by
wound macrophages has a pivotal role as a stimulator of
fibroblast collagen and other matrix protein deposition.
Topical TGF-/3 stimulates repair in macrophage-
deficient wounds and acts directly upon fibroblast col-
lagen metabolism. New vessel growth brings oxygen and
nutrients. bFGF released following the breakdown of
extracellular matrix and VEGF released from infiltrating
cells together stimulate angiogenesis. Increased endo-
thelial cell proliferation may well be detrimental for
normal repair. KGF produced by dermal celIs stimulates
re-epithelialization and as a topical application, stimu-
lates epithelial regeneration. Thus, tissue repair is a
cellular cascade driven by specific polypeptide medi-
ators. We can begin to dissect the nature of conditions
that impair repair in vivo. The identification of specific
molecular defects coupled with the development of
defined clinical end-points will allow the therapeutic
manipulation of tissue repair.
REFERENCES
I . Ross R. Inflammation, cell proliferation and connective tissue formation in
wound repair. In: Hunt TK, ed. Wound Healing and Wound Infection:
Theory and Surgical Practice. New York Appleton-Century-Crofts, 1980;
1-8.
2. Antoniades HN. PDGF: a multifunctional growth factor. BaillPres Clin
Endocrinol Metub 1991; 5 595-613.
3. Pierce GF, Mustoe TA, Lingelbach J, Masakowski VR, Gramates P, Deuel
TF. Transforming growth factor /l reverses the glucocorticoid-induced
wound-healing deficit in rats: possible regulation in macrophages by platelet
derived growth factor. Proc Natl Acad Sci USA 1989; 8 9 2229-2233.
4. Deuel TF, Kawahara RS, Mustoe TA, Pierce GF. Growth factors and
wound healing: platelet-derived growth factor as a model cytokine. Annu
Rev Med 1991; 4 2 567-584.
5. Yoshimura T, Yuhki N, Moore SK, Appella E, Lerman MI, Leonard EJ.
Human monocyte chemoattractant protein-1 (MCP-I). Full-length cDNA
cloning, expression in mitogen-stimulated blood mononuclear leucocytes,
and sequence similarity to mouse competence gene JE. FEBS Lett 1989; t44:
487493.
6. Rollins BJ, Walz A, Baggiolini M. Recombinant human MCP-IIJE induces
chemotaxis, calcium flow and the respiratory burst in human monocytes.
Blood 1991;78: 1112-1116.
7. Massague J. The transforming growth factor$ family. Annu Rev Cell Biol
1990; 6 597-641.
8. Wakefield LM, Smith DM, Flanders KC, Sporn MB. Latent transforming
growth factor$ from human platelets. A high molecular weight complex
containing precursor sequences. J Biol Chem 1988; 263 76467654.
9. lgnotz RA, Massague J. Transforming growth factor# stimulates the
expression of fibronectin and collagen and their incorporation into extra-
cellular matrix. J Biol Chem 1986; 269 43374345.
10. Edwards DR, Murphy G, Reynolds JJ. Transforming growth factor beta
modulates the expression of collagenase and metalloproteinase inhibitor.
EMBO J 1987; 6: 1899-1904.
11. Wahl SM. Transforming growth factor beta (TGF-P) in inflammation: a
cause and a cure. J Clin Zmmunol 1992; I2 61-74.
12. Baird A, Esch F, Mormede P, et a / . Molecular characterisation of fibroblast
growth factor: distribution and biological activities in various tissues.
Recent Prog Horm Res 1989; 4 2 143-205.
13. Mignatti P, Morimotto T, Rifkin DB. Basic fibroblast growth factor, a
protein devoid of a secretory signal sequence, is released by cells via a
pathway independent of the endoplasmic reticulum Golgi complex. J Cell
Physiol 1992; 151: 81-93.
14. Vlodavasky I, Folkman J, Sullivan R, et a/. Endothelial cell derived basic
fibroblast growth factor: synthesis and deposition into sub-endothelial
matrix. Proc Nut/ Acad Sci USA 1987; 84: 2292-2296.
9
15. Montesano R, Vassalli JD, Baird A, Guillemin R, Orci L. Basic fibroblast
growth factor induces angiogenesis in vitro. Proc. Natl Acad Sci USA 1986;
8 3 7297-7301.
16. Banda MJ, Berron GS, Murphy G, Werb Z, Dwyer KS. Proteinase
induction by endothelial cells during wound repair. Prog Clin Biol Res 1988;
266 117-130.
17. Mignatti P, Tsuboi R, Robbins E, Rifkin DB. In vitro angiogenesis on the
human amniotic membrane: requirement for basic fibroblast growth factor-
induced proteinases. J Cell Biol 1989; 108: 671482.
18. Folkman J, Klagsbrum M. Angiogenesis factors. Science 1987; 235
442447.
19. Broadley KN, Aquino AM, Woodward SC, e f al. Monospecific antibodies
implicate basic fibroblast growth factor in normal wound repair. Lab Invest
1989; 61: 571-575.
20. Leung DW, Chachianes G, Kuang W, Goeddel D, Ferrara N. Vascular
endothelial growth factor is a secreted angiogenic mitogen. Science 1989;
246 13061309.
21. Ferrara N, Houck KA, Jakeman LB, Winer J, Leung DW. The vascular
endothelial growth factor family of polypeptides. J Cell Biochem 1991; 47:
211-218.
22. Pepper MS, Ferrara N, Orci L, Montesano R. Potent synergism between
vascular endothelial growth factor and basic fibroblast growth factor in the
induction of angiogenesis in vitro. Biochem Biophys Res Commun 1992; 189
82483 I.
23. Rubin JS, Osada H, Finch PW, Taylor WG, RudikofT S, Aarson SA.
Purification and characterisation of a newly identified growth factor specific
for epithelial cells. Proc Nut/ Acad Sci USA 1989; 86: 802-806.
24. Antoniades HN, Galanopoulos T, Neville-Golden J, Kiritsy CP, Lynch SE.
p53 expression during normal tissue regeneration in response to acute
cutaneous injury in swine. J Clin Invest 1994; 9 3 220622214.
25. Whalen GF. Solid tumours and wounds: transformed cells misunderstood
as injured tissue. Lancet 1990; 336 1489-1492.
26. Berse B, Brown LF, Van de Water L, Dvorak HF, Senger DR. Vascular
permeability factor (vascular endothelial growth factor) gene is expressed
differentially in normal tissues, macrophages and tumors. Mol Biol Cell
1992; 2 211-220.
27. Grotendorst GR, Grotendorst CA, Gilman T. Production of growth factors
(PDGF and TGF-P) at the site of tissue repair. Prog CIin Biol Res 1988; 266:
47-54.
28. Cooper DM, Yu Z, Hennessey P, KO F, Robson MC. Determination of
endogenous cytokines in chronic wounds. Ann Surg 1994; 9 688-691.
29. Leibovich SJ, Ross R. The role of the macrophage in wound repair: a study
with hydrocortisone and antimacrophage serum. Am J Pathol 1975; 78:
71-91.
30. Goldberg GI, Wilhelm SM, Kronberger A, Bauer EA, Grant GA, Eisen
AZ. Human fibroblast collagenase. Complete primary structure and homol-
ogy to an oncogene transformation induced rat protein. J Biol Chem 1986;
261: 6600-6605.
31. Sricken GP, Welgus HG. Human skin fibroblast collagenase inhibitor:
purification and biochemical characterisation. J Biol Chem 1983; 258:
12252-12255.
32. Knighton DR, Fiegel VD. Macrophage derived growth factors in wound
healing. Regulation of growth factor production by the oxygen micro-
environment. Am Rev Respir Dis 1989; 140: 1108-1 11 1.
33. Bernfield M, Sanderson RD. Syndecan, a developmentally regulated cell
surface proteoglycan that binds extracellular matrix and growth factors.
Philos Trans R Soc London 1990; 327: 171-186.
34. Werner S, Peters KG, Longaker MT, Fuller-Pace F, Banda MJ, Williams
LT. Large induction of keratinocyte growth factor expression in the dermis
during wound healing. Proc Natl Acad Sci USA 1992; 8 9 6896-6900.
35. Montessano R, Orci L. Transforming growth factor beta stimulates col-
lagen matrix contraction: implications for wound healing. Proe Natl Aead
Sci USA 1988; 8 5 48944897.
36. tenDijke P, lwata KK. Growth factors for wound healing. BioITechnology
1989; 7: 793-798.
37. Pierce GF, Mustoe TA, Lingelbach J, et a / . Platelet-derived growth factor
and transforming growth factor$ enhance tissue repair activities by unique
mechanisms. J Cell Biol 1989; 109: 430-433.
38. Pierce GF, Brown D, Mustoe TA. Quantitative analysis of inflammatory
cell influx, procollagen type 1 synthesis and collagen cross-linking in
incisional wounds: influence of PDGF-BB and TGF-8,. J Lab Clin Med
1991; 117: 373-382.
39. Slavin J, Hunt JA, Nash JR, Williams DF, Kingsnorth AN. Recombinant
basic fibroblast growth factor in red blood cell ghosts accelerates incisional
wound healing. Br J Surg 1992; 7 9 918-921.
40. Davidson JM, Zoia 0, Liu M. Modulation of transforming growth factor-
beta 1 stimulated elastin and collagen production and proliferation in
porcine vascular smooth muscle cells and skin fibroblasts by basic fibroblast
growth factor, transforming growth factor-alpha, and insulin-like growth
factor 1. J Cell Physiol 1993; 155 149-156.
41. Pierce GF, Tarpley JE, Yanagihara D, Mustoe TA, Fox GM, Thomason A.
Platelet-derived growth factor (BB homodimer), transforming growth
factor$,, and basic fibroblast growth factor in dermal wound healing. Am
J Pathol 1992; 1 4 0 1375-1388.
10 J. SLAVIN
42. Staino-Coico L, Krueger G, Rubin JS, et ul. Human keratinocyte growth
factor effects in a porcine model of epidermal wound healing. J Exp Med
1993; 178 865-878.
43. Adzick NS, Longaker T. Scarless fetal healing: therapeutic implications.
Ann Surg 1992; 215: 3-7.
44. Shah M, Foreman DM, Ferguson MW. Control of scarring in adult wounds
by neutralizing antibody to transforming growth factor beta. Lancet 1992;
339 213-214.
45. Lawrence WT, Norton JA, Sporn MB, Gorschboth C, Grotendorst GR.
The reversal of adriamycin induced healing impairment with chemoattract-
ants and growth factors. Ann Surg 1986; 203: 142-147.
46. Salomon GD, Kasid A, Bernstein E, Buresh C, Director E, Norton JA.
Gene expression in normal and doxorubicin-impaired wounds: importance
of transforming growth factor-beta. Surgery 1990; 108: 318-323.
47. Cromak DT, Porras-Reyes B, Purdy JA, Pierce GF, Mustoe TA. Accelera-
tion of tissue repair by transforming growth factor ,8,: identification of
action with radiotherapy induced specific healing deficits. Surgery 1993; 113
3&42.
48. Slavin J , Unemori E, Hunt TK, Amento E. Transforming growth factor
beta (TGF-B and dexamethasone have direct opposing effects on collagen
metabolism in low passage human dermal fibroblasts in vitro. Growth
Factors 1994; 11: 205-213.
49. Kawahara RS, Deng ZW, Deuel TF. Glucocorticoids inhibit the transcrip-
tional induction of JE, a platelet-derived growth factor-inducible gene.
J Biol Chem 1991; 2 2 6 13261-13266.
SO. Beck LS, DeGuzman L, Lee WP, Xu Y, Siege1 MW, Amento E. One
systemic administration of transforming growth factor beta-1 reverses age or
glucocorticoid impaired wound healing. J CIin Invest 1993; 9 2 2841-2849.